Robert Howey MBA, MHA, CPA Director, Toyon Associates Advanced Topics in Medicare Cost Reporting: Reimbursement for Organ Acquisition Robert Howey MBA, MHA, CPA Director, Toyon Associates test

Objective After the session, you will be able to: Better understand three advanced areas related to organ acquisition reimbursement for Medicare Use this information to evaluate the reporting at your transplant center Also as it relates to the TFC role

Agenda Kidney Paired Donations Medicare Secondary Payer Organs Counting Medicare Organs

Kidney Paired Donations

Kidney Paired Donations Hospital A DA Only applicable to external swaps RA

Kidney Paired Donations Hospital A Hospital B DA DB Only applicable to external swaps RA RB

Kidney Paired Donations Incremental kidney acquisition costs to receiving transplant center: Packaging Transportation (Note: travel costs of the donor are not allowable for kidney acquisition) Additional tests requested post match Source: Provider Reimbursement Manual (CMS Pub. 15-1), Chapter 31, Section 3106

Kidney Paired Donations Responsibilities of donating transplant center: Include donor I/P nephrectomy charges on W/S D-4 Part I Reduce hospital I/P donor nephrectomy charges to cost (use latest published CCR in Impact File on CMS website) Bill recipient CTC the calculated cost from step 2 Increase Medicare and Total usable organs by one on W/S D Part III, Lines 62 & 63 Include payment from recipient CTC as Revenue for Organs Sold on W/S D-4, Part III, Line 66 Source: Provider Reimbursement Manual (CMS Pub. 15-1), Chapter 31, Section 3106

Kidney Paired Donations Responsibilities of receiving transplant center: Include payment to donating transplant center for donor I/P nephrectomy in kidney acquisition cost center Transplant count based upon recipient’s insurance (similar to any other transplant) Routine follow-up care for donor Source: Provider Reimbursement Manual (CMS Pub. 15-1), Chapter 31, Section 3106

Tips with KPD Establish processes and responsibilities for each department involved Communication plan Billing/collecting to/from receiving CTC Reducing charges to cost Recording revenue received Counting organs appropriately

Kidney Paired Donations Other Challenges with KPD (Not Kidney Acquisition) Donor Complications Out-of-Network Services

Medicare Secondary Payer Organs

Medicare Secondary Payer Benefits To collect the shortage in organ acquisition payment between the primary payer to what Medicare would have paid if Medicare were primary.

Medicare Guidelines Medicare secondary benefits may be payable if: Payment < charges for Medicare covered services Payment < gross amount payable by Medicare Not accept or not obligated to accept primary payment as payment in full Source: Provider Reimbursement Manual (CMS Pub. 15-1), Chapter 31, Section 3104

Payment Comparison Primary Payer Medicare Transplant $40,000 Organ Acquisition $65,000 Total Payment $85,000 $105,000

Necessary Steps Need to bill Medicare (if Secondary) even if no payment is expected Contractual language for commercial payer does not indicate that primary payment is considered “payment in full”

Medicare Secondary Payer Example Primary = Commercial Secondary = Medicare Provider does not accept payment as payment in full

Medicare Secondary Payer (Step One) Compare Primary payment to Medicare Commercial vs. Medicare Payment Total Charges Primary Payment Medicare DRG OAC Total Medicare Qualify? 1 $180,000 $125,000 $40,000 $65,000 $105,000 No 2 $150,000 $85,000 Yes Cost per Organ = Worksheet D-4 Part III (Line 69 divided by Line 63)

Medicare Secondary Payer (Step 2) Calculate percentage of payment for organ acquisition and determine offset Determine Offset Total Charges Primary Payment Payment as a % of Charges SAC Charge Offset 1 $180,000 $125,000 69% $75,000 N/A 2 $150,000 $85,000 57% $42,500

Medicare Secondary Payer Summary Increase Medicare usable organs by one Include $42,500 on D-4, Part III Line 66 as Revenue for Organs Sold

Helpful Hints Must bill as MSP Properly identify Medicare Secondary Payer Perform calculation on accounts with MSP For those that qualify, review contracts for ”payment in full” language and exclude if exists Claim eligible MSP organs on MCR Offset portion of OAC payment from primary

Counting Medicare Organs

Medicare Usable Organs Medicare Ratio Medicare Usable Organs Total Usable Organs Medicare Primary Transplants Total Transplants Medicare Secondary Transplants (if Medicare had some liability) Deceased Donor Organs Organs Sold to Other Hospitals (e.g., Paired Exchange)

Medicare Organs Defined Medicare usable organs include organs transplanted into Medicare beneficiaries (excluding Medicare Advantage beneficiaries), organs that had partial payments by a primary insurance payer in addition to Medicare, organs sent to other CTCs, organs sent to OPOs and kidneys sent to MRTCs (that have a reciprocal sharing agreement with the OPO in effect prior to March 3, 1988 and approved by the contractor).  Source: Provider Reimbursement Manual (CMS Pub. 15-1), Chapter 31, Section 3115A

Medicare Organs Defined Medicare usable organs do not include organs used for research, organs sent to veterans’ hospitals, organs sent outside the United States, organs transplanted into non-Medicare beneficiaries, organs that were totally paid by primary insurance other than Medicare, organs that were paid by a Medicare Advantage plan, organs procured from a non-certified OPO and kidneys sent to MRTCs (without a reciprocal sharing agreement with the OPO in effect prior to March 3, 1988 and approved by the contractor).  Source: Provider Reimbursement Manual (CMS Pub. 15-1), Chapter 31, Section 3115A

Medicare 45 20 5 75 100 130 Medicare Ratio 45% 100% 57.7% Primary/ MSP Tx DD (OPO)* External KPD* Children’s Hospital* Total Medicare 45 20 5 75 100 130 Medicare Ratio 45% 100% 57.7%

Medicare 45 20 5 75 100 130 Medicare Ratio 45% 100% 57.7% Primary/ MSP Tx DD (OPO)* External KPD* Children’s Hospital* Total Medicare 45 20 5 75 100 130 Medicare Ratio 45% 100% 57.7% * Include hospital charges on W/S D-4 Part I and payments received on W/S D-4 Part III, Line 66.

Medicare 45 20 5 75 100 130 Medicare Ratio 45% 100% 57.7% Primary/ MSP Tx DD (OPO)* External KPD* Children’s Hospital* Total Medicare 45 20 5 75 100 130 Medicare Ratio 45% 100% 57.7% * Include hospital charges on W/S D-4 Part I and payments received on W/S D-4 Part III, Line 66.

Medicare 45 20 5 75 100 130 Medicare Ratio 45% 100% 57.7% Primary/ MSP Tx DD (OPO)* External KPD* Children’s Hospital* Total Medicare 45 20 5 75 100 130 Medicare Ratio 45% 100% 57.7% * Include hospital charges on W/S D-4 Part I and payments received on W/S D-4 Part III, Line 66.

Medicare 45 20 5 75 100 130 Medicare Ratio 45% 100% 57.7% Primary/ MSP Tx DD (OPO)* External KPD* Children’s Hospital* Total Medicare 45 20 5 75 100 130 Medicare Ratio 45% 100% 57.7% * Include hospital charges on W/S D-4 Part I and payments received on W/S D-4 Part III, Line 66.

Takeaways Proper reporting of KPD costs Determining MSP organs Counting appropriate Medicare organs

Thank you! Let’s Stay in Touch! Robert Howey (888) 514-9312, ext. 3147 robert.howey@toyonassociates.com

Internet-Only Manuals (IOM) Operational Management of Medicare Organ Acquisition Cost Centers (Presented by John Rogers and Robert Howey)Section I: Ideas and Strategies for Managing Medicare Organ Acquisition Cost Centers CMS References Paper Based Manuals Provider Reimbursement Manual, Part I, Chapter 31 Internet-Only Manuals (IOM) Medicare Benefit Policy Manual (Pub. 100-02, Chapter 11, Section 140) Medicare Claims Processing Manual (Pub. 100-04, Chapter 3, Section 90) https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/index.html