April 17, 2012
Debbra Curtis, CPA – New Horizons Healthcare
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• Medicaid reimburses FQHCs (hereafter Centers) under the
Alternative Payment Methodology (APM), a cost based rate.
Centers are paid an all-inclusive per visit rate based on
reasonable costs as reported on its annual cost report. During
the year, Medicaid pays an interim rate and reconciliation to
actual costs are made with the annual cost report.
• Reimbursement rates are limited by urban and rural upper
payment limits set annually by CMS. The reimbursement rate
applicable to each Center is communicated to the Center in
the Medicaid Cost Settlement letter.
• PHBV Partners LLP (formerly Clifton Gunderson LLP)
administers Virginia’s Medicaid program by, in-part,
processing cost reports and Wrap Around requests.
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• If Medicaid HMO payments are less than a Center’s Medicaid
reimbursement rate, Medicaid pays the difference.
• The Wrap Around is a request for reimbursement of the
difference between HMO payments received and the
Medicaid reimbursement rate.
• PHBV Partners assigns an analyst to each center. Your cost
report and Wrap Around requests are submitted to PHBV
Partners to the attention of your assigned analyst. That
person is your contact for questions and assistance.
• There are no report formats for the Wrap Around provided by
PHBV Partners or Medicaid.
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• Frequency
– There is no requirement for the frequency of submission. PHBV
Partners recommend quarterly. Centers may choose to submit twice
per year or only once when the cost report is prepared. Quarterly
submission is recommended for cash flow purposes.
• Locations
– For multiple locations which are included on one cost report, only one
Wrap Around is prepared for each submission (one Wrap Around per
group NPI number).
• Detail report
– After deciding the period of time you will submit (i.e. January 2012
through March 2012), compile a detailed report of all Medicaid HMO
visits for that period of time. All HMO payments must be accounted
for before you can prepare the Wrap Around.
– Detail must include a unique identifying number (EHR claim number
for example), date of service, gross charge and HMO payment.
– The detail report is sent with the Wrap Around request so do not
include patient names, social security numbers, etc.
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– Indicate the time period covered by the report.
– Summarize your detailed Medicaid HMO visits into
the following categories:
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Medical (including behavioral health)
Inpatient
Dental
Medical FAMIS (including behavioral health)
Inpatient FAMIS
Dental FAMIS
– NOTE – FAMIS visits must be listed separately as indicated here.
– For each category total the following:
• Number of visits
• Gross Charges
• Payments
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Center Name
Medicaid Wrap Around Summary
Medicaid HMO Patient Visits, Charges and Payments
January 2012 through March 2012
Medical
Inpatient
Dental
Medical FAMIS
Inpatient FAMIS
Dental FAMIS
Number of
Visits
400
Gross
Charges
54,000
100
90
20,000
13,500
HMO
Payments
25,000
7,900
6,000
Wrap Around payment calculation:
In this example, there were 490 HMO medical visits with payments of $31,000 during the three month
period January 2012 through March 2012. If the Center’s Medicaid reimbursement rate is $120, the Wrap
Around payment on the medical visits would be $27,800 calculated as:
490 visits x $120 =
$58,800
Less HMO payments
($31,000)
Wrap Around payment
$27,800
Dental Wrap Around payment would be calculated the same using the Dental reimbursement rate.
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• Make sure your detail report totals agree to your
summary totals.
• Retain your detail in the event you are audited
and must pull individual patient records.
• Send your Wrap Around summary and detail
reports along with a letter requesting the wrap
around to:
PHBV Partners LLP
[Your assigned analyst’s name]
4461 Cox Road, Suite 210
Glen Allen, VA 23060
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April 17, 2012
PHBV Partners LLP
Ms. Your Analyst
4461 Cox Road, Ste. 210
Glen Allen, VA 23060
Re:
Center name
Medicaid Provider # xxxxxxxxxx
Dear Ms. Analyst:
Enclosed please find the Medicaid HMO Wrap Around Report for [Center name] for the period January 1, 2012 through March 31,
2012.
If you have any questions regarding this report, please contact me at xxx-xxx-xxxx.
Sincerely,
Your Name
Your title
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• Medicaid HMO information is included on Exhibit
A. Wrap Around payments are also included.
– Use your Wrap Around summaries submitted during
the year for ease of entering this information.
– Visit, gross charge and HMO payment information is
entered by the six categories on the applicable line g-l
on Exhibit A.
– Wrap around information is entered at the bottom of
Exhibit A (cash advances). The total carries to the
applicable line g-l, column 5.
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PAID BY PRIMARY
AMOUNT RECEIVED FROM
CARRIER & PATIENT
INTERMEDIARY/HMO
PAY
1
2
3
4
1 Paid by Intermediary/HMO during the fiscal period on remittances at applicable tentative rate.
VISITS
(ENCOUNTERS)
g
h
i
j
HMO Clinic
HMO Inpatient Hospital
HMO Dental
HMO FAMIS Clinic
HMO FAMIS Inpatient
K
Hospital
l HMO FAMIS Dental
CASH ADVANCES:
TOTAL CHARGES
CASH ADVANCES
TOTAL
PAYMENTS
5
6
4,200
567,000
263,000
241,000
504,000
1,500
203,000
94,000
86,000
180,000
DATE
11/19/2010
1/24/2011
5/2/2011
7/25/2011
CLINIC
FAMIS CLINIC
11/19/2010
1/24/2011
5/2/2011
7/25/2011
HMO CLINIC
52,000
57,000
56,000
76,000
241,000
HMO FAMIS CLINIC
17,000
18,000
22,000
29,000
86,000
HMO IN-PT HOSP
HMO DENTAL
HMO FAMIS IN-PT HOSP
HMO FAMIS DENTAL
*this cost report excerpt does not include all lines on Exhibit A. Only certain lines are included here for purpose of
this example.
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Questions?
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