Third Party Billing Project for UIHPs

NCUIH’s current Payment System Reform (PSR) initiative was first conceived in the Third Party Billing Proposal (TPBP), submitted to the Office of Management and Budget in 2011. The Third Party Billing Project, which is funded via Indian Health Service and subcontracted to a specialized consultant firm, responded to the chronic underfunding of Urban Indian Health Programs (UHIPs). The project allows UHIPs to access and maximize revenue through non-Indian Health Service sources. Increasing funding through third parties is crucial for providing comprehensive, quality health care for American Indians and Alaska Natives living in cities across the US. Unfortunately, there are still many political, contextual, and cultural barriers and challenges that that negatively impact UHIP third-party billing. The initiative also expanded its scope to incorporate other elements equally important for the financial health of our member programs, such as accreditation, Health Information Technology, and other concerns.

This page is intended to be a repository for all tools produced under this initiative in past years, and our Knowledge Resource Center contains background documents and information.

If you are a NCUIH Member Organization and would like to join the PSR initiative activities, please contact our Technical Assistance and Research Director, Dr. Kimberly Fowler, Ph.D. at kfowler@ncuih.org or (202) 544-0344.

Objective 1. Provide practical and ready-to-use knowledge and information tools for UIHP Improvement in GPRA reporting and third-party billing initiatives; Revenue Process Organization.

Expected Outcome: Enhanced Third-Party Billing for UIHPs.

Objective 2. UIHPs will be provided with accurate information on health reform policies for community dissemination and federal partners will be better informed of urban issues that need addressing.

Expected Outcome:Increased policymaker education/ Information dissemination/ assistance and support to members.

Improved Payment Systems to address the Health Care Reform

Under health care reform, it is also expected that there will be an increase of newly eligible insured AI/AN people living in UHIP service areas. These numbers have steadily risen over the last two “Open Enrollment” periods in the states that have adopted Medicaid expansion. These provisions will substantially decrease the number of the uninsured, but they will also require UIHPs to work directly with Health Insurance Marketplaces to ensure benefits are obtained for AI/AN patients to access to quality healthcare.  Education and guidance to implement and sustain the changes that are being enforced now, including active enrollment for insurance exemptions, will have to be a priority in order for UIHPs to continue to be prepared to help their patients and community. The increase in the number of patients served under health care reform may also seriously impact UIHP access to funding, which makes outreach to AI/AN people for enrollment in CMS programs and the Health Marketplace so critical in the upcoming years. Technical assistance, education, and research in urban Indian communities will be extremely important in developing resources for improving access to and quality care for AI/ANs. The complexities of Medicaid and Medicare provisions can create barriers, thus technical assistance to UIHPs on how to become involved in Health Insurance Marketplaces and how to be approved as Essential Community Providers and Certified Application Counselors (CAC) will be just as important.

Patient centered Health Care and Value-based Payment Methodologies

As the larger US health care delivery system prepares to move toward more patient-centered and value-based payment methodologies, UIHPs must be prepared for the possible phasing out of reimbursement-based methodologies. If these more generous reimbursement methodologies are eliminated, UIHPs will need to have the data and infrastructure in place to compete more aggressively for each reimbursement dollar. Empowered with data, such as that available through Electronic Health Records and leveraging referral networks of primary care and specialist providers, UIHPs must be able to demonstrate that each health care dollar appropriated to Title V UIHPs is spent as efficiently as possible. Because UIHPs have long been severely underfunded and have not had the benefit of the OMB/All-inclusive rate, UIHPs are already adept at leveraging meager base resources for additional funding elsewhere. This provides a tremendous opportunity for UIHPs to lead the I/T/U system toward a more modern and efficient delivery of health care services provided in furtherance of Trust Responsibility. In this way, UIHPs can provide the entire I/T/U system with guidance, best practices, and technical assistance toward the design and implementation of these new health care delivery models.

As UIHPs explore new models of health care delivery such as the Patient-Centered Medical Home model and participation within Accountable Care Organizations, NCUIH and our member programs are poised to be an invaluable resource to IHS and tribally-operated facilities in implementing these new and innovative models of value-based payment. With the participation of our member programs, NCUIH can design and support such new models, and provide critical lessons learned and best practices to federal, state, and local agencies, tribes, national Indian organizations, and education and safety networks. Through our membership on the Medicare and Medicaid Policy Committee (MMPC), UIHPs have access to a brain trust of health care policy experts with decades of experience designing and implementing health care delivery models. NCUIH is uniquely positioned to act as both a resource for our member programs as they seek to chart new and innovative models of health care delivery, and also to act as a conduit through which tribal and federal partners can learn from the experiences of UIHPs in their attempts to provide more efficient and coordinated health care to AI/AN people.

Medicare Prospective Payment System

One of the key challenges for UIHPs in the wake of the Affordable Care Act is how to better coordinate health care services for Native patients so that services are delivered as efficiently as possible. The transition of FQHCs to a Medicare prospective payment system (PPS) in which Medicare payment is made based on a predetermined, fixed fee amount, is a vital advocacy area for UIHPs to stay informed of the changes and be prepared for implementation. NCUIH will continue to work with Federal agencies and workgroups, such as Tribal Technical Advisory Group (TTAG) and Medicare and Medicaid Policy Committee (MMPC), to be sure that proposed measures are inclusive of urbans and appropriate for healthcare delivery at UIHPs.