HomeMy WebLinkAboutResolution - 2013-R0278 - Lubbock County Medical Indigent Program Provider Agreement - 09/10/2013Resolution No. 2013-RO278
September 10, 2013
Item No. 5.11
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 agreement the Lubbock County
Hospital District d/b; a University Medical Center to cooperate to provide certain public health
services for indigent residents of Lubbock County; NOW THEREFORE:
BE IT RESOLVED BY THE CITY COUNCIL OF THE CITY OF LUBBOCK THAT the Mayor
is hereby authorized and directed to execute the 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 this 10th day of September _ ---,2013.
GLE . OBERTSON, MAYOR
ATTEST:
Re ecca Garza, City Secretary
APPROVED AS TO
CONTEN
cats L�
Scott Snider, Assistant City Manager
Resolution No. 2013—RO278
LUBBOCK COUNTY MEDICAL INDIGENT PROGRAM ("LCMI")
PROVIDER AGREEMENT
City of Lubbock Health Department
806 18th Street
Lubbock, TX 79401
Mailing Address:
City of Lubbock Health Department
P.O. Box 2000
Lubbock, TX 79408
This Agreement is between the Lubbock County Hospital District, d/b/a University Medical Center
("UMC') and the City of Lubbock Health Department ("Provider").
The Lubbock County Hospital District, d/b/a University Medical Center ("UMC') has established a
medical indigent program whereby it furnishes medical and hospital care to eligible needy
residents of Lubbock County.
Provider's mission is to protect the health, safety, and welfare of the citizens through preventing
epidemics and the spread of disease; educating and empowering people to adopt healthy and
responsible behaviors; promoting the quality and accessibility of health services; and developing
new insights and innovative solutions to health problems
UMC and Provider desire to cooperate to provide public health services for Lubbock County.
THEREFORE, in consideration of the mutual covenants and agreements, and subject to the
conditions 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 Jail, Lubbock County Youth Facility, and Lubbock
County Community Correctional Facility.
1.2 "Covered Services" means ONLY THOSE SERVICES LISTED IN EXHIBIT A TO THIS
AGREEMENT. which Exhibit A is incorporated into this Agreement.
1.3 "Program" means a service of UMC to furnish medical and hospital care to eligible 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
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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
medical community; (d) not primarily for the convenience of the Beneficiary, the
Beneficiary's physician or other provider; (e) the most appropriate supply or level of
service which can safely be provided; and, (f) consistent with the Program medical policy,
utilization management program, quality assurance requirements, and the terms and
conditions of the Program. Utilization review and utilization management shall be provided
by the UMC Managed Care Review Committee, and which shall also oversee and determine
"Medical Necessity."
1.5 "Provider" means the City of Lubbock Health Department.
1.6 "UMC Managed Care Review Committee" means a committee established by UMC to
review care provided to LCMI and other managed care patients.
ARTICLE 2: TERM AND TERMINATION
2.1 Term. The term of this Agreement begins on its execution and continues through
September 30, 2014. At the end of the term of this agreement, this agreement shall renew
only by written agreement of the parties.
2.2 Termination. This Agreement may be terminated upon the occurrence of any of the
following events:
(a) The date of dissolution or liquidation of Provider or UMC, whichever first 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 31st day subsequent to such notice;
(c) Provider is debarred, suspended, proposed for debarment, declared ineligible, or
voluntarily excluded from participation in a government program by any federal
department 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 rendering 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 agreement, 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
facilities and personnel to be determined by Provider, Provider shall provide Covered
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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 services 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.
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 shall, at its own expense, provide and maintain facilities and provide
professional and allied personnel to provide all necessary and appropriate services.
(b) Provider shall, at its own expense, provide and maintain the organizational and
administrative capabilities to carry out its duties and responsibilities under this
agreement.
(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 supervision and involvement required by Medicare and Medicaid guidelines.
3.5 Insurance. Provider, at its sole cost and expense, shall maintain such professional
insurance coverage or self-insurance as shall be necessary to insure Provider against any
claim or claims for damages arising by reason of personal injuries or death occasioned,
directly or indirectly, in connection with such services.
ARTICLE 4: ELIGIBILITY 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
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limited to frequently missed appointments, abusive/disruptive behavior, 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 Managed Care Review
Committee for the following services to Beneficiaries prior to providing the service. The
Managed Care Review Committee meets each Wednesday for the purpose of making
determination of preauthorization. The Director of Case Management of UMC will
communicate to Provider orally and in writing of the determination of preauthorization.
Procedures requiring preauthorization are as follows:
Surgical Procedures performed in Operating Room suites;
Pain Procedures; and
Cath Lab Procedures.
The Provider's failure to obtain preauthorization may result in denial of payment.
ARTICLES: 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 policies and procedures, copies of which shall be provided to Provider at
Provider's request.
(b) UMC shall pay Provider for Covered Services an amount equal to the prevailing
Texas Medicaid fee schedule plus 10%.
(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 effort to exhaust all other sources of benefits
and must cooperate in providing information for program applications. If a patient
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becomes eligible 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 eligible for the Program.
Retroactive eligibility 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.
(d) Provider shall collect copayments, if applicable, from Beneficiaries. Copayment
amounts are listed in the Program policies and guidelines.
(e) Provider shall submit claims to UMC in the manner in which Provider usually
submits claims. Each claim shall include patient identifying information, the
program for which the patient is qualified (Medical Indigent), dates of service, CPT
Codes, ICD-9 /10Codes, 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 Managed Care Review 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 electronically using a HIPAA-compliant format unless
agreed otherwise by the parties.
ARTICLE 6: ADMINISTRATION
6.1 Access to Records.
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(a) Provider shall prepare and maintain patient business and medical records for all
services delivered 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
for the release of a Beneficiary's business and medical records by Provider to 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
under this agreement. UMC must furnish Provider with a written authorization
signed by the patient allowing release of medical 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 Managed
Care Committee relative to the services performed under this agreement
6.3 Relationship of Parties.
(a) No provision of this agreement is intended to create any relationship between
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, joint enterprise 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 medical 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 occupy the position of intended third party beneficiaries of the obligations
assumed by either party 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.
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(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 favor of Provider, with payment to be timely made in full.
If Provider believes the decision is incorrect, the Managed Care Review committee
shall review the appeal for a final decision.
(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 UMC Managed Care Review
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 in the Exhibits on an
annual basis. Notwithstanding the effective date of this agreement, such request for
renegotiation shall 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.
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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 affect the 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 shall inure to the benefit of the
parties and their respective heirs (as applicable), legal representatives, successors, and
permitted assigns. The parties acknowledge that their services are unique and agree that
they may not assign this Agreement nor any rights, interests, or obligations hereunder
without the written consent of the non -assigning party.
6.13 Entire Agreement. This Agreement contains the entire agreement and understanding
between the parties and it supersedes all prior written agreements, understandings, and
representations relating to the subject matter of this Agreement.
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 Secretary"), the United States Comptroller General, or the Texas Department of
Health, and their duly authorized representatives, this contract and all books, documents,
and records necessary 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 records.
6.16 Certification. Each party certifies that neither it nor its principals is presently debarred,
suspended, proposed for debarment, declared ineligible, or voluntarily excluded from
participation 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 involvement in a government program.
6.17 Non -Discrimination. Each party shall provide services without discrimination on the basis
of race, color, national origin, age, sex, disability, or political or religious beliefs.
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 Insurance Portability & Accountability Act of 1996 and its
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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.
CITY OF LUBBOCK HEALTH DEPARTMENT ("PROVIDER")
By: Date: September 10, 2013
Glen C. R rtson, Mayor
ATTEST:
By:
B cky Garza, City Secretry
APPROVED AS TO CONTENT:
Y'
Scott Snider, Assistant City Manager
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EXHIBIT A
COVERED SERVICES
Reimbursement: Medicaid Rate plus 10%
Adult Immunizations
MMR
TDaP
TB Skin Test
Rabies Vaccine
Influenza (1)Sanofi Pasteur
Pharmaceuticals
Influenza (2) G1axoSmithKline
Pharmaceuticals
Hepatitis A
Hepatitis B
Twinrix
Menveo
_ STDs
Full Panel Test*
• Chlamydia
• Syphilis
• HIV
• Gonorrhea
Physician Visit CPT Code
99202
Physician Visit CPT Code
99204
Medicaid Rate for Full Panel not available: UMC will pay $24.88/panel test
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