Physician Medicaid Supplemental Payments—Deadline for Initial Claims and Other Issues
With more Medicaid rate cuts around the corner, Louisiana hospitals must consider every opportunity to help alleviate their growing reimbursement shortfalls. One such option for some facilities is Louisiana’s Physician Supplemental Payment Program, which provides for additional payments tto qualifying hospitals for professional services delivered to Medicaid patients. This program (sometimes referred to as the “Physician UPL Program”) allows the Department of Health and Hospitals to make payments to non-state-owned public hospitals for dates of service back to July 1, 2010.
The Physician UPL Program has been widely utilized by Louisiana local governmental hospitals, helping them capture enhanced payments for Medicaid services provided by the physicians employed or contracted by them. Although most eligible hospitals are utilizing the program, all should be aware of several important related issues.
Filing deadline: Perhaps the most urgent of these new developments is a recently implemented filing deadline. Federal law prohibits retroactive Medicaid payments greater than two years by quarter. Until now, there was no urgency – eligible hospitals could begin filing at any time, and could always file for any newly-identified claims. Now, however, qualifying providers that would like to receive supplemental payments for dates of service in the third quarter of calendar year 2010 must submit the required data by mid-June. With every subsequent quarter, the deadline will re-set to correspond with this two year requirement. A new deadline, for example, will be in effect for data submissions for payment for services rendered between October 1, 2010 and December 31, 2010.
Written agreement required: In addition to establishing a submission deadline, additional guidance has been provided to participating hospitals on a number of important issues. In particular, the Physician UPL Program requires that a provider be “under contract” (i.e. that a contract exists to provide services) in order for the hospital to receive supplemental reimbursement for that physician’s services. The requirement was recently clarified that the qualifying contract must be in writing. A verbal arrangement will not meet this requirement. The written contract must also be in place at the time of service. Note that a retroactive agreement is acceptable for the purposes of this program as long as it pertains to actual services performed at the hospital during the applicable supplemental payment dates of service.
Requirements when the physician owns the Medicaid claims: Other guidance relates to situations where the practitioner is “under contract” with the hospital and the practitioner performs his or her own billing (i.e., the physician, rather than the hospital, owns the billings and the reimbursement). In these situations, questions arise regarding the elements needed to meet the “employer/employee” type relationship required for the hospital to receive the supplemental payments. In such cases, it is important to distinguish between those practitioners that are seeing their own patients at the hospital, such as for rounding purposes, and those practitioners that are fulfilling a need for the hospital. If the practitioner must follow the hospital department’s policies and procedures and if the hospital is responsible for the overall supervision of the services being performed, then the requirement has been met. Examples of services include the provision of emergency department coverage or handling all pathology department services.
Compliance issues: Finally, participating hospitals should remember that these supplemental claims require the same level of compliance analysis as any other governmental claim involving physician contracts. For example, if the hospital elects to share the supplemental payments with the physician, that creates a compensation arrangement for Stark purposes and a payment to a referring provider for anti-kickback purposes. Similarly, submitting the data and certifications to the Medicaid contractor that are required to receive the supplemental payments constitutes a claim for governmental reimbursement and, if the data is intentionally or recklessly incorrect, could be considered a false claim.
In summary, supplemental Medicaid payments for physician services are a great potential benefit to Louisiana’s local governmental hospitals. They are not, however, different from other governmental claims, and participating hospitals must keep up with and comply with all of the applicable rules.