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Providers press DSS on facility fees, vaccines and fetal-surgery costs; agency offers reconciliation safeguards
Summary
Providers asked technical questions about outpatient facility fees, vaccines and fetal-surgery costs; DSS said facility claims are excluded from case rates, vaccines and some procedures will be paid fee-for-service, and actuaries will identify and cap reconciling outliers.
Providers on the DSS forum pressed the agency for billing details and cost protections, naming outpatient facility fees, vaccines, anesthesiology and fetal surgery as immediate concerns.
Charles (Mercer) and Grace (actuarial support) repeatedly clarified that facility claims for outpatient or inpatient services are excluded from the case rate and will remain part of the target price and reconciliation. Grace said, “the case rate is only going to cover professional service costs” and that anything billed as a facility claim is not part of the case-rate payment.
Key operational clarifications - Facility claims:…
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