Physician Upper Payment Limit (UPL) Supplemental Payment Strategies
Medicaid agencies across the country grapple with ensuring sufficient access to primary, specialty, and dental care services to the Medicaid population. By implementing a Physician Medicaid Supplemental Payment strategy, Medicaid agencies as well as physician and non-physician practitioners affiliated with public, medical, and dental schools can increase funding to improve access to care and availability of services. PCG has assisted such critical safety net providers across the U.S. to implement these strategies and maximize supplemental funds. We have constructed these strategies both for the Medicaid fee-for-service (FFS) model, and Medicaid managed care delivery systems. In many cases, these supplemental funds have been used to hire additional physicians, improve retention of existing physicians, and create population-based health care programs, thus preserving or expanding access to care.
PCG can show you how to launch and implement a Physician Medicaid Supplemental Payment Program.
How can we help?
- Designing the Supplemental Payment Calculation Methodology – When developing a Medicaid supplemental payment strategy, Medicaid rates and supplemental payments can be based upon a number of different upper payment limit (UPL) ceilings including:
- Medicaid cost,
- Medicare payment levels, or
- An average commercial rate.
Our team understands the nuances of each of these strategies and will explore all of the options to determine the methodology that maximizes federal funding while adhering to Medicaid.
- Determining State Share Funding Mechanisms – State Medicaid agencies and public providers will need to determine how to finance the state share associated with the additional supplemental payments. PCG has experience with strategies from an intergovernmental transfer, to redirection of state appropriations, certification of public expenditures, or a provider assessment. We will work with your agency and provider community to determine the best strategy to limit risk and minimize cash flows.
- Obtaining Centers for Medicare and Medicaid Services (CMS) Approval –PCG has experience with both developing a Medicaid state plan amendment and completing the section 438.6(c) Preprint associated with a Medicaid managed care pass-through payment strategy. Our team will work with your agency and/or provider community to prepare all of the necessary documentation to submit to CMS for approval. We will also work to respond to any requests for additional information, prepare revenue estimates, and provide supporting calculations to actuaries for development in Medicaid managed care capitation rates.
- Implementing the Program and Performing Ongoing Supplemental Payment Calculations – Once a program is approved, it is important that calculations are performed each quarter to support the draw-down of federal funds. Our team can help streamline the calculation processes using our proprietary tools to prepare the calculations.
- Providing CMS Audit Support – PCG applies decades of Medicare and Medicaid experience when assisting clients through routine audits and responding to findings, if any.
To date, our work designing and implementing Medicaid Physician UPL Supplemental Payment strategies has resulted in:
- $500 M – PCG has generated over $500 million in new Medicaid supplemental payments.
- 9 States – We have helped nine different states to implement Medicaid Physician UPL Payment programs.
- 14 Public Academic Medical Facilities and Physician Practice Plans – Our team has assisted over a dozen physician practice plans to implement innovative supplemental payment strategies to ensure and enhance access for Medicaid beneficiaries to important preventative care services.
Interested in learning more about Physician Medicaid Supplemental Payment strategies? Contact us today to get started!