Policy Unit

% of Policy, Budget and Reimbursement (PBR) forms finalized prior to effective date of change

50.0%SFQ1 2021

Line Bar
Notes on Methodology
  • Please note in the above chart the solid trend line represents the total % and the dotted trend line represents DVHA's %
  • The target for all departments for this measure is 80%

Partners
  • Contact for Change (varies)
  • Lead Department Business Office
  • Program Integrity Unit
  • AHS Finance
  • DXC
Story Behind the Curve

Changes to Medicaid programs, services, and policies require a coordinated review to ensure alignment with federal and state regulations as well as Vermont Medicaid policies and practices. The Policy, Budget and Reimbursement (PBR) form provides a tool to support the systematic coordination of AHS departments and units and provides essential documentation regarding the change. The routine use of the PBR form creates a process that serves as an internal safeguard against any unintended consequences of proposed changes.

Policy, Budget & Reimbursement (PBR) forms require review and approval from the lead department business office, DVHA Reimbursement Unit, DVHA Program Integrity Unit, Medicaid Policy Unit, AHS Finance, and the DXC Contract Lead. The goal is to have approval from all before the change is effective and to issue public notice, if required.

The Medicaid Policy Unit manages the PBR process for changes to Medicaid. Having a PBR signed by all reviewers prior to effective date indicates the health and proper utilization of the PBR process. It strengthens the change to have had fiscal, policy, reimbursement, and program integrity review it and allows time for public notice (if required).

If we are not finalizing PBRs prior to their effective dates, we are at risk for the following:

  • Poor budgeting:  Adding new coverage for services or making other Medicaid changes without understanding the fiscal impact ahead of time inhibits DVHA’s and the Agency’s ability to manage the Medicaid budget.
  • Loss of, or inability to, receive federal match:  Changes to the Medicaid program can require federal approval, or at a minimum, federally required public notice. Without a system that ensures we check for these needs prior to implementation, the chance that we miss a federal approval or public notice requirement increases.
  • Non-compliance with state and federal policies:  We cannot ensure accuracy of Medicaid changes without a coordinated review by subject matter, financial, coding, reimbursement, and policy experts.
  • Public engagement:  Public notice and other public engagement has the most value when conducted prior implementation. By ensuring have internally engaged each other prior to a Medicaid change, we can increase our ability to also engage externally as well.
  • Cost of mistakes:  It can be costly to implement a Medicaid change (in MMIS or otherwise) that then needs to revised after implementation because certain considerations or connections were not made. By maximizing accuracy via the PBR Process, we increase the likelihood that it is done correctly the first time.

Quarter 3 and 4 have a decrease due to staffing resources and COVID-19 response.

Last updated:  10/15/2020

Strategy

Variables impacting the performance measure:

  • Staff awareness of PBR process and requirements
  • Quality of work put into PBR completion
  • Agency business processes for planning, budgeting, contracting, etc.
  • Hashing out MMIS or other necessary IT requirements
  • Policy Unit’s ability to expeditiously route PBRs
  • Reviewers’ ability to expeditiously review PBRs

Ways to improve:

  • Continue to work with units and departments to:
    • Ensure awareness of PBR requirements
    • Discuss ways in which the PBR can work with their business processes and/or their business process can be modified to allow for more PBR pre-planning
  • Work with departments to think about ways to have more of an ongoing methodology to their annual rate updates rather than have it be driven by one-off changes that are not formula-driven (i.e. any additional dollars they get from the legislature divided by the number of clients providers say they will serve that year).
Scorecard Result Container Indicator Measure Action Actual Value Target Value Tag S R I P PM A m/d/yy m/d/yyyy