Governing for Results 13 - Washington State Digital Archives

Health Care Authority
UMP Fee Schedules and Provider Reimbursement Policies
Prior to July 1, the Uniform Medical Plan (UMP) professional provider fee
schedule applied the same reimbursement rates regardless of where the
procedure was performed. These reimbursement rates included a facility
component, representing the overhead costs that would be incurred by a
physician who performed the procedure in his/her own office. In cases where
the procedure was performed in a hospital or other health care facility, the UMP
would also usually pay a separate claim submitted by the facility for their costs.
Effective July 1, 2000, the UMP implemented a dual-level reimbursement
approach for professional procedures that recognized the site of service. This
change effectively eliminated the duplicate payment of overhead costs and
provides more appropriate reimbursement of the actual costs incurred by the
physician in providing the service. Also effective July 1, 2000, the UMP began
reimbursing laboratory, radiology, and therapy services billed by hospitals using
the same fee schedules that apply for independent laboratories and other
providers billing these same services. Previously, the UMP reimbursement to
hospitals for these services was based on a percentage of billed charges. As a
result, hospitals were frequently receiving higher reimbursement than other
providers for comparable services.
Results
★ Applies UMP reimbursement policies more equitably to different types of
providers and practice arrangements.
★ Eliminated duplicate payment of facility overhead for certain professional
procedures.
★ Improves UMP's ability to control increases in hospital reimbursement for
laboratory, radiology, and therapy services.
★ Reduces member coinsurance costs for these services.
★ Supports UMP goal of controlling premium increases and providing health
care to customers at an affordable cost.
Team Name: Improving Provider Reimbursement Policies
Team Members: Kathy Fancher, Cheryl Mustard, Krista Shufelt, Cynthia
Ray, Janet Peterson
CONTACT: Janet Peterson, (206) 521-2013
95