Encounter Reporting

In 2013 the Centers for Medicare & Medicaid Services (CMS) began requiring encounter reporting from Programs of All-Inclusive Care for the Elderly (PACE®), Medicare Advantage Plans and Medicare Special Needs Plans, which submit service encounter data for use in calculating Medicare risk-adjusted payments. Previously, only diagnostic and demographic characteristics of enrollees were used to calculate payments.

ICD-10

The purpose of the NPA Model ICD-10 Superbill is to facilitate the coding and collection of comprehensive PACE participant diagnoses that are high in prevalence, require the allocation of significant health care resources, and are generally chronic rather than acute in nature.

Medicare Data Submission Calendars and Instructions

In accordance with 42 CFR §423.322, PACE organizations are required to provide the Centers for Medicare & Medicaid Services (CMS) with any data required to ensure accurate prospective, interim and/or final reconciled payments, including, but not limited to, the following: test data, Prescription Drug Event (PDE) records, enrollment transactions, Direct and Indirect Remuneration (DIR) data, discrepancy records, and premium payment data:

• 2018, 2019, 2020 Payment Run Notice
• 2019 MARx Calendar
• 2019 PDE Submission Timetable
• Final 2018 DIR Reporting Requirements
• Guidance for Reporting and Returning Medicare Advantage Organization and/or Sponsor-Identified Overpayments to CMS
• Notice Reporting Overpayments
• Overpayment Brochure

Medicare Part D

PACE organizations are required to provide all medically necessary drugs to their participants. Today, most of the drugs PACE organizations provide are through the Part D benefit. NPA provides assistance to PACE organizations is understanding Part D policies and how they apply to PACE in addition to advocating on Part D issues on behalf of PACE organizations.

Medicare Payment Notices

Each year CMS issues its 45 Day Notice of Payment Letter in which CMS reveals proposed changes in Medicare payment policy. This letter kicks off an intense time of analysis and comment on the part of NPA and its members. At the end of the process CMS issues the Final Notice of Payment. Relevant documents for the past few years of Medicare payment notices are below.

PACE Data Analysis Center (PDAC)

NPA works with the Department of Community and Preventive Medicine at the Unveristy of Rochester to evaluate the impact of the CMS-HSS risk adjustment model on the Medicare payment to PACE. Learn more about PACE Data Analysis Center (PDAC) reports.

Payment and Medicare Risk Adjustment

One of the unique features of PACE is that it is able to combine funding from Medicare, Medicaid and private sources to create a pool of resources to meet each participant’s needs. Medicaid payment is negotiated between the provider and the state with some federal oversight. Learn more.

State Medicaid Payment

NPA works with members to address state Medicaid payment policy issues.