November 12, 2014
Area(s) of Interest: Payor Issues and Reimbursement Practice Management Public Payors
The California Department of Health Care Services (DHCS) has taken steps to correct a problem with the Affordable Care Act primary care rate increase unique to Child Health and Disability Prevention Program Services (CHDP) providers.
Before the rate increases were implemented, some practices were previously instructed by DHCS to bill at their Medi-Cal rates. This caused concern—based on DHCS's pricing logic of paying the lesser of Medicare’s rate or the billed charges—that some practices would not qualify for the retroactive increases once the systems were updated to process claims at the higher rates. At CMA and other stakeholders' urging, DHCS agreed to a workaround to allow these practices to be paid at the higher rates.
DHCS has created a web application for onetime submission of the physician's usual and customary rates (UCR), which will allow the practice to receive the higher reimbursement intended by the rate increase.
After receipt of UCR submissions from physicians, DHCS will replace billed amounts with the UCR rates submitted to calculate ACA payments due. The UCR web application is now open for submission but only for a limited time. To access the UCR application, log in to the Medi-Cal website using a valid existing user ID (National Provider Identifier) and then click on the "Elig" tab. The deadline to submit your usual and customary rates is November 28, 2014. Note the system updates that will allow physicians to submit claims at their UCR amount isn’t scheduled until late December and any claims billed after the deadline will be caught in the true up scheduled for the first half of 2015.
Also not all vaccine codes are listed, for example Vaccine for Children (VCF), as they are already systematically set to pay at Medicare rates. For further clarification, access the "UCR Web Application instructions" linked in Medi-Cal's November 3 provider bulletin.
Remember, to qualify for enhanced payment for fee-for–service Medi-Cal and Medi-Cal managed care plans, you must first self-attest to your eligibility. The deadline to attest, if you haven’t already done so, is December 31, 2014. Practices that have attested but have not yet received any addition funds are encouraged to confirm the accuracy of the information submitted through the attestation process. Practices with question can call Medic-Cal’s Telephone Service Center at (800)541-5555.
For more information on this topic, see CMS’s "Medi-Cal Primary Care Physician Rate Increase FAQS," available free to members in CMA’s online resource library.