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 $7,408.86 (2025'26) and to $7,617.79 (2026'27), reflecting updated Medicare pricing. - Laguna Honda Hospital: DPH staff said Laguna Honda is moving from an historic "all-inclusive" charge construct to line-item billing for room and ancillary services; staff said the ordinance language was amended to remove the unused all-inclusive rate and reflect present billing practice. - Systemwide increases: DPH proposed increases tied to state and local guidance: behavioral health increases of roughly 3.08% for 2025'26 and 2.82% for 2026'27 to align with DHCS Medi-Cal rates, and a 2.67% / 2.82% increase for other physical-health patient rates consistent with the controller's CPI-based guidance.

Commissioners pressed for clarity on several points. Commissioner Guggenheim asked whether DPH could be confident Medicare and Medi-Cal payments would match the charge amounts; Sir said DPH has reasonable confidence for government payers because payments follow fee schedules but noted commercial insurers pay based on their own allowed amounts. Commissioner Chao and others asked repeatedly whether specific line items in the packet were professional fees or facility fees; Sir answered, "These are the professional fees," when asked about clinic-level numbers.

Commissioners also questioned the composition of bundled codes (for example, Sir explained the SUBLOCADE monthly code can bundle dispensing, administration, counseling and toxicology testing). Commissioners asked for clarity on CPT/HCPCS mappings, how often some bundled services are actually provided, and how DPH expects commercial plans to reimburse in practice.

Outcome and next steps After extended discussion, President Green proposed delaying the decision and asked staff to prepare the additional documentation requested by commissioners. The commission voted to table the patient-rate ordinance to the full commission meeting on May 19, 2025. The packet and amended language will be supplemented with more detailed back-up showing fee components, example CPT/HCPCS associations where possible, and a clearer explanation of assumptions used for commercial reimbursement projections.

Quotes (from the meeting) "These are the professional fees," Matthew Sir said when commissioners asked whether the clinic numbers included facility charges. "I would like to propose that this be delayed in for 2 weeks," President Green said as commissioners sought more context before approval.

Speakers - Matthew Sir, Health Network Revenue Cycle and Reimbursement Director (government) - President Green (chair, San Francisco Health Commission) (government) - Commissioner Guggenheim (San Francisco Health Commission) (government) - Commissioner Chao (San Francisco Health Commission) (government) - Commissioner Christian (San Francisco Health Commission) (government) - Secretary Morowitz (Commission secretary) (government)

Authorities - regulation: "Medicare claims processing manual, transmittal 13088" (referenced_by:["patient-rate ordinance presentation"]) - funding: Prop C (referenced_by:["Director's Report funding for 822 Geary"]) - program: Medi-Cal (referenced_by:["patient-rate ordinance presentation"])

Actions - {"kind":"other","identifiers":{},"motion":"Approval of the fiscal-year 2025-26 and 2026-27 patient-rate ordinance (as presented)","mover":"not specified","second":"not specified","vote_record":[],"tally":{},"legal_threshold":{},"outcome":"tabled","notes":"Commission voted to table and requested supplemental documentation; new hearing set for 2025-05-19."}

Clarifying details - {"category":"SUBLOCADE frequency change","detail":"DPH is aligning buprenorphine injectable (SUBLOCADE) billing frequency from weekly to monthly per CMS guidance","value":true,"source_speaker":"Matthew Sir"} - {"category":"naltrexone rate change","detail":"Naltrexone (Vivitrol) rate adjusted modestly to reflect Medicare pricing","value":"$7,408.86 (2025-26); $7,617.79 (2026-27)","source_speaker":"Matthew Sir"} - {"category":"Laguna Honda billing","detail":"Laguna Honda moving from historic 'all-inclusive' rates to line-item billing for ancillary and room charges","source_speaker":"Matthew Sir"} - {"category":"tabled_to","detail":"Motion to table patient-rate ordinance until May 19, 2025","value":"2025-05-19","source_speaker":"President Green"}

Proper_names - {"name":"Laguna Honda Hospital","type":"facility"} - {"name":"SUBLOCADE","type":"other"} - {"name":"Vivitrol","type":"other"}

Provenance - {"block_id":"block_1460.95_1481.0851","local_start":0,"local_end":49,"evidence_excerpt":"Good afternoon, commissioners. My name is Matt Sir. I'm the reimbursement and revenue cycle director for the San Francisco Health Network.","reason_code":"topicintro"} - {"block_id":"block_3449.425_3456.8052","local_start":0,"local_end":67,"evidence_excerpt":"Everyone in favor of tabling this motion until May 19, please say aye. Aye.","reason_code":"topicfinish"}

topics:[{"name":"healthcare_finance","justification":"Central policy item: hospital patient rates, payer reimbursement, and billing structure","scoring":{"topic_relevance":1.00,"depth_score":0.90,"opinionatedness":0.05,"controversy":0.60,"civic_salience":0.95,"impactfulness":0.85,"geo_relevance":1.00}}]