UMWA Funds' Information for Medical Providers

Payment Levels

It is Funds policy to pay providers an appropriate amount for the care they provide to beneficiaries. In general, this means that the Funds will pay the providers the amount that is deemed appropriate by Medicare. In some situations, the Funds uses the exact Medicare fee schedule published by the Center for Medicare and Medicaid Services (CMS - formerly HCFA) in accordance with the Social Security Act. In other situations, such as outpatient hospital services and skilled nursing facility services, the Funds pays providers by a slightly different mechanism than Medicare uses, but the final payments are almost exactly the same as recommended by CMS.

Funds Fee Schedules

The current Funds' fee schedules are as follows:

• Physician services are paid at the Medicare fee schedule (resource based relative value system).
  
  
• Inpatient services are paid at the Medicare DRG rate.
  
  
• Outpatient services that are billed with a CPT or HCPCS code are paid at the appropriate Medicare fee level.
  
  
• Outpatient services that are not billed with a CPT or HCPCS code are paid on Medicare's percent of charge basis as calculated by the Funds.
  
  
  • A hospital may request a change in the percentage paid by submitting documentation, such as the hospital's settled cost report, that Medicare paid them at a different rate. The Funds will then pay the hospital at that specific rate.
    
    
  • The Funds' outpatient rates will be updated retroactively on an annual basis.
    
    
  • The Funds' method of outpatient reimbursement will be modified to conform to the Center for Medicare and Medicaid Services' prospective payment methodology when published and implemented by CMS.
  
  
• Durable medical equipment is paid at the contracted discounts below the Medicare fee schedule.
  
  
• Home health services are paid at the Funds' fee schedule.
  
  
• After Medicare's skilled nursing facility days are exhausted, the Funds pays for skilled nursing facility services at the Funds' fee schedule.
  
  
• Ambulance services are paid at the Funds' fee schedule.

For information about how to obtain a copy of the fee table, providers may contact Junia Dugue by e-mail - jdugue@umwafunds.org.

Special Payment Arrangements

Some providers offer special discounts to the Funds. Others provide special services to the Funds beneficiaries. These special providers are paid using specially contracted arrangements.