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United States Marshals Service's Prisoner Medical Care

Report No. 04-14
February 2004
Office of the Inspector General

Appendix IX
Re-Pricing Contract with Healthnet, Inc.

The re-pricing contract establishes a centralized system to re-price medical claims incurred by the U.S. Marshals Service. The contractor re-prices all USMS medical claims according to Medicare rates and its preferred pricing schedules to determine the lowest cost to the USMS.

Effective November 29, 1999, the agency was granted legislative authority (PL 106-113, amended Title 18 U.S.C. §4006), to authorize the USMS to pay prisoner medical claims not to exceed the lesser of the Medicare or Medicaid rate.

Contractor Services

The contractor receives medical claims from the district offices and reviews them to determine if they are valid. Invalid claims are those claims that are: incomplete, duplicates, improperly submitted, illegible, or missing mandatory information.

The contractor then correctly re-prices all valid medical claims. These claims are re-priced in accordance with the Medicare Correct Coding and Payment Initiative Rules and Procedures (Public Law 101-239). The contractor provides and operates an automated processing system for re-pricing claims submitted by USMS district offices. The contractor also determines if their preferred pricing rates should be applied to generate additional savings for the USMS.

All processed claims are then returned to the sending district along with an explanation of benefits (EOB) for each claim and a district batch summary sheet. The districts then pay the medical care provider the re-priced amount. The contractor will also maintain automated records in a database to track savings and related USMS medical program data. The contractor also provides the districts and the OIMS with various reports in manual and electronic format in accordance with the contract.

If a sending district later finds that a processed claim should not be paid then it must also inform the OIMS and the contractor in writing of such changes so that the USMS claims database is accurate with regard to savings achieved.

Contractor Reports

The contractor generates and sends a monthly transaction report to each district that lists all claims received and processed for that district.

Re-pricing Contractor Automated Reports

The contractor shall furnish the USMS with required statistical information and reports. Each report will display the report period, the fiscal year, and be broken out by district on a separate sheet, and with a national summary page. Standard reports to be provided to the USMS include:

(1) District batch summary report - Report shall display the district batch number, district name and number, date received, the prisoner's names, claim number, provider, and date of service. Valid and invalid (both incomplete and duplicate) claims shall be listed in separate sections of the report so that the sending district can follow up promptly on incomplete claims for resubmission.
(2) Explanation of benefits for each claim.
(3) Monthly prisoner transaction report (sorted and displayed by prisoner) Report will display the prisoner's names sorted first in alphabetical order and then sorted alphabetically by medical care provider, report columns will show prisoner name, prisoner number, provider, claim number, district batch number, date received to district, amount billed, Medicare amount, USMS allowed amount, amount saved, and percentage saved. Sub-totals of activity by prisoner and for each district will be displayed as well as a national summary sheet provided. This report will include only valid claims processed for the month.
(4) Report will display the provider's names sorted.
(5) Monthly report of invalid claims will contain two sections (one of incomplete claims and the second of duplicate claims submitted. Section 1 (incomplete claims) will display prisoner name and number, provider, claim number assigned, amount billed, description of missing information, date of service, date received by contractor and the district transmittal sheet number. Section 2 (duplicate claims submitted) shall be sorted first by district and then alphabetically by prisoner name. Report columns will display the prisoner name, prisoner number, original claim number, each of the dates a duplicate was received by contractor, date returned to district, provider, date of service and amount billed, the district transaction batch number.
(6) Monthly hospitalization report (sorted and displayed first by the hospital and then by the prisoner), hospital, prisoner, total number of hospital days, DRG, amount billed, USMS allowed amount, amount saved, percentage saved. The reports will be broken out by district with a summary sheet with national totals.
(7) Year to date reports.
(8) Special reports.
(9) Monthly invoice - Each month the contractor shall generate a master invoice for the OIMS broken out by district to reflect the number of patients, valid claims processed, invalid claims handled, amount billed, amount allowed, amount saved, and percentage saved.

The contractor shall also send a copy of the monthly transaction report, which reflects district activity for the month to each district. The monthly transaction report shall contain a certification block to be signed and dated by the district. The OIMS will require that each district promptly return a certified copy of the monthly transaction report summary to support payment to the contractor each month.

All inpatient hospital claims are independently priced and verified by the contractor at the correct DRG by using the Centers for Medicare and Medicaid Service's (CMS) approved pricing program to calculate the Medicare allowable cost. The contractor also applies any new Medicare pricing initiatives as soon as CMS mandates their implementation.

Once the proper DRG has been ascertained, the contractor uses a CMS approved Prospective Payment System to calculate 100 percent of the Medicare allowable cost.

The contractor shall review and date/time stamp all district batches of medical claims/transmittal sheets. The contractor shall review the batches to identify valid and invalid claims and enter all claims received and also have an automated mechanism in place to track and report on any duplicates received from the districts.

Valid claims are those submitted on a district transmittal sheet, on the proper CMS form, and contain at a minimum all the required information. It is the responsibility of the sending district to verify USMS prisoner custody and to ensure that all claims submitted for processing are complete and are not duplicates.

The contractor shall process and send back to the district for payment, all valid claims within five calendar days of receipt. An explanation of benefits (EOB) shall be completed for each valid claim processed.

Invalid claims are claims not submitted on the proper form or missing information considered mandatory. Duplicate claims will also be considered invalid. Information on invalid claims shall be reported back to the sending district in the district batch summary. All duplicate claims shall be stamped "duplicate" and returned to the district of origin with the district batch in which it was received.