Whew! The UDS season and the frantic activities to gather all the clinical, operational, and financial data is finished. It is tempting to simply complete this annual exercise and move on to the next thing grabbing our attention. However, before we expunge our brains of all that information, we should pause and take some time, while it is still relatively fresh, to consider what story the data tells of the past year. Specifically, if there are any reasons we could request a change in scope of services for our FQHC’s Medicaid PPS rate(s).
It is critical to the financial sustainability of FQHCs to routinely evaluate whether they have qualifying change in scope of services and maintain appropriate reimbursement from Medicaid through their PPS rate(s). Even if the FQHC is in a state with an alternative payment methodology (APM) it is important to keep the PPS rate updated.
While the specifics of a change in scope of services request varies from state to state, there are some foundational factors. Section 1902 of the Social Security Act requires State Medicaid Plans to adjust PPS rates to take into account increases or decreases in the scope of services provided by the FQHC. This is further explained in the 2001 guidance from the Centers for Medicare & Medicaid Services (CMS) memo describing a change in the scope of services as “a change in the type, intensity, duration, and/or amount of service.” These four categories describe what is considered a triggering event, or an event that may result in the average cost to provide FQHC services to patients to change, thus resulting in the need to have the PPS rate adjusted for this new average cost.
Comparing the recent UDS Tables to the data in the past couple of years can reveal if there have been any triggering events. While an increase in costs doesn’t equal a triggering event, it can point to changes in services or activities that may qualify. Looking at Table 8A alongside Table 5 can highlight if there has been a new service added, a shift in the type of providers, or a change in the mix of services that would result in a change in type, intensity, or duration of services provided. Table 6A can also provide insight regarding changes in increased intensity and/or duration with increased percentages of patients that have chronic conditions need additional time for care to manage their conditions, such as asthma and other respiratory diseases, diabetes, heart disease, hypertension and obesity.
If you would like assistance in doing this type of evaluation, CLC has staff who are experienced in PPS change in scope processes and can provide support or do the analysis for you. Please reach out to info@communitylinkconsulting.com for more information or to receive a quote.
References:
Section 1902(bb) of the Social Security Act (42 U.S.C. § 1396a(bb))
Memorandum from Richard Chambers, Acting Director, Family and Children’s Health Programs Group, Health Care Financing Administration (now CMS), to Associate Regional Administrators (Sept. 12, 2001), re: BIPA Section 702 PPS for FQHCs.