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

Transcription

1 Thursday, February 12, p.m. Central time Taking the Stress Out f the Luisiana 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 Susan Miller, CPA Partner BKD, LLP smiller@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 DSH Recap DSH Eligibility DSH Calculatins Payr Buckets Cmmn Blunders Financial Reprting 3 // experience access 3 DSH RECAP 4 2

3 DSH Recap Audit surveys Myers & Stauffer will be cmpleting SFY 2012 Medicaid DSH audit fr all Luisiana hspitals Audit will cmpare hspital s actual uncmpensated care cst (UCC) t DSH payment received fr SFY 2012 t determine if any verpayments exist Any verpayments identified during this 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 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 general public n December 22, 1987» CMS Clarificatin Hspitals wh pened after December 22, 1987, cannt be grandfathered in under secnd exceptin (Additinal Infrmatin f the DSH Reprting & Audit Requirements Part 2) 7 DSH Eligibility What if I qualified when payment was calculated but d nt qualify nce audit is cmplete? CMS indicated in Additinal Infrmatin f the DSH Reprting & Audit Requirements Part 2 that if 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 funds Alternatively, if a hspital was nt initially deemed eligible but is later determined t be eligible, state shuld make a payment t that hspital in accrdance with its state plan 8 4

5 DSH CALCULATIONS

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7 13 PAYOR BUCKETS 14 7

8 Medicaid FFS Primary (In-State) Data surce State MMIS data (EIDR) must be used per DSH Reprting & Audit Requirements Part 2 Internal data will nly be allwed if it is recnciled t state detail. Must be able t explain variances in tw data sets What shuld be included? All Medicaid FFS primary patients Medicaid cst reprt settlements Medicaid inpatient utlier payments Ptential issues/pprtunities Shadw claims 15 Medicaid Managed Care (In-State) Data surce Internally generated ( Exhibit C ) What shuld be included? All Medicaid Managed Care primary patients Ptential issues/pprtunities Must be sure t exclude any Title XXI claims (CHIP/SCHIP) Managed care bundled payments exclude prfessinal piece Shadw claims need t be separately identified 16 8

9 Medicare/Medicaid Crssvers (In-State) Data surce State MMIS data (EIDR) Nte: If yu are a Critical Access Hspital (CAH), Medicare pays at 101% f cst; nce payments are cnsidered, ttal impact f crssver data will be minimal What shuld be included? Patients with traditinal Medicare primary/medicaid secndary Ptential issues/pprtunities Revenue cde 001 is a subttal that shuld nt be reprted All data in EIDR fr inpatients & utpatients is cmbined & shuld be reprted as inpatient n survey 17 Other Medicaid Eligibles Data surce Internally generated ( Exhibit C ) What shuld be included? Any patient wh is Medicaid eligible & nt reprted elsewhere n survey Nte that patient must have had active Medicaid cverage at time f service & hspital service must rdinarily be cvered by Medicaid Claims with Medicare Managed Care r Cmmercial Insurance Primary/Medicaid r Medicaid Managed Care secndary 18 9

10 Uninsured Data surce Internally generated ( Exhibit A & B ) What shuld be included? KEY If yu include ppulatin in uninsured charges, yu must als include 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 place f service e.g., A patient wh nly has Medicare Part A but receives utpatient services culd be included as uninsured fr utpatient visit assuming they d nt have additinal cverage Patients wh have insurance but insurance never pays because they need additinal infrmatin frm patient creditable insurance is never verified 19 Uninsured What shuld be included? Patients wh meet definitin f uninsured under 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 service received (must still be a Medicaid cvered hspital service) CANNOT include Denials fr timely filing Denials fr medical necessity Denials fr precertificatin 20 10

11 Uninsured Patient payments (cash basis) Every patient payment received during 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 amunt f fees paid t cllectin agency n payments received 21 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 hspital n behalf f patient, must be included in calculatin f hspitalspecific DSH limit CMS justificatin Exclusin f these claims leads t artificially inflated DSH limits & permits a hspital t be paid twice n same cst 22 11

12 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 Hspital des nt necessarily have t have billed fr that stay but patient must have active Medicaid cverage & have received a Medicaid-cvered hspital service 23 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 Medicaid Inpatient Utilizatin Rati (MIUR). 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 24 12

13 Rural Health Clinic (RHC) Small rural hspitals shuld cmplete DSH Survey specifically designed fr RHC(s) Similar rules apply fr data cllectin as with hspital data Medicaid & crssver data are frm EIDR reprts Hspital shuld generate data fr uninsured, ther medicaid eligibles & ut-f-state payrs 25 COMMON BLUNDERS 26 13

14 Blunder #1 Misgruped Cst Centers Issue Hspital had nt gruped survey charges in accrdance with 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 charges in accrdance with cst reprt including all department allcatins Result Cst increased by $165,

15 Blunder #2 Excluding Allwable Ppulatins Issue Small CAH hspital received a DSH payment f apprximately $2 millin Cmpleted audit & results indicated facility had a liability f nearly $435,000 Slutin Identified additinal allwable patient ppulatins nt previusly reprted (current year & prir year) Result Liability reduced t apprximately $63,000 resulting in a savings f $372, Blunder #3 Cst Centers Exceed Ttal Issue Rutine days r ancillary charges reprted in survey exceed ttal fr that cst center n 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 cst reprt per DSH instructins 30 15

16 31 Blunder #4 Mismatched Uninsured Data Issue Patients may be included as uninsured in patient payment listing wh have dates f service during year; hwever, these patients are nt included in uninsured charges listing Slutin Match 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 uninsured charges but shuld als have been remved frm uninsured patient payment listing 32 16

17 Blunder #5 Overstating Uninsured Payments Issue Patient payments d nt specifically apply t hspital r physician charges. Payments can be allcated between tw based n charges n the patient accunt Slutin When pulling data frm system, include all data elements s this calculatin can be cmpleted, i.e., pull ttal hspital charges & physician charges fr each accunt Result Remving estimated prfessinal fee payments will result in lwer payments, & therefre, an increase in net uncmpensated care cst (UCC)

18 Blunder #6 Insurance Status Updates Issue Insurance status nt updated in patient accunting system, e.g., a patient cmes int hspital & claims t have Blue Crss. When EOB arrives, it states cverage terminated prir t admit date. If their insurance status is nt updated n accunt, this claim may never get included in 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 35 Blunder #7 Accepting All Adjustments Issue Hspital submitted a DSH survey shwing a significant underpayment but audit adjustments reduced UCC $500,000 swinging 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 Reviewed adjustments & submitted arguments t crrect errneus adjustments Result Errneus adjustments reversed & hspital did nt have a liability 36 18

19 Blunder #8 Lack f Prir Planning Issue A system cnversin r data purge makes required data unavailable at time f audit Slutin Plan ahead! If data is nt ging t be available, wrk with IT persnnel t pull data ut f system befre it purges. Als shuld be able t pull every patient payment received during perid regardless f service date Result Ensures that yu will cmply with Medicaid DSH regulatins & reduce risk f being unable t supprt payment received 37 FINANCIAL REPORTING 38 19

20 Financial Reprting Knwn Luisiana Medicaid Disprprtinate Share Hspital liabilities Unknwn/Estimated Medicaid Disprprtinate Share Hspital liabilities Timing f financial reprting 39 // experience access 39 Financial Reprting Challenges Luisiana Medicaid Disprprtinate Share Hspital audits are tw t three years after year under audit Infrmatin used fr surveys is smetimes difficult t btain Sme IT Systems are limited n ability t track necessary infrmatin 40 // experience access 40 20

21 Questins? Thank Yu! Je Watt, Partner Beth Ann Stansbury, Senir Cnsultant II Susan Miller, Partner 21

22 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. CPE Credit CPE credit may 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 44 22

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