J11 Part A Provider Audit and Reimbursement Update

Transcription

1 J11 Part A Provider Audit and Reimbursement Update 1

2 Agenda Operational Update SSI Update Rural Floor Budget Neutrality Adjustment Wage Index 2014 EHR Audits Contacts 2

3 Operational Update - Audit Columbia, SC SC, NC, HHH Richmond, VA (NGS) VA, WV, NC Springfield, IL No longer J11 Appeals Columbia, SC 3

4 Operational Update - Reimbursement Columbia, SC All states Rate Reviews Transitioning to a 4 th and 8 th month review period Audit Adjustment Factors Rate Reviews Tentative settlements 4

5 SSI Update Settlements Staggered settlements Pre-2006 remain on hold 2007 (2006) (most are in current year workplan) No official CMS guidance will continue to be on hold No new documentation 5

6 SSI Update Settlements 2007 South Carolina 31 Planned settlements 20 Completed 5 Adjustment letters pending 2008 South Carolina 37 Planned settlements 2009 South Carolina 40 Planned settlements 6

7 SSI Update Reopenings 2006 and SC Reopenings planned SC Completed SC Reopenings planned SC Completed 2008 One reopening planned for Rehab unit Reimbursement Latest published SSI percentages used in rate reviews, tentative settlement 7

8 RFBN Adjustment Settlement Agreements Amended Cost Reports Acceptance No tentative settlement Reopening Requests Requests for Payment 8

9 Wage Index 2014 PUF published in October 2012 Missing many files Re-published November 9, 2012 Revision Requests Deadline extended to December 10 Early submission recommended account pending 9

10 Wage Index 2014 Desk reviews start December 10 or sooner Pension Defined Benefit Plan 100% Review CMS Website Development of Pension Costs Desk Reviews completed February 6 Submission of findings to CMS Rebuttal Period ends March 3 Appeal Period ends April 17 10

11 Wage Index 2014 Pension Plan costs Pension Defined Benefit Plan 100% Review CMS Update Development of Pension Costs Update October 2012 Wage Index Pension Cost Schedule Allowable costs cash basis Average Annual Employer Contributions 36 Consecutive Calendar Months 11

12 EHR Audits Meaningful Use Audits Audits performed by Figloizzi and Company Audits have started on attestations Audit schedules/details have not been shared with MACs/FIs Payment Audits Audits performed by MACs/FIs CMS to select the sample of providers No timetable to start audits 12

13 EHR Audits Meaningful Use audit may/may not occur prior to Payment audit Payment Audit Desk Audit Applicable to cost reporting periods of 12 months only Completed at same time as regular desk review or as close to timeframe as possible 13

14 EHR Audits Payment Audit Audit Field Audit vs. In-House Audit Audit work to be performed in conjunction with regular audit Avoids duplicate work May be instances where the EHR work will be completed separately 14

15 EHR Audits Payment Audit Desk Review Proper cost reporting Proper transition factors Payment reconciliation Review of 110 and 118 PSR Reports or provider alternative data Pre-scoping of Audit work 15

16 EHR Audits Payment Audit Audit scope Incentive Payment Calculation provides clues as to areas subject to review IPPS: Initial Amount x Medicare Share x Transition Factor CAH: Reasonable costs of EHR Technology x Medicare Share + 20% (not to exceed 100%) 16

17 EHR Audits Medicare Share: Inpatient Part A Days + Inpatient Part C Days Total Inpatient Days x ((Total Eligible Charges Charges applicable to Charity Care)/Total Eligible Charges) Expect reviews to focus in part on Medicare Share elements 17

18 EHR Audits Audit Objectives Verify Medicare Part A and Part C as well as Total Inpatient days Verify hospital charges and charity care charges Verify total discharges (IPPS) Verify reasonable cost of EHR assets (CAH) Ensure costs have not previously been claimed (CAH) 18

19 EHR Audits Inpatient Days Medicare days: 110 and 118 PSR Reports Total days: Routine and ICU days Census Reports Policies and Procedures Count conforms with hospital policies and procedures Count conforms with Medicare policy * Counted as full days * Day begins at midnight * Day of admission is counted; day of discharge excluded (same day admission/discharge = 1 day) 19

20 EHR Audits Total Hospital Charges Financials vs. Revenue and Usage Reports Routine Revenue Test 20

21 EHR Audits Charity Charges W/S S-10 Line 20, Col 3 Reconciliation of charges Listing of charity charges Patient name Dates of service Patient Account Number Name of insurer (private, Medicare, etc.) Total (gross) charges Charity charges 21

22 EHR Audits Charity Charges Review of charity policies Conforms with PRM I Section 312 Ensure policy is followed Charity charges calculated properly Exclusions: Charges applicable to Medicare patients (ded. and coins. claimed as bad debts and charity care allowances have no relationship to Medicare patients) Courtesy discounts, other discounts Physician and Professional charges 22

23 EHR Audits Total Discharges (IPPS) Listing of discharges Reconciliation of reported discharges Review of medical records and/or other appropriate documentation to support discharge count 23

24 EHR Audits Reasonable cost of EHR Assets (CAH) Listing of EHR Assets Identify each asset; notate lease or purchase Tag number/location of each asset Type of use, i.e., will it be shared with non-ehr systems Name of purchaser (hospital, home office, etc.) Date of purchase/virtual lease Acquisition cost 24

25 EHR Audits Reasonable cost of EHR Assets CAH must support reasonableness of cost Reconciliation of costs Verify costs Invoices, purchase orders Previous purchases; treatment of previously claimed depreciation Physical inspection of assets Interview of staff using assets Exclude interest, previous depreciation and costs that cannot be capitalized (internal training, internally developed software) 25

26 EHR Audits Reasonable cost of EHR Assets Leased Assets (previously thought to be non-allowable for EHR) Virtual purchase Fair market value (determined by the provider) Excludes cost elements such as depreciation, interest and insurance Assets also used for non-ehr purposes Separately identifiable Reasonableness of allocation methodology (i.e., hours of use) 26

27 EHR Audits Reasonable cost of EHR Assets Home Office Purchase support for allocations Direct allocation Functional allocation Group purchase Amount claimed must be actual cost incurred by provider 27

28 EHR Audits Previously incurred costs Plant ledger and depreciation schedules Costs should not be duplicated on depreciation schedules Remove via worksheet A-8, line 32 28

29 EHR Audits References ARRA of 2009, Pub. L HITECH ACT 42 CFR , , and FR Vol. 75, No. 144 dated 7/28/2010, Pgs PRM I, 104.1, 104.4, A, , 110 and 312 PRM-II, , , 4012, 4023, , 4013, and 4016 CMS Website - FAQs 29

30 Contact Information Key Contact Information For filing of Cost Reports Courier Service Palmetto GBA Attn: Cost Report Acceptance (AG-330) 2300 Springdale Drive, Building One Camden, SC U.S. Postal Service Palmetto GBA Attn: Cost Report Acceptance (AG-330) Post Office Box Columbia, SC

31 Contact Information Key Contact Information HITECH Payment Issues/Hospice Caps Jim Peebles at or (803) Courier Service Palmetto GBA Attn: Jim Peebles, Manager (AG-330) 2300 Springdale Drive, Building One Camden, SC U.S. Postal Service Palmetto GBA Attn: Jim Peebles, Manager (AG-330) Post Office Box Columbia, SC

32 Contact Information Key Contact Information Reimbursement Issues Michelle Anderson at or (803) Courier Service Palmetto GBA Attn: Michelle Anderson, Supervisor (AG-330) 2300 Springdale Drive, Building One Camden, SC U.S. Postal Service Palmetto GBA Attn: Michelle Anderson, Supervisor (AG-330) Post Office Box Columbia, SC Alternate Contact: Jim Peebles, Manager 32

33 Contact Information Key Contact Information Provider Audit Issues relating to the cost report, desk reviews, audits, and settlements Palmetto GBA Provider Audit, AG-320 Post Office Box Columbia SC Contact: Scott Neely (or assigned manager) Manager, Provider Audit (803) (direct line) (803) (fax) Wage Index account is pending 33

34 Contact Information Key Contact Information Provider Audit Filing of Cost Report Appeals and Reopenings Palmetto GBA Cost Report Appeals and Reopenings, AG-380 Post Office Box Columbia SC Contact: Cecile Huggins Supervisor, Provider Appeals and Reopenings (803) (direct line) (803) (fax) 34

35 Contact Information Contact Information for Cost Report Appeal and Reopening Requests Two addresses have been created for the electronic submission of cost report appeals and cost report reopening requests: Filing of Cost Report Appeals Filing of Cost Report Reopenings 35

36 Contact Information PRRB appeals correspondence that providers send to the Blue Cross and Blue Shield Association should now be sent via to In the Subject line, reference the case number first, followed by the case name, followed by the nature of the correspondence. For example: Subject: PRRB Case No ; ABC Hospital; Provider Preliminary Position Paper There is no need to send a paper copy 36