A state university’s medical school wished to develop and implement a fee-for-service (FFS) physician upper payment limit (UPL) program for physicians and providers serving Medicaid beneficiaries. Before the work began, the state already had a Medicaid FFS physician UPL program in place, one that reimburses services at the upper limit of cost. The university, however, wished to design and seek state and federal approval for an additional UPL program to ensure reimbursement up to the average commercial rate (ACR). Prior to Sellers Dorsey’s involvement, efforts for the new program had begun but were halted during negotiations at the state level. It was then that the university sought Sellers Dorsey’s help in renewing those efforts.
From its beginning, the project required close collaboration with both the university and state officials, with all parties coordinated on a path toward state and federal approval. Our team helped prepare both sides of the effort for CMS review and approval, and we reviewed past documents and calculations related to the initial efforts of the program before our involvement. We also provided an ACR demonstration, collaborated with the university to estimate the program’s potential federal gain, and presented the idea along with our findings to the State. Following these initial efforts, we drafted public notices, state-plan amendments (SPAs), and responses to CMS requests for additional information, and we began identifying potential sources of non-federal share for the program. We also helped the university develop a memorandum of understanding (MOU) with the state regarding the use of these funds, and we provided expert advice on answering budget committee questions related to the program.
Through these careful efforts, we helped issue a public notice and submit a Medicaid SPA to CMS, winning approval less than a year later after a period of further questioning and answering. Following the program’s implementation, the initial payments garnered over $62 million in its first year.