Medicaid Reimbursement and Payment Reform Consulting Services

The vendor required to provide Medicaid reimbursement and payment reform consulting to achieve its goals of promoting a high-quality provider network through payment model and reimbursement structures that are modern, sustainable, and aligned with the state’s quality, access, and affordability goals.
- Medicaid rate setting and fee schedule
1. Inpatient prospective payment system (IPPS)
•    Provide services for payment modeling and rate setting development related to the state Medicaid IPPS. 
•    These services include but are not limited to collecting and analyzing claim information, modeling various payment scenarios, developing and maintaining hospital-specific peer groups to reimburse similar types of hospitals at the same base rate, and comparing Medicaid reimbursement as a percentage of medicare reimbursement.
•    Responsible for conducting a full IPPS rebase at least once every four years. 
•    The following elements: hospital base rates, per diem rates, medicare-severity diagnosis related groups (MS-DRGS) relative weights, medicare DRG grouper version, hospital specific cost-to-charge (CCRS), psychiatric additive factors, add-on amounts, outlier payment percentages, fixed outlier values, and various payment policies including, but not limited to transfer, short stay, and waiting placement. 
•    Successful bidder shall provide analytic support and reimbursement subject matter expertise to state in updating these components as well as developing Medicaid specific reimbursement strategies.
•    Extensive knowledge of Medicare’s IPPS and IPF PPS. 
•    Successful bidder shall advise state of any changes resulting from Medicare’s IPPS and IPF PPS final rules prior to rebasing the Medicaid IPPS.
•    Present multiple model options to state aligning with budgetary directives as communicated by the state prior to modeling. 
•    Models shall contain hospital level impacts by Medicaid designated peer groupings.
•    Initial draft of the IPPS model to state within 30 calendar days following the release of the medicare IPPS and IPF PPS final rules. 
•    Final model draft is due to state no later than august 15th or other date as specified by state.
2. Outpatient prospective payment system (OPPS)
•    Provide services for payment modeling and rate setting development related to the state Medicaid OPPS. 
•    These services include but are not limited to collecting and analyzing claim information, modeling various payment scenarios, and developing and maintaining hospital specific peer groups to reimburse similar types of hospitals at the same base.
•    Provide analytic support and reimbursement subject matter expertise to state in updating hospital base rates, fixed outlier threshold, outlier payment percentages, status indicators, ambulatory payment classifications (APCS), packaged revenue codes, composite pricing, and comprehensive APCS as well as developing Medicaid specific reimbursement strategies.
•    Have expertise in Medicaid rate setting for outpatient services that are not typically covered or reimbursed by medicare.
•    Present multiple model options to state aligning with budgetary directives as communicated by state prior to modeling. 
•    Models shall contain hospital level impacts by Medicaid designated peer groupings.
3. Resource based relative value scale (RBRVS)
•    Provide services for payment modeling and rate setting development related to the state Medicaid RBRVS. 
•    These services include but are not limited to collecting and analyzing claim information, modeling various payment scenarios, developing and maintaining reimbursement methodologies, and service level impact analyses.
•    Provide analytic support and reimbursement subject matter expertise to state in updating relative value units (RVUS), geographic practice cost indices (GPCIS), conversion factors, identifying newly valued codes, and developing Medicaid specific reimbursement strategies.
•    Present multiple model options to state aligning with budgetary directives as communicated by the state prior to modeling. 
•    Models shall contain physician service level impacts by category of service.
4. Durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS)
•    Provide analytic support and reimbursement subject matter expertise to state in updating capped rental items, analyzing adoption of medicare payment modifiers, and developing Medicaid specific reimbursement strategies.
•    Provide services for payment modeling and rate setting related to the state Medicaid DMEPOS. 
•    These services include but are not limited to collecting and analyzing claim information, modeling various payment scenarios, developing and maintaining reimbursement methodologies, and conducting provider level impact analyses.
•    Initial draft of the DMEPOS model to state within 7 calendar days following the receipt of the Medicaid DMEPOS fee schedule layout provided by state. 
•    Final model is due to state no later than October 30th or other date as specified by state.
5. Federally qualified health center and rural health center (FQHC and RHC) annual prospective payment system (PPS) and change in scope updates
•    Provide analytic support and reimbursement subject matter expertise to state in the annual update to the Vermont Medicaid PPS rate to include adjustment for medicare economic index (MEI) when requested by state. 
•    Successful bidder shall also provide analytic support and reimbursement subject matter expertise to state in review and analysis of FQHC and RHC change in scope (CIS) requests and any resulting adjustment to rates, when requested by the state.
6. Disproportionate share hospital (DSH) payments
•    Provide analytic support, reimbursement subject matter expertise and a general review of the annual DSH payment calculations prepared by state if requested by state.
•    Provide analytic support and reimbursement subject matter expertise to state in any future changes to the program including payment calculations, policy changes or alternative reimbursement methodologies should the program be changed or eliminated, when requested by the state.
7. Graduate medical education (GME) review
•    Provide calculations, analytic support, and reimbursement subject matter expertise to state with annual GME methodology review.
•    Work with state to amend and implement any policy or methodological changes to the GME program during the term of the contract, when requested by state.
- Development and implementation of value-based payment strategies
•    Provide model design, analytic support, and reimbursement subject matter expertise to state in the development and implementation of Medicaid alternative payment model and value-based payment initiatives and strategies across departments in the agency of human services and the continuum of state health care and human services system (including, but not limited to, hospital and professional services, mental health services, substance use disorder treatment services, maternal and child health, and long-term services and supports). 
•    Medicaid payment models shall be aligned with the broader health care reform and system transformation goals of the state, and aligned with multi-payer initiatives where appropriate and dictated by the state.
•    Successful bidder shall demonstrate expertise in implementation of alternative and value-based payment models, including but not limited utilizing encounter data to monitor the utilization of services, quality of care, and payment model financial reconciliation, designing value-based incentive funds, pay for performance scoring methodologies and other quality frameworks, and designing models that introduce levers such as predictability and flexibility and cost efficiency in order to incentivize high-quality clinical decision-making among providers. 
•    Successful bidder shall demonstrate knowledge and expertise in designing value-based payment model quality frameworks that create strong incentives for high-quality care delivery, drive improvement and increased accountability for providers, and include specific, best-practice quality metrics that are appropriate for the payment model. 
•    In support of these goals, successful bidder shall conduct research on national value-based initiatives, analyze claims information, study rate structures, conduct provider surveys, and model payment and fiscal impact scenarios representing options for state’s consideration and potential implementation. 
•    Successful bidder shall demonstrate the ability to leverage expertise from cutting-edge trends in value-based payment models from other state Medicaid agencies or national programs. 
•    Successful bidder shall meet with state at least monthly, or as requested by state, to discuss models, prepare for and attend meetings with providers and other stakeholders, and write draft and final methodologies for selected initiatives. 
•    For each model under consideration for implementation, successful bidder shall deliver drafts and final methodologies to state according to state timelines to allow for timely implementation. 
•    Prior to the start of model implementation, successful bidder shall provide analytic support and reimbursement subject matter expertise to state in drafting public notices, responding to public comment and related questions, preparing state plan amendment submissions or alternative payment model prior approval submissions to centers, and responding to centers questions.