Presented by: David McMahon, Senior Manager Michael Horoho, Manager
AGENDA ITEMS Recap of Final Rule Hospital documentation and how it corresponds to preparation of Disproportionate Share Reporting Schedule Issues & results of 2009 data
REASON FOR THE DSH AUDIT RULE To ensure that the hospital specific DSH limits have not been exceeded. Hospital specific DSH limit is uncompensated costs incurred during the year of furnishing hospital services by the hospital to individuals who either are eligible for medical assistance under the State plan or have no health insurance (or other source of third party coverage) for services provided during the year.
42 CFR 447.299(C) REPORTING REQUIREMENTS Applies to State Fiscal Year 2005 and after Reports must be created by State Medicaid Agency with the following information for each hospital receiving DSH payments: 1.Hospital Name 2.Estimate of Hospital Specific DSH Limit 3.Medicaid Inpatient Utilization Rate 4.Low Income Utilization Rate 5.State Defined DSH Qualification Criteria 6.IP/OP Medicaid Fee For Service (FFS) Basic Rate Payments
42 CFR 447.299(C) REPORTING REQUIREMENTS Reports must be created by State Medicaid Agency with the following information for each hospital receiving DSH payments: 7.IP/OP Medicaid Managed Care Organization Payments 8.Supplemental/Enhanced Medicaid IP/OP Payments 9.Total Medicaid IP/OP Payments 10.Total Cost of Care for Medicaid IP/OP Services. 11.Total Medicaid Uncompensated Care 12.Uninsured IP/OP Revenue
42 CFR 447.299(C) REPORTING REQUIREMENTS Reports must be created by State Medicaid Agency with the following information for each hospital receiving DSH payments: 13.Total Applicable Section 1011 Payments 14.Total Cost on IP/OP Care for Uninsured 15.Total Uninsured IP/OP Uncompensated Care Costs 16.Total Annual Uncompensated Care Cost 17.Disproportionate Share Hospital Payments States must report DSH payments to all hospitals under the authority of the approved Medicaid State Plan.
42 CFR 447.299(C) REPORTING REQUIREMENTS States must report all 17 fields of data for payments to in-state hospitals. States can report a minimum of the following fields for out-of-state hospitals: Hospital Name Estimate of Hospital Specific DSH Limit Medicaid Inpatient Utilization Rate Low Income Utilization Rate State Defined DSH Qualification Criteria IP/OP Medicaid Fee For Service (FFS) Basic Rate Payments Supplemental/Enhanced Medicaid IP/OP Payments Total Medicaid IP/OP Payments Disproportionate Share Hospital Payments
Hospital documentation needed in order to populate the Disproportionate Share Reporting Schedule (DRS)
REPORTING PERIODS Certain documentation is needed by cost reporting period in order to verify requirements by MSP rate year Medicaid State Plan (MSP) rate year Audits must be completed with information on the MSP rate year §447.299(c) MSP rate year October 1-September 30 If the hospital cost report period does not coincide with the MSP year, then documentation needed may be two or more cost reports
ACTUAL COST DETERMINATION FOR HOSPITAL WITH FISCAL YEAR NOT CORRESPONDING TO MSP RATE YEAR Medicaid State Plan rate year is 9/30/2010. Hospital cost reporting period end June 30 th. Hospitals cost report for 6/30/10 and 6/30/11 are obtained. MMIS data and hospital data is separated as follows: 10/1/09-6/30/10 and 7/1/10-9/30/10. Charges and payments applied to specific cost report for actual payment calculation.
OB REQUIREMENT Request list #1 2 obstetricians with staff privileges and are Medicaid approved physicians and UPIN numbers Exceptions to OB requirement Rural facilities may have two physicians with staff privileges at the hospital that have agreed to perform non-emergency obstetrics Patients are predominately under (18) years of age Facility did not offer non-emergency obstetric services as of December 22, 1987 Hospital must meet the OB requirements to qualify for DSH under §455.304(d)
MIUR (MEDICAID INPATIENT UTILIZATION RATE) MIUR must not be less than 1% Medicaid inpatient days / total inpatient days Sub-provider days are included Swing beds SNF days are not be included in calculation
WORKING TRIAL BALANCE Request list #2 Cost report period If the cost report period does not coincide with the MSP rate year, two or more trial balances will need to be provided that fall within the MSP rate year Required to be submitted with Medicare Cost Report
AUDITED FINANCIAL STATEMENTS Request list #3 Cost report period Identify possible source of revenue needed to offset cost of care Required to be submitted with Medicare Cost Report
EXPENSES AND REVENUE MAPPING TO WORKSHEETS A & C OF MEDICARE COST REPORT Request list #4 Cost report period Used in conjunction with the trial balance to ensure proper matching of cost and charges are reported on the Medicare cost report Cost to charge ratios are used to determine costs for both Medicaid and Uninsured If already shown on submitted WTB then this is N/A
TRANSPLANT PROVIDERS Request list #5 List of Useable Organs within MSP period Medicaid by organ Uninsured by organ Payment information Medicaid FFS Out of State (FFS, Dual Eligible, MCO) Dual Eligible Individuals with no source of third party insurance
CROSSWALKS Request list #6 (Medicaid) and #7 (Self-Pay) Used to map revenue codes included in patient detail requests to cost centers of cost report Provide crosswalks in excel format by cost report period If crosswalk is not provided/useable then charges are allocated on a percent to total of charges reported on the cost report
.ECR FILE Request list #8 Current version of CMS form 2552-96 or 2522- 10 Cost to Charge ratios adjusted to include CRNA GME included
PROVIDER PAYER/INSURANCE CODE LISTING WITH DESCRIPTIONS Request list #9 MSP rate year Listing needed to determine what codes are self pay, insurance, or other payers. Any payer/insurance codes included in patient detail request must correspond to the payer code listing.
DETAIL LISTING OF SELF-PAY PAYMENTS Request list #10 Payment Date during the MSP year Payments should be on a cash basis and agree to the MSP rate year, regardless of the date when charges were incurred Compared to Uninsured Data to limit to collections on Uninsured Accounts only
OUT OF STATE MEDICAID AGENCIES PATIENT DETAIL Request list # 11 Inpatient and Outpatient Medicaid FFS, MCO, Dual Eligibles related to Out of State Medicaid Beneficiaries Discharge Dates within MSP year Used in calculation of Medicaid Uncompensated Care
OUT OF STATE MEDICAID AGENCIES PATIENT DETAIL (CONTINUED) Detailed log of: Inpatient or Outpatient Account number Medical record number Patient name Admit and Discharge Date Charges Payments Payer Code Revenue Code
MEDICAID DUAL ELIGIBLE PATIENT DETAIL Request list #12 Inpatient and Outpatient Accounts where Alabama Medicaid is Secondary Payer Discharge Dates within MSP year Medicare Bad Debt Log Used in calculation of Medicaid Uncompensated Care
MEDICAID DUAL ELIGIBLE PATIENT DETAIL (CONTINUED) Detailed log of: Inpatient or Outpatient Account number Medical record number Patient name Admit and Discharge Date Charges All Payments Payer Code Revenue Code
MEDICAID MATERNITY WAIVER PATIENT DETAIL Request list # 13 Inpatient and Outpatient Medicaid Maternity Waiver MCO Discharge Dates within MSP year Used in calculation of Medicaid Uncompensated Care
MEDICAID MATERNITY WAIVER PATIENT DETAIL (CONTINUED) Detailed log of: Inpatient or Outpatient Account number Medical record number Patient name Admit and Discharge Date Charges Payments Payer Code Revenue Code
OUT OF STATE SUPPLEMENTAL/ENHANCED/DSH PAYMENTS Request list #14 Any Supplemental or Enhanced Medicaid Payments and Medicaid DSH Payments received from Out of State Medicaid Agencies during MSP rate year Used to offset Medicaid Costs in Uncompensated Care Calculation
MEDICAID ELIGIBLE NOT BILLED PATIENT DETAIL Request list #15 Discharge Dates within MSP year Used in calculation of Medicaid Uncompensated Care Medicaid not billed is usually when hospitals have not billed because of: Exhausted days (Over 16 Days) Liability exceeds charge s
MEDICAID ELIGIBLE NOT BILLED PATIENT DETAIL (CONTINUED) Detailed log of: Inpatient or Outpatient Account number Medical record number Patient name Admit and Discharge Date Charges Payments Payer Code Revenue Code
UNINSURED PATIENT DETAIL Request list #16 Individuals with no source of third party insurance Discharge Dates within MSP year Detail is tested and used to calculate Uninsured Uncompensated Care
UNINSURED PATIENT DETAIL (CONTINUED) Detailed log of: Inpatient or Outpatient Account number Medical record number SSN (Last four digits) Patient name Admit and Discharge Date Charges Payments Payer Code Revenue Code
CREDIT AND COLLECTION POLICY Request list #17 Required to verify that hospitals attempt collection efforts for all self pay patient balances and that all collection effort recoveries received during the MSP year are recorded to patient specific accounts and offset for DSH limit
UNINSURED CLEANING Cleaning analysis to be performed a.Is the claim a duplicate entry b.Is the claim outside of the fiscal period being tested c.Does the SSN and name on the claim match the Medicaid Eligibility Listing received from the State of Alabama Medicaid Agency for the period under review. In addition, does the date of service or discharge date fall during the recipients eligibility period d.Does the account number on the claim match the account number on the listing of Dual Eligible, Out of State, Maternity Waiver, Medicaid Not Billed Residents received from the Hospital
UNINSURED CLEANING (CONTINUED) e.Is the insurance code for a claim a code for credible third party insurance f.For claims that matched in step e., is the insurance workers compensation and if so was there a payment made by this insurance h.Does any payment that was received for the claim exceed 40% of the total charge i.Were any payments received on a claim with no charges
UNINSURED VS. UNDERINSURED Eligibility for credible coverage is determining factor Uncompensated – provider does not receive payment for charges – self pay/no pay, exceeds coverage, co-pays, coinsurance, deductibles not met. Uninsured – no coverage from any outside source Underinsured – health insurance does not cover services
UNINSURED VS. UNDERINSURED Auto Insurance and Workers compensation If claim is denied and zero amount is paid, patient is considered uninsured If any payment is made, patient is considered insured by third party Charity Care Not considered insurance Patients are required to meet certain criteria based on hospitals written policy Accounts will not be sent to collections for recovery, but written off to bad debt Any payments from patients should still be offset and submitted as self- pay uninsured
HOSPITAL BASED PHYSICIANS Request #18 Dates of Service within MSP Listing of physicians with cost removed for professional fees on WS A-8 and A-8-2 of Medicare Cost Report. Include relative value units or charges for each physician Include total payments received from Medicaid and on behalf of individuals with no source of third party insurance
HOSPITAL BASED CRNA AND NON- PROFESSIONAL OR OTHER PHYSICIAN SERVICES Requests #19 and #20 Dates of Service within MSP Non-Professional or Other Physician can Include: Nurse Practitioner Physician Assistants Dentists Certified Nurse Midwives Clinical Social Workers Clinical Psychologists Optometrists
HOSPITAL BASED CRNA AND NON- PROFESSIONAL OR OTHER PHYSICIAN SERVICES (CONT.) Total amount of charges excluded from Worksheet C Costs Removed for these services on A-8 Include total payments received from Medicaid and on behalf of individuals with no source of third party insurance
HOSPITAL BASED AMBULANCE, DME, PRESCRIPTION PHARMACY Request #21, #22, #23 Dates of Service within MSP Year Submit charges and payments for Dual Eligible, Out of State Medicaid, Medicaid Eligible not Billed, and accounts with no source of third party insurance
HOSPITAL BASED HOME HEALTH AGENCY Request #24 Dates of Service within MSP Year Patient account detail for home health visits and charges (Exclude Medical Social Services) Include Dual Eligible, Out of State Medicaid, MCD eligible but not billed, and accounts with no source of third party insurance
HOSPITAL BASED HOSPICE Request #25 Dates of Service within MSP Year Patient account detail for billed unduplicated days and payments Include Dual Eligible, Out of State Medicaid, MCD eligible but not billed, and accounts with no source of third party insurance
HOSPITAL BASED RURAL HEALTH CLINIC AND FEDERALLY QUALIFIED HEALTH CENTER Requests #26 Dates of Service within MSP Year RHC and FQHC visits and payments received Include Dual Eligible, Out of State Medicaid, MCD eligible but not billed, and accounts with no source of third party insurance
HOSPITAL BASED RENAL DIALYSIS Request #27 Dates of Service within MSP Year Patient account detail of renal dialysis treatments, and payments Include Dual Eligible, Out of State Medicaid, MCD eligible but not billed, and accounts with no source of third party insurance
PROVIDER DOCUMENTATION ISSUES Patient Detail Unavailable (Data Storage Vendor) Useable crosswalks Self pay data submitted based on Discharge Date not Payment Date Patient detail with charges but no payments No response on OB request
FINDINGS FROM SFY 2009 DSH AUDIT 46 hospitals exceeded the DSH Limit due to lack of documentation from hospitals. 10 hospitals did not provide sufficient documentation to determine the hospital was DSH eligible.
FINAL COMMENTS MOVING FORWARD FOR SFY 2010 Lack of documentation can severely impact the Alabama Medicaid Agencys claiming of certified public expenditures for SFY 2010 Potential disallowance of undocumented CPE which will impact Medicaid funding of other services during SFY 2014
FINAL COMMENTS MOVING FORWARD FOR SFY 2010 Final test run prior to Alabama Medicaid Agency having to redistribute monies from one private hospital to another private hospital due to hospitals exceeding DSH limits. Alabama Medicaid Agency will be issuing a memorandum concerning the requirement to comply with the DSH documentation process and DSH audit.