2018 Medicare Fee-For-Service Prospective Payment Systems (As of 2/2/2018)

Transcription

1 2018 Fee-For-Service Prospective Systems Capital s Year Oct-Sept Oct-Sept Jan-Dec Jan-Dec Oct-Sept: cost- year Rehab. Hospice DME Services for Jan-Dec Oct-Sept Oct-Sept Oct-Sept Jan-Dec Oct-Sept Oct-Sept Jan-Dec. Jan.-Dec. Jan.-Dec. Jan-Dec. Oct.-Sept. Oct.-Sept. Oct Sept. Mandatory participation ends on Feb Patient Severity Sequestration 752 Severity Diagnosis related groups MS-DRGs APCs ASC-APCs Claims Based CPT codes Case mix groups (CMGs) with comorbid conditions MS-DRGs with LOS, age and co-morbid condition adj. Resource utilization groups (66, using RUG IV) Home health resource groups (153 HHRGs) Long term care MS-DRGs 5 service levels (See above.) 8 levels, including ground and air. ESRD PPS rate, adj. for specific patient demographic CPT-codes Resource- Based, Relative Value Units (RVUs) Claims Based Claims Based Claims Based 2% 2% 2% 2% 2% 2% 2% 2% 2% 2% 2% 2% 2% 2% 2% 2% 2% 2% 2% Base Rates Wage Index > 1: Standard per : $3, Lbr $1, NonLbr-outc and MU. $3, $1, for non-, but is MU); $3, $1, for reported, but no MU. $3, $1, (non- of & no MU) Wage Index < or = 1: $3, $2, $3, $2, for non-, but is MU; $3, $2, for reported, but no MU Federal rate per $ factor per procedure ($78.636) or ($77.063) if no of Program Per Diem = $ Rural Health Clinic Cost Per Visit, capped at $83.45 Federally Qualified Health Centers (FQHCs) = PPS, based on adjusted base rate. 340B-eligible hospitals paid at approximately. 73% of K codes APC amount Diagnostic Clinical Lab procedure fee schedule: paid at median charge of commercial carriers factor per procedure ($45.575) or ($44.674) if no of For acute inpatient and acute outpatient, is at 101% of allowable costs. For, is made according to the specific service PPS system. Method I or Method II billing available for physicians. Prof. fee and facility (site) originating fee. Facility fee = $ Standard amount per ($15,838) or ($15,521) if no of Per diem base rate ($771.35) or ($755.92) if no of ECT: ($332.08) or ($ if no of. s for age, LOS, comorbidity and DRG Federal rate per diem applied to RUG IV Resource Utilization Groupings (RUGs) Urban lowest rate = $ Rural lowest rate = $ National 60 day episode rate: $3, $2, (if no of ) Low Utilization Per Visit Rates: SN: $143.40; PT: $156.76; OT: $157.83; ST: $170.38; SW: $229.86; HHA: $64.94 Reduce above by 2% if outcome data is not submitted. Standard amount per ($41,415) or ($40,587) if no of Service rates Routine Home : first 60 days: $192.78; rest of days: $ Continuous Home : $976.42, (24 hr. home care). IP respite care: $ General IP admission: $ Annual perbeneficiary limit of $28,689. Reduce the above rates by 2% if no quality data is submitted. Service rates, land and air; overall increase of 0.7%; base rates = $ (ground); $3, (fixed wing); & $3, (rotary air) Mileage: $7.23 (ground); $8.65 (fixed wing) & $23.09 (rotary) Blended amount: 100% of the ESRD PPS bundled rate of $ Fee Schedule- Competitive Bidding Factors per procedure are $ for medical and $ for anesthesia. Voluntary, demo. 4 model options: Model 1:48 MS-DRGs, all inpatient ; Model 2: all of ; Model 3:all ; Model 4: PPS rate paid including all inpatient hospital and physician. 2% minimum discount to ; reconciled at the end of the year. Mandatory for IPPS hospitals in 3 Illinois MSAs: Cape Girardeau, Decatur and St. Louis, then voluntary after Feb., year model Includes all inpatient, outpatient, physician and of. Applied to s with MS-DRGs 469 & 470. Interim FFS ultimately reconciled with a discounted blended target price hospital specific & regional. Stop-loss cap of 5% and a stop-gain of 5%. Voluntary for IPPS hospitals in 9 Illinois MSAs: Bloomington, Champaign- Urbana, Cape Girardeau, Chicago- Naperville- Elgin, Decatur, Rockford, Rock Island, Springfield and St. Louis. 5-year model Includes all inpatient, outpatient, physician and of. Applied to s with MS-DRGs ; ; ; and Interim FFS ultimately reconciled with a discounted blended target price hospital specific & regional. $3, $2, (non- & no risk in 2018, but a stop-gain of 5%.

2 2018 Fee-For-Service Prospective Systems MU. Capital s Rehab. Hospice DME Services for Market Basket Estimate 340B Budget Neutrality increase Urban/Rural Area Salary / Labor Share ACA Mandated Reductions to the Rate ACA Productivity Document. and Coding (Behavioral) Offset 2-Midnight Rule Recovery 2.7% 1.3% 2.7% 1.7% 2.7% 1.4% 2.6% 2.6% 2.6% 2.5% 2.7% 2.7% 1.1% 1.5%; hospitalbased, +0.7%; free-standing, +0.5% Swing Bed, SNF for Rural CAHs are costreimbursed at 101%. Wage index = 69.6% or 62% of Occupational mix adj. 0.75% Geographic factor (GAF) 3.19% 60% 0.75% 50% 14.9% rural add-on; rural facilities now in urban areas do not receive the add-on 70.7% 17% rural addon 75.0% 1.0% 0.75% Urban and rural rates. 70.8% 3.0% add-on for rural agencies sunset Dec. 31, % 66.2% 1.0% 1.5% 0.75% Various % add-on for rural mileage ( Super Rural Bonus ) thru Sept RBRVS-GPCI index 70% Wage Index = % 1.1% 1.2% ; 0.6% 0.6% 0.5% 0.6% 0.6% 0.6% 0.6% 0.6% 0.6% 0.46% increase 0.97% 0.6% 0.6% RVU updates; 0.5% update per MACRA; 0.09% for mis-valued codes. 5% add for HMSAs? Work GPCI Rural floor. RBRVS fee, PA & CNP = 85%, PT=75%, RN- Midwife = 100% DSH-Adj. for High Volume of Low Income Patients Graduate Education 25% of historical DSH hospital + 75% add-on for Uncomp.. % of uninsured estimated at 8.1% for 2018 by Office of the Actuary. Indirect med. education adj. (IME) factor of 5.5%; DGME adj. based on # of resident FTEs and Per- Resident amt. Pmt. For costs of and DSH IME Low income patient (LIP) Factor = Teaching Variable Adj. Factor = Teaching Variable (IME) Adj.

3 2018 Fee-For-Service Prospective Systems Paramedic Programs. Capital s Rehab. Hospice DME Services for Excessive Costs of Treatment HOPD Offcampus, siteneutral policy Outcome incentive / penalty Value-Based Purchasing (includes Process, HCAHPS, Mortality & Efficiency domains) Readmission Reduction $26,601 2% contrib. to pool; bonus or penalty Capped at 3% in FFY2018 $4,150; Newlyacquired or relocated, non-exempted facilities paid at 40% of OPPS rates. $8, $11, qualified E/R: 12% incr. in day 1 per diem. 128% per diem for AIDS patients. CMI for nonroutine supplies. Base rate = $ OASIS data. Demo to begin in 2016, for s in $27,381 PPS Outlier Thresholds are $77.54-adult and $ pediatrics. 2.0% add-on for quality data (PQRS) and 2.5% for e- prescribing. 2.0% - 4.0% penalties for not- for some docs that are not meaningful users. Value-Modifier for cost comparison. + or 2-4%. - Acquired Conditions (HAC) - Acquired Conditions- Reduced DRG Pmt. H.I.T. Incentive / Penalty, beginning in FFY2015) 1.0% penalty if in the top 25% nationally in HACs. Reduced DRG classification for HAC during the stay Yes-75% to the MB incr. if no MU. 1.0% penalty if in the top 25% nationally in HACs. If not MU, CAH: paid at 100% of cost. Yes. PQRS penalty for nonparticipation also applies.

4 2018 Fee-For-Service Prospective Systems Packaged Clinical lab adj. Capital 2.0% s Rehab. Hospice DME Services for Dependent Sole- Community Rural Referral Center 10 hospitals in Illinois; add-on for difference between costs and IPPS; sunset on Sept 30, is the higher of IPPS rate or 1982, 1987, 1996 or 2006 inflated cost per case Base rate, + increased DSH adj. is the higher of OPPS rate or 1982, 1987, 1996 or 2006 inflated cost per case Low-Volume Treatment Episodes 12 hospitals in Illinois qualify under ACA criteria (assuming that 15 mile distance is met); add-on to the base rate, up to 1,600 s;, sunset on Sept. 30, 2017 transfers transfers CMGs Interrupted stays episodes /Change in condition outliers/ interruption of stay Therapy Caps PT/OT/ST GPCI Rebasing Caps on therapy : $2,010 each for PT/ST & OT 25% in the Practice Expense RVU for same day, multiple procedures. Forecast error 25% Rule suspended in FFY 2018 if more than 25% of total admissions from one facility

5 2018 Fee-For-Service Prospective Systems Site-neutral Advanced Planning Bad Debt s Patient Financial Liability Per Benefit Period: $1,340 deduct; $335 co-ins from day 61-90; $670 coins. From day Capital 40% of APC s for acquired HOPD after 11/2/2015 $183-Ded.; $ premium, income adjusted; 20% of APC amt.; 100% of therapy charges after cap. 40% of ASC- APC s for acquired H- ASC after 11/2/2015 Same as s Coinsurance = 20% of covered charges. 20% of facility fee amount Rehab. Same as Same as Per Benefit Period: $ per day from day , 100% of charges after 100 days. None Approx. 45% of cases would be reclassified as site-neutral cases, paid 1/2 acute DRGs and 1/2 LTC DRGS. Based on cost report year. Same as Hospice None 20% of feeschedule 20% co-ins of ESRD-PPS DME 20% co-ins. Of approved Services First 30 minutes = $80.64; $75.60 for each additional 30 minutes. 20% of feeschedule for NOTES: 1. Base rates shown are not adjusted for wage index differences, or provider-specific s such as IME, DSH, or those relating to the quality-based programs (VBP, Readmissions, HACs and Meaningful Use). 2. s for to Advantage patients are not presented here; those s are made to individual providers based on their contractual agreements with the specific plans.