Changes to MERC Medicaid Revenue Report for Data Year 2010 MERC Committee Meeting – 7 December 2012 Minnesota Department of Human Services Performance Measurement and Quality Improvement Division Ginny Zawistowski ([email protected]) The methodology for the MERC Medicaid Revenue Report has been revised based on feedback from the MERC Technical Workgroup and DHS policy staff. A draft report using the new methodology, using 2010 claims data, has been produced for members of the Technical Workgroup to review. Note: The draft report is for testing purposes only and should not be considered to be the actual MERC revenue estimates for the 2012 grant. The MERC Provider ID numbers from the previous MERC report were used in this report. Data issues addressed by the revised methodology include 1) the need to estimate training site revenue for managed care claims, and 2) the need to allocate dollars among training sites billing under a consolidated NPI. Overview of revised methodology: 
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There are six parts to the revenue calculation for training sites: o Global fee‐for‐service (FFS) payment‐to‐charge ratio calculations, by category of service (COS) and by claim group (Medical, Inpatient, Outpatient, Pharmacy, Dental) o Report 1: FFS claims, non‐consolidated pay‐to providers o Report 2: Managed care claims, non‐consolidated pay‐to providers o Report 3: FFS claims, consolidated pay‐to providers o Report 4: Managed care claims, consolidated pay‐to providers o (Report 5: Managed care encounters by MCO and pay‐to provider – supplemental information not used in revenue calculation) o Report 6: CCDS and Uncompensated Care Pool payments On Reports 1 and 3 (FFS), reimbursement amounts on FFS claims where a MERC training site is a pay‐to provider are reported. On Reports 2 and 4 (managed care), revenue for each MERC training site is estimated by multiplying the submitted claim charges by a matched payment‐to‐charge ratio based on FFS claims. o On Report 2, matching is by COS. If COS is missing or cannot be matched, then claim group is used. o On Report 4, matching is by claim group. (COS cannot be determined for most managed care claims with a consolidated pay‐to provider). o For inpatient claims, a provider‐specific payment‐to‐charge ratio is used wherever possible. o For non‐inpatient claims, a global payment‐to‐charge ratio is used. On Report 4 (managed care, consolidated pay‐to providers), a percentage is applied to the total submitted charges for each consolidated NPI to estimate the submitted charges for each MERC training site under that consolidated NPI. This percentage is based on the percentage of FFS claim charges for those MERC training sites under their consolidated NPIs (“proxy” calculation). This percentage is applied before the payment‐to‐
charge ratio is applied. Report 6 will show CCDS grant payments and Uncompensated Care Pool payments, to capture revenue after the changes to GAMC in 2010. MERC Report ‐ Payment to Charge Ratio by Claim Group
Report: Payment to Charge Ratio by Claim Group
Claim Group
Total Reimbursement Amount
Dental
Inpatient
Global Claim Group ‐ FFS Payment to Charge Ratio
Total Claim Charges
$26,697,889
$68,232,221
39.12798%
$421,258,650
$1,379,650,298
30.53373%
$2,729,990,579
$3,515,943,595
77.64603%
Outpatient
$341,348,870
$970,570,528
35.16992%
Pharmacy
$290,104,466
$574,802,995
50.47024%
Medical
Notes for Report: Payment to Charge Ratio by Claim Group
1) Medicare Crossover claims are excluded.
2) TPL and Spenddown are included.
3) Data are limited to all FFS non‐consolidated providers with CY 2010 service dates.
4) Data are limited to MHCP MA and GAMC to align with MERC legislation.
5) Data are from the DHS Administrative database as of 10‐29‐12. 6) The FFS Payment to Charge Ratio is a is calculated from other columns in the report . It is calculated by dividing the Total Reimbursement Amount by the Total Claim Charges.
Page 1 of 1
Report Payment to Charge Ratio by Claim Group 120612
Draft 11‐05‐12
MERC Report ‐ Payment to Charge Ratio by Category of Service Draft
Report: Payment to Charge Ratio by Category of Service
Category of Service
Category of Service Description
001
005
006
007
013
014
015
019
020
021
022
029
030
032
033
034
035
037
038
039
040
041
043
044
045
046
051
052
053
054
055
056
057
058
062
063
071
072
073
INPATIENT HOSPITAL GENERAL
CHILD WLFR TARGETED CASE MGMNT
INPATIENT HOSP REHABILITATION
OUTPATIENT HOSPITAL SERVICES
ICF‐DD
INPATIENT HOSPITAL IMD
INPATIENT LONG TERM HOSPITAL
DAY TRAINING AND HABILITATION
HOME HEALTH SERVICES
CONSUMER DIRECTED CARE
TRANSITIONAL SERVICES
RTC ‐ MENTAL HEALTH
PHARMACY SERVICES
MEDICAL SUPPLY/DME
MODIFICATIONS AND ADAPTATIONS
FAMILY COUNSELING & TRAINING
BEHAVIORAL PROGRAM SERVICES
TRANSPORT, AMBULANCE
PERSONAL CARE SERVICES
CHILD & TEEN CHECKUP OUTREACH
CHILD AND TEEN CHECKUP
ANESTHESIA
PHYSICIAN SERVICES
CASE MANAGEMENT OTHER
DENTAL
MENTAL HEALTH
PHYSICAL THERAPY
IEP
SPEECH THERAPY
OCCUPATIONAL THERAPY
PODIATRY
AMBULATORY SURGERY
CHIROPRACTIC
AUDIOLOGY
CONSOLIDATED TREATMENT FUND
CTF EXTND CARE/HALFWAY HOUSE
CASE MANAGEMENT MENTAL HEALTH
HOSPICE
INPATIENT HOSP NEO‐NATAL ICU
Page 1 of 4
Report Payment to Charge Ratio by COS 120612
Draft 12‐06‐12
Total Reimbursement Amount Total Claim Charges
$354,056,292
$67,334,577
$6,141,438
$82,517,530
$2,768,158
$6,719,222
$15,814,128
$194,604,553
$22,904,455
$94,288,468
$267,103
$1,542,350
$290,104,565
$48,997,723
$9,740,271
$588,919
$1,719,340
$18,213,198
$406,223,604
$10,775,190
$16,565
$6,652,547
$131,243,302
$72,166,476
$26,650,180
$159,414,555
$5,103,491
$54,640,196
$3,628,885
$7,484,783
$801,307
$3,311,521
$909,654
$440,414
$25,891,678
$4,830,230
$61,614,245
$34,257,533
$16,184,721
$1,222,557,019
$67,640,979
$22,801,207
$234,896,276
$2,786,392
$15,157,492
$35,369,894
$194,846,778
$40,703,372
$94,599,108
$270,860
$1,404,317
$574,802,995
$101,902,085
$10,505,672
$640,200
$2,557,095
$55,447,371
$445,143,913
$10,818,157
$19,878
$38,492,730
$484,460,812
$73,873,003
$62,531,957
$254,148,700
$18,870,573
$56,522,759
$12,351,020
$20,501,165
$2,833,594
$12,143,839
$2,968,527
$1,507,714
$28,267,033
$5,049,087
$62,491,872
$43,520,885
$47,435,841
Global Category of Service ‐ FFS Payment to Charge Ratio
28.96031%
99.54702%
26.93471%
35.12935%
99.34560%
44.32938%
44.71070%
99.87568%
56.27164%
99.67162%
98.61322%
109.82919%
50.47026%
48.08314%
92.71440%
91.98988%
67.23800%
32.84772%
91.25669%
99.60283%
83.33176%
17.28261%
27.09059%
97.68992%
42.61850%
62.72491%
27.04471%
96.66937%
29.38125%
36.50906%
28.27882%
27.26915%
30.64327%
29.21069%
91.59673%
95.66541%
98.59561%
78.71516%
34.11918%
MERC Report ‐ Payment to Charge Ratio by Category of Service Draft
Report: Payment to Charge Ratio by Category of Service
Category of Service
Category of Service Description
074
075
076
077
078
079
080
084
087
088
089
090
091
093
094
095
096
097
100
101
102
103
104
105
106
107
108
109
110
111
113
114
115
116
118
119
121
122
124
INPT HOSPITAL NON DRG
EYEGLASSES/CONTACT LENSES
PROSTHETICS AND ORTHOTICS
HEARING AIDS
VISION
RADIOLOGY, TECHNICAL COMPONENT
LABORATORY
SWING BED SERVICES
END‐STAGE RENAL DIALYSIS
PUBLIC HEALTH NURSING
PRIVATE DUTY NURSING
NURSE MIDWIFE SERVICES
NURSE PRACTITIONER SERVICES
CHORE
COMPANION SERVICES
HOME DELIVERED MEALS
HOMEMAKER SERVICES
CARE GIVER TRAINING
ACCESS SERVICES
ACCESS TO APPEAL
ADULT DAY CARE
FOSTER CARE
SUPPORTED EMPLOYMENT SERVICES
SUPPORTED LIVING SERVICES
STRUCTURED DAY PROGRAM SVC
RESPITE CARE
ASSISTED LIVING SERVICES
INDEPENDENT LIVING SKILLS
IN‐HOME FAMILY SUPPORT
DEV DISABILITIES SCREENING
PASARR ‐ MENTAL HEALTH
EXTENDED HOME HEALTH AIDE
LTC CONSULTATION‐PAS
EXTENDED MEDICAL SUPPLIES/DME
EXTENDED OCCUPATIONAL THERAPY
EXTENDED PERSONAL CARE
EXTENDED PHYSICAL THERAPY
EXTENDED PRIVATE DUTY NURSING
EXTENDED RESPIRATORY THERAPY
Page 2 of 4
Report Payment to Charge Ratio by COS 120612
Draft 12‐06‐12
Total Reimbursement Amount Total Claim Charges
$20,802,211
$2,650,878
$6,012,373
$1,250,714
$2,138,131
$43,462,877
$33,473,299
$6,173
$5,127,341
$1,720,547
$89,162,427
$3,618,128
$16,272,699
$77,001
$39,010,860
$5,118,429
$13,842,451
$34,422
$32,790,046
$246
$19,339,350
$310,802,388
$17,188,315
$661,191,172
$2,349,509
$30,179,496
$90,962,525
$34,530,954
$31,429,413
$4,156,619
$9,662
$1,172,570
$4,714,188
$4,983,427
$3,048
$8,739,057
$8,831
$1,030,262
$169,532
$34,880,533
$4,899,627
$10,729,192
$3,567,954
$8,292,343
$184,938,501
$136,150,128
$60,638
$51,502,187
$2,886,636
$131,638,959
$5,610,387
$32,430,688
$80,593
$42,157,033
$5,446,704
$16,068,903
$36,587
$35,058,114
$246
$20,468,679
$341,178,433
$17,244,951
$668,021,307
$2,376,384
$30,717,108
$102,281,088
$36,168,238
$44,529,922
$4,185,287
$10,304
$1,724,105
$4,790,678
$5,269,365
$6,006
$10,067,489
$17,468
$1,606,681
$192,095
Global Category of Service ‐ FFS Payment to Charge Ratio
59.63846%
54.10367%
56.03752%
35.05410%
25.78439%
23.50126%
24.58558%
10.17954%
9.95558%
59.60387%
67.73255%
64.48982%
50.17685%
95.54315%
92.53701%
93.97297%
86.14434%
94.08170%
93.53055%
100.00000%
94.48265%
91.09673%
99.67158%
98.97756%
98.86912%
98.24980%
88.93386%
95.47314%
70.58044%
99.31502%
93.76947%
68.01038%
98.40336%
94.57358%
50.75577%
86.80474%
50.55349%
64.12362%
88.25392%
MERC Report ‐ Payment to Charge Ratio by Category of Service Draft
Report: Payment to Charge Ratio by Category of Service
Category of Service
Category of Service Description
126
142
143
EXTENDED TRANSPORTATION
BUY‐IN PART A
BUY‐IN PART B
Page 3 of 4
Report Payment to Charge Ratio by COS 120612
Draft 12‐06‐12
Total Reimbursement Amount Total Claim Charges
$8,315,761
$10,124
$4,175,509
$8,537,906
$10,124
$4,178,635
Global Category of Service ‐ FFS Payment to Charge Ratio
97.39813%
100.00000%
99.92521%
MERC Report ‐ Payment to Charge Ratio by Category of Service Draft
Notes for Report:Payment to Charge Ratio by Category of Service 1) Medicare Crossover claims are excluded.
2) TPL and Spenddown are included.
3) Data are limited to all FFS non‐consolidated providers with CY 2010 service dates. 4) Data are limited to MHCP MA and GAMC to align with MERC legislation.
5) Data are from the DHS Administrative database as of 10‐29‐12.
6) The Global Category of Service ‐ FFS Payment to Charge Ratio is calculated by dividing the Total Reimbursement Amount by the Total Claim Charges. Page 4 of 4
Report Payment to Charge Ratio by COS 120612
Draft 11‐16‐12