Taking the Stress Out of the Missouri Medicaid Disproportionate Share Hospital (DSH) Surveys & Financial Reporting Considerations

Transcription

1 Thursday, January 29, p.m. Central time Taking the Stress Out f the Missuri Medicaid Disprprtinate Share Hspital (DSH) Surveys & Financial Reprting Cnsideratins Je Watt, CPA Partner BKD, LLP jwatt@bkd.cm Beth Ann Stansbury, CPA Senir Cnsultant II BKD, LLP bstansbury@bkd.cm T Receive CPE Credit Participate in entire webinar Answer plls when they are prvided If yu are viewing this webinar in a grup Cmplete grup attendance frm with Title & date f live webinar Yur cmpany name Yur printed name, signature & address All grup attendance sheets must be submitted t training@bkd.cm within 24 hurs f live webinar Answer plls when they are prvided If all eligibility requirements are met, each participant will be ed their CPE certificates within 15 business days f live webinar 1

2 Agenda Missuri DSH Recap DSH Eligibility DSH Calculatins Payr Buckets Cmmn Blunders Financial Reprting 3 // experience access 3 MISSOURI DSH RECAP 4 2

3 Missuri Medicaid DSH Recap PAYMENT Surveys December 31, 2014 The SFY 2016 payment surveys were due t the state. Surveys will be used t calculate DSH payments unless a regulatin change ccurs AUDIT Surveys January 7, 2015 Myers & Stauffer mailed the SFY 2012 audit surveys which are due February 16 Any verpayments identified in the SFY 2012 audit will be subject t recupment 5 DSH ELIGIBILITY 6 3

4 DSH Eligibility Tw federal requirements t qualify fr a DSH payment Must have a Medicaid Inpatient Utilizatin Rate (MIUR) greater than 1% Must have tw bstetricians with staff privileges at the hspital wh have agreed t prvide bstetric services t Medicaid individuals (Rural hspital can be any physician with staff privileges wh has agreed t perfrm nnemergency bstetric services) Exceptins: Inpatient ppulatin predminantly under 18 years f age Facility did nt prvide nnemergency bstetric services t the general public n December 22, 1987» CMS Clarificatin Hspitals wh pened after December 22, 1987, cannt be grandfathered in under the secnd exceptin (Additinal Infrmatin f the DSH Reprting & Audit Requirements Part 2) 7 DSH Eligibility What if I qualified when the payment was calculated but d nt qualify nce the audit is cmplete? CMS indicated in the Additinal Infrmatin f the DSH Reprting & Audit Requirements Part 2 that if the hspital n lnger qualifies fr a DSH payment, it will be treated as a cmplete verpayment t that hspital & they will be required t pay back the funds Alternatively, if a hspital was nt initially deemed eligible but is later determined t be eligible, the state shuld make a payment t that hspital in accrdance with its state plan 8 4

5 DSH CALCULATIONS 9 DSH Calculatins 10 5

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8 PAYOR BUCKETS 15 Medicaid FFS Primary (In-State) Data Surce State MMIS data must be used per the DSH Reprting & Audit Requirements Part 2 Internal data will nly be allwed if it is recnciled t the state detail. Must be able t explain the variances in the tw data sets What shuld be included? All Medicaid FFS Primary patients Ptential Issues/Opprtunities Nt all patients wh have Medicaid will be in the state s data E.g., Patients where Medicaid has n cst sharing r denied the claim might nt be included in the state s data but they might be allwable n the survey E.g., Patients wh have cmmercial insurance r Medicare Managed Care primary/medicaid secndary might nt be included in the state data 16 8

9 Medicaid Managed Care (In-State) Data Surce Internally generated ( Exhibit C ) What shuld be included? All Medicaid Managed Care primary patients Ptential Issues/Opprtunities Must be sure t exclude any Title XXI claims (CHIP/SCHIP) Managed Care bundled payments exclude prfessinal piece 17 Medicare/Medicaid Crssvers (In-State) Data Surce State MMIS data r Internally generated ( Exhibit C ) Nte: If yu are a Critical Access Hspital (CAH) it may nt be wrth taking the time t generate internal data. Medicare pays CAHs at 101% f cst regardless f the data surce; nce payments are cnsidered the ttal impact will be minimal What shuld be included? Patients with traditinal Medicare primary/medicaid secndary D nt include patients with Medicare Managed Care primary/medicaid secndary Payment rates differ between traditinal Medicare & Medicare Managed Care E.g., CAH payments will be adjusted t 101% f the cst reprted here 18 9

10 Medicare/Medicaid Crssvers (In-State) Ptential Issues/Opprtunities emo Med Charges if using state MMIS data Inpatient data includes nly rutine days & payments Recmmend estimating charges based n either days r payments 19 Other Medicaid Eligibles Data Surce Internally generated ( Exhibit C ) What shuld be included? Any patient wh is Medicaid eligible that was nt reprted elsewhere n the survey Patients with Medicaid but Medicaid did nt pay n the accunt. Denied fr timely filing, n precertificatin, n cst sharing (Nte that the patient must have had active Medicaid cverage at the time f service & the hspital service must rdinarily be cvered by Medicaid) Claims with Medicare Managed Care r Cmmercial Insurance Primary/Medicaid r Medicaid Managed Care secndary (generally thse with n Medicaid cst sharing will nt be in the state s data must include all payments received n these claims) Ptential Issues/Opprtunities Auditrs are perfrming duplicate checks t remve any claims identified in multiple data sets (state & hspital data) 20 10

11 Uninsured Data Surce Internally generated ( Exhibit A & B ) What shuld be included? KEY If yu include the ppulatin in Uninsured Charges, yu must als include the ppulatin in the Patient Payments Self-pay primary with n surce f third-party cverage Liability claims where the third-party insurance was nt legally liable t cver hspital care & there is n ther surce f cverage Patients wh d nt have cverage fr the place f service E.g., A patient wh nly has Medicare Part A but receives utpatient services culd be included as uninsured fr the utpatient visit assuming they d nt have additinal cverage Patients wh have insurance but the insurance never pays because they need additinal infrmatin frm the patient creditable insurance is never verified 21 Uninsured What shuld be included? Patients wh meet the definitin f uninsured under the December 3, 2014, Final Rule Patients whse lifetime insurance limits have been reached Patients whse benefits have been exhausted Patients whse insurance package des nt cver the service received (must still be a Medicaid cvered hspital service) CANNOT Include Denials fr timely filing Denials fr medical necessity Denials fr precertificatin 22 11

12 Uninsured Patient Payments (Cash basis) Every patient payment received during the cst reprt perid must be reprted (insured & uninsured clearly identified) Must include patient payments received thrugh a cllectin agency during the year. Wuld be able t remve frm thse payments the amunt f fees paid t the cllectin agency n the payments received 23 December 3, 2014 Final Rule Exhausted Benefits Patients wh have exhausted benefits prir t btaining services are uninsured; individuals wh exhaust benefits during a stay are insured All csts & revenues assciated with Medicaid eligibles that have a surce f private insurance cverage, including all third-party payr revenues received by the hspital n behalf f the patient, must be included in the calculatin f the hspital-specific DSH limit CMS Justificatin Exclusin f these claims leads t artificially inflated DSH limits & permits a hspital t be paid twice n the same cst 24 12

13 Out-f-State Medicaid FFS Data Surce Out-f-state PS&R r internally generated ( Exhibit C ) What shuld be included? Any patient wh has active Medicaid cverage frm an ut-f-state agency shuld be included The hspital des nt necessarily have t have billed fr that stay but the patient must have active Medicaid cverage & have received a Medicaid cvered hspital service 25 Other Medicaid Eligibles Versus Uninsured Why des this matter? Only data reprted in a Medicaid clumn (FFS primary, MCO, MCR/MCD Crssvers, Other Eligibles, OOS MCD) will be used t calculate the Medicaid Inpatient Utilizatin Rati (MIUR). The uninsured data is nt used in this calculatin T qualify t receive a DSH payment under federal regulatins, a hspital must have a MIUR >1% A hspital can be federally deemed (must receive a DSH payment) based n their MIUR 26 13

14 COMMON BLUNDERS 27 Blunder #1 Misgruped Cst Centers Issue Hspital had nt gruped survey charges in accrdance with the cst reprt grupings. Cst reprt allcated revenue cdes t multiple cst centers but hspital had pted t simplify reprting & did nt allcate charges Slutin Regruped the charges in accrdance with the cst reprt including all department allcatins Result Cst increased by $165,

15 29 Blunder #2 Excluding Allwable Ppulatins Issue Small CAH hspital received a DSH payment f apprximately $2 millin Cmpleted the audit & results indicated the facility had a liability f nearly $435,000 Slutin Wrked with the client t identify sme additinal allwable patient ppulatins nt previusly reprted (current year & prir year) Result Liability reduced t apprximately $63,000 resulting in a savings f $372,

16 Blunder #3 Cst Centers Exceed Ttal Issue Rutine days r ancillary charges reprted in the survey exceed the ttal fr that cst center n the cst reprt Slutin Cmpare ttal survey charges t ttal cst reprt charges. Verify grupings fr any red flags identified Result Prperly grup Medicaid & Uninsured days & charges in accrdance with the cst reprt per DSH instructins

17 Blunder #4 Mismatched Uninsured Data Issue Patients may be included as Uninsured in the patient payment listing wh have dates f service during the year; hwever, these patients are nt included in the uninsured charges listing Slutin Match the tw data sets t identify this type f red flag Result Payments being included were identified as nn-allwable services. These were prperly excluded frm the uninsured charges but shuld als have been remved frm the uninsured patient payment listing 33 Blunder #5 Overstating Uninsured Payments Issue Patient payments d nt specifically apply t hspital r physician charges. Payments can be allcated between the tw based n charges n the patient accunt Slutin When pulling data frm the system, include all data elements s this calculatin can be dne, i.e., pull the ttal hspital charges & physician charges fr each accunt Result Remving the estimated prfessinal fee payments will result in lwer payments & therefre an increase in the net uncmpensated care cst (UCC) 34 17

18 35 Blunder #6 Insurance Status Updates Issue Insurance status nt updated in the patient accunting system, e.g., A patient cmes int the hspital & claims t have Blue Crss. When the EOB arrives, it states that cverage terminated prir t the admit date. If their insurance status is nt updated n the accunt, this claim may never get included in the uninsured data queries Slutin Wrk with patient accunting t update all accunts based n verified financial class/payr plan Result Easier t identify all allwable claims & cmply with DSH regulatins 36 18

19 Blunder #7 Accepting All Adjustments Issue Hspital submitted a DSH survey shwing a significant underpayment but audit adjustments reduced the UCC $500,000 swinging the hspital frm underpaid t verpaid Examples f adjustments made Payments adjusted t equal ttal charges frm the PS&R Medicare/Medicaid crssver payments were 110% f cst (CAH Medicare pays at 101%) Slutin BKD reviewed adjustments & submitted arguments t crrect errneus adjustments Result Errneus adjustments reversed & the hspital did nt have a liability 37 Blunder #8 Lack f Prir Planning Issue A system cnversin r data purge makes the required data unavailable at the time f audit Slutin Plan ahead! If the data is nt ging t be available, wrk with IT persnnel t pull the data ut f the system befre it purges. Als shuld be able t pull every patient payment received during the perid regardless f service date Result Ensures that yu will cmply with Medicaid DSH regulatins & reduce the risk f being unable t supprt the payment received 38 19

20 FINANCIAL REPORTING 39 Financial Reprting Knwn Missuri Medicaid Disprprtinate Share Hspital liabilities Unknwn/Estimated Medicaid Disprprtinate Share Hspital liabilities Timing f financial reprting 40 // experience access 40 20

21 Financial Reprting Challenges Missuri Medicaid Disprprtinate Share Hspital audits are tw t three years after the year under audit Infrmatin used fr the surveys is smetimes difficult t btain Sme IT Systems are limited n the ability t track the necessary infrmatin 41 // experience access 41 Questins? 21

22 Thank Yu! Je Watt, Partner Beth Ann Stansbury, Senir Cnsultant II Cntinuing Prfessinal Educatin (CPE) Credits BKD, LLP is registered with the Natinal Assciatin f State Bards f Accuntancy (NASBA) as a spnsr f cntinuing prfessinal educatin n the Natinal Registry f CPE Spnsrs. State bards f accuntancy have final authrity n the acceptance f individual curses fr CPE credit. Cmplaints regarding registered spnsrs may be submitted t the Natinal Registry f CPE Spnsrs thrugh its website: The infrmatin in BKD webinars is presented by BKD prfessinals, but applying specific infrmatin t yur situatin requires careful cnsideratin f facts & circumstances. Cnsult yur BKD advisr befre acting n any matters cvered in these webinars. 22

23 CPE Credit CPE credit will be awarded upn verificatin f participant attendance Fr questins, cncerns r cmments regarding CPE credit, please the BKD Learning & Develpment Department at training@bkd.cm 45 23