Obstetric Services: Global-fee Method of Payment

(A) Definition of Global Fee. The global fee is a single inclusive fee for all prenatal visits, the delivery, and one postpartum visit. The global fee is available only when the conditions in 130 CMR 405.423 are met. (B) Conditions for Global Fee. (1) General Requirements. Only the CHC may claim payment of the global fee. To qualify to receive a global fee payment, the CHC must coordinate a minimum of six prenatal visits, the delivery, and postpartum care, provided by a physician, a nurse, a certified nurse practitioner, a certified nurse midwife, or a physician assistant who is qualified to perform such services and is a contractor or employee of the CHC. Such an employee or contractor must not be receiving a salary from a hospital or institution to perform the same service. For example, if a staff physician from a hospital performs a delivery while on hospital salary for that service, the CHC must not bill for the global fee for that delivery, but may bill fee for service for the medical visits. However, those visits are not covered if provided by someone receiving a hospital or institutional salary to perform the same service. (2) Standards of Practice. All the components of a global fee must be provided at a level of quality consistent with the standards of practice of the American College of Obstetrics and Gynecologists. (3) Coordinated Medical Management. The CHC must provide referral to and coordination of the medical and support services necessary for a healthy pregnancy and delivery. This includes (a) tracking and follow-up of the patient's activity to ensure completion of the patient care plan, with the appropriate number of visits; (b) coordination of medical management with necessary referral to other medical specialties and dental services; and (c) referral to WIC (the Special Supplemental Food Program for Women, Infants, and Children), counseling, and social work as needed. (4) Health Care Counseling. In conjunction with providing prenatal care, the CHC must provide health care counseling to the woman over the course of the pregnancy. Topics covered must include, but are not limited to, the following: (a) EPSDT screening for teenage pregnant members; (b) smoking and substance abuse; (c) hygiene and nutrition during pregnancy; (d) care of breasts and plans for infant feeding; (e) obstetrical anesthesia and analgesia; (f) the physiology of labor and the delivery process, including detection of signs of early labor; (g) plans for transportation to the hospital; (h) plans for assistance in the home during the postpartum period; (i) plans for pediatric care for the infant; and (j) family planning. (5) Obstetrical-risk Assessment and Monitoring. The CHC must manage the member's obstetrical-risk assessment and monitoring. Medical management requires monitoring the woman's care and coordinating diagnostic evaluations and services as appropriate. The professional and technical components of these services will be reimbursed separately and should be billed for on a fee-for-service basis. Such services may include, but are not limited to, the following: (a) counseling specific to high-risk patients (for example, antepartum genetic counseling); (b) evaluation and testing (for example, amniocentesis); and (c) specialized care (for example, treatment of premature labor). (C) Multiple Providers. When more than one provider is involved in prenatal, delivery, and postpartum services for the same member, the following conditions apply. (1) The global fee may be claimed only by the CHC and only if the required services (minimum of six prenatal visits, the delivery, and postpartum care) are provided directly by a physician, a nurse, a certified nurse practitioner, a certified nurse midwife, or a physician assistant who is qualified to perform such services and is a contractor or employee of the CHC. (2) If the CHC bills for the global fee, any provider who is not a contractor or employee of the CHC, but who performed prenatal visits or postpartum visits for the member may claim payment for such services only on a fee-for-service basis. If the CHC bills for the global fee, no other provider may claim payment for the delivery. (3) If the CHC bills on a fee-for-service basis, any other provider may claim payment on a fee- for-service basis for prenatal, delivery, and postpartum services provided to the same member. (D) Recordkeeping for Global Fee. The CHC is responsible for documenting, in accordance with 130 CMR 405.412, all the service components of a global fee. This includes services performed by contractors and employees of the CHC. A member's risk assessment and all their medical visits must be recorded in a way that allows for easy review of their obstetrical history. Hospital and ambulatory services must be clearly documented in each member's record.