Special Notice / Hearing: None__
Vote Required: Majority
To: Honorable Board of Supervisors
From: Louise F. Rogers, Chief, San Mateo County Health
Chester J. Kunnappilly, MD, Chief Executive Officer, San Mateo Medical Center
Subject: Amendment to the Agreement with Crossroads Health LLC to Provide Overpayment and Credit Balance Resolution Services
RECOMMENDATION:
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Adopt a resolution authorizing an amendment to the agreement with Crossroads Health LLC to provide overpayment and credit balance resolution services, extending the term of the agreement through December 31, 2025 and increasing the maximum amount authorized to be expended by $787,150, to an amount not to exceed $2,395,225.
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BACKGROUND:
In accordance with 42 U.S.C. § 1320a-7k(d) of the Medicare and Medicaid program integrity provisions and other applicable regulations, credit balances on accounts receivables, which are primarily from Medicare and Medicaid, must be identified and an overpayment resolution initiated to return the funds to the payor within 60 days after discovery. San Mateo Medical Center (SMMC) is responsible for achieving its goals relating to the compliant, accurate and timely return of credit balances and overpayments. Crossroads Health LLC (Crossroads) has been providing overpayment and credit balance services to SMMC since April 2021. In December 2021, SMMC completed a Request for Proposals (RFP) and Crossroads was elevated because of their documented effectiveness in resolving overpayments and credit balances. On April 5, 2022, SMMC entered into a new agreement with Crossroads for the term of April 1, 2022, through March 31, 2023, in an amount not to exceed $120,000, with subsequent amendments extending the term through March 31, 2025, and increasing the maximum amount authorized to be expended into the agreement to $1,608,075.
DISCUSSION:
When the RFP was originally completed in December 2021, the projection for the monthly number of credit balances that needed to be resolved by an outside vendor was 1,200. Since that time, the volume of credit balances has increased substantially, due to additional compliance audits being performed. These additional audits are the result of SMMC’s recent Federal Corporate Integrity Agreement, as well as SMMC’s expansion of its auditing program to include more proactive monitoring of high-risk areas.
Because of this increased audit workload, existing SMMC staff are finding it difficult to process credit balances in the timeframe required by the Medicare and Medicaid program regulations. As a result, SMMC enlisted Crossroads to increase its services provided, resolving approximately 4,800 accounts per month to ensure that SMMC complies with Medicare and Medicaid requirements.
County Attorney has reviewed and approved the resolution and amendment as to form.
The resolution contains the County’s standard provisions allowing amendment of the County fiscal obligations by a maximum of $25,000 (in aggregate).
It is anticipated that 100% of SMMC’s credit balances in accounts receivables will be identified and resolution offered to the payor within 60 days of discovery.
PERFORMANCE MEASURE:
|
Measure |
FY 2024-25 Estimated |
FY 2025-26 Projected |
|
Percentage of SMMC’s credit balances in accounts receivables identified, and resolution offered to the payor within 60 days of discovery |
100% |
100% |
EQUITY IMPACT:
Crossroads Health LLC’s continued overpayment and credit balance resolution services positively impact equitable health care delivery by ensuring that services provided to County patients are appropriately documented, charged, and billed correctly. In the past 12 months, 68.3% of SMMC’s patients were enrolled in Medi-Cal with an additional 6.1% of SMMC’s patients enrolled in the “Access to Care for Everyone” (ACE) program. SMMC’s patients span a wide spectrum of races, ethnicities, gender, and gender-identities. Within the past 18 months, the largest cohorts of specialty care patients at SMMC were female (56%), Hispanic or Latino (58%), and primarily Spanish speaking (55%).
FISCAL IMPACT:
The term of the amended agreement is April 1, 2022 through December 31, 2025. This amendment increases the agreement amount by $787,150 to an amount not to exceed $2,395,225 for the forty-five-month term. Funds in the amount of $491,969 are included in the SMMC FY 2024-25 Adopted Budget. Funds in the amount of $295,181 will be included in the SMMC FY 2025-26 Recommended Budget.
Expenses at SMMC are covered by fees for services or third-party payors whenever possible. The portion of expenses for services provided to the medically indigent or to those covered by programs that do not meet the full costs of care is covered by the County’s General Fund contribution to SMMC and is within the existing annual appropriation.