Medicaid
OHA's Medicaid Web site has updates and information on the coverage and financing of Medicaid for Ohio's vulnerable and medically needy citizens, as well as OHA's advocacy efforts to keep payments to hospitals adequate to cover the cost of care.
Medicaid is a state and federally funded program for eligible low-income and medically vulnerable people. The State Children’s Health Insurance Program (SCHIP) came into existence as part of the Balanced Budget Act of 1997. SCHIP was designed to build on Medicaid to provide insurance coverage to “targeted low-income children” who are uninsured and not eligible for Medicaid, typically from families with incomes up to 200 percent of the federal poverty level. In Ohio, Medicaid is administered by the Ohio Department of Job and Family Services (ODJFS) in conjunction with 88 cooresponding county departments. In 2009, the federal government reimburses the state almost three-quarters of every dollar spent on Medicaid health care services in Ohio.
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State operating budget for fiscal years 2010 and 2011.
Use of Unlisted Procedure Codes on Outpatient Medicaid Bills Challenged
June 25, 2010:
In its Spring 2010 Ohio Medicaid Quality Monitor Permedion, the Ohio Department of Job and Family Services' (ODJFS) quality review contractor, outlines its concerns that hospitals may be inappropriately using unlisted CPT procedure codes on outpatient Medicaid bills.
ODJFS initially brought the issue to the OHA Finance Committee's attention during the public rule review that preceded the implementation of the 2010 outpatient hospital fee schedule. While examining the payment-to-statewide-cost of various code sets in the fee schedule, ODJFS discovered that codes for unlisted surgery and for services billed under Paragraph K of OAC 5101:3-2-21 were being reimbursed at an high rate compared to others. See the January OHA Finance News for additional background on the 2010 Medicaid outpatient hospital fee schedule.
While part of the payment anomaly can be attributed to the fact that these services are paid on the basis of a percentage-of-charge, ODJFS stated it is concerned that services being billed with unlisted CPT codes, particularly those related to dental services, may not be covered in a hospital setting. The Finance Committee replied that most of the dental care being billed by hospitals relate to services delivered in an emergency setting or to patients requiring non-routine sedation.
ODJFS nonetheless stated it intends to carefully review both unlisted procedure codes and the services being billed under Paragraph K to determine whether they are being over-paid. The Spring 2010 Permedion newsletter represents the start of that process and hospitals are advised to review it respond appropriately.
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