Michigan Patient Accounting
Association
Oct. 31, 2014
Vickie R. Kunz
Senior Director, Health Finance
Michigan Health & Hospital Association
1
Who is the MHA?
• Advocacy organization representing all hospitals in
Michigan.
• Activities include:
– State advocacy and policy on Medicaid funding and
policy issues
– Federal advocacy and policy on Medicare and
Medicaid issues
– MHA Keystone Center – Quality Improvement and
Patient Safety Initiatives
– BCBSM Contract Administration Process
• Unique to Michigan
2
Payer Issues
• The role of the MHA is to assist in resolving
systematic payer issues.
• Individual hospital contracts determine terms and
conditions and take precedence.
• Communicate issues to Marilyn Litka-Klein
(mklein@mha.org) or Vickie Kunz
(vkunz@mha.org) at the MHA.
3
Examples of MHA Involvement in Other Issues
• Other activities identified by/for the MHA membership
– Maximize federal funding in state Quality Assurance
Assessment Program (QAAP)
– Medicaid implementation of Critical Access Hospital
takeback that included “reject” vs “no-pay”, impact on
Medicare reimbursement
– Michigan Managed Care Rebid process
– Medicaid implementation of MI Health Link (formerly
dual eligible project)
– HFMA/MPAA/ACMA, etc. outreach
– BCBSM DRG validation audits
– No-fault insurance payment rates
4
CMS RAC Appeals Settlement Proposal
• Administrative Law Judge (ALJ) appeals back log –
CMS proposes 68% of funds due (net of deds/coins)
if hospital withdraws all pending appeals.
• Hospitals must submit request for settlement by
Oct. 31, 2014.
– CMS to provide payment 60 days after CMS acceptance
• No timeframe for CMS to accept
– PPS hospitals and CAHs are eligible- Rehab and Psych
Hospitals are not eligible.
• See Oct. 20 MHA Monday Report Article which
includes a link to CMS’ Oct. 9 presentation.
5
CMS ALJ Settlement Proposal – cont.
• These claims would not be counted for Medicare GME, IME
and DSH.
• Many hospitals that have appealed to the ALJ have had
positive outcomes, therefore diminishing the value of this
proposal.
• Due to the significant backlog at the ALJ, it may be years
before a hospital receives a positive decision and its payment
under the current appeals process.
• Hospitals are encouraged to carefully evaluate
whether to request settlement.
6
General Quality-Based Program
Themes
• Increased financial exposure each year (max exposure shown below)
HAC = Hospital Acquired Condition (HAC) Reduction Program; RRP = Readmission Reduction Program; VBP = Value
Based Purchasing Program
7
OPPS & HHA Final Rules
• CMS is expected to release these rules by Nov. 1, effective
Jan. 1, 2015.
• MHA will provide details as soon as possible, including
hospital-specific analyses in the next few weeks.
8
2015 Medicare FFS Deductibles and Coinsurance
• Part A deductible – increasing by $44 from $1,216 to $1,260.
– Inpatient hospital, SNF, home health services
• Coinsurance
– $315 for days 61-90 of hospitalization
– $630 for lifetime reserve days
– $157.50 for days 21-100 of extended care services
• Part B monthly premium unchanged at $104.90.
– Adjusted upward for higher income beneficiaries.
• Part B deductible unchanged at $147.
9
Medicare Advantage Plans
• As of October 2014, 30 plans operating in Michigan, with
569,000 or approximately 32% of Michigan’s 1.8 million
Medicare beneficiaries enrolled.
− Enrollment up 6,000 since July.
− Up to 20 plans in some counties.
• Review MA payment rate for all plans.
• CAH entitled to Medicare cost reimbursement.
• Each MA plan may determine own utilization model and is
not required to maintain electronic transactions.
• Many MA have instituted “RAC-like” utilization programs.
• Matrix of MA plans by county available at MHA website –
updated quarterly, with MHA Monday Report article.
− Oct. 27 MHA Monday Report.
10
Medicaid
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Fee-for-Service Payment Recoveries
• See L-letter 14-28, dated Sept. 30, 2014.
• Approximately $3 million in payment recoveries for Healthy
Michigan Plan enrollees that were retroactively enrolled in
HMOs and had claims paid under Medicaid fee-for-service.
• MSA completed payment recoveries on Oct. 16 vouchers.
• Hospitals should re-bill these services to the Medicaid HMO.
• HMOs obligated to pay claim even though prior authorization
not received.
12
72-Hour Rule
• MSA processing change for CAHs, cancer and
children’s hospitals resulted in claim rejections rather
than no-pay status for Medicare deductible/co-pay
amounts for dual eligible individuals.
• Potential impact to Medicare bad debt
reimbursement
• MSA modifying system so that claims will be
processed and noted with “no pay status” which
allows claim to be included for Medicare bad debt
purposes.
• Hospitals will need to rebill claims rejected for dates
of service on/after Jan. 1 2013.
13
MI Health Link
• Integrated care demonstration project for individuals dually-eligible for
Medicare and Medicaid.
• Integrated care organizations are in the process of contracting with
hospitals in the four demo regions.
• Nine plans in Macomb and Wayne counties, two in 8 Southwest counties,
one plan in UP.
• Hospitals in these regions are responsible for negotiating contracts with
the Integrated Care Organizations.
• In late September, MSA announced its intent to require hospitals to
contract with at least 2 ICOs in order to be eligible for payments from the
outpatient uncompensated care DSH pool.
– Status uncertain whether MSA will issue a proposed policy if sufficient patient access is
achieved by hospitals contracting with ICOs.
14
Continued, MI Health Link
• Opt-in enrollment begins Jan. 1, in Southwest Michigan and
the Upper Peninsula, with passive enrollment starting Apr. 1.
• Opt-in enrollment begins May 1, in Macomb and Wayne
Counties, with passive enrollment starting July 1.
• Statewide implementation won’t occur until after 3-year
demonstration project ends.
• Payments to non-contracted hospitals should be Medicare
rates including IME, GME, DSH.
15
FY 2015 Budget
• New $11 million OB Stabilization Pool – GF/Federal $
– Payments to be distributed as part of the monthly HRA payments for
October, November and December 2014
• Continued Rural Access Pool - $35 million – GF/Federal $
– HMO payments to be distributed monthly as part of the HRA
payments
– FFS payments to be distributed quarterly
• New tax-funded $85 Million DSH Pool
– $70 Million to be distributed to Large/Urban Hospitals
– $15 Million to be distributed to Small/Rural Hospitals
• More aligned with hospital provider tax paid to support these payments.
• Payments will be distributed Sept. 2015
16
Hospital Reimbursement Reform Initiative
• 2013 meetings with hospitals, MSA steering committee
finalizing areas to implement
• Representatives include small, medium, and large hospitals
and CAHs
• Several ideas discussed:
· statewide inpatient rate with hospital adjustors,
· APR-DRG for inpatient
· Increase in outpatient payments financed with reduced inpatient
rates
· Medicaid OPPS rates are 53% of Medicare OPPS rates
· DSH methodology changes
· HRA methodology changes
· GME methodology changes
17
MSA Proposed Policy # 1442-DRG
• Jan. 1, 2015:
–
–
–
–
DRG and Rehab per diem rate update
Update DRG Grouper from Version 31.0 to Version 32.0
Mandates birth weight reporting, needed for APR-DRGs
Prospective capital rate
• Oct. 1, 2015:
– APR-DRG implementation
– Statewide rate implementation, with appropriate hospital adjustors
• Comments due to MSA Nov. 14.
18
MSA Short Stay Rate
• Workgroup efforts continue to develop a short stay rate for
payment of short stay cases for Medicaid FFS and HMO.
• Short stay rate would apply to specific diagnosis codes for
non-surgical cases.
• Established short stay rate would be paid to hospitals
regardless of hospital determination of inpatient or
observation status.
• If patient meets criteria for inpatient admission, patient days
should be counted for Medicare DSH purposes.
• Target implementation July 1, 2015.
19
Newborn Claim Requirements
•
•
•
•
•
•
Dates of service Oct. 1, 2014 and after
Type of admission/visit
Birth weight
C-section/inductions related to gestational age
Both FFS & HMO claims
Informational edits now, but will be required Jan. 1, 2015
– Claims without data for 2015 dates of services will be rejected
20
HMO Rebid Process
• Request for proposal expected to be released in January or
February.
• New contracts will be effective Oct. 1, 2015.
• $7 billion annually in payments from the state.
21
Healthy Michigan Plan
• 433,000 individuals enrolled in HMP as of Oct. 27,
with approximately 300,000 individuals in a
Medicaid HMO.
• FY 2014 – Hospitals received $72 million in HRA
payments.
• No QAAP tax associated with these payments.
• FY 2015 HRA payments for these enrollees
projected at approximately $20 million monthly.
• All counties have achieved enrollment.
22
Continued, Healthy Michigan Plan
• CMS confirmed that Healthy Michigan Plan inpatient
days should be included for Medicare DSH
calculations.
• Hospital registration staff encouraged to use
CHAMPS to determine which patients are HMP
versus regular Medicaid.
• Can use 270/271 batch transactions
• Hospitals required to report both FFS and HMO HMP
data separately on MMF.
23
BCBSM DRG Validation Audits
• Consultant found BCBSM erred in removing codes for BMI
and cerebral edema
• Other audit areas for improvement
• Sept. 24 education session, webinar available
• 2014 audits will be reviewed for compliance with consultant
findings
• MHA advocated for retroactive adjustment
– BCBSM has not finalized retroactive policy
24
Days in Accounts Receivable
• Results based on 25 hospitals that submitted data to
the MHA Monthly Financial Survey (MFS) for period –
January - July 2014 versus January – July 2013:
• Medicare – Days in A/R unchanged at 31 days.
• Medicaid – Days decreased from 30 days to 28 days.
• BCBSM – Days decreased slightly from 30 to 29 days.
• Overall – Days in A/R were unchanged at 40 days.
25
Nov. 4 Voters Will Decide….
•
•
•
•
•
•
U.S. Senate (1 seat, open)
U.S. House of Representatives (14 seats, 4 open)
Governor
Attorney General
Secretary of State
State Supreme Court (2R incumbents, 1 open
seat)
• State Senate (38 seats, 10 open seats)
• State House of Representatives (110 seats, 41
open seats)
26
Dates to Remember
• Last day to register for general election: Oct. 6
• General election: Nov. 4
27
MHA Resources
•
Monday Report is available FREE to anyone and is distributed via email each
Monday morning.
– Go to website and select “Newsroom”, then Monday Report
•
MHA Monday Report – electronic publication issued weekly
•
Request password if you don’t have one.
– Email Donna Conklin at dconklin@mha.org to obtain MHA member ID
number
•
Advisory Bulletins – Extensive communications available only to MHA
members, as needed. (Require password to obtain from website).
•
Hospital specific mailings as needed for various impact analyses, etc.
•
Periodic member forums
•
See mha.org for other resources.
•
Monthly Financial Survey (MFS) provides free benchmarking of financial and
utilization statistics.
28
???Questions???
Vickie Kunz
Senior Director, Health Finance
Michigan Health & Hospital Association
110 West Michigan Avenue, Suite 1200
Lansing, MI 48933
Phone: (517) 703-8608
Fax: (517) 703-8637
email: vkunz@mha.org
29
Michigan Loses Seniority
• U.S. Senate
– Sen. Carl Levin
(35 yrs)
• U.S. House of Representatives
–
–
–
–
–
Rep. John Dingell
Rep. Dave Camp
Rep. Mike Rogers
Rep. Gary Peters
Rep. Kerry Bentivolio
(59 yrs)
(23 yrs)
(13 yrs)
(5 yrs)
(2 yrs)
Total experience + seniority lost = 137 years
30
General Election 2014 - State Legislature
• Senate – 38 seats
–
–
–
–
10 open seats
First election since 2011 redistricting
29 open seats in 2010
Majority Leader Randy Richardville is term limited
• House of Representatives – 110 seats
– 41 open seats
– 70 lawmakers will have no more than 2 years of
legislative experience
– Speaker of the House Jase Bolger is term limited
31
Objective & Useful Information
www.MIVote.org
• Non-partisan guide to candidates and issues
Secretary of State- michigan.gov/vote
• Elections in Michigan website
www.MichiganTruthSquad.com
• Non-partisan website providing analyses of campaign ads and
literature from candidates for Gov., state Legislature and Congress
www.mha.org (click on election logo)
• MHA election web page containing candidate information and
election information pertinent to hospital community
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