Current through Register Vol. 50, No. 9, September 20, 2024
A. Qualifying Criteria. Effective for dates
of service on or after February 21, 2017, in order to qualify to receive
supplemental payments, physicians and other eligible professional service
practitioners must be:
1. licensed by the
state of Louisiana;
2. enrolled as
a Louisiana Medicaid provider; and
3. employed by, or under contract to provide
services in affiliation with, a state-owned or operated entity, such as a
state-operated hospital or other state entity, including a state academic
health system, which:
a. has been designated
by the department as an essential provider. Essential providers include:
i. LSU School of Medicine-New
Orleans;
ii. LSU School of
Medicine-Shreveport;
iii. LSU
School of Dentistry; and
iv.
LSU-state-operated hospitals (Lallie Kemp Regional Medical Center and Villa
Feliciana Geriatric Hospital); and
b. has furnished satisfactory data to LDH
regarding the commercial insurance payments made to its employed physicians and
other professional service practitioners.
B. Qualifying Provider Types. For purposes of
qualifying for supplemental payments under this Section, services provided by
the following professional practitioners will be included:
1. physicians;
2. physician assistants;
3. certified registered nurse
practitioners;
4. certified nurse
anesthetists; and
5. dentists.
6. - 21. Repealed.
C. Payment Methodology
1. The supplemental payment to each
qualifying physician or other eligible professional services practitioner in
the practice plan will equal the difference between the Medicaid payments
otherwise made to these qualifying providers for professional services and the
average amount that would have been paid at the equivalent community rate. The
community rate is defined as the average amount that would
have been paid by commercial insurers for the same services.
2. The supplemental payments shall be
calculated by applying a conversion factor to actual charges for claims paid
during a quarter for Medicaid services provided by the state-owned or operated
practice plan providers. The commercial payments and respective charges shall
be obtained for the state fiscal year preceding the reimbursement year. If this
data is not provided satisfactorily to LDH, the default conversion factor shall
equal "1". This conversion factor shall be established annually for qualifying
physicians/practitioners by:
a. determining
the amount that private commercial insurance companies paid for commercial
claims submitted by the state-owned or operated practice plan or entity;
and
b. dividing that amount by the
respective charges for these payers.
3. The actual charges for paid Medicaid
services shall be multiplied by the conversion factor to determine the maximum
allowable Medicaid reimbursement. For eligible non-physician practitioners, the
maximum allowable Medicaid reimbursement shall be limited to 80 percent of this
amount.
4. The actual base Medicaid
payments to the qualifying physicians/practitioners employed by a state-owned
or operated entity shall then be subtracted from the maximum Medicaid
reimbursable amount to determine the supplemental payment amount.
D. Supplemental payments for
services provided by the qualifying state-owned or operated physician practice
plan will be implemented through a quarterly supplemental payment to providers,
based on specific Medicaid paid claim data.
AUTHORITY NOTE:
Promulgated in accordance with
R.S.
36:254 and Title XIX of the Social Security
Act.
