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Prepared for Mass Health 2002. New outpatient hospital payment methodology.

Prepared for Mass Health 2002. New outpatient hospital payment methodology.

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  • Frequently, presenters must deliver material of a technical nature to an audience unfamiliar with the topic or vocabulary. The material may be complex or heavy with detail. To present technical material effectively, use the following guidelines from Dale Carnegie Training®.   Consider the amount of time available and prepare to organize your material. Narrow your topic. Divide your presentation into clear segments. Follow a logical progression. Maintain your focus throughout. Close the presentation with a summary, repetition of the key steps, or a logical conclusion.   Keep your audience in mind at all times. For example, be sure data is clear and information is relevant. Keep the level of detail and vocabulary appropriate for the audience. Use visuals to support key points or steps. Keep alert to the needs of your listeners, and you will have a more receptive audience.

Presenting The P.A.P.E. Presenting The P.A.P.E. Presentation Transcript

  • New Outpatient Methodology….
    • Presenting the P.A.P.E.
    • October 11, 2002
  • What is a P.A.P.E. ?
    • P ayment
    • A mount
    • P er
    • E pisode
  • Historical
    • Decision to adopt A.P.G. method.
    • Prospective payment system.
    • Bundling of services.
    • Outlier payments for high cost services.
    • Three day windowing.
    • Phased implementation.
  • Goals of New Methodology
    • Administrative simplicity.
    • Predictable and verifiable payment.
    • Recognition of higher cost procedures.
    • Encouragement of cost efficiency.
    • Prospective rate setting.
    • Timely implementation. HRY04.
  • Why not use APC?
    • Time frame for implementation.
    • APC still being revised.
    • Future MMIS version will allow us to incorporate APC to evaluate service mix.
  • New Methodology
    • Per visit rate for each hospital based on a statewide efficiency adjusted cost and the hospital specific intensity of the MassHealth OP visits.
    • (CY01 GPSR * CCR)/Number of Visits
    • Repricing of CY01 claims, removing windowing and recalculation of outliers with updated CCRs
    • (Repriced claims/CF)/Number of Visits
    • Avg. Cost per Visit/Hospital’s Avg. APG Weight
  • New Methodology (Continued)
    • 5. As with the IP methodology, we will compare case mix adjusted costs to develop an efficiency adjusted statewide standard Mass Health cost per visit.
    • 6. Inflation adjustments to reflect HRY04 costs.
    • Inflated efficiency adjusted statewide standard cost times hospital specific APG weight equals P.A.P.E.
    • Does not require any changes to billing practices.
  • Lab
    • Pay per fee schedule.
    • Reprice lab claims using fee schedule.
    • Offset P.A.P.E. by average lab claim per episode.
  • Example P.A.P.E. Calculation (For Discussion Purposes Only)
  • Recap
    • Hospital specific OP Payment Amount per Episode (P.A.P.E.), similar to S.P.A.D.
    • Removal of the 3-day windowing element.
    • Incorporation of outliers within the P.A.P.E.
    • Lab carved out to fee schedule.
    • Simplified payment reconciliation.
    • Recognition of each hospital’s OP case mix.
  • Related Reviews
    • OP Edit Sub-Committee – reviewing all OPD edits.
  • P.A.P.E. Project Team
    • Kim Alexander
    • Gail Arnold
    • Dawn Butler
    • Steve Davis
    • Victoria Greeke
    • David Kerrigan
    • Bob Moran
    • Jim Murphy
    • Elizabeth Pressman
    • Nancy Savoie
    • Mohamed Sessay
    • Darrin Shaffer
  • Thank you!