FL AHCA Outpatient Prospective Payment System Design

Florida AHCA Outpatient Prospective Payment System Design

Fourth OPPS Public Meeting November 20, 2015

Table of Contents

Section 1 ? Policy Decisions Reviewed in November by Governance Committee Section 2 ? Results of Simulation 07 Section 3 ? Review of Policy Decisions

November 20, 2015

Page 2

Section 1

Policy Decisions Reviewed in November by Governance Committee

Policy Decisions Reviewed in November by Governance Committee

Outlier Payments - Discussion

? According to 3M, none of the state Medicaid Agencies that have

implemented an EAPG payment method have included an outlier policy.

? Medicare APC-based OPPS does make outlier payments. The outlier

fixed loss threshold is $2,775 for calendar year 2015 and CMS is proposing increasing the threshold to $3,650 for calendar year 2016. Also, Medicare's marginal cost percentage is 50%.

? Recommendation for Florida Medicaid's OPPS is not to include outlier

payments

Draft and Confidential November 20, 2015

Page 4

Policy Decisions Reviewed in November by Governance Committee

Outlier Payments - Estimates

? Broad estimates of outlier payment ? separate simulations were not

run

? Marginal cost factor is 80% ? Includes only hospitals (not ASCs ? because we don't have cost)

Outlier

Number of Claim Amount of

Percent of

Outlier Lines Paying Payment

Total

Threshold Outlier

Through Outlier Payment

$ 2,000

21,122 $ 28,693,210

2%

$ 3,000

9,190 $ 17,416,470

2%

$ 4,000

5,038 $ 11,841,280

1%

$ 5,000

3,092 $ 8,694,546

1%

Draft and Confidential November 20, 2015

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