Enhanced Physician Payment Reimbursement

 

The South Carolina Department of Health and Human Services (SCDHHS) recently received final CMS approval for its proposed payment methodology for the Affordable Care Act (ACA) Primary Care Physician rate increase for both the Fee for Service (FFS) and Managed Care Organizations (MCOs).  SCDHHS continues its work on this project to ensure that it is implemented accurately, quickly and within the CMS mandates for these enhanced payments.  

Medicaid FFS ACA enhanced physician payment for those providers meeting the requirements outlined in previous bulletins will begin with providers receiving enhanced payment for qualifying claims processed beginning July 17, 2013.  Attested providers will receive payment based on the enhanced fee schedule for qualifying claims processed beginning July 17, 2013, in their remittance advice dated July 26, 2013.  All claims for these and future dates of service will process via the regular claims payment schedule. 

All FFS providers who attested on or before April 19, 2013,will receive enhanced reimbursement by retroactive gross adjustment for qualifying claims processed with a date of service between January 1, 2013, and July 16, 2013, on the remittance advice dated August 16, 2013.

All FFS providers who attested on or after April 20, 2013, will receive retroactive payments on claims with a date of service on or after the first day of the month of attestation.  This payment could include claims with dates of service beginning April 1, 2013 through July 16, 2013.  Payments for these claims will also be included on the remittance advice dated August 16, 2013.

SCDHHS’ first ACA enhanced physician payment to the MCOs is expected to be distributed by July 19, 2013.  The payments made by SCDHHS to the MCOs for the ACA enhanced primary care rate increase will be based on the encounter data submitted by the MCO for the first quarter of 2013 by physicians who had appropriately attested.

Enhanced payments to MCOs will be for dates of service January 1, 2013, through March 31, 2013.  The MCOs will receive gross level payment for all qualifying providers, along with a report of the information at the individual physician level.  The MCOs will be responsible for reimbursing each provider their qualifying share within 30 days of SCDHHS’ payment to the MCO.  This payment process will be repeated quarterly for MCOs through December 2014.

During implementation, some physicians who attested are not included in the payment cycle for one of the following reasons:

 

  • Pediatric Sub-Specialists do not meet the requirements as outlined in previous bulletins.
  • Teaching Physicians are exempt from participating in this program because they are covered under an enhanced payment program, the Supplemental Teaching Payment Program, as outlined in the Medicaid State Plan.
  • Some physician attestations failed because the NPI or Provider Type submitted on the attestation document was invalid.

Physicians who meet any of the above exceptions have been removed from both the FFS and MCO list of attested providers, except for physicians who are currently only enrolled with an MCO. The Provider Service Center (PSC) is currently sending notification to providers with failed attestations via the email address provided during the attestation process.  Providers who have questions regarding their attestation validation should call the PSC at 1-888-289-0709.

Providers who meet the requirements for the ACA enhanced physician reimbursement are encouraged to attest as soon as possible to qualify for enhanced payments.

The registration portal is available at: www.scdhhs.gov/physicianattestation

For more details on this implementation, including the bulletins and Questions and Answers, please visit the SCDHHS website at www.scdhhs.gov.  This bulletin applies to fee-for-service, Medical Home Networks (MHNs) and MCOs.  If you have any questions regarding this bulletin, please contact the PSC at (888) 289-0709.  Thank you for your continued support of the South Carolina Healthy Connections Medicaid Program.

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