Providers press DSS on facility fees, vaccines and fetal-surgery costs; agency offers reconciliation safeguards

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: Outpatient and inpatient facility fees are excluded from the case-rate payment and handled through target-price reconciliation; only professional claims billed under the attributed TIN and correct specialty type are candidates for case-rate payment.
- Vaccines and certain procedures: Panelists said vaccines (flu, COVID) and some services such as IUD insertion are intended to be excluded from the case rate and paid fee-for-service; DSS said it will verify and publish the included/excluded lists.
- Anesthesiology and specialty billing: Grace said anesthesiology or other specialties receive case-rate payment only if billed by the correct professional specialty type within the attributed TIN; otherwise such claims are fee-for-service.
- Consultative MFM and ER visits: Grace and Charles explained that attribution hinges on the presence of a trigger code on the professional claim; an MFM or ER consult that includes a trigger code can change attribution even if performed in an emergency setting.
- High-cost fetal-surgery episodes: Providers raised concerns about fetal surgery costs and frequency. A participant reported a rise from near-zero in the draft test period up to about 25 last year and projected more next year. Charles and Brad said actuaries will examine historical claims during reconciliation and that very expensive episodes can be identified and capped or excluded from reconciliation if they are anomalous.

What DSS will do next
DSS said it will publish the pay-code lists, post FAQ clarifications, provide one-on-one follow-ups and ask providers to flag unusual events so the actuarial team can adjust reconciliation methods or caps for outliers. The agency emphasized that the draft numbers do not yet include a $21 add-on payment and that dry-run outputs are for benchmarking, with final incentive payments determined only after a performance year.