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Maximzing OB-GYN Revenue with Medicaid Reimbursement

October 21, 2013

CHCs have the opportunity to maximize Medicaid reimbursement for obstetrical care due to the unique encounter rate reimbursement afforded during the antepartum period. For non-CHC providers, AND for commercial payers compensating a CHC, payment is made primarily via a “global surgical package” which essentially means payment is a lump sum.  This singular “global payment” is intended to cover all services related to “normal and uncomplicated” service revolving around the antepartum visits, delivery, and a post-partum follow visit.  Commercial payers can pay from $2,000 to $2,500 for a vaginal delivery while “global OB” for Medicaid can be as little as $1,200. However, as a CHC each outpatient/clinic based encounter (i.e., all antepartum and the post-partum follow up) should be paid the full Medicaid encounter rate.

For example, if a CHC had a Medicaid encounter rate of $130 a visit, and assuming only ten antepartum encounters, this CHC should be paid $1,300… and this is just for antepartum care. Additionally, CHCs who perform the delivery are also eligible for “delivery only” service (e.g., CPT code 59409, vaginal delivery only). Medicaid payment for the ”delivery only” can range from $600-$900. This results in CHCs receiving for Medicaid Obstetrical care, as much or more than what most commercial payers compensate for the identical services; i.e., total Medicaid compensation can be well in excess of $2,000 vs. the more typical “Medicaid OB Global” payment of $900 to $1,200. Certainly, this disparity cannot last but for the time being, CHCs would be foolish to not maximize this revenue opportunity.

To be clear, some Medicaid Managed Care Entities (MCEs) today pay the global obstetrical package fee vs. paying individual antepartum and postpartum visits. However, most states with MCE market penetration still afford, based on state specific CHC manuals/guidance, Medicaid “wrap payment” for all Medicaid eligible encounters.  As such, CHCs are entitled to encounter rate dollars for all antepartum/postpartum visits and not just the global OB.  Resolution of any disparity is often a matter of explaining to, and at times lobbying against, the MCE to assure capture of all payments for which the CHC is eligible.  It is not unheard of to witness some strong-arming by the primary care association or a sympathetic elected official.

There is always the logistical challenge of getting providers and ancillary staff to adequately “code” the services and the obstacle of correctly establishing “edits” or table updates which output the necessary encounter rate coding (e.g., T1015). However, in the end, these are worthwhile and manageable tasks necessary to achieve PMG’s motto of “get paid as much as possible when able so you can give it away when you want or need to.”

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