Rate Setting for Public and Private Health Facilities

Institutional providers are faced with a maze of regulations regarding rate setting and reimbursement methodologies. Each provider classification has unique rules and restrictions which govern reimbursement. With all the regulatory changes that occur within each of the payer types, navigating this maze is very cumbersome. PCG can help with expertise in rate reviews and reimbursement consulting for facilities including:

• Acute Care facilities (DRG/PPS)
• Inpatient Rehabilitation Facilities (PPS)
• Inpatient Psychiatric Facilities (PPS)
• Children's Hospitals (TEFRA, Cost Reimbursed)
• Skilled Nursing Facilities (RUGS/PPS)
• Intermediate Care Facilities
• Community Mental Health Centers

PCG’s rate setting and reimbursement consulting knowledge and experience is grounded in a core set of principles, including:

• A comprehensive understanding of the Medicare principles of reimbursement established in Provider Reimbursement Manual (PRM) 15-1;
• Knowledge of Medicaid State Plan sections (Section 4.19);
• Knowledge and understanding of all costs, utilization, productivity standards, and/or efficiency factors which affect specific rate calculations.

PCG Expertise

PCG consultants have extensive experience with CMS cost reporting requirements and provide clients with unmatched cost reporting services, including but not limited to:

Chargemaster Reviews: Charge sensitivity analysis to identify opportunities to make changes to the facility CM to maximize reimbursement from charge-based payer through optimization of the facility charge structure;

Medicare Cost Based IP Part B Ancillary and Physician Billing: Development of rates for reimbursement on a cost basis for IP ancillary services and Physician services;

Medicare Wage Index Review: Reviews providers Medicare Wage Related Cost detail to ensure all allowable wage related salary, fringe benefits, contract labor and Physicians costs are properly captured;

Medicare TEFRA Target Limit Exception Requests: Preparation of TEFRA appeals for cost reports not impacted by the BBA or the BBRA;

Medicaid Rate Reviews: Calculation of cost based rates for public providers to maximize compliance with State Plan methodologies and improve reimbursement to the facility.

Among our clients:

• Commonwealth of Massachusetts,  Executive Office of Health and Human Services
• State of Florida, Department of Children and Families 
• State of Louisiana, Department of Health and Hospitals 
• State of Missouri, Department of Mental Health
• State of Texas 
• State of Wisconsin, Department of Health and Family Services

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