National Council of Urban Indian Health
1 Massachusetts Avenue NW
Suite 800-D
Washington, DC 20001
Phone: 202.544.0344
What is Third Party Billing?
Due to the United States’ failure to fully fund its trust obligation to provide health services to American Indians and Alaska Natives, Urban Indian Organizations (UIOs) must rely on reimbursement from third-party payers to provide health services to American Indians and Alaska Natives (AI/ANs) living in urban settings.
About NCUIH’s Research on Third-Party Billing for UIOs
NCUIH is currently participating in a research project on third-party billing for UIOs. The project was commissioned by the Centers for Medicare & Medicaid Services (CMS). NCUIH participates in the project through a contract with NORC at the University of Chicago.
For more information on NCUIH’s projects on these topics see:
2024 Medicaid Reimbursement at UIOs During COVID-19
Recent Trends In Third-Party Billing At Urban Indian Organizations: Medicaid Reimbursement Rates At Urban Indian Organizations During The Covid-19 Pandemic
2023 PCCM/IMCE Report
Recent Trends in Third-Party Billing at Urban Indian Organizations: A Focus on Primary Care Case Management and Indian Managed Care Entities
This report serves as an update to the National Council of Urban Indian Health’s previous reporting on recent trends in third-party billing. This report focuses on the experience of urban Indian organizations enrolled in Medicaid and the Children’s Health Insurance Program as a primary care case manager (PCCM)or Indian Managed Care Entity (IMCE).
Key findings related to UIO Experience with PCCM/IMCE:
- Benefits for UIOs and patients included:
- PCCM services improved continuity of care for Medicaid and CHIP enrollees
- UIOs have a comprehensive view of the patient’s care, reducing need for self-advocacy and reporting
- Best practices included:
- Strong working relationships with state Medicaid offices and Tribal Relations Liaisons, and other partners
- Use of state Urban Confer and/or incorporation of UIOs into state Medicaid Tribal Consultations
- Challenges included:
- Insufficient capitation rate for UIOs providing PCCM services
- Poor communication with state Medicaid offices
- Lack of 100% FMAP for UIOs resulting in UIO exclusion from PCCM program
2022 Report: ARPA and 100% FMAP
Recent Trends in Third Party Billing at Urban Indian Organizations: Impact of the American Rescue Plan Act and 100% FMAP Provisions
This report serves as an update to NCUIH’s previous reporting on recent trends in third-party billing. This report focuses on the role of Medicaid trends against the background of pandemic-era changes in Urban Indian Healthcare legislation and impact of the temporary 100% FMAP Provision in Section 9815 of the American Rescue Plan Act (ARPA).
Findings:
- $70,407,559 of UIO Medicaid costs would shift from State governments to the Federal government if all 22 states with UIOs drew 100% FMAP during the two-year period of the temporary 100% FMAP provision.
- If 100% FMAP provision is extended beyond eight quarters, NCUIH predicts that over 10 years, $547 million would be shifted from states the federal government. This estimate is less than half the increase predicted by previous projections, by virtue of factoring in existing state FMAP and Medicaid spending rates.
- UIOs have not received any direct financial benefits from the passage of the temporary 100% FMAP Provision.
Figure 1: Distribution of $70,407,559 of cost-shifting from temporary 100% provision.
2022 Report: Medicaid Managed Care
Recent Trends in Third-Party Billing at Urban Indian Organizations: A Focus on Medicaid Managed Care
This report serves as an update to NCUIH’s previous reporting on recent trends in third-party billing. This report examines the history of managed care in Medicaid and the relationship between managed care organizations and Urban Indian Organizations (UIOs) in selected states.
Key Findings:
- Medicaid managed care beneficiaries comprised 63 percent of the UIO patient population, submitted 68 percent of the claims, and produced 61 percent of the Medicaid payment revenue.
- The average amount paid for each managed care claim was $132, compared to the average amount of $176 paid for non-managed care claims.
- In 2019, 4 percent of managed care claim lines were denied, and 5 percent of non-managed care claim lines were denied.
- UIOs who felt that they do not have a good working relationship with managed care organizations often cited the need for improved communication to strengthen that relationship.
- UIOs also noted that some managed care organizations lacked familiarity with the needs of AI/AN patients living in urban areas.
- UIOs also emphasized the need for UIOs to work with other UIOs, Tribes, and other similarly situated health care providers to amplify their voice and strengthen their bargaining power to advance key Medicaid priorities.
2021 Third-Party Billing Reports
Recent Trends in Third-Party Billing at Urban Indian Organizations: A Focus on Medicaid, Telehealth, and Pandemic Response
This report provides an overview of billing methods and payment methodologies that Urban Indian Organizations (UIOs) use for third-party reimbursement, with a special focus on Medicaid. The report includes analyses of UIO Medicaid claims from the Transformed Medicaid Statistical Information System (T-MSIS). The report uses data from calendar year 2018, which was the most current T-MSIS data available.
Findings:
- UIOs provided services to 86,335 Medicaid Beneficiaries.
- 19% of UIO Medicaid Beneficiaries were categorized as “American Indian or Alaska Native” within the Race/Ethnicity variable.
- UIOs received $108 million in Medicaid reimbursement.
- The rate of claims denial for beneficiaries categorized as “American Indian or Alaska Native” within the Race/Ethnicity variable was (3.39%), which was lower than the average rate of 6.2% for all beneficiaries.
- The rate at which UIO claims were denied was correlated with a state’s policy environment. In states participating in the Affordable Care Act (ACA) Medicaid Expansion Program, 4.64% of claims made by a UIO were recorded as denied in T-MSIS. In Non-Expansion states,11.39% of UIO claims were denied.
A recording of a CMS Webinar presentation on the report is available on YouTube here.
A copy of the Webinar slideshow is available from CMS here.
2021 Telehealth Report
Telehealth Policy and Urban Indian Organizations
This report describes the impact of telehealth policies on UIOs. First, the report explains four broad categories of telehealth technology and the applicable reimbursement policies. Then the report compares Medicaid reimbursement telehealth policies from six states, both prior to the Covid-19 pandemic and during the pandemic. The report concludes with a summary of telehealth challenges and opportunities
A recording of a CMS Webinar presentation on the report is available on YouTube.
2020 Third-Party Billing Report
Recent Trends in Third-Party Billing at Urban Indian Organizations
This report provides an overview of billing methods and payment methodologies that Urban Indian Organizations use for third-party reimbursement, with a focus on IHS appropriations, third-party reimbursement rates, HHS Grants and HRSA Health Centers.
- In FY18, UIOs received $672 per AI/AN patient from IHS’s Urban Indian line item.
- The average Medicaid reimbursement rate UIOs receive is around $245 – nearly half the 2020 all-inclusive rate of $479 available to tribal and IHS facilities. The lowest rate NCUIH has on record was $70 in 2018; 50% of UIOs receive between $170 and $300 per encounter.
- In FY2019, HHS grants from sources other than IHS totaled $48.4 million, just under the $51.3 million appropriated under the Urban Indian Health IHS line item that year.
- 60% of the grants that UIOs received from Health and Human Services (HHS) between FY13-FY19 did not come from IHS, with 31% awarded by HRSA (31%), 19% by SAMHSA (19%), 4% by the CDC (4%), and 3% by ACF.
UIOs that are HRSA Health Centers are serving an increasing number of Homeless Health Center patients – 8349 clients in FY2018 (up 150% from four years prior). HRSA Health Centers also serve around 1100 Veterans and 500 Agricultural workers, and these levels were relatively stable between 2015 and 2018.
ACA Info for Providers
Providers
The Affordable Care Act (ACA) and the Indian Health Care Improvement Act (IHCIA) provide a number of important benefits for urban Indian health providers:
- The law permanently reauthorizes the IHCIA.
- The law declares that it is the policy of the United States, in fulfillment of its special trust responsibilities and legal obligations to Indians, to ensure the highest possible health status for urban Indians and to provide all resources necessary to affect that policy.
- The law expands opportunities for urban Indian health program staff recruitment through the National Health Service Corps.
- The law authorizes urban Indian health programs to purchase Federal Employee Health Benefits for their employees.
- The law provides a “right of recovery” for urban Indian health programs to recover payment for services provided to patients carrying out-of-network insurance coverage.
- The law expands Medicaid and affordable insurance through Health Insurance Marketplaces, allowing urban Indian health programs to bill third-party payers rather than relying on their limited Title V funds.
ACA Benefits for Patients
More choices to access insurance coverage
- Use the Indian Health Service if eligible and accessible.
- Access coverage through Medicare, Medicaid, CHIP, if eligible.
- Purchase affordable, quality coverage through Health Insurance Exchanges.
- In many states, Medicaid eligibility is expanded to individuals with incomes up to 133% of federal poverty level.
Benefits for American Indians and Alaska Natives
- Special monthly enrollment periods for eligible AI/ANs to sign up for Health Insurance Exchange coverage every month (no waiting for open enrollment).
- No cost-sharing for eligible AI/ANs who receive care through the IHS, Tribal health programs, or Urban Indian health programs.
- No cost-sharing for eligible AI/ANs earning less than 300% of poverty level who receive care at any health care facility.
- Many AI/ANs are exempt from the tax penalty that would otherwise apply to individuals who do not obtain health insurance coverage.
Covers young adults under 26
- If you’re under 26 years old, you may be able to get insured under a parent’s plan. You can join, remain, or return to a parent’s plan even if you’re married, attending school, not living with your parents, eligible to enroll in your employer’s plan, or financially independent.
Provides free preventive care
- You may be eligible for free preventive screenings, like mammograms, colonoscopies, and blood pressure and cholesterol tests. This does include coverage for vaccines and new preventive services for women.
ACA Patient Protections
The ACA Requires insurance companies to cover people with pre-existing health conditions
- Health insurance plans can’t charge you more or turn you down because you’re sick or have a health condition. They also can’t charge women more than men. The only exception is for grandfathered individual health insurance plans.
Holds insurance companies accountable for rate increases
- Rate Review: helps protect you from unreasonable rate increases. Insurance companies must now publicly justify any rate increase of 10% or more before raising your premium. This does not apply to any grandfathered plans.
- 80/20 Rule: ensures that insurance companies spend at least 80% of the money they take in from premiums on your health care and quality improvement activities (instead of on administrative, overhead, and marketing costs). This is also referred to as the Medical Loss Ratio (MLR).
Makes it illegal for health insurance companies to arbitrarily cancel your health insurance just because you get sick
- It’s now illegal for insurance companies to cancel your coverage simply because you made an honest mistake or left out information that has little bearing on your health.
- You will be given at least 30 days’ notice prior to the cancelation of your coverage.
Ends lifetime and yearly dollar limits on coverage of essential health benefits
- Insurance companies can’t set a dollar limit on what they spend on essential health benefits for your care during the entire time you’re enrolled in that plan. These are often referred to as lifetime limits.
- Yearly dollar limits are not allowed on essential health benefits.
Guarantees your right to appeal
- Internal Appeals: You can ask your insurance company to reconsider its decision to deny payment for a service or treatment. The insurance company must review its decision.
- External Review: If your insurance company still denies payment, the law allows you to have an external review. The review will be done by an independent organization that will decide if the insurance company should pay or not.
IHCIA
Within the Affordable Care Act (ACA), the Indian Health Care Improvement Act (IHCIA) was re-authorized. It helps AI/ANs. The IHCIA, which authorizes health care services for AI/ANs through the Indian Health Service (IHS), was first approved by Congress in 1976 and then reauthorized in 2000. The ACA makes the re-authorization of this law permanent and authorizes new programs within the IHS to ensure it is more equipped to meet its mission to raise the health status of AI/ANs to the highest level.
Here are some of the newly created functions under the IHCIA:
- The law gives IHS the authority to establish expanded services such as behavioral and mental health treatment and prevention, long-term care services, dialysis services, care for Indian veterans, and urban Indian health programs.
- A health care professional employed by a tribally operated health program is exempt from state licensing requirements if the professional is licensed in any state. The IHCIA also aims to have the health care professional join or continue in an Indian health program.
- A tribe or tribal organization that carries out a program under the Indian Self-Determination and Education Assistance Act and a UIO that carries out a program under Title V of IHCIA is authorized to purchase coverage for its employees through the Federal Employees Health Benefits Program (FEHB).
Traditional Healing at UIOs and Meta-Analysis
Recent Trends in Third-Party Billing at Urban Indian Organizations: Thematic Analysis of Traditional Healing Programs at Urban Indian Organizations and Meta-Analysis of Health Outcomes
This report serves as an update to the National Council of Urban Indian Health’s previous reporting on recent trends in third-party billing.
- This report focuses on how Urban Indian Organizations (UIOs) administer, evaluate, and fund traditional healing services.
- UIOs rely on Medicaid claims revenue to maintain services, but many UIOs have reported difficulty receiving reimbursement for traditional healing services.
- Recognizing the importance of culturally appropriate care, four states have initiated efforts to expand reimbursement for these services at Indian Health Service facilities, Tribal Health Centers, and UIOs. Arizona, California, Oregon, and New Mexico have submitted Traditional Healing reimbursement proposals to the Centers for Medicare & Medicaid Services (CMS) using Section 1115(a) demonstration waivers.
Traditional Healing Report One Pager
Find more resources around Traditional Healing here, ncuih.org/traditional.
Thematic Analysis of Traditional Healing (TH) Programs at Urban Indian Organizations and Meta-Analysis of TH Health Outcomes
Traditional Healing Meta-Analysis Works Referenced
The Payment Systems Reform Initiative
Through its Payment System Reform initiative, NCUIH provides technical assistance and training to address structural challenges introduced by the implementation of Health Care Reform, as well as helping to improve intervention programs. UIHPs can be the frontline to help reduce the alarming disparities of Indian Country, specifically in urban settings. National Healthy People 2020 goals (which aim to reduce health disparities) can be achieved through the targeted implementation of health care reform, which can improve program revenues (e.g., through increased opportunities for third-party billing) and ensure a focus on the quality of care (e.g., through PCMH accreditation).
In order to acquire the benefits provided by the Affordable Care Act, clinics and health programs across the US are accommodating a renewed payment system that incorporates the Third Party Billing System, as well as other structural components to keep their financial structure up and running.
In recent years, NCUIH has operated the Payment Systems Reform Project through its analyst contractor, Medical Business Advocates LLC (MBA), which accounts for highly specialized technical expertise on Medicare, Medicaid, and private insurance. MBA also possesses very specific knowledge on the use of the Indian Health Service’s Resource and Patients Management System. Additionally, MBA possesses specific knowledge about UIHPs and a high level of cultural competency.
NCUIH’s Payment Systems Reform is comprised of two main activities:
- Program Support: guided work on improving practices for ICD-10 implementation and third-party billing accuracy for UIHP billing/ coding and executive staff through a Payment Systems Reform Community of Learning.
- Rationale/purpose: new models of health care delivery payment, as well as new ICD codes for billing/ coding will be instituted beginning in the Fall of 2015 and UIHPs will need to be prepared for these changes in order to reduce impact on financial reimbursement delivery. Revenue streams and financial data reporting are heavily dependent on full and accurate implementation of third party- billing processes, which require UIHP staff training and technical assistance.
- Activities: support on ICD-10-CM, GPRA, PPS Review, A/R Management implementation through conference calls and WebEx sessions
- Technical Representation: work with federal partner workgroups regarding health care reform to provide technical assistance and representation for UIHPs.
- Rationale/purpose: Urban representation at meetings pertaining to CMS initiatives and health reform partnerships with federal agencies is necessary to advance the needs of urban and to remain up to date on new initiatives that could affect the urban AI/AN community.
- Activities (Stepping Stones): Support and provide input to partners on health reform, participation at meetings/ calls, disseminate information to membership and constituencies
If you are an NCUIH Member Organization and would like to join the PSR initiative activities, please contact Kimberly Fowler, Ph.D- Technical Assistance and Research Director- at kfowler(at)ncuih.org
Traditional Food at UIOs and UIO Research on Traditional Healing
Recent Trends In Third Party Billing: Thematic Analysis of Traditional Food Programs at Urban Indian Organizations and Research on Traditional Healing
Find more resources around Traditional Healing here, ncuih.org/traditional.
Traditional Food Infographic
Traditional Food Infographic Citations