Uncompensated Care Payments and Worksheet S-10. HFMA Maine Chapter

Transcription

1 Uncompensated Care Payments and Worksheet S-10 HFMA Maine Chapter January 11, 2018

2 Disproportionate Share & Uncompensated Care Payments 2

3 Medicare DSH Payments Total payment is the sum of the following: Historical DSH payment methodology Reduced by 75% Uncompensated Care Payment Factor 1: 75% of historical DSH payments Factor 2: Reduction in uninsured population Factor 3: Hospital allocation percentage Factor 1 Factor 2 Pool Factor 3 UC Pmt $11.7 Billion - $4.9 Billion = $6.8 Billion x %= $1,140,973 3

4 Uncompensated Care Payment ACA states there shall be no administrative or judicial review of the following: Any estimate of the Secretary for purposes of determining the factors Any period selected by the Secretary for such purposes 4

5 Uncompensated Care Payment Factor 3 Hospital Allocation Percentage Ratio of hospital to national uncompensated care Three-year average of ratios Implemented for FY 2017 payments and beyond Calculate percentage for each of three years Calculate average of three percentages 5

6 Uncompensated Care Payment Factor 3 Hospital Allocation Percentage (Continued) Days as proxy for Uncompensated Care Used exclusively through FY 2017 Medicaid days SSI days Worksheet S-10 Uncompensated Care Data Begin transition to Worksheet S-10 in FY 2018 Used exclusively from FY 2020 forward Includes charity care Includes bad debts Excludes unreimbursed Medicaid shortfalls 6

7 Uncompensated Care Payment Factor 3 Transition from Days Proxy to Worksheet S-10 Data Payment Year Year in Blend Data Used Days Proxy UC Data Medicaid Days SSI Days WS S-10 FY 2018 Year Year Year FY 2019 Year Year Year FY 2020 Year Year Year

8 Worksheet S-10 8

9 Historical Concerns Historical concerns with Worksheet S-10 New worksheet Confusing and incomplete instructions Lack of audit experience and audit workplan Lack of payments based on S-10 data Lack of correlation to other data sources CMS issued significant new guidance and updated Worksheet S-10 in Transmittal 11 9

10 New Guidance Transmittal 11 Released September 29, 2017 Effective for cost reports beginning on or after October 1, 2013 Changes to Worksheet S-10 Charity care definition revised to include uninsured discounts Bad debts must be net of recoveries Non-Medicare bad debts are subject to cost-to-charge ratios (CCR) Added Line so non-reimbursable Medicare bad debts are not subject to CCR Deductibles and coinsurance amounts are not subject to CCR Charges for insured non-covered days beyond limit are subject to CCR 10

11 Worksheet S-10 Overview Required under Balanced Budget Refinement Act Reports uncompensated cost of care Hospitals only Section 1886(d) Critical Access Hospitals Uses EHR Payments (FY cost reports) Uncompensated Care Payments (based on FY 2014 cost reports and later) Data analysis 11

12 Worksheet S-10 Overview Consists of the following elements: Cost-to-Charge Ratio (CCR) Unreimbursed cost Medicaid Children s Health Insurance Program (CHIP) Indigent care programs Grants, donations and appropriations Uncompensated Care Charity care Bad debts 12

13 Cost-to-Charge Ratio Line 1 Cost-to-Charge Ratio Calculated Field No input required Costs: Worksheet C, Part I, Line 202, Column 3 Charges: Worksheet C, Part I, Line 202, Column 8 Excludes Physician and professional costs and charges Physician RCE overages Graduate medical education costs Non-reimbursable cost centers Uncompensated and indigent care cost computation 1 Cost to charge ratio (Worksheet C, Part I, Line 202, Column 3, divided by Column 8)

14 Medicaid Medicaid 2 Net revenue from Medicaid 2,000,000 3 Did you receive DSH or supplemental payments from Medicaid? Y If Line 3 is yes, does Line 2 include all DSH or supplemental payments from 4 Medicaid? N 5 If Line 4 is no, enter DSH or supplemental payments from Medicaid 500,000 6 Medicaid charges 6,000,000 7 Medicaid cost (Line 1 times Line 6) 2,400,000 8 Difference between net revenue and costs for Medicaid program (Line 7 minus Lines Lines 2 and 5). If Line 7 is less than the sum of Lines 2 and 5, then enter zero. 400,000 14

15 Medicaid Line 2 Medicaid Net Revenue Payments for services provided in cost report year Actual receipts, plus Expected receipts All IP and OP Title XIX covered services Include Medicaid Managed Care Include expansion CHIP (otherwise under Title XIX) Include Medicaid primary only Exclude Medicaid secondary Exclude physician and professional services Net of provider taxes and assessments 15

16 Medicaid Line 3 DSH or Supplemental Payments Yes or No Line 4 DSH or Supplements Payments in Medicaid Payments? Yes or No Line 5 - DSH or Supplemental Payment Amount Enter amount if Line 4 is No 16

17 Medicaid Line 6 Medicaid Charges Charges should correspond to Payments on Line 2 Covered services only Include Medicaid Managed Care Line 7 Medicaid Cost Calculated Field Line 8 Medicaid Shortfall Calculated Field Must be zero or greater 17

18 CHIP Children's Health Insurance Program (CHIP) 9 Net revenue from stand-alone CHIP 200, Stand-alone CHIP charges 650, Stand-alone CHIP cost (Line 1 times Line 10) 260, Difference between net revenue and costs for stand-alone CHIP (Line 11 minus Line 9). If Line 11 is less than Line 9, then enter zero. 60,000 18

19 CHIP CHIP State Children s Health Insurance Program Stand-alone CHIP programs only Not eligible under Title XIX Amounts based on services provided in cost report period Exclude physicians and professional services Include managed care plans, if applicable 19

20 State & Local Indigent Care Other state or local government indigent care program 13 Net revenue from state or local indigent care program (not included on Lines 2, 5, or 9) 100,000 Charges for patients covered under state or local indigent care program (not in Lines 6 14 or 10) 300, State or local indigent care program cost (Line 1 times Line 14) 120, Difference between net revenue and costs for state or local indigent care program (Line 15 minus Line 13). If Line 15 is less than Line 13, then enter zero. 20,000 20

21 State & Local Indigent Care Line 13 Payments for State & Local Indigent Care Applicable to services provided in cost report period Payments identified with specific patients Documented in patient accounting system Line 14 Charges for State & Local Indigent Care Charges should correspond to payments on Line 13 Covered services only 21

22 Grants, Donations & Unreimbursed Cost Grants, donations and total unreimbursed cost for Medicaid, CHIP and state/local indigent care programs 17 Private grants, donations, or endowment income restricted to funding charity care 15, Government grants, appropriations or transfers for support of hospital operations 30, Total unreimbursed cost for Medicaid, CHIP, and state and local indigent care programs (Sum of Lines 8, 12, and 16) 480,000 22

23 Grants, Donations & Other Income Line 17 Private Grants, Donations & Endowments Non-governmental grants, gifts & investment income Received in cost report year Restricted to funding uncompensated or indigent care Line 18 Governmental Grants, Appropriations & Transfers Funds received or expected for cost report year Designated for hospital operations Include general operating support and special purposes Not just related to uncompensated care Include charity care pools, net of provider taxes or assessments Exclude non-operating, such as capital or research 23

24 Uncompensated Care Charity Care Uncompensated Care - Charity Care Uninsured Insured Total Charity care charges and uninsured discounts for the entire facility 3,200,000 1,250,000 4,450, Cost of patients approved for charity care and uninsured discounts 1,280,000 1,250,000 2,530,000 Payments received from patients for amounts previously written 22 off as charity care 50,000 15,000 65, Cost of charity care (Line 21 minus Line 22) 1,230,000 1,235,000 2,465, Does the amount on Line 20, column 2, include charges for patient days beyond a length-of-stay limit imposed on patients covered by Medicaid or N other indigent care program? If Line 24 is yes, enter the charges for patient days beyond the indigent care program's length-of-stay limit 0 24

25 Charity Care & Uninsured Discounts Adjustments Must be based on charity care (CCP) or financial assistance (FAP) policies May be full or partial discount Include entire facility, including sub-providers Exclude physician and professional services Exclude courtesy allowances Courtesy Discount Prompt Pay Discount Employee Discount Friends & Family Exclude Medicare bad debts 25

26 Charity Care Charges Line 20, Column 1 Uninsured Patient Charges Uninsured patients Coverage from entity without contractual relationship with provider Non-covered Medicaid or indigent care services 26

27 Charity Care Charges Line 20, Column 1 Uninsured Patient Charges Cost report year beginning prior to October 1, 2016 Charges for services provided during cost report year Actual adjustments, plus Accounts receivable Record full charges Total initial payment obligation 27

28 Charity Care Charges Line 20, Column 1 Uninsured Patient Charges Cost report year beginning on or after October 1, 2016 Write-offs during cost report year Service dates may be prior to cost report year Charges Full or partial discount Report charges patient is not responsible for paying 100% of charges for 100% discount 75% of charges for 75% discount 28

29 Charity Care Charges Line 20, Column 2 Insured Patient Charges Deductible & Coinsurance Amounts Public programs Private insurer with relationship Exclude Medicare bad debt Non-covered charges for days in excess of length of stay limits Medicaid or indigent care program Included in CCP or FAP 29

30 Charity Care Charges Line 20, Column 2 Insured Patient Charges Cost reports beginning prior to October 1, 2016 Actual and expected write-offs from services during cost report year Cost reports beginning on or after October 1, 2016 Write-offs in current cost report period, regardless of service date 30

31 Charity Care Cost Line 21 Cost of Charity Care Column 1 Uninsured Patients Charity Care Charges from Line 20 times CCR from Line 1 Column 2 Insured Patients, sum of: Deductible & Coinsurance Amounts Total amount from Line 20 reduced by Line 25 charges Not reduced by CCR Non-covered charges for days in excess of length of stay limits Charges from Line 25 times CCR from Line 1 31

32 Charity Care Payments Line 22 Charity Care Payments Patient payments for charge categories reported on Line 20 Exclude payments from following sources: Insurers Grants and other funding sources for charity care Physician or professional services 32

33 Charity Care Payments Line 22 Charity Care Payments Cost reports beginning prior to October 1, 2016 Payments received or expected for service dates in cost report year Cost reports beginning on or after October 1, 2016 Payments received in the cost report year Exclude payments not reported as write-offs on Line 20 in any year 33

34 Net Cost of Charity Care Line 23 Net Cost of Charity Care Calculated, charity care costs (Line 21) less charity care patient payments (Line 22) Cannot be less than $0 Line 24 Are non-covered charges for days in excess of length of stay limits included in Line 20, Column 2? Line 25 If Line 24 is Yes, amount of non-covered charges for days in excess of length of stay limits included in Line 20, Column 2 Amount used in calculations at Line 21, Column 2 34

35 Bad Debts Uncompensated Care - Bad Debts 26 Total bad debt expense for the entire hospital complex 4,000, Medicare reimbursable bad debts for the entire hospital complex 325, Medicare allowable bad debts for the entire hospital complex 500, Non-Medicare bad debt expense (Line 26 minus Line 27.01) 3,500, Cost of non-medicare and non-reimbursable Medicare bad debt expense 1,575, Cost of uncompensated care (Line 23 column 3 plus Line 29) 4,040, Total unreimbursed and uncompensated care cost (Line 19 plus Line 30) 4,520,000 35

36 Bad Debts Line 26 Total Bad Debts Total facility bad debts, net of recoveries Write-offs in cost report period, regardless of service date Include gross Medicare bad debts from settlement pages Include patient responsibility only Exclude amounts due from insurers Exclude physician and professional services Do not duplicate charity care amounts Line 27 Reimbursable Medicare Bad Debts Flow, sum of reimbursable Medicare bad debts from settlement schedules 36

37 Bad Debts Line Gross Medicare Bad Debts Flow, sum of gross Medicare bad debts from settlement schedules Line 28 Non-Medicare Bad Debt Calculated Total bad debt (Line 26) less Medicare bad debt (Line 27.01) Line 29 Cost of Bad Debts Calculated, sum of: Non-Medicare bad debt (Line 28) times CCR (Line 1) Non-reimbursed Medicare bad debt (Line less Line 27) 37

38 Uncompensated Care Totals Line 30 Cost of Uncompensated Care Calculated Sum of cost of charity care (Line 23) and bad debt (Line 29) Line 31 Total Unreimbursed and Uncompensated Care Calculated Sum of Unreimbursed Care (Line 19) and Uncompensated Care (Line 30) 38

39 Prospective Actions Continue to monitor guidance from CMS and others Prepare and submit revised S-10 data Update policies and procedures Charity care Financial assistance policies Uninsured patient policies Bad debt policies Educate patient registration and patient accounting personnel Monitor write-offs and test for adherence to policies Timeframes Documentation Develop new reports to appropriately capture charity care and bad debt adjustments 39

40 Revised Worksheet S-10 Submissions Years subject to revised S-10 instructions after initial filing: FY 2014 Revised S-10 submission due 9/30/16 and 1/2/18 Will CMS allow for additional revisions? FY 2015 Revised S-10 submission due 1/2/18 Will CMS allow for additional revisions? FY 2016 No due date published for revisions to FY 2016 cost report FY 2017 Revisions may be necessary for cost reports filed prior to submission of Transmittal 11 on 9/27/17 Likely short period cost reports 40

41 Revised Worksheet S-10 Submissions Revised Worksheet S-10 Submissions Original Cost Report Is As-Filed Submit amended cost report If filing for S-10 revision deadline, only direct revisions to S-10 If filing outside S-10 revision window, make revisions to S-10 and other cost report elements Settled Cost Report Submit reopening request for S-10 revisions MAC Acceptance For FY 2014 and FY 2015 revisions, MACs were instructed to accept amended and reopening requests for S-10 Anticipate similar guidance for FY 2016 revisions 41

42 Questions? Aaron Green Phone: