Health Commission tables patient-rate ordinance after lengthy questions on billing, drug-treatment rates

The San Francisco Health Commission on May 5 delayed a vote on the department's proposed patient-rate ordinance for fiscal years 2025'26 and 2026'27, saying commissioners needed more detail on how rates were calculated and how commercial insurers would interact with the listed charges.

The ordinance, presented by Matthew Sir, reimbursement and revenue cycle director for the San Francisco Health Network, included three amended items and broader annual rate changes. Sir told the commission the amendments include: aligning the injectable buprenorphine (SUBLOCADE) rate with a CMS change from weekly to monthly bundled administration under Medicare claims processing transmittal 13088; modest adjustments to naltrexone (Vivitrol) pricing; and a change at Laguna Honda Hospital from an older "all-inclusive" rate structure to line-item billing for ancillary and room charges.

Why it matters: adopted patient rates are a baseline hospitals use to bill commercial insurers and to calibrate revenue expectations. Commissioners said they want clearer documentation showing which components are professional fees, which are facility fees, and how Medicare and Medi-Cal fee schedules were applied so the city can judge whether DPH will be reimbursed as expected.

Key details presented - SUBLOCADE: Sir said DPH is changing the SUBLOCADE rate to reflect CMS'mandated monthly bundling. He cited the Medicare transmittal and said the rate shown in the packet is adjusted to the monthly basis (Sir provided a draft figure in the presentation). For 2025'26 the packet listed the updated SUBLOCADE rate and for 2026'27 a second-year figure was given. - Vivitrol (naltrexone injectable): the packet moved the rate slightly from $7,146.85 to…