IN WITNESS WHEREOF, the parties hereto, by their duly authorized representatives, have affixed their hands. | |
Seton Medical Center |
COUNTY OF SAN MATEO |
By: |
By: |
J. Marc Golan Chief Financial Officer DCHS Bay Area |
Richard S. Gordon President, Board of Supervisors San Mateo County |
Date: |
Date: |
ATTEST: | |
By: | |
Clerk of Said Board | |
Revised 6/03 | |
Long Form Agreement/Non Business Associate |
Exhibit “A” | ||||||||||||
In consideration of the payments set forth in Exhibit “B”, Contractor shall provide the following services: | ||||||||||||
I. |
Diagnostic and Tertiary Care Services | |||||||||||
A. |
In consideration of the payments provided for in Schedule B, paragraph I, of this Agreement, Contractor shall provide the full range of its available diagnostic and therapeutic services on a 24 hour/7 days a week basis to medically indigent patients referred in writing by County, subject to the provision of Schedule B, paragraph I. | |||||||||||
B. |
In the event that the patient must be hospitalized in Contractor's facility, Contractor's medical staff shall confer with San Mateo Medical Center medical staff to determine if or when a transfer to San Mateo Medical Center is medically appropriate. Medical records of the patient's stay at Contractor’s facility shall accompany the patient. | |||||||||||
C. |
County shall supply appropriate medical information to Contractor Concerning patients referred to Contractor. | |||||||||||
D. |
The services provided must be specifically referred by a member of San Mateo Medical Center’s medical staff and approved by San Mateo Medical Center Administration on a referral form provided by County and will accompany the patient. | |||||||||||
E. |
County indigents who present at Contractor's facility without being referred In writing by San Mateo Medical Center are expressly excluded from the terms of this Agreement. If a County indigent presents at Contractor's facility, Contractor shall contact San Mateo Medical Center's Admitting Department for transfer and/or authorization. | |||||||||||
F. |
In the event of the referral of a Medi-Cal pending patient, the County shall have six (6) months to provide proof of eligibility. After this time, the Contractor will be reimbursed at the agreed upon rate. | |||||||||||
Exhibit “B” | ||||||||||||
I. |
In consideration of the services provided by Contractor in Exhibit “A”, County shall pay Contractor based on the following fee schedule: | |||||||||||
Seton Medical Center | ||||||||||||
Inpatient and O/P Services Contract Rates | ||||||||||||
for San Mateo Medical Center | ||||||||||||
Inpatient |
Rate |
Type | ||||||||||
1. |
Medical/including Pediatrics |
$1,285 |
Per diem | |||||||||
2. |
Surgical |
$1,285 |
Per diem | |||||||||
3. |
Telemetry |
$1,285 |
Per diem | |||||||||
4. |
ICU/CCU |
$1,285 |
Per diem | |||||||||
5. |
NICU level 2 (Rev 172) |
$1,285 |
Per diem | |||||||||
6. |
Cardiovascular Surgery |
See attached rate schedule | ||||||||||
7. |
PTCA/Angioplasty |
See attached rate schedule | ||||||||||
8. |
Cardiac Catheterization |
See attached rate schedule | ||||||||||
9. |
Brachytherapy: Seeds: |
$16,200 Invoice cost |
Case rate |
|||||||||
10. |
Lithotripsy |
$2,185 |
Phased |
|||||||||
$4,364 |
Single | |||||||||||
$6,556 |
Bilateral | |||||||||||
11. |
Boarder Baby (Rev 170, 171) |
|||||||||||
12. |
Maternity – Vaginal |
$1,285 |
Per diem |
|||||||||
13. |
Maternity – C Section |
$1,285 |
Per diem |
|||||||||
14. |
Implants/Prosthetics |
100% |
Invoice Cost |
|||||||||
Outpatient |
Rate |
Type | ||||||||||
1. |
Other O/P |
50% |
Billed charges | |||||||||
2. |
OP Laboratory |
100% |
Medicare APC fee schedule | |||||||||
3. |
OP Radiology |
100% |
Medicare APC fee schedule | |||||||||
4. |
OP Surgery |
100% |
Medicare Area 06 RBRVS fee schedule | |||||||||
5. |
OP Renal Dialysis |
100% |
Medicare Area 06 RBRVS fee schedule | |||||||||
6. |
OP Cath |
100% |
Medicare Area 06 RBRVS fee schedule | |||||||||
7. |
OP PTCA |
100% |
Medicare Area 06 RBRVS fee schedule | |||||||||
8. |
Implants |
100% |
Invoice Cost | |||||||||
9. |
MRI (excludes Gadolinium) |
Medicare APC rates | ||||||||||
10. |
AICD |
Invoice cost |
||||||||||
11. |
Gadolinium |
Invoice cost |
||||||||||
Notes: |
Rates are exclusive of Professional Services and separately paid for by SMMC. Medicare rate will be current fee schedule at time service is provided. | |||||||||||
A. |
The preceding per diem rates apply to each approved, medically necessary day of service and includes payment for all services rendered during the admission including but not limited to: pre-admission services for provider within 24 hours of admission, room, board, nursing care, surgery and recovery suites, equipment, supplies, laboratory, radiology, pharmaceuticals and other services incidental to the admission. | |||||||||||
B. |
The preceding outpatient surgery rates apply to all services rendered during the surgery including but not limited to: pre-operative outpatient services within 24hours of the surgery, nursing care, surgery and recovery suites, equipment, supplies, laboratory, radiology, pharmaceuticals and other services incidental to the surgery. | |||||||||||
C. |
The preceding rates exclude professional services that are not billed under the Contractor's TIN. Laboratory rates will be understood to mean lab services associated with referred patients as well as lab specimen referrals for which no advance case management paperwork will be required. | |||||||||||
D. |
The preceding rates apply to all authorized services available from Contractor. Hospital services are described in the hospital services inventory attached as Exhibit I. | |||||||||||
E. |
Pre-admission services provided within 72 hours of admission will be included in the first per diem. | |||||||||||
F. |
Contractor shall be reimbursed per current HCFA billing guidelines. | |||||||||||
G. |
Per diem rates exclude hospital-based physician fees. | |||||||||||
H. |
The services provided must be referred by a member of San Mateo Medical Center's medical staff and authorized by the Case Management Department or Hospital Administration. A valid outside authorized referral form must accompany the patient. | |||||||||||
I. |
Contractor shall provide a combined billing which details all services performed and the charges therefore, excluding hospital-based physician's fees. All billings will be subject to a utilization review process prior to payment. A copy of an authorized outside referral form must accompany all billings. | |||||||||||
J. |
Contractor shall bill all other payors including, but not limited to, Medi-Cal outpatients, Medicare outpatients, private insurance patients and "full pay" patients. County shall bear no financial responsibility for such patients. | |||||||||||
K. |
Per Medi-Cal guidelines, as the Provider of Service, Contractor must complete and submit a Treatment Authorization Request (TAR) Form 50-1 to the appropriate Medi-Cal field office. County will provide information on the Outside Referral Form that will enable Contractor to complete these TARs. | |||||||||||
L. |
In the event that a patient referral to Contractor by County under this Agreement is subsequently determined to be eligible for third-party payment, Contractor shall claim against third-party payor and County shall bear no financial responsibility for such patient. | |||||||||||
M. |
In the event of the referral of a Medi-Cal pending patient, the County shall have six (6) months to provide proof of eligibility. After this time, the Contractor will be reimbursed at the agreed upon rate. If patient is subsequently found eligible for Medi-Cal after payment has been made, San Mateo Medical Center will provide proof of retroactive eligibility to Contractor. Any payment made to Contractor must be reimbursed to San Mateo Medical Center within thirty (30) days of such notification. | |||||||||||
The term of this agreement is July 1, 2005 to June 30, 2006. In no event shall total payment exceed $600,000. | ||||||||||||
DRG |
Description |
Case Rate |
104 |
Cardiac valve procedure with cardiac cath |
$57,373.58 |
105 |
Cardiac valve procedure without cardiac cath |
$41,684.25 |
106 |
Coronary bypass with PTCA |
$53,431.51 |
107 |
Coronary bypass with cardiac cath |
$38,659.30 |
108 |
Other cardio thoracic procedures |
$39,311.44 |
109 |
Coronary bypass without PTCA or cardiac cath |
$28,569.99 |
110 |
Major cardiovascular procedures with cc |
$29,590.92 |
111 |
Major cardiovascular procedures without cc |
$17,646.84 |
115 |
Perm cardiac pacemaker implant w/AMI, heart failure or shock |
$24,743.64 |
116 |
Other Perm card pacemaker implant or PTCA with coronary artery stent implant |
$16,568.58 |
117 |
Cardiac pacemaker revision except devise replacement |
$9,581.01 |
118 |
Cardiac pacemaker devise replacement |
$11,263.82 |
124 |
Circulatory disorders exc AMI with card cath & complex diag |
$10,348.87 |
125 |
Circulatory disorders exc AMI with card cath without complex diag |
$7,784.64 |
514 |
Cardiac Defibrillator Implant w Cardiac Cath (no longer valid) |
|
515 |
Cardiac Defibrillator Implant without Cardiac Cath |
$36,299.47 |
516 |
Percutaneous Cardiovascular Proc with AMI |
$19,579.48 |
517 |
Perc Cardio Proc with Coronary Artery Stent without AMI |
$15,642.82 |
518 |
Perc Cardio Proc without Coronary Artery Stent or AMI |
$12,417.78 |
526 |
Percutaneous Cardiovascular Proc W Drug Eluting Stent W AMI |
$22,381.64 |
527 |
Percutaneous Cardiovascular Proc W Drug Eluting Stent without AMI |
$18,192.99 |
535 |
Cardiac Defibrillator Implant with Cardiac Cath with AMI/HF/SHOCK |
$62,475.00 |
536 |
Cardiac Defibrillator Implant with Cardiac Cath without AMI/HF/SHOCK |
$47,514.60 |