JK Medicare Administrative Contract
Updates – Audit & Reimbursement
April 13-17, 2015
Disclaimer
National Government Services, Inc. has produced this material
as an informational reference for providers furnishing services in
our contract jurisdiction. National Government Services
employees, agents, and staff make no representation, warranty,
or guarantee that this compilation of Medicare information is
error-free and will bear no responsibility or liability for the results
or consequences of the use of this material. Although every
reasonable effort has been made to assure the accuracy of the
information within these pages at the time of publication, the
Medicare Program is constantly changing, and it is the
responsibility of each provider to remain abreast of the Medicare
Program requirements. Any regulations, policies and/or
guidelines cited in this publication are subject to change without
further notice. Current Medicare regulations can be found on the
Centers for Medicare & Medicaid Services (CMS) Web site at
http://www.cms.gov.
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No Recording
• Attendees/providers are never permitted to
record (tape record or any other method) our
educational events
– This applies to our Webinars, teleconferences, live
events, and any other type of National Government
Services educational event
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Agenda
• Cost Report Filing
• PS&R
• Correspondence
• EHR Incentive Payments (HITECH)
• Audit Workload
• FY 2016 Wage Index Timeline Reminder
• HITECH Cost Report Audits
• Cost Report Appeals Update
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Cost Report Filing
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Filing Your Cost Report
Refer to our Cost Report Submission Checklist on our web site
Go to www.ngsmedicare.com  select Part A line of business  click on “Cost Reports” menu at
top  link on right side of page to “Cost Report Submission Checklist”
Form CMS-339 is
listed because some
provider types still
require a separate
submission. It is built
into the hospital cost
report and not
required to be
separately filed.
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Filing Your Cost Report
• Must be postmarked by the due date (12/31/14 FYE cost
reports are due 6/1/15)
– CMS does not recognize metered postmarks
– If you use a meter, we will use the receipt date for the postmark date
• Ensure accuracy of your subunits listed on Worksheet S-2
− We cannot alter your cost report
− We will request you to re-submit if it does not match our STAR system
• Please include a contact name and email address if we should
have any questions
Options:
− Cost report S-2 Part 2 lines 41-43
− Cover letter or include Cost Report Submission Checklist
− Connex submission form has contact name and email
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Filing Your Cost Report
• We request that you don’t bind any hardcopy
documentation that is mailed (we need to scan it for our
electronic workpapers)
• Request copy of FISS PIP/Pass Thru report (summary of
biweekly payments) from PS&R mailbox
PSR@anthem.com
• Any lump sum payments/recoupments must be tracked by
providers (not available in report format from NGS)
• If you are claiming protested amounts, include an
explanation.
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NGS Connex Provider Portal
• Providers are encouraged to use the Web Portal to submit
requested information to NGS.
• Create a user account and request a user ID by registering at
www.NGSConnex.com
• Advantages of using Connex:

No need to encrypt PHI/PII.

Submission is instantaneous.

Connex maintains record of all submissions.

Save shipping time and cost.

More secure than shipping.
• The Connex web site has a link to “Quick Steps Job Aid” which is
helpful for new users.
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NGS Connex Provider Portal
• One common mistake is that users forget to hit “submit” after
attaching the files to their submission. Look at the “My History” to
confirm the submission.
• Worksheet S still requires original signature and must be mailed.
Ideal submission: Everything through NGS Connex and the 1
sheet of paper (Wkst S with original signature) through the mail.
• Whatever makes the submission complete constitutes the receipt,
i.e. if the files are uploaded through NGS Connex on 5/28/15 and
the Wkst S is mailed on 6/1/15, the postmark date is considered
6/1/15 and the receipt date will be whenever that Wkst S is
received in our office.
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Filing Your Cost Report
• Cost Reports should be mailed to:
National Government Services, Inc.
Audit and Reimbursement
Cost Report Processing Unit
P.O. Box 4900
Syracuse, New York 13221-4900
Overnight courier address:
National Government Services, Inc.
Audit and Reimbursement
Cost Report Processing Unit
5000 Brittonfield Parkway, Suite 100
East Syracuse, New York 13057
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Filing Your Cost Report
Email your passwords for encrypted electronic files to both:
Deb Thomsen
Deborah.Thomsen@anthem.com
AND
Christine Chamberlain
Christine.Chamberlain@anthem.com
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Overpayment Check
• If your cost report indicates a net payment due to Medicare, a
check must be mailed to the lockbox when the cost report is filed
• Please include a copy of your Worksheet S settlement summary
with your check to insure proper processing.
•
Do not send original signature Worksheet S to the lockbox
• Extended Repayment arrangements should be made for an
acceptable payback schedule, prior to submission.
 Call Customer Care at 1-888-855-4356.
 NGS web site information on ERS: www.ngsmedicare.com, click on
Overpayment from top menu bar, click on “Apply for an Extended
Repayment Schedule”
• Please do not send your check with your cost report package.
• Please include a copy of the check with the cost report
submission.
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Overpayment Check
Checks are to be made payable to National Government Services,
Inc. and should be forwarded for New York and Connecticut
providers to the following address:
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Regular Mail:
Express / Overnight Mail:
National Government Services, Inc.
13001 Part A Non-MSP
P.O. Box 809366
Chicago, IL 60680-9366
U.S. Bank
Attn: Lockbox #809366
5300 South Cicero Ave
Chicago, IL 60638
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Bad Debt Lists
Supporting documentation for Bad Debts claimed –
• It is imperative that a listing of bad debts include all data elements,
as applicable, required by CMS, PRM 15-2 § 4004.2:
 Patient Name
 HIC Number
 Beginning Date Of Service
 Ending Date Of Service
 Indigency & Wel. Recip (Medicaid Number)
 Date of First Bill Sent To Beneficiary
 Date Collection Efforts Ceased
 Medicare Remittance Advice Date
 Deductible
 Coinsurance
 Total
Each bad debt listing
(i.e. hospital Part A,
hospital Part B, and
separate listing for
each unit) should
agree to the cost report
The list must be submitted with the cost report. If list is incomplete,
tentative settlement and / or pass through payments could be
impacted.
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Provider Statistical and
Reimbursement (PS&R) Report
PS&R
• Managed care days must be on PS&R Report Type 118 to
be allowed on the cost report
− Claims must meet timeliness standard (12 months from discharge)
− No exceptions
• Hospital Acquired Condition (HAC)
− Flowing to “Other”
− Will be programmed into PS&R on its own line (in process)
• Transition from IACS to EIDM
− Delayed – no estimated timeframe yet
− If login suspended for non-use, you cannot get re-set through IACS

Contact NGS PS&R mailbox PSR@anthem.com
• Any PS&R related inquiries: PSR@anthem.com
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Correspondence
Correspondence
Official correspondence (reminder letters, past due letters, settlement letters, mass mailings,
etc.):
• In order to make this change, you must complete a CMS 855A application with NGS
Provider Enrollment.
• The reason for filing the application in section 1A would be “changing your Medicare
information”.
• In section 1B you would select what is changing. In this case it would be “Authorized
Official” or “Delegated Official”.
• Please complete all of the required sections associated with that option in order to add an
Authorized or Delegated Official. You may complete this application via PECOS or paper
application.
Here are the links:
http://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/Downloads/cms855a.pdf
https://pecos.cms.hhs.gov/pecos/login.do
• Default (either Authorized or Delegated to receive official correspondence) is set in our
STAR system.
• You can specify which one as long as they are already on the 855A
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Correspondence
Correspondence related to desk reviews (Audit and Reimbursement contact):
• Cannot be the contact for official correspondence
• Can be changed or modified with email/letter to our dept
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EHR Incentive Payments
EHR Incentive Payments
A tentative review will be completed on all cost reports for HITECH
payments, usually in conjunction with the Medicare Part A tentative
review.
• HITECH tentative settlement will not be paid/recouped as part of
the Medicare Part A cost report tentative
• HITECH tentative payments are not to be netted with the Part A
tentative payment.
− Information will be furnished to Payment File Development Contract
(PFDC), payment or demand letter will be furnished by PFDC
− Medicare administrative contract (MAC) does not include responsibility for
HITECH payment transactions
• MAC role is to validate data elements in cost report and transfer to
PFDC
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EHR Incentive Payments
Some items that NGS A&R has learned from PFDC:
•
•
•
•
•
•
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Demand letters issued by PFDC contain limited information due to limited information
passed to them
All letters are sent to the hospital’s master address on the 855A application (physical
address)
PFDC does not issue payment letters
− If you receive a payment from PFDC, consider what was the last settlement you
received (tentative or final) applicable to EHR
If you do not send a check, the overpayment will be referred to the US Treasury for other
collection efforts.
− Cannot be recouped from A/B Medicare Trust Fund payments
Overnight mailing address is not in the letter:
US Bank
5300 South Cicero Ave
Lockbox 809366
Chicago, IL 60638
Checks should be payable to NGS or the HITECH Payment Center
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Jurisdiction K Audit workload
JK Audit Workload – Year 2
• 3/1/15 – 2/28/16
• Primary areas of focus
• Desk reviews and Audits
•
Predominant hospital inventory – FY 2013 cost reports
•
Exceptions - backlogged cost reports and some FY 2014 cases
• HITECH desk review/audits
• Final Settlements
•
Includes - cases held for issues such as FY 12 & 13 SSI, PS&R, outlier reconciliation,
other backlogs etc.
• FY 2013 cost reports for FY 2017 Wage Index rates (Our reviews begin
9/15)
• Re-openings/Appeals
• Medicare Secondary Payer audits
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FY 2016 Wage Index Timeline
Reminder
FY 2016 Wage Index Update
 December 8, 2014 – Deadline for MACs to notify State hospital
association regarding hospitals that fail to respond to issues raised
during desk review
 December 16, 2014 – Deadline for MACs to complete all desk
reviews for wage index desk and occupational mix data
 February 13, 2015 – Release of revised FY 2016 wage index and
OM PUFs on the CMS website
 March 2, 2015 – Deadline for hospitals to submit requests for
corrections to errors or revisions of desk review adjustments
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FY 2016 Wage Index Update
 April/May 2015 – Approximate date proposed rule will be
published
 April 8, 2015 – Deadline for MACs to transmit final revised wage
index and occupational mix data
 April 15, 2015 – Deadline for hospitals to appeal MAC
determinations and request CMS’ intervention
 Late April 2015 – Final FY 2016 wage index data compiled and
sent by CMS to MACs for verification
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FY 2016 Wage Index Update
 May 1, 2015 – Release of final FY 2016 wage index and OM data
on CMS website
 June 1, 2015 – Deadline for hospitals to submit correction
requests to both CMS and their MAC to correct errors due to CMS
or MAC mishandling
 August 1, 2015 – Approximate date for publication of FY 2016 final
rule
 October 1, 2015 – Effective date of FY 2016 wage index
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HITECH Cost Report Updates
AGENDA
• Audit process and timing
• Hot Topic: Review of charity care charges
• Charity care recommendations
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Audit Process and Timing
• CMS selection of HITECH Cost Report Audits
• Communication and timing of audits
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Hot Topic: Review of Charity Care Charges
Areas to be covered
• Understanding W/S S-10 Line 20
• Provider’s charity care policy
• Obtaining an accurate and complete charity care listing
• Documentation requirements
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Charity Care W/S S-10
.
Line 20 is separated into two columns
• Column 1 (Uninsured) enter full charge of patients who are given a
full or partial charity care write-off
• Column 2 (Insured) for patients covered by a government or
private insurer enter the deductible and /or coinsurance payments
given a charity write-off
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WS S-10 Uncompensated Care
Charity Care defined as
• Hospital demonstrates patient unable to pay
• Patient qualifies under the hospital’s charity care policy
• Includes full & partial charity care write-offs
• Excludes courtesy discounts
• Excludes discounts to uninsured who fail to qualify for charity
• Unpaid amounts associated with charity care are not considered as
an allowable Medicare Bad Debt
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WS S-10 Uncompensated Care
Line 20 does not include
• Government payment shortfalls
• Bad debts
• Discounts to patients that do not meet the hospital’s charity care
policy ( i.e. courtesy discounts)
• Charity care furnished by physicians or other professionals
• Excludes Medicare patients (See 75 FR, No.144, dated July 28,
2010, pages 44456-57)
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Charity Care Policy
As a Medicare contractor we need to determine whether the
hospital’s policies are sufficient and reasonable for determination of
charity care information used in the EHR incentive payment
calculation.
The policy must outline how the hospital is actually undertaking a
review of patients ability to pay for Services.
What types of areas should be addressed
• Eligibility criteria for financial assistance-free & discounted (partial
charity) care
• Describes the basis for calculating amounts charged to patients
eligible for financial assistance under the policy
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Charity Care Listing
Charity Care Charges
Documentation subject to request
• Listing in excel format (separated by insured and uninsured)
• Name of patient
• Dates of service (report based on discharge date within the CR reporting
period)
• Patient account number
• Name of health insurer (public or private), or uninsured status. (if private
insurer, listing must specify if insurer has a contractual relationship with the
hospital) NO Medicare Charges
• Total (gross) charges for the services
• Charity care charges (defined by CMS Pub 15-2 Section 4012)
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Audit Review
Charity Care Charges
Documentation subject to request
• Sample review to charity care listing
• Uniform Bill (UB) to verify total gross charges, insured vs. uninsured
• Review to ensure compliance with hospital’s charity care policy
• Insured (public or private) – remittance advice for deductible/coinsurance
• Charges claimed should not include courtesy or other discounts for patients
who did not qualify as a charity care patient
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Charity Care Recommendations
Recommendations
Review your charity care policy (Make sure it can be supported in
documentation of individual cases)
Common areas of weakness that should be addressed
• Method by which patients may apply for financial assistance
• State Regulations
• Data Collection
• Partial Payments
• Asset /Income Requirements
• Federal Poverty Level
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Cost Report Appeals
Cost Report Appeals – 42 CFR 405.1835
A provider (but no other individual, entity, or party) has a right to a Board hearing,
…..for specific items claimed for a cost reporting period covered by an intermediary
or Secretary determination, only if—
(1) The provider has preserved its right to claim dissatisfaction …..by either
(i) Including a claim for specific item(s) on its cost report for the period
where the provider seeks payment that it believes to be in accordance with
Medicare policy; or
(ii) Effective with cost reporting periods that end on or after December
31, 2008, self-disallowing the specific item(s) by following the applicable
procedures for filing a cost report under protest,
(2) The appeal is filed no later than 180 days after the date of the receipt of the intermediary or
Secretary decision (5 mailing days are assumed)
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Cost Report Appeals – 42 CFR 405.1835
Continued
A provider (but no other individual, entity, or party) has a right to a Board hearing,
…..for specific items claimed for a cost reporting period covered by an intermediary
or Secretary determination, only if—
3) the following thresholds are met:
– Providers have the legal right to file an appeal PRRB Individual – effect is $10,000 or
greater and involves only one provider and one fiscal year end
– Fiscal Intermediary Hearing – effect is less than $10,000
– Group Cases – Case involves two or more providers (same FYE) and effect is $50,000 or
greater
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Cost Report Appeals – National Inventories
National Inventories Open Cases per BCBSA
16000
14000
13907
12000
10000
9410
9781
8233
8000
Open Cases
6928
6000
4784
4000
2000
0
Sep 30 2002
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Sep 30 2012
Sep 30 2013
Feb 14 2014
Sep 30 2014
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Jan 31 2015
NGS MAC Contracts Servicing Appeals
J6 – IL, WI and MN
JK – NY, CT, ME, MA, NH, RI, VT
JJ – TN, AL, GA - Effective 6/1/15
In the following slides, NGS has included some appeal information
related to J6 to provide comparisons between JK and another MAC.
It is for informational purposes only.
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Cost Report Appeals – Inventory as of 1/31/2015
12000
13%
6%
5%
24%
9785
10000
8000
6000
4000
2320
2000
1249
611
460
J6
JJ
0
JK
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Total
National
Cost Report Appeals – JK Receipts Trend
120
103
100
94
80
79
75
73
62
60
64
62
64
70
63
56
2013
44
40
39
31
31
24
20
12
7
12
13
11
14
6
0
Jan
47
Feb
Mar
April
May
June
July
Aug
Sept
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Oct
2014
Nov
Dec
Cost Report Appeals – J6 Receipts Trend
80
75
70
60
55
56
49
50
46
2014
40
2013
37
28
30
26
18
20
20
20
15
19
13
10
3
0
Jan
48
18
7
2
0
27
Feb
Mar
April
7
7
7
May
June
July
3
Aug
Sept
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Oct
Nov
Dec
Appeal Inventory Comparison
900
839
800
683
700
607
600
JK PRRB
489
500
JK Groups
420
400
300
200
375
330
305
J6 Group
203
140
226 234
209
199
115 123
100
0
9/30/2011
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J6 PRRB
9/30/2012
9/30/2013
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9/30/2014
Cost Report Appeals – In Summary
NGS and all MACs are seeing increased receipts and inventories due
to:
 Release of Hold on NPRs
 Overlapping requests for appeals and reopenings
 Bifurcating (splitting) issues into distinct issues (i.e. DSH)
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Cost Report Appeals – In Summary cont.
Appeal impact
 More time spent on front-end work such as processing and posting mail,
position papers, jurisdictional challenges.
 Less time for resolution and closures due to mass receipts.
 Work has become more resource intensive on a per case basis.
 PRRB is scheduling a large majority of the cases with Pre-2006 FYE for
hearing in an effort to bring the inventory down. Many of these cases have not
have much activity for several years. This causes both the hospitals and NGS
to review the cases to determine if the case can be resolved or needs to go
hearing.
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Questions
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Audit & Reimbursement Contacts
Gene Nickerson, A&R Director
Gene.Nickerson@anthem.com
207-253-3325
Sandra O’Connor, Reimbursement Manager
Sandra.O’connor@anthem.com
315-442-4986
Kathy Hales, Appeals Manager
Kathy.Hales@anthem.com
317-841-4585
Kevin Glorioso, Audit Manager
Kevin.Glorioso@anthem.com
315-442-4046
Randy Bailey, Audit Manager
Randy.Bailey@anthem.com
618-204-5825
Christine Chamberlain, Reimbursement Lead
Christine.Chamberlain@anthem.com 315-442-4039
Kelly Foster, Reimbursement Lead
Kelly.Foster@anthem.com
315-442-4045
Danene Hartley, Appeals Lead
Danene.Hartley@anthem.com
304-346-7612
Pam VanArsdale, Appeals Lead
Pam.VanArsdale@anthem.com
513-448-1086
Kyle Browning, Appeals Lead
Kyle.Browning@anthem.com
618-731-1655
Justin Clark, Audit Lead
Justin.Clark@anthem.com
603-222-7532
Ray Powelson, Audit Lead
Ray.Powelson@anthem.com
603-222-7550
Lynn Watts, Audit Lead
Lynn.Watts@anthem.com
765-620-8513
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