Managing Purchased/Referred Care and
Leveraging the Affordable Care Act


The Contract Health Services (CHS) Program (recently retitled Purchased/Referred Care) is a complex program, especially for those who are new or existing employees or are a tribe contemplating taking Purchased/Referred Care over from the Indian Health Service. It is important to become familiar with and to accurately apply 1) the Federal Regulations that govern Purchased/Referred Care as an IHS or tribally operated program; 2) the referral and payment process; 3) new Purchased/Referred Care provisions in the Indian Health Care Reauthorization Act; 4) Health Care Reform; and 5) the impact of ICD-10 to name of few.

It is also important to know how to navigate through the complexities of the various health care delivery systems as efficiently and effectively as possible for the benefit of your patients and their health. Using our sample documents and management tools, you’ll learn how to improve Purchased/Referred Care business practices; maximize your Purchased/Referred Care dollars using existing data resources and tools. In this eye-opening class, we’ll discuss ways to grow health care as a business, cap costs, leverage federal funding, be accountable, build credibility and have new revenue which can be used to expand services to tribal members.

Our expert faculty will help you understand recently issued addendums and Section 206 of the Indian Health Care Improvement Act (IHCIA). You’ll also become versed in Purchased/Referred Care program redesign. Participants will explore how to cap Purchased/Referred Care costs through building relationships with medical groups, MCO’s and utilizing opportunities under PPACA. You’ll leave this class with strategies for making health insurance exchanges work for your target population – both in terms of providing quality coverage and drawing in opportunities for economic growth.

T O P I C S   I N C L U D E

History of Indian Health Care in the U.S.

  • The War Department
  • Bureau of Indian Affairs
  • Indian Health Service

Summary of Health Services

  • Direct Care
  • Contract Health Services
  • Exceptions

Notification Criteria for Purchased/Referred Care

  • 72-Hour Rule
  • Exception to 72-Hour Rule
  • Non-Emergency Routine Referrals
  • Pertinent information needed

Determining Purchased/Referred Care Eligibility

  • Tribal affiliation
  • Residency requirements
  • Close, social and economic ties
  • What’s new under the Re-Authorization of the IHCIA?

Authorizing Payment for Purchased/Referred Care

  • Allowable and unallowable services
  • Who decides the level of medical priority to authorize funding:
    • Role of the CEO/Health Center Director
    • Role of the Clinical Director
    • Role of the Physician
  • What’s new under the Indian Health Care Re-authorization Improvement Act?

Authorizing Payment for Purchased/Referred Care

  • Medicaid, Medicare and Private Insurance
  • County indigent funds
  • What types of insurances are NOT considered alternate resources?

Request to Authorize Payment for Services

  • Emergency services
  • Emergency services w/admission
  • Referral from physician
  • Tracking the referral in RCIS, RPMS, EHR or other method
  • Timely authorization process

Purchased/Referred Care Committee

  • Recommended members to Purchased/Referred Care committee
  • Role of each member of the committee
  • On-going communication for all parties involved
  • Catastrophic Health Emergency cases

Role of Case Management

  • Establish networks and contacts
  • Role of  case manager and/or Purchased/Referred Care staff
  • Purchased/Referred Care orientation to non-IHS facilities
  • Notification of ER visit/admission/referral from physician/ CHEF cases

Issuance of the Purchase Order

  • RCIS, RPMS or other method
  • Timely issuance and obligation amount of purchase order
  • PO payment process for IHS, tribes and the providers
  • Providers prohibited by Federal law to pursue patients for payment

Medicare-Like Rates

  • Who is subject to MLR rules?
  • Paying open market or billed charges
  • Medicare fee schedule

IHS and Purchased/Referred Care Fiscal Intermediary

  • Role of the FI in the Purchased/Referred Care payment process for IHS and tribes
  • MLR, contracted rates with providers
  • FI reports

Denial of Payment

  • Denial reasons
  • Timely issuance of denial letter to patient and provider
  • Appeal rights and process

Catastrophic Health Emergency Fund (CHEF)

  • The CHEF reimbursement criteria
  • CHEF reimbursement process
  • The importance of case management


Federal Medical Care Recovery Act (FMCRA)

  • What FMCRA is not
  • How to invoke FMCRA for IHS and tribes

Eight Strategies to Reduce Purchased/Referred Care Costs

  • Establish contracts w/high volume providers
  • Negotiating rates on a per patient basis or w/low volume providers

Patient and Physician Role in the Purchased/Referred Care Program

  • Provider education
  • Patient education

Capping Costs

  • Building relationships with medical groups and MCO's
  • Seizing opportunities under PPACA
  • CMS addendums and Section 206 of the IHCIA
  • Purchased/Referred Care (formerly CHS) program redesign

Growing the Health Care Business

  • Forward funded health systems with revenue opportunities:
    • Maximizing Medicaid and Medicare enrollment and billable moments
    • Marketing and outreach
    • Medicaid expansion
  • Educating the workforce (billers, benefits coordinators)
  • Payment for service (full cost recovery)
  • 3rd party revenue goal setting

Leveraging Federal Funding and Federal Status

  • Exploring target populations:
    • Section 813 of the IHCIA (reach others)
  • Getting paid:
    • Section 206 of the IHCIA
    • CMS Addendums - compelling payment without the commitment
  • Looking for opportunity:
    • Health insurance exchanges (insurance products, payment strategies and billing opportunities)
    • Tribal organization advantages (HRSA funding, business beyond health care)
    • Higher revenue for higher quality


  • Health care compliance (from the front door to the bottom line)
  • Medicare/Medicaid conditions for participation
  • Section 813 of the IHCIA (assurances)
  • Quality care standards
  • Third-party revenue expenditure

Building Credibility

  • Tribal cooperatives (business building and resource sharing)
  • Payment strategies (a customer and a provider)
  • Quality improvement plan
  • Tribal opportunities

*Topics subject to change.


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