Price Based Reimbursement Update – RUGs Billing as of November 1st

As you know, Virginia Medicaid has made the shift to individual RUGs-based billing for dates of service on and after November 1st.  DMAS has made some updates to the FAQs available on their website and we encourage you to review the questions and answers.  

For example, DMAS indicates that under the price-based RUGs methodology, “If the calculated price-based reimbursement exceeds the charges, DMAS will pay the calculated rate. The lesser of billed charges theory will not apply to price-based reimbursement payments (emphasis added).”  This is very important to some members who were concerned that the price-based rates for the high intensity RUGs could actually exceed the private pay rate (charges).  As indicated, DMAS will pay the calculated rate even if that rate exceeds charges.  As CCC nursing facility reimbursement is required to follow the FFS methodology, the MMPs are required to take the same approach (if you experience otherwise, please let us know immediately through the CCC Issue Log.

In other updates related to RUGs-based payment, DMAS Claims processing can now accept multiple RUGs with relevant dates of service on one claim.  The September 26th billing memo indicated that “Unlike Medicare, if there is a change in the RUG assignment during the billing period, a separate claim should be submitted with revenue code “0022” and the new RUG code should be reported for the dates of service to which the new RUG assignment applies.”  DMAS has just provided VHCA notice that “We have tested the system and confirmed the ability to accept multiple RUGs for both FFS and crossover claims as of November 3rd.  We have updated the billing guidance to allow nursing facilities to bill multiple RUGs on a claim.  We will be issuing a notice to nursing facilities to announce the updated billing instructions through GoFileRoom on Wednesday [11/5].”

DMAS has also announced they will be publishing a recorded WebEx session detailing billing instructions for nursing facility price-based reimbursement effective November 1, 2014.  The recorded session will be available for providers to view no later than November 5, 2014, according to DMAS (the presentation can be found by clicking here).  DMAS will also be conducting live Question and Answer (Q&A) sessions on November 13 (2 pm) and 14 (9 am and 2 pm), according to their website, to answer questions about the billing procedures for price-based reimbursement.  Registration for the live sessions will be available on the DMAS website under Learning Network, Current and Upcoming Training Events, or Upcoming WebEx Sessions.

Finally, DMAS has also provided a copy of a clean claim and resulting remittance advice that reflects the testing of the claim submission and payment process for the new methodology.