A Short Presentation Offering Clear and Concise Explanation On

Update on PEND and Medicaid
MCO Payment Reductions
Jake O’Shea, MD, FACEP
President, Virginia College of
Emergency Physicians
2 Medicaid Delivery Systems in Va
• DMAS (“fee-for-service”)
• Managed care organizations (MCOs)
DMAS Fee-for-service
• Completely state run
• 2012: 34% of beneficiaries / 41% of spending
– $4696 per beneficiary
Managed Care Organizations (MCOs)
• DMAS contracts with managed care
companies, who administer the policies
– Medallion II contract
• Examples: Anthem Healthkeepers, Virginia
premier, Optima Family Care
• 2012: 66% of beneficiaries / 59% of spending
– $3441 per beneficiary (vs. $4696 for DMAS!)
How ED Physicians get paid less
– Aka ‘Pend, review, and reduce’ level 3 claims
• MCO: Reduction to ER Triage Fees
• Long standing policy of DMAS to pend
charges, request review of the entire chart
– If deemed non-emergent , reduced to $22.06
• Used to apply to 99281, 99282, 99283, 99284,
• Now applies to 99283 only
– VACEP played major role in eliminations
• Not subject to VA prudent layperson standard
MCOs: Reduce to ER Triage Fees
• Sporadic (only 99283) until 2012, when it
became more common
– VA Premier and Anthem Healthkeepers
• Now, 99283, 99284, and 99285 may be
subject to “Prudent Layperson” review, often
by a medical director
• Claims are deemed “Non-emergency” and
reduced to triage fee of $22.06
DMAS Pend Program: History to date:
• Pre-2011: Efforts with Pat Finnerty
– Program narrowed from all claims to just 99283
– Opined that complete elimination required budgetary
• 2011: Budget amendment
– Not adopted because of priority of “safety net”
• 2012: Coalition building and budget amendment
– MSV voted: Pend elimination as legislative priority
– Budget amendment not adopted (transportation)
Current State: Coalition
• MSV support elimination of DMAS PEND
• Secretary Hazel supports eliminating both
DMAS PEND AND MCO “Triage fee” reductions
• Theoretically DMAS can eliminate MCO
reductions by changing Medallion II Contract
– DMAS reluctant to do so while the fee-for-service
PEND program remains on the books
What’s next?
• DMAS PEND program
– Ask Secretary Hazel to advocate for inclusion of
PEND elimination in Governor’s budget.
• MCO ER Triage fee reduction:
– Asked Secretary Hazel to direct MCOs to stop
reducing payments to ED Providers
– While working with the Administration on DMAS
PEND elimination, advocate that DMAS remove ER
Triage Fee language from Medallion II contract
How can you help?
• Participate in VACEP letter writing campaign
to the Governor asking him to eliminate PEND
in the budget and remove ‘ER triage fee’
language from MCO contracts.
• Donate to EMPAC!
Contact Jake O’Shea, MD, FACEP
Email: [email protected]

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