Job Description:

Scope of Work:

• DSS is seeking a qualified individual for the review, analysis, and implementation of changes to Medicaid hospital policies and reimbursement methodologies.
• The intent of the work is to explore the modernization of Medicaid’s hospital reimbursement methodologies including potentially transitioning hospitals to APR-DRG and more widespread reimbursement of outpatient hospitals through the APC methodology.
• The qualified individuals will also assist with the modernization of Medicaid hospital policies. In addition, the work will also include review, analysis, and recommendations regarding Medicaid’s ambulatory surgical center reimbursement methodology and policies.
• The qualified individual will also provide ongoing support to DSS regarding periodic updates to hospital policies and reimbursement methodologies.

Desired Outcomes from this Engagement:

1. A comprehensive analysis of South Dakota Medicaid’s current methodologies for reimbursement in comparison with contemporary practices, including those used by other state Medicaid programs.

2. A recommendation for modernization and level-setting of how South Dakota Medicaid resourcing is paid as reimbursement to providers.

3. A work plan for how to successfully achieve the recommended change in methodologies.

4. Assistance and guidance with the implementation of adopted recommendations.

The following is a high-level overview of Medicaid’s current reimbursement methodologies:

• Large in-state inpatient hospitals are reimbursed using MS-DRG.
• Weights are state-specific and the outlier methodology is state-specific, charge-based methodology. For outpatient services, these hospitals are reimbursed using the Medicare APC methodology and Medicare weights.
• DRG and APC base rates for hospital-specific.
• DRG-exempt units and hospitals are generally reimbursed on a per diem basis.
• Smaller in-state hospitals and out-of-state hospitals are reimbursed based on a percent of billed charges for both inpatient and outpatient services.

Proposals to Work Orders will be reviewed for ability to meet the State needs and there is no guarantee of award. reimbursement rate.

Dialysis outpatient hospital units are reimbursed using a fee-forservice and percent of billed charges methodology. Dialysis clinics are reimbursed on a fee-for-service methodology.

Ambulatory surgical centers are reimbursed using a grouper methodology that is based on a previous Medicare grouper methodology.

The activities requested of the successful candidate include but are not limited to:

1. Develop a work plan for the project that includes target dates, a list of deliverables, opportunities for stakeholder consultation and engagement, and the assignment of responsible parties. The work plan also is to include a recommended implementation date. The work plan must include regular, periodic meetings between the successful candidate and DSS.

2. Conduct a review and analysis regarding South Dakota Medicaid’s current hospital and ambulatory surgical center reimbursement methodologies and policies and provide a report with recommended changes.

Desired Outcome: 1

a. Analysis and validation of Medicaid claims data.

b. Analysis of system considerations and implementation of changes in DSS’s MMIS system.

Desired Outcome: 2

c. Propose a recommendation for a DRG methodology and standard weight set for reimbursing inpatient hospital services.

DSS prefers to transition from MSDRG to a DRG methodology suitable for the Medicaid population such as APR-DRG.

d. Propose options and a recommendation for reimbursement methodologies for inpatient and outpatient hospitals that are not currently reimbursed under the DRG or APC methodology such as out-of-state hospitals, smaller rural hospitals, and specialty hospitals or units.

e. Propose options and a recommendation for reimbursement methodologies for dialysis services including outpatient hospital units and dialysis clinics.

f. Propose options and recommendations for value-based payments for inpatient and outpatient hospital services aligned with industry standards and best practices based on the experience of other state Medicaid agencies and other payers. The proposal may include a phased approach with initial pay for reporting before implementing performance pay.

g. Propose options and a recommendation for a reimbursement methodology for ambulatory surgical centers.

h. Propose a system of classifying or grouping like hospitals for purposes of uniform reimbursement methodologies and uniform DRG and APC base rates.

i. Propose options for implementation of a DRG outlier methodology that is cost based and aligns with Medicare or standard Medicaid methodologies.

DSS prefers an outlier methodology that targets 10 percent or less of overall DRG payments being outlier payments.

j. Prepare initial rate modeling calculations for DSS to consider including DRG base rates, revisions to the DRG outlier payment methodology, APC base rates, dialysis services, and ambulatory surgical center rates. Proposals to Work Orders will be reviewed for ability to meet the State needs and there is no guarantee of award.

k. Prepare provider-specific and general Medicaid cost coverage analysis based on Medicaid’s current reimbursement methodology and the proposed rate modeling calculations.

l. Propose recommended ongoing monitoring and maintenance of the reimbursement methodologies that may be conducted by DSS, the successful candidate, or another vendor.

Desired Outcome: 3

m. Provide a written report of recommended changes to Medicaid policies and reimbursement methodologies based on industry standards, best practices, and State-specific factors.

Recommendations must be provided in writing and must include associated estimated fiscal impacts. The successful candidate will also provide DSS with a briefing on recommended changes and incorporate DSS feedback regarding the recommended changes.

n. Provide other research and analysis to DSS related to the Scope of Work as requested by DSS. 3. Assistance with implementing proposed recommendations and other provider policy and reimbursement-related changes.

The work may include but is not limited to:

a. Implement changes recommended by the successful candidate and adopted by DSS in the above-referenced report including developing final reimbursement rates.

b. Assist DSS with stakeholder communication and implementation activities including preparing presentations, calculation, exhibits, and other materials for communicating project details to hospitals.

c. Attend stakeholder meetings virtually or in person as determined by DSS as necessary.

d. Assist DSS with go-living planning and claims system testing if needed.

e. Assist DSS with drafting policy changes including administrative rules, state plan amendments, and provider manuals as well as any associated public notice documents.

f. Assist DSS with other implementation work related to the Scope of Work as requested by DSS. 4.

The successful candidate may provide ongoing support for periodic changes to reimbursement methodologies and policy after the implementation of recommended changes.

The work may include but is not limited to:

a. Assist with the implementation of updated DRG versions and weights.

b. Assist with implementation of updates to base rates including implementation of inflationary rate increases appropriated by the State legislature.

c. Assist with updates to the DRG outlier methodology.

d. Assist with ongoing monitoring and analysis of claims payments.

e. Provide a report of recommended reimbursement methodology and policy changes on at least an annual basis.

f. Provide other ongoing support to DSS related to the Scope of Work as requested by DSS.

Work location: 700 GOVERNORS DRIVE PIERRE, SD 57501.

Contact:

Joy - HR Recruiter

Cell:925-230-9484

Info Way Solutions LLC

Job Type: Contract

Pay: $25.00 - $30.00 per hour

Expected hours: 40 per week

Benefits:

• 401(k)
• Dental insurance
• Health insurance
• Life insurance
• Paid time off
• Vision insurance

Schedule:

• Day shift
• Monday to Friday

Work setting:

• Medical office

Education:

• High school or equivalent (Preferred)

Experience:

• Reimbursement: 2 years (Preferred)
• Medicaid claims data: 2 years (Preferred)

Ability to Commute:

• Pierre, SD 57501 (Preferred)

Ability to Relocate:

• Pierre, SD 57501: Relocate before starting work (Preferred)

Work Location: In person