HomeMy WebLinkAboutResolution - 2024-R0290 - Interlocal Agmt, Lubbock County Medical Indigent Prog. Provider Agmt, UMCHS - 06/11/2024Resolution No. 2024-R0290
Item No. 5.18
June 11, 2024
RESOLUTION
WHEREAS, the City Council of the City of Lubbock has determined that it is in the best
interest of the citizens of the City of Lubbock to enter into an interlocal agreement with the
Lubbock County Hospital District, d/b/a UMC Health System, to cooperate to provide certain
public health services for indigent residents of Lubbock County; NOW THEREFORE:
BE IT RESOLVED BY THE CITY COUNCIL OF TIIE CITY OF LUBBOCK:
THAT the Mayor is hereby authorized and directed to execute the interlocal agreement
entitled, "Lubbock County Medical Indigent Program Provider Agreement" on behalf of the City
of Lubbock Health Department, and any associated documents.
Passed by the City Council on June 11 2024 ___ _
�-- ---
AT � ST:
Courtney az, City Secretary
APPROV�D AS TO CONTCNT:
Bill H erton, Deputy Manager
APPROVED AS TO PORM:
chael Foster, A istant City Attorney
RGS.LCMI Program Provider Agreement
5.29.24
Resolution No. 2024-R0290
LUBBOCK COUNTY MEDICAL INDIGENT PROGRAM
PROVIDER AGREEMENT
City of Lubbock Health Department
Address: P.O. Box 2000, Lubbock, TX 79457-0001
NPI: 1528265535
Tax ID: 75-6000690
UMC Contract ID: 617
This Agreement is between the Lubbock County Hospital District, d/b/a UMC Health System
("UMC") and the City of Lubbock, acting by and through its Health Department ("Provider").
The Lubbock County Hospital District, d/b/a UMC Health System ("UMC") has established a medical
indigent program whereby it furnishes medical and hospital care to eligible needy residents of lub-
bock County. UMC requires physician services for inpatient rehabilitation for its eligible patients.
Provider desires to provide services to qualified Lubbock County Medical Indigent (LCMI) patients.
THEREFORE, in consideration of the mutual covenants and agreements, and subject to the condi-
tions and limitations set forth in this Agreement, Provider and UMC agree as follows:
ARTICLE 1: DEFINITIONS
1.1 "Beneficiary" means a resident of Lubbock County who UMC has determined is eligible for
assistance from the Medical Indigent Program, including eligible Lubbock County residents
who are inmates of the Lubbock County 1ail, Lubbock County Youth Facility, and Lubbock
Counry Community Correctional Faciliry.
1.2 "Covered Services" means medical services that are covered under the prevailing Medi-
caid guidelines and those approved bythe UMC LCMI Committee.
1.3 "Program" means a service of UMC to furnish medical and hospitat care to eligibte needy
residents of Lubbock County through the Lubbock County Medical Indigent Program. It is
not an insurance program; it is a medical financial assistance program.
1.4 "Medically Necessary" or "Medical Necessity" means that a health care service or supply
for the treatment of an injury, illness, or other medical condition as determined by the UMC
is: (a) appropriate and necessary for the symptoms, diagnosis, or direct care and treatment
of the medical condition; (b) provided for the diagnosis or direct care and treatment of the
medical condition; (c) within standards of good medical practice within the organized medi-
cal community; (d) not primarilyfo�the convenience ofthe Beneficiary, the Beneficiary's phy-
sician or other provider; (e) the most appropriate supply or level of service which can safely
be provided; and, (f) consistent with the Program medical poticy, utilization management
program, quality assurance requirements, and the terms and conditions of the Program. Uti-
lization review and utilization management shall be provided by the UMC LCMI Committee,
and which shall also oversee and determine "Medical Necessity."
LCMI Provider Agreement Page 1
City of Lubbock Health Department
1.5 "Provider" means City of Lubbock Health Department for services provided by its physicians
and employed or contracted advanced practice providers.
1.6 "UMC LCMI Committee" means a committee established by UMC to review care provided
to LCMI patients.
ARTICLE 2: TERM AND TERMINATION
2.1 Term. The term of this Agreement begins on its execution and continues through April 30,
2025. This Agreement shall renew automaticatly each May 15' for four successive one-year
terms.
2.2 Termination. This Agreement may be terminated upon the occurrence of any of the follow-
ing events:
(a) The date of dissolution or liquidation of Provider or UMC, whicheverfirst occurs;
(b) A material breach by either party of any covenants or obligations of this Agreement,
provided that such party fails to cure same within thirty (30) days after written notice
of default by the other party, as of the 31 st day subsequent to such notice;
(c) Provide� is debarred, suspended, proposed for debarment, declared ineligible, or
voluntarily excluded from participation in a government program by any federal de-
partment or agency or by the State of Texas; or
(d) By either party upon 60 days written notice to the other party.
2.3 Continuation of Services. If UMC's relationship with Provider terminates at any time during
which any Beneficiaries are receiving services from Provider, Provider agrees to continue ren-
dering its normal and customary services on behalf of such Beneficiaries and to continue
charging its fees for such services, in accordance with the terms and provisions of this agree-
ment, until such time as Beneficiary is discharged or transferred. UMC similarly agrees that
UMC will render payment for services so delivered in accordance with the reimbursement
terms of this agreement.
ARTICLE 3. OBLIGATIONS OF PROVIDER
3.1 Provision of Services. Within the usual and customary capacity and capabilities of its facil-
ities and personnel to be determined by Provider, Provider shall provide Covered Services to
the Beneficiaries. All services shall be provided to the Beneficiaries in the same manner, in
accordance with the same standards, and within the same time availability as Provider's ser-
vices to its other patients. Provider shall comply with all verification and preauthorization
requirements described below. Each physician who provides services under this Agreement
must be a member of UMC's medical staff.
LCMI Provider Agreement Page 2
City of Lubbock Health Department
3.2 Change in Services. Provider agrees to notify UMC in writing of any substantial change in
the types of inpatient or outpatient services offered.
3.3 Licensure and Certification. At all times during the term of this Agreement, Provider shall
be appropriately licensed and certified in accordance with federal and state law.
3.4 Performance.
(a) Provider shatl, at its own expense, provide and maintain facilities and provide profes-
sional and allied personnel to provide all necessary and appropriate services.
(b) Provider shall, at its own expense, provide and maintain the organizational and ad-
ministrative capabilities to carry out its duties and responsibilities under this agree-
ment.
(c) Provider shall use its best efforts to see that services provided by a resident physician
shall not be billed to UMC unless the attending physician provides the level of super-
vision and involvement required by Medicare and Medicaid guidelines.
3.5 Insurance. Provider, at its sole cost and expense, shall maintain such professional insur-
ance coverage as shall be necessary to insure Provider against any claim or claims for dam-
ages arising by reason of personal injuries or death occasioned, directly or indirectly, in
connection with such services.
3.6 Medical Education. The parties desire to advance medicat education, aid in meeting the
increasing demand for trained health professionals, and make available better health ser-
vices to patients. Provider agrees to participate in TTUHSC medicat and graduate medical
education programs, including the training of residents, interns, and fellows in Provider's
specialty.
3.7 340B Referral Agreement. UMC refers its patients to Provider as needed for consultation
and medical care. If UMC provides prescribed drugs to a referred patient, the following shall
apply:
3.7.1 Responsibiliryfor Care. Pursuant to 340B Program regulations, the responsibilityfor
the overall care of the UMC patients referred, as well as the use of any 3406 drugs
transferred to an individual patient, remains with UMC.
3.7.2 Care and Documentation. Provider witl provide care and documentation regarding
referred patients in accordance with the following process:
a. Provider will document all medical encounters with UMC patients in a man-
ner consistent with current professional standards and which meet record
requirements as set forth by federat and state statutes and regulations.
b. Provider will enter notes on patient care and treatment directly into
UMC/TTUHSC's Electronic Health Record (EHR) system, where available, so
LCMI Provider Agreement Page 3
City of Lubbock Health Department
that it can be accessed electronically, real-time by UMC health care profes-
sionals for patient follow up or Provider shall provide copies of inedical en-
counter notes to UMC upon request, if above documentation cannot be com-
pleted electronically.
ARTICLE 4: ELIGIBIIITY AND PREAUTHORIZATION
4.1 Eligibility. UMC shall accept and process applications for the Medical Indigent Program.
UMC will inform Provider of eligibility through established mechanisms.
4.2 Identification and Verification. UMC shall establish a mechanism for the purpose of
identifying Beneficiaries.
(a) Beneficiaries of the Lubbock County Medical Indigent Program receive benefits
for a designated period and shall have identification cards.
(b) Provider, prior to providing services for LCMI services, may verify eligibility by:
(1) Checking the coverage card, or other identification, of each patient;
or
(2) Contacting UMC Resource Assistance office.
(c) Provider, by giving written notice to UMC and patient, may terminate the
physician-patient relationship of a medical indigent patient who has not fulfilled
his/her responsibilities in the physician-patient relationship including, but not
limited to frequently missed appointments, abusive/disruptive behavior, and
failure to follow the treatment plan recommended by the physician.
4.3 Preauthorization. Unless the Beneficiary has a medical emergency, as determined by
Physician, Provider shall obtain written authorization from the LCMI Committee for the
following services to Beneficiaries priorto providingthe senrice. The LCMI Committee meets
each Wednesday for the purpose of making determination of preauthorization. The Director
of Case Management of UMC will communicate to Provider oralty and in writing of the
determination of preauthorization. Procedures requiring preauthorization are as follows:
Surgical Procedures performed in OR suites;
Pain Procedures; and
Cath Lab Procedures.
The Provider's failure to obtain preauthorization may result in denial of payment.
ARTICLE 5: PAYMENT PROVISIONS
5.1 Schedule of Reimbursement. UMC shall pay Provider for services provided under this
Agreement as follows:
(a) UMC shall determine eligibility of indigent residents in accordance with its Medical
Indigent poticies and procedures, copies of which shall be provided to Provider at
Provider's request.
LCMI Provider Agreement Page 4
City of Lubbock Health Department
(b) UMC shatl pay Provider for Covered Services an amount equal to the prevailing Texas
Medicaid fee schedule. If the service is not included in the Medicaid fee schedule,
UMC shall pay Provider an amount equalto the prevailing Medicare fee schedule.
(c) UMC may conduct an audit of claims, using Medicaid guidelines, which may include
a review of patient medical records. The audit may result in the retroactive denial of
claims and recovery of payments for procedures that are not medically necessary,
procedures that have not been preauthorized as required, insufficient
documentation to support the service or level of billing, individuals who are not
eligible for benefits under the Program. If UMC identifies a consistent deficiency in
billing by Provider, UMC, using statistically valid means or representative samples,
may extrapolate the amount of the billing error to the number of claims submitted to
determine the total amount of the billing error for reconciliation purposes. Before
formalizing any audit and subsequent extrapolation, UMC shall, in advance, notify
Provider of the anticipated need for such action(s).
(d) Payment for services is conditional upon Provider's compliance with
preauthorization requirements, timely and accurate submission of claims, and
compliance with the requirements of this agreement.
(e) UMC is the payor of last resort. If the patient is eligible for any other financial
assistance program, the patient is not eligible for most benefits under the Program.
The patient must make a good faith effortto exhaust all other sources of benefits and
must cooperate in providing information for program applications. If a patient
becomes eligibte for any other financial assistance program, UMC will recoup any
payments made to Provider for services that are billable to the financial assistance
program without regard to filing deadline rules of the financial assistance program.
If a patient becomes ineligible under the Program, UMC will recoup any payments
made to Provider for services provided during the time of ineligibility.
5.2 Billing Procedures.
(a) Only beneficiaries with LCMI as their primary coverage are covered under this
Agreement. If the Beneficiary has health benefits coverage from a third-party payor
other than UMC (commercial insurer, government program, employer health plan or
reimbursement plan), the Beneficiary is not eligible for services under this
Agreement, and Provider shall not submit a claim for services to UMC.
(b) As soon as possible after providing services to a Beneficiary, Provider shall furnish to
UMC a claim for services. Provider must file the claim within 90 days after the date of
service or the date the Beneficiary is approved as eligibte for the Program.
Retroactive etigibility for indigent care beneficiaries is limited to 90 days prior to the
date of approval.
(c) Provider shall accept the payment from UMC as payment in full and shall not bill
Beneficiary except for copayments.
LCMI Provider Agreement Page 5
City of Lubbock Health Department
(d) Provider shall collect copayments, if applicable, from Beneficiaries. Copayment
amounts are listed in the Program policies and guidetines.
(e) Provider shall submit claims to UMC in the manner in which Provider usually submits
claims to Texas Medicaid. Each claim shall include patient identifying information,
the program for which the patient is qualified (Medical Indigent), dates of service, CPT
Codes, ICD-9 Codes, physician identifying information, and the billed charges.
However, for services for which a Medicaid payment code does not exist but which
are approved by the LCMI Committee, payment for that code/service shall be based
on the Medicare fee schedule.
5.3 Payment of Benefits.
(a) In the event of any overpayment, duplicate payment, or other payment in excess of
that to which Provider is entitled, Provider shall make repayment to UMC within thirty
(30) days of notification and proof by UMC of such overpayment, duplicate payment,
or other excess payment.
(b) UMC shall pay Provider electronicatly using a HIPAA-compliant format unless agreed
otherwise by the parties.
ARTICLE 6: ADMINISTRATION
6.1 Access to Records.
(a) Provider shall prepare and maintain patient business and medical records for all
services detivered to Beneficiaries. These records shall be prepared and maintained
as required by law.
(b) UMC shall secure a legally appropriate written authorization from each Beneficiary
forthe release of a Beneficiary's business and medical records by Providerto UMC.
(c) Provider shall make available to UMC or its designated representative, for review and
duplication, any or all records and data, business and medical, maintained by
Provider pertaining to payments, claims, and services rendered to Beneficiaries
underthis agreement. UMC mustfurnish Providerwith a written authorization signed
by the patient allowing release of inedical records to UMC
(d) Provider and UMC shall be subject to all applicable laws and regulations concerning
confidentiality of patient medical records.
6.2 Utilization Review. Provider agrees to participate in UMC's utilization review LCMI
Committee relative to the services performed under this agreement
6.3 Relationship of Parties.
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City of Lubbock Health Department
(a) No provision of this agreement is intended to create any relationship betwesn
Provider and UMC other than that of independent entities contracting with each other
solely for the purpose of affecting the provisions of this agreement. The relationship
of Provider and the UMC will not be construed or interpreted to be a partnership or
joint venture.
(b) It is understood and agreed that the operation and management of facilities and
rendition of care and treatment by Provider shall be solely and exclusively under its
control, and UMC shall have no right or authority over the operation of Provider,
rendition of inedicat care, or selection of professional and other staff.
(c) Neither of the parties to this agreement, nor any of their respective employees,
agents or representatives, will be construed to be the agent, employee, or
representative of the other, or liable for any acts of omission or commission on the
part of the other.
6.4 Declaration that Beneficiaries are not Third Party Beneficiaries under This Agreement.
Notwithstanding mutual recognition that services under this agreement will be rendered by
Provider to Beneficiaries, it is not the intention of either Provider or UMC that Beneficiaries
occupythe position of intended third party beneficiaries of the obligations assumed by either
parry to this Agreement and no Beneficiary shall have the right to enforce any such obligation.
6.5 Assignment or Delegation of Duties. UMC and Provider recognize that the services covered
by this agreement are personal and nondelegable. No assignment or delegation of the rights,
duties or obligations of this Agreement shall be made by Provider without the express written
approval of a duly authorized representative of UMC.
6.6 Dispute Resolution.
(a) Provider and UMC agree to meet and confer in good faith to resolve any problems or
disputes that may arise under this agreement.
(b) If Provider believes UMC incorrectly denied all or part of the charges and wants to
obtain a review of the benefit determination, Provider shall:
(i) submit a written request for review to UMC; and
(ii) include in the written request the items of concern regarding UMC's
determination and all additional information (including medical
information) that Provider believes has a bearing on why the
determination was incorrect.
On the basis of the information supplied with the request for review to UMC, together
with any other information available to it, UMC will review its prior determination for
correctness. Provider will be notified in writing of UMC's decision and the reasons
for it within thirty (30) days of UMC's receipt of the request for review. If no response
is received by Provider within 30 days, the dispute will be deemed to be resolved in
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City of Lubbock Health Department
favor of Provider, with payment to be timely made in full. If Provider believes the
decision is incorrect, the LCMI committee shall reviewthe appealfor a finaldecision.
(c) UMC and Provider will cooperate to resolve any complaints by patients. A patient's
complaint will be forwarded to Provider for appropriate review and action.
Complaints not resolved will be reviewed through the UMC's grievance mechanism.
(d) UMC and Provider will cooperate to resolve any complaints involving Hospital's
treatment of Provider's patients or conduct of Hospital personnel regarding the
above. A Provider's complaint will be forwarded to the LCMI Committee for
appropriate review and action.
6.7 Amendment and Modification.
(a) This agreement may be amended only by mutual written consent of duly authorized
representatives of Provider and UMC.
(b) Either party may request in writing renegotiation of the rates on an annual basis.
Notwithstanding the effective date of this agreement, such request for renegotiation
shatl be made in writing at least sixty (60) days prior to the anniversary date of this
agreement. The current rates will remain in effect until new rates have been agreed upon
or this agreement has terminated or expired.
6.8 Waiver. The waiver by either party of a breach or violation of any provision of this Agreement
shall not operate as or be construed to be a waiver of any subsequent breach of any provision
of the Agreement.
6.9 Notice. All notices required or permitted to be given under this Agreement shall be sufficient
if furnished in writing, sent by registered mail, to the party's last known principal office.
6.10 Governing Law. This Agreement shall be interpreted, construed, and governed according to
the laws of Texas. Venue shall be in Lubbock, Lubbock County, Texas for all purposes.
6.11 Severability. If any term or provision of this agreement is held to be invalid for any reason,
the invalidity of that section shall not affectthe validity of any other section of this agreement,
provided that any invalid provision is not material to the overall purpose and operation of this
agreement. The remaining provisions of this agreement shall continue in full force and effect
and shall in no way be affected, impaired, or invalidated.
6.12 Assignment. This Agreement shall be binding upon and shatl inure to the benefit of the par-
ties and their respective heirs (as applicable), legal representatives, successors, and permit-
ted assigns. The parties acknowledge that their services are unique and agree that they may
not assign this Agreement nor any rights, interests, or obligations hereunderwithout the writ-
ten consent of the non-assigning party.
6.13 Entire Agreement. This Agreement contains the entire agreement and understanding be-
tween the parties and it supersedes all prior written agreements, understandings, and rep-
resentations relating to the subject matter of this Agreement.
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City of Lubbock Health Department
6.14 Compliance. The parties acknowledge that they are subject to applicable federal and state
laws and regulations, and policies and requirements of various accrediting organizations.
Each party will enforce compliance with all applicable laws, regulations, and requirements,
and will make available such information and records as may be reasonably requested in
writing by the other party to facilitate its compliance, except for records that are confidential
and privileged by law. Each party shall have or designate a Compliance Officer or liaison with
whom compliance issues shall be coordinated.
6.15 Access to Records by Agencies. The parties agree that until the expiration of six years after
the furnishing of services provided under this Agreement, the parties will make available to
the Secretary of the United States Department of Health and Human Services ("the Secre-
tary"), the United States Comptroller General, or the Texas Department of Health, and their
duly authorized representatives, this contract and all books, documents, and records nec-
essary to certify the nature and extent of the costs of those services. If a party carries out the
duties of this Agreement through a subcontract, the subcontract will also contain an access
clause to permit access by the Secretary, the United States Comptroller General, the Texas
Department of Health, and their representatives to the related organization's books and rec-
ords.
6.16 Certification. Each party certifies that neither it nor its principals is presently debarred, sus-
pended, proposed for debarment, declared ineligible, or voluntarily excluded from participa-
tion in this contract or any government program by any federal department or agency or by
the State of Texas. EACH PARTY WILL DISCLOSE IMMEDIATELY TO THE OTHER PARTY the
name of any person who has an ownership or controlling interest or is an agent or managing
employee who is convicted of a criminal offense related to the person's invotvement in a gov-
ernment program.
6.17 Non-Discrimination. The Parties will provide services without regard to a patient's race,
color, religion, sex (including pregnancy), national origin, age, physical or mental disability,
genetic information, status as a protected veteran, or any other legally protected category,
class or characteristic.
6.18 Patient Information. To the extent that a party has access to or prepares records containing
confidential patient information, the party shall: (1) use the records only for the purpose of
providing services under this Agreement; (2) protect the confidentiality of patient information
in compliance with all state and federal laws, including, without limitation, the Health Insur-
ance Portability & AccountabilityAct of 1996 and its implementing regulations ("HIPAA"); and
(3)take reasonable precautions to prevent any unauthorized disclosure of records provided
or prepared under the terms of this Agreement. The parties agree to execute such additional
documents and agreements as necessary to comply with HIPAA.
Signatures are on the following page.
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City of Lubbock Health Department
CITY OF LUBBOCK ("PROVIDER") UNIVERSITY MEDICAL CENTER ("UMC")
By: By:
r �
Tray Payne �1�Blin�londay, May 27, 2024
Mayor Sr. Vice President, Chief Business
Development Officer
EST:
Courtney Paz, City S cret
APP VED TO CONTENT:
U
Katherine Wells, City of Lubbock Health Director
APPROVED AS TO FORM:
Rachael Foster, A si ant City Attorney
LCMI Provider Agreement Page 10
City of Lubbock Health Department