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Contract Health Care...

In seeking to clarify the individual and definitive roles of IHS Contract Health Services (CHS) versus that of CSKT Health department, the purpose of each must be understood. So often, IHS beneficiaries and the general public assume the two are one and the same. This however, is not the case.

The Indian Health Service (IHS) is funded each year through congressional appropriation. It is not an entitlement program, such as Medicare or Medicaid and is not an insurance program. CHS is a payer of last resort.

Direct health care services are provided to persons eligible to access medical providers employed at Tribal Health Clinics. Services include for example, routine checkups, immunizations, physicals, prescriptions and dental services.

Contract Health Services (CHS) are services the Indian Health Service is unable to provide in its own facilities. CHS is a federally operated program where resources are used to purchase care in the private sector. Persons who are CHS eligible have access to services provided in or through private sector clinics and hospitals, as well as Direct Services. Payments made for such services are authorized based on clearly defined guidelines and are subject to availability of funds. Presently, congressional appropriations cover an estimated 60% of health care needs of eligible American Indian and Alaska Native people. This means Contract Health Services must be prioritized, with life-threatening illnesses or injuries being given the highest priority.

In October of 2005, CSKT Administration elected to return fiscal and operational management of Contract Health Services to the Indian Health Service. Here on the Flathead Reservation, tribal individuals can choose between selecting medical Primary Care Providers (P.C.P.) located at CSKT Tribal Health facilities or those in the private sector. Patients may change their P.C.P., but this change cannot occur more than two times in a calendar year. The P.C.P. submits referrals for “routine” diagnostic services, referral requests for specialized imaging/tests/procedures and referrals to specialist physicians. The P.C.P. must be consulted before all of the previous mentioned health services are obtained. Visits to a private sector P.C. P. are limited to five (5) visits per year. Tribal Health P.C.P. visits are not limited, however the Tribal Health Provider must be the patients selected P.C.P. A P.C.P. can write to IHS requesting more visits be allowed due to chronic health conditions such as Diabetes, Rheumatoid Arthritis, etc. If approved, the patient will notify IHS prior to every visit. If the patient cannot be seen by their Primary Care Provider, a partner in the practice can be seen. Independent P.C.P.’s not having a partner, must submit a referral for the patient to be seen by another provider BEFORE the patient is seen at another clinic. It is important to note Emergency Rooms are for true emergencies, not for care that can be done by the P.C.P. or because it is convenient.

The following listing for specialists, diagnostics, and procedures is not all inclusive, but gives a general guideline of what is eligible for CHS. All of the following services require the P.C.P. to submit a referral form to IHS along with supporting documentation for review and approval. Reviews are completed Thursday mornings by the Medical Review Committee. The P.C.P. is faxed a listing indicating approval or deferment/denial of their referrals for that week. ROUTINE DIAGNOSTICS can be ordered when the referral is submitted and does not have to go through the entire review process to be approved.

Routine Diagnostics: Include lab work, x-ray, barium swallow study, mammogram, ultrasound and treadmill.

Specialty Physicians: The following specialist consultation will be covered with approved referrals for Physicians (and Nurse Practitioners or Physician Assistants in the physicians practice) who specialize in: surgery, cardiology, gastrology, pulminology, urology, obstetrical, ENT (Ear, Nose, Throat), orthopedics, nephrology, neurology, oncology, rheumatology, endocrinology and podiatry. When specific conditions exist, allergy/immunology, dermatology and infectious disease may be approved.

Specialized Imaging: MRI, CT, HIDA scan, and EEG.

Procedures Requiring Prior Approval: EGD (Endoscopy), Colonoscopy, Biopsy, IUD placement, and surgery.

Procedures Not Covered: Sleep Study, Pain Management, Injections requiring anesthesia or a surgical setting (such as epidural steroid injections), EMG/nerve conduction study, Tubal ligation, Vasectomy, DEXA scan/QCT/bone density, screening colonoscopy, genetic testing, and second opinions.

Surgery: The following is the process to have surgery approved. The only time a surgery can be done before going through the process is if there is immediate threat to life or limb. The surgery will then be reviewed after all reports are submitted to IHS and it is determined to be emergent.

  1. P.C.P. evaluates patient; a referral for diagnostics may be submitted. The P.C.P. refers patient to be evaluated by a Surgeon/Specialist. Referral is approved.
  2. The Surgeon/Specialist evaluating a patient may submit a referral for diagnostic services. The Surgeon/Specialist submits a request for surgery, including notes of evaluation findings, any diagnostic reports, the diagnosis and what surgery is needed.
  3. Thursday morning the Medical Review Committee (Professional Medical Providers/Physicians/Practitioners) review the surgeries submitted that week. The surgery is rated emergent according to the threat to life or limb (i.e. life threatening, loss of a limb and irreversible damage).
  4. IHS writes a letter either approving or deferring the surgery. The letter is mailed to the patient, and a copy is sent to the Surgeon/Specialist, the P.C.P., and the Tribal Health R.N. in the patient’s community.
  5. Approved surgeries must be completed as soon as possible. To delay the surgery indicates it is not emergent and should not have been rated as such.
  6. When surgery is deferred, the patient has 30 days from the date of deferment/denial, to write a letter of appeal to the Area Director of Indian Health Service and the address is indicated on the deferment/denial letter.

Tips

  1. Keep your information current with Tribal Health Patient Registration. Notify them of any change in address, phone number, emergency contact, new insurance, when insurance ends, change in job, etc.
  2. Call IHS before you have a procedure done, see a specialist, or have surgery, to be certain everything is in order and approved.
  3. Be certain all Clinics, Providers, Hospitals, etc. have your insurance information and are aware you are covered by IHS.
  4. If you receive a bill in the mail Don’t Throw It Away! First call the sender of the bill right away and ask if they billed your insurance. IHS is the payer of last resort, meaning they pay the balance after insurance, Medicare, Medicaid, or any other coverage. After all others have paid, HIS covers the remainder for eligible or approved care.
  5. Contact IHS if you have any questions; we are here to assist you.

IHS/Contract Health Services
Phone: (406) 745-3525
Fax: (406) 745-3530

Indian Health Service - Health System Specialist
Spina Grant ext. 5053

Contract Health Service Technicians
Gladys Brown ext. 5009
Katie Tapia ext. 5117
Rhonda Hendren ext. 5043

Referral & Surgery Review Coordinator
Lorrie Meeks ext. 5007


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