Supplemental Payment Program & UPL Demonstration Development
2018–presentProvider-level payment modeling and Upper Payment Limit demonstrations for state Medicaid supplemental payment programs supporting over $95M in annual payments, built to withstand CMS review and absorb new participating providers without a methodology redesign.
Problem
A state Medicaid agency needed annual supplemental payment calculations and Upper Payment Limit (UPL) demonstrations that could withstand CMS review while accounting for changing provider participation, reimbursement policies, cost report updates, and regulatory requirements.
Approach
Designed and maintained provider-level payment models using commercial-to-Medicare rate ratio calculations, hospital financial data, cost reports, and claims experience, covering both hospital and ground ambulance provider populations. Built the UPL demonstrations required to justify the payments to CMS, and supported annual program updates, State Plan Amendment documentation, payment validation, and provider onboarding, backed by data validation, methodology documentation, and assumption testing to keep the program consistent and defensible year over year.
Outcome
Designed and maintained supplemental payment programs and UPL demonstrations supporting more than $95 million in annual supplemental payments: approximately $91 million for hospitals and $4 million for ground ambulance providers. Over 6 years, these programs have generated approximately $130 million in federal funding. Built a repeatable, provider-level modeling process that absorbs newly participating providers and annual data updates without a methodology redesign each cycle, reducing implementation risk and keeping payment operations continuous.