DSH Presentation

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DISPROPORTIONATE SHARE
HOSPITAL (DSH) REPORTING
SCHEDULE PREPARATION
DSH YEAR 2010
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 30th.
• Hospital’s 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 252210
• 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 charges
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 Worker’s 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 hospital’s 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 selfpay uninsured
Non-Traditional Services
Documentation
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 NONPROFESSIONAL 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 NONPROFESSIONAL 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
REQUEST LIST
• One single excel file template will be provided
• Do not send PHI (protected health information) via e-mail
• FTP sites – Terms of Use Agreement
• Electronic format is preferred
• Do not submit detailed logs in .pdf format or hardcopy
• If unable to use template provided, identify documentation
by corresponding number on request list
• Please submit all documentation by April 15th, 2013
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 Agency’s
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.
QUESTIONS???
CONTACT INFORMATION
• Michael Horoho
• [email protected]
• David McMahon
• [email protected]
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