Medi-Cal reimbursement for District hospitals has gone through numerous changes. In addition to the conversion to a Medi-Cal DRG-based system beginning on January 1, 2014 for District hospitals that receive Medi-Cal inpatient fee-for-service payment, many other changes have and are occurring. These include a shifting away from fee-for-service reimbursement to a managed care approach both by population and geography. Often a decrease in reimbursement results from these changes. At the same time, however, various supplemental reimbursement/payment programs have been developed and implemented to improve the reimbursement levels for District hospitals. However, with the likely replacement of the Affordable Care Act (ACA), these supplemental payment programs are in jeopardy of being reduced, modified or even eliminated making it even more important to improve access to these supplemental funds.

Many of these supplemental payment programs are linked together through combined payment caps and are based upon the volume of services provided to the Medi-Cal and uninsured population. These payment programs can no longer be monitored on an individual program basis and must be looked at in the aggregate. They require on-going hospital data monitoring to ensure that each hospital is able to provide the information that is required in order obtain its most appropriate level of reimbursement. In addition, the balancing and timing of each supplemental payment program is critical to ensure that reaching the payment cap in one program does not cause a lower payment in another program.

SCA assists the District Hospital Leadership Forum (DHLF) in identifying and developing these new programs and works directly with the State and Federal governments in implementing such programs on behalf of all District hospitals as a group. Once these programs are approved and ready for implementation, it is then the responsibility of each District hospital to develop its own relevant processes to ensure qualification and its ability participate in each related funding mechanism. In addition, each participating hospital must be able to capture and report the necessary data and provide support to claim the funding associated with each these programs. SCA can provide individual hospital consulting services to assist clients with participating in and obtaining the most appropriate funding level related to these supplemental payment programs. Specifically, SCA assists its Clients with the following programs:

  • Addressing Medi-Cal inpatient fee-for-service DRG-based payment system reimbursement and payment issues.
  • Capturing and reporting AB 113 Medi-Cal inpatient fee-for-service intergovernmental transfer (IGT) program source data reported to OSHPD.
  • Advising with the negotiation of Managed Care “rate range” IGT opportunities. Recently published federal regulations in this area implementing a ten year transition plan to shift away from lump sum payments to add-ons to payment rates further complicates this process.
  • AB 915 fee-for-service outpatient certified public expenditure (CPE) program utilizing Medi-Cal cost report and payment data.
  • Capturing and ensuring that the source data related to the expanded Quality Assurance Fee programs for District Hospitals will accurately represent and result in the hospital receiving its appropriate funding level.
  • Providing PRIME project development, implementation and reporting monitoring and guidance. This involves monitoring progress related to the completion of each project’s infrastructure milestones, collection of baseline data and consultation with respect to metric definition modifications and revisions.