EXHIBIT 10.32
ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM ADMINISTRATION
DIVISION OF BUSINESS AND FINANCE
CONTRACT AMENDMENT
Page 1 of 3 Plus Attachments
- --------------------------------------------------------------------------------
AMENDMENT NO.: 2. CONTRACT NO.: 3. EFFECTIVE DATE OF AMENDMENT: 4. PROGRAM:
07 YHO4-0001-03 APRIL 1, 2004 DBF-TPL
- --------------------------------------------------------------------------------
5. CONTRACTOR/PROVIDER NAME AND ADDRESS:
Health Choice Arizona
1600 W. Broadway, Suite 260
Tempe, Arizona 85282-1136
- --------------------------------------------------------------------------------
6. PURPOSE: To add Credit Balance Review services to assist in cost
efficiency for the health plans.
- --------------------------------------------------------------------------------
7. The above referenced contract is hereby amended as follows:
A. Pursuant to the agreement on page 79, Contract Clauses,
paragraph #30, Changes, this contract is being modified to
include the Credit Balance Review Project. This service is
being made available under the AHCCCS contract with Public
Consulting Group (PCG). The details of this program are provided
on page 2 of this amendment.
B. This pilot program shall be reviewed at the close of one full
cycle to determine the effectiveness of the program. At that time
a determination shall be made whether to continue the program. In
the event it is decided to continue the program, it cannot
continue beyond the statutory term of the governing contract that
ends March 2008.
C. Credit balance refund payments will be forwarded to PCG who will
identify and verify the balance. PCG will forward all collected
monies to AHCCCS. AHCCCS will in turn, disburse 10% of the funds
collected to PCG in accordance with the Pricing Schedule in the
AHCCCS contract. The remainder of the funds (90%) will be
disbursed by AHCCCS to the participating health plans and program
contractors. There will be no additional fees assessed for these
services.
NOTE: Please sign, date and return both originals to: Gary L. Callahan, Contract Management Supervisor
AHCCCS Contracts and Purchasing
701 E. Jefferson, MD 5700
Phoenix, AZ 85034
8. EXCEPT AS PROVIDED FOR HEREIN, ALL TERMS AND CONDITIONS OF THE ORIGINAL
CONTRACT NOT HERETOFORE CHANGED AND/OR AMENDED REMAIN UNCHANGED AND IN FULL
EFFECT. IN WITNESS WHEREOF THE PARTIES HERETO SIGN THEIR NAMES IN AGREEMENT.
- --------------------------------------------------------------------------------
9. NAME OF CONTRACTOR: 10. ARIZONA HEALTH CARE COST
HEALTH CHOICE ARIZONA CONTAINMENT SYSTEM
- --------------------------------------------------------------------------------
SIGNATURE OF AUTHORIZED INDIVIDUAL: SIGNATURE:
/S/ CAROLYN ROSE /S/ MICHAEL VEIT
- --------------------------------------------------------------------------------
TYPED NAME: TYPED NAME:
CAROLYN ROSE MICHAEL VEIT
- --------------------------------------------------------------------------------
TITLE: TITLE:
CHIEF EXECUTIVE OFFICER CONTRACTS AND PURCHASING ADMINISTRATOR
- --------------------------------------------------------------------------------
DATE: APRIL 29, 2004 DATE: MAY 11, 2004
- --------------------------------------------------------------------------------
PAGE 2 OF 3
CREDIT BALANCE REVIEW PROJECT
I. PURPOSE:
The purpose of this amendment is to implement a credit balance review pilot
program by Public Consulting Group, Inc. (PCG) on behalf of Health Choice
Arizona (Health Plan/Program Contractor) through PCG's contract with the Arizona
Health Care Cost Containment System (AHCCCS).
II. DEFINITIONS:
CREDIT BALANCE REVIEW is the process used to identify and recover any Medicare
or Third Party resource overpayment retained by a provider for a Medicaid
member.
ONE FULL CYCLE is defined as the time necessary to mail letters, follow up, and
response time for participants; along with time to follow up on non-responses;
review and process responses and payments and any final reporting to confirm
cost effectiveness of the project. This would also include time for the on-site
reviews. It is anticipated that one full cycle would run approximately six (6)
months.
III. PROCESS:
PCG's credit balance program is comprised of two parts, which when used in
conjunction, have proven to be effective recovery tools. The process begins when
AHCCCS notifies the selected provider by mail requesting they conduct a
self-audit for credit balances. This will be accompanied by the AHCCCS Health
Plan/Program Contractor third party resource refund worksheet (Attachment A).
Instructions in this letter allow a provider to return overpayments, which may
exclude them from an on-site review. After sufficient time has been allowed for
all to respond, the next step is to select providers for on-site reviews of the
provider's credit balance process. Providers are selected for this review based
upon their comparative returns of credit balances in the self-audit, AHCCCS and
the Health Plan/Program Contractor preference, and the likelihood of credit
balances existing. AHCCCS will generate a second letter to the provider
notifying them of the on-site review, explaining the scope, and including a list
of accounts that have been targeted for review. This list will be identified
through a series of data analysis programs designed to create a profile of a
member/patient with a potential credit balance. To perform this function, PCG
will use a combination of data files including paid claims history, encounter
data, and eligibility files. In addition, provider accounting procedures are
verified to ensure the proper posting of contractual allowances, etc. PCG will
schedule these reviews approximately thirty (30) days after the provider
receives the notification.
Any credit balance accounts under current review or previously identified by the
Health Plan/Program Contractors shall be reported to AHCCCS prior to PCG's
scheduled review. These accounts should be reported on the AHCCCS Health
Plan/Program Contractor credit balance accounts under review worksheet
(Attachment B) with supporting documentation. This worksheet shall be forwarded
to Public Consulting Group, Inc. (PCG) to the address sited on the bottom of the
worksheet. There will be no recovery fee associated to these accounts.
The letter from AHCCCS instructs providers to send refund balances to PCG. PCG
will receive and identify these refunds. AHCCCS will require PCG to process
these refunds in the same manner as currently required by our contract with PCG.
AHCCCS will require PCG to research the refunds and to provide a monthly
disbursement report of the refund amounts due to the health plans and program
contractors. AHCCCS will disburse a payment in the amount due to the health
plans and program contractors. In the event Reinsurance is included in the
credit balance, AHCCCS will be reimbursed up to the amount of the reinsurance
payment pursuant to Section D, Program Requirements, Paragraph 57, Reinsurance
of this contract and the Health Plan/Program Contractor will retain the residual
balance. The Health Plan/Program Contractor will not be required to adjust their
encounters related to past reinsurance claims as a result of any findings.
PAGE 3 OF 3
An electronic report of all claims identified as credit balances where
reimbursement is received from the provider, will be generated for the Health
Plan/Program Contractor and for AHCCCS to ensure proper adjustment of the claims
on PMMIS. Any credit balance discovered in either the self-audit or the on-site
audit shall be paid to PCG. PCG will research and verify cases needing
adjustments as a result of the credit balance. Once a full cycle has been
completed, the project will be evaluated to determine cost effectiveness and if
the program should be continued. Depending on the pilot program's success, this
program may be implemented quarterly, semi-annually or annually.
ATTACHMENT A
THIRD PARTY RESOURCE REFUND WORKSHEET
AHCCCS PROVIDER NAME: PAGE: OF
------------------- ------- ------
AHCCCS PROVIDER ID NUMBER: COMPLETED BY:
------------------- -----------------
DATE: / /
-----------------
- ------------------------------------------------------------------------------------------------------------------------------------
TOTAL
AMOUNT PAID
MEMBER/ TOTAL BY THIRD THIRD PARTY
PATIENT DATE OF CLAIM TOTAL AMOUNT PARTY RESOURCE/ REFUND REASON
MEMBER/PATIENT AHCCCS SERVICE REFERENCE BILLED PAID BY RESOURCE/ INSURANCE AMOUNT FOR
NAME ID PERIOD NUMBER (CRN) CHARGES AHCCCS INSURANCE NAME DUE REFUND
--------------
FROM TO
- ------------------------------------------------------------------------------------------------------------------------------------
- ------------------------------------------------------------------------------------------------------------------------------------
- ------------------------------------------------------------------------------------------------------------------------------------
- ------------------------------------------------------------------------------------------------------------------------------------
- ------------------------------------------------------------------------------------------------------------------------------------
- ------------------------------------------------------------------------------------------------------------------------------------
- ------------------------------------------------------------------------------------------------------------------------------------
- ------------------------------------------------------------------------------------------------------------------------------------
- ------------------------------------------------------------------------------------------------------------------------------------
- ------------------------------------------------------------------------------------------------------------------------------------
- ------------------------------------------------------------------------------------------------------------------------------------
- ------------------------------------------------------------------------------------------------------------------------------------
This is to certify that the information contained in this report is true, accurate and complete, to the best of my knowledge.
I understand that AHCCCS will rely on this certification at the time AHCCCS certifies its expenditures to the Centers for
Medicare and Medicaid Services on Form CMS-64.
AUTHORIZED SIGNATURE DATE:
------------------------------------ ---------------------------
Forward worksheet to Public Consulting Group, Inc. P.O. Box 4049 Tallahassee, Fl 32315 Attention: Catherine Cox
ATTACHMENT B
AHCCCS HEALTH PLAN AND PROGRAM CONTRACTOR
Credit Balance Accounts Under Review Worksheet
HEALTH PLAN/PROGRAM
CONTRACTOR NAME: PAGE: OF
--------------------- ------- ------
HEALTH PLAN/PROGRAM
CONTRACTOR ID NUMBER: COMPLETED BY:
--------------------- -----------------
DATE: / /
-----------------
- -----------------------------------------------------------------------------------------------------------------------
MEMBER/
AHCCCS AHCCCS MEMBER/ PATIENT ENCOUNTER/ TOTAL THIRD PARTY
PROVIDER PROVIDER PATIENT AHCCCS DATE OF CLAIM REFERENCE BILLED RESOURCE/INSURANCE
NAME ID NUMBER NAME ID SERVICE PERIOD NUMBER (CRN) CHARGES NAME
--------------
FROM TO
- -----------------------------------------------------------------------------------------------------------------------
- -----------------------------------------------------------------------------------------------------------------------
- -----------------------------------------------------------------------------------------------------------------------
- -----------------------------------------------------------------------------------------------------------------------
- -----------------------------------------------------------------------------------------------------------------------
- -----------------------------------------------------------------------------------------------------------------------
- -----------------------------------------------------------------------------------------------------------------------
- -----------------------------------------------------------------------------------------------------------------------
- -----------------------------------------------------------------------------------------------------------------------
- -----------------------------------------------------------------------------------------------------------------------
- -----------------------------------------------------------------------------------------------------------------------
- -----------------------------------------------------------------------------------------------------------------------
- -----------------------------------------------------------------------------------------------------------------------
This is to certify that the information contained in this report is true, accurate and complete, to the best of my knowledge.
I understand that AHCCCS will rely on this certification at the time AHCCCS certifies its expenditures to the Centers for
Medicare and Medicaid Services on Form CMS-64.
AUTHORIZED SIGNATURE DATE:
------------------------------------ ---------------------------
Forward worksheet to Public Consulting Group, Inc. P.O. Box 4049 Tallahassee, Fl 32315 Attention: Catherine Cox