2 General Information RE DRG Implementation Where can we get information about how the Agency is implementing DRGs in Florida FFS Medicaid?

Transcription

1 1 Capitated Health Plan Provider Reimbursement As I understand it the managed care organizations are not required to change their inpatient reimbursement method but could do so. If Medica implements this new reimbursement method, is this for only contracted hospitals? If so, how would a non-participating hospital that has provided services to a Medica member be paid? Should it not be the DRG method for non-participating hospitals? 2 General Information RE DRG Implementation Where can we get information about how the Agency is implementing DRGs in Florida FFS Medicaid? 7/22/13- DRG is applicable to Medicaid-enrolled hospital providers in FFS. Health Plans may choose their own form of payment method to hospitals. Health Plans may choose to pay such providers using DRGs. For emergency services, if the Capitated Health Plan cannot negotiate a rate with a non-participating inpatient provider, then the Medicaid rate will be used. See the Medicaid Health Plan Contract, Attachment II, Section V, H.7.m. for specific requirements. Beginning with July 1, 2013 inpatient admissions, the Medicaid rate is the DRG rate. 7/16/13- Please familiarize yourself with the information and documents (frequently asked questions, Quick Reference Guide) provided through the link below. In addition, at the end of this link there is another link to the AHCA Medicaid Institutional Provider Cost Reimbursement page. The cost reimbursement page provides information on the DRG pricing conversion process, DRG simulation results by provider, and the DRG calculator. ault.aspx 3 45-Day Calculation If we have calculations based on prorated days (i.e. exhausted 45 day, authorization only covers partial stay, crossover eligibility), do we enter full length of stay in 3M or partial/approved stay? If a member is inpatient but the Health Plan is not responsible for the entire stay (i.e. only part of the stay is authorized), how is this calculated? Are only the authorized days entered in the calculator under "Medicaid Eligible Days?" Are the non-covered charges carved out under "Submitted Charges?" Do we need to pro-rate any calculation? 7/22/13- This item is still under discussion at AHCA for Managed Care. The Agency looks forward to receiving feedback from FAHP s subgroup and other health plans regarding this issue. Feedback should be submitted to AHCA prior to the 7/23/13 meeting. Information regarding how the 45-day cap is being handled under the DRG pricing method for Florida Medicaid FFS is provided in the response to the first question on page 5 of this link: %20PRICING/DRG%20FAQ% pdf Page 1

2 4 Calculator Maintenance/Updates Will the State provide notification when the calculator has maintenance or 7/22/13- The Calculator is intended more as a communication tool than updates? Will the calculator always be accessible (including a production-ready piece of software. Also, it is only useable to process Sat/Sun)? (*CSO concern of slowness with multiple users one claim at a time, which makes it impractical for processing large accessing at the same time or website crashing; therefore, volumes. For those who do find the calculator to be helpful, we expect we would like to save/use internally). Will the State provide that they will download a copy of the calculator to their own notification when the calculator has maintenance or computer(s). Under normal operations, the Calculator will be updated updates? Will the calculator always be accessible (including just prior to the beginning of each fiscal year, and again in mid- Saturdays/Sundays)? November when self-funded IGT amounts have been finalized for the fiscal year. In this first year of DRG implementation, there is one more resetting of DRG base rate planned. It will be effective 3/1/2014. The Calculator will be updated related to this re-calculation of the DRG base rate. The calculator posted is the final version. If there is an update that is needed we will post it to our website. The calculator is accessible 24/7 via website. Please note that it is recommended that users download the calculator and work on the downloaded version. 5 Non-Covered Charges - Per State Calculator "Also referred to as "covered charges." Generally this equals hospital billed amount because there are rarely non-covered charges on a claim. " Do we carve out non-covered charges based on benefits set-up before entering "Submitted Charges?" Need to confirm the definition of non-covered charges in State Calculator. Please confirm the definition of "Non Covered charges" within the Calculator/Submitted Charges instructions. Are "NonCovered Charges" billed amounts associated with items that deny outside of the benefit plan? Do they also include charges for non-covered days (i.e. only part of the stay was authorized)? 7/16/13- In the DRG Calculator the non-covered charges are intended to be only those self-reported by the hospital in field locator 48 on the UB- 04 paper claim form an in the equivalent field on the 837I electronic transaction. As stated in this question, providers very rarely put anything other than $0 in this field, so the value applicable for cell E7 of the DRG Calculator can generally be thought of as full charges submitted by the hospital on the claim. Page 2

3 6 Yearly update - Identified in State call that November updates will be retrospective, March updates will be 7/16/13- Yes, the update in November will be retrospective back to July prospective in a recent training call, it was noted that a 1, Also, yes, the update effective March 1, 2014, will be retro-update will occur in November (effective back to prospective covering admissions from March 1, 2014 through June 30, 7/1/13)? Please confirm. Also, what is the cycle for As mentioned in the answer to question two, normal operations updates moving forward? after year 1 are anticipated to include only two (not three) annual updates to DRG base rate and policy adjustors. They will be effective at the beginning of the state fiscal year, July 1 st, and again around mid- November, after self-funded IGTs are finalized. This is no different than how this recalculation was done under per diem day Limit Exhaustion During Hospital Stay - If a member exhausts his/her 45 day limit during a stay, how is the reimbursement handled? Is it prorated by covered days after the DRG calculation is achieved? (*State calculator states: Recipient exhausted his/her 45-day benefit limit prior to admission (in which case only emergency services are reimbursed.) (If a recipient has at least one day of coverage remaining within his/her 45-day benefit limit at the time of admission, then Medicaid eligible days should be set equal to the full length of stay.) Please confirm that if a member has at least 1 day remaining in his/her 45-day inpatient benefit limit at the time of admission, the Health Plan is responsible for the entire stay. 8 Partial Stay: If an authorization only covers a partial stay, how is reimbursement handled? Is it prorated by covered days, accounted for within eligible charges the calculator, or accounted for in 3M "from-to" date? If an authorization only covers a partial stay, how is reimbursement handled? Is it prorated by covered days, accounted for within eligible charges the calculator, or accounted for in 3M "from-to" date? 7/16/13- Charges and date of service should always be those applicable for the complete hospital stay. Proration is performed based on the number of covered days entered into cell E9 of the DRG Calculator. Page 3

4 9 DRG Average Length of Stay - if needed, should we refer to State calculator (DRG Table, Column C Average Length of 7/16/13- Yes, please use the APR-DRG average lengths of stay provided Stay)? If the Health Plan needs to determine the average in Column C of worksheet DRG Table within the DRG Calculator. The length of stay associated with a DRG, would it be average lengths of stay included in the calculator are the national appropriate to use the information within the State average lengths of stay determined by 3M and distributed with 3M s calculator (DRG Table, Column C - Average Length of Stay? APR-DRG grouping software. 10 Out of State processing - Confirm how to handle. Does the DRG calculator account for out of state facilities? If not, how should they be processed? 11 POA Exempt Diagnosis Codes: Can you supply us with the diagnosis codes that the Centers for Medicare and Medicaid Services (CMS) has determined to be exempt under the POA indicator, such as external cause of injuries codes? Are there any additional diagnosis codes outside the E range which should be set up to exclude from requirement of a POA indicator on the claim. 12 DRG Average Length of Stay: We need clarification on the DRG posted power point which is being conducted by AHCA. It s reflecting that if the assigned DRG s average day stay is less than what facility is billing than AHCA is using the lesser of day count towards members 45 inpatient day max. 7/16/13- In the DRG Calculator, the value entered in cell E14 should be Non-Par. With this value, the Calculator will retrieve default values that are applicable for out-of-state facilities. 7/22/13- Below is the link to the CMS website where the POA exempt diagnosis codes can be found: Guidance/Guidance/Transmittals/downloads/r1019otn.pdf Is AHCA expecting the health plans to follow this step as well? Page 4

5 13 POA Indicator Do you know or can you find out if we are paying a facility at their old Per diem rate vs. DRG, are the 7/16/13- FFS Medicaid requires entry of the Present on Admission health plans still required to obtain Present On Admission (POA) indicator as appropriate in its inpatient hospital claims under (POA) indicator before paying the claim? This is a new DRG. In accordance with section 2702 of the Patient Protection and requirement if paying a hospital at DRG rate. Affordable Care Act (ACA), the Florida Medicaid State Plan and 42 CFR section 434.6(12) and , and effective July 1, 2013, inpatient hospital providers are required to report Provider-Preventable Conditions (PPCs). Regardless of its use of DRG or per diem payment method, the Health Plan must identify these conditions in order to appropriately process payments. 14 FL Add-On Payments Reimbursing at more than 100% What is the State s expectation of the MCO reimbursing at more than 100%? Below are the FL Add-On Payments for which we would like some clarification regarding the MCO financial responsibility. IGT Automatic Payment IGT Self-Funded Payment Newborn Hearing Screening o If the MCO is not responsible for this additional payment, then: Are these charges to be excluded from the MCO DRG calculation? Does excluding these charges somehow alter the MCO DRG determination, e.g., needing to exclude certain diagnoses? Page 5

6 15 IGT Add-Ons Are the amounts that will actually be paid to hospitals (starting July 1) for the automatic IGT add-ons the 7/22/13- The automatic IGTs to be used in state fiscal year 2013/2014 amounts that are on the DRG calculator on the Agency are listed in the DRG Calculator and in the Provider DRG Rate website? If so, are they subject to change during the year Worksheet posted on the AHCA website. There is no plan for these and if they do how will hospitals and plans be notified? numbers to change during the year. 16 Self-Funded Add-Ons and Updates We are assuming the amounts on the DRG calculator for self-funded add-ons are estimates until the actual IGT LOA's are signed later this year, is that correct and how will plans and hospitals be notified of those amounts? The assumption is those will be retroactive to July 1? 17 DRG Calculation Updates Can you explain the two reconciliations of the base rate that are to take place later in SFY 13-14, how will you notify the plans and hospitals of those amounts and can you confirm they are not retroactive? These are in the last two paragraphs in the Inpatient line item in the GAA. 18 DRG Reimbursement For Non Par facilities that are paid 100% of Medicaid allowable does that mean APR DRG reimbursement after 7/1/13? 19 Out-of-State Reimbursement For Out of State facilities that are paid 100% of Medicaid allowable does that mean APR DRG reimbursement after 7/1/13? 20 FL Medicaid Provider IDs for Out-of-State Hospitals If out of state facilities are to be paid at APR-DRG, that will require these providers to have a FL Medicaid ID, correct? How will that work? 7/22/13-Yes, the self-funded IGT payments in the DRG Calculator, and in the Provider DRG Rate Worksheet currently posted on the AHCA website, are estimates based on 2012/2013 self-funded IGT distributions. The Agency will recalculate these numbers after the actual IGT letters of agreement are finalized for SFY 2013/2014. When the new values become effective (on or before November 15, 2013), they will be retroactive back to July 1, 2013, and they will be posted on our Medicaid cost reimbursement website. 7/16/13- See response to question 6. The updated DRG calculation by facility based on these two reconciliations will be posted to the Cost Reimbursement website. 7/16/13- FFS Medicaid, for dates of services July 1, 2013 or later, will pay using DRGs. See the response to Question #1. 7/16/13- FFS Medicaid, for dates of services July 1, 2013 or later, will pay out-of-state hospitals using DRG. 7/16/13- Yes, all out-of-state hospitals must have Medicaid IDs to be reimbursed by FFS Medicaid, as was true prior to July 1, Page 6

7 21 Grace Period Is there a grace period to allow payers the ability to administer APR-DRG reimbursement for non-par 7/16/13- For Florida FFS Medicaid, there is no grace period for DRG hospitals? If so, what is that period? reimbursement. 22 Interim Claims Will AHCA be posting the per diem for interim claims? Background: Depending on the payment policies set by the state, some acute care inpatient claims may fall outside the DRG payment. These may be claims for services or providers carved out of the DRG payment method, or they may be interim claims from providers for services that are included in DRG payment. Both Carved out items and interim claims are commonly paid per diem model, although they can also be paid as a percentage of charges. Unlike carved-out services, the per diem for interim claims is set relatively low as it is intended to be a temporary, partial payment. The interim claim per diem gives hospitals some reimbursement for cash flow purposes, while still leaving the hospital with an incentive to submit a final claim when the recipient is discharged. 23 Other Provider Reimbursement For Physical Rehabilitation, Long Term Acute Care and Mental Health providers: Has AHCA chosen to pay these providers with another method, such as a per diem method, instead of paying via DRGs? 24 Other Provider Reimbursement Are Critical Access, Children s Cancer, Federally Qualified Health Centers and Rural Health Clinics going to be excluded from the Medicaid APR-DRG payment method? 7/16/13- Florida FFS Medicaid is not paying interim claims. 7/16/13- Florida FFS Medicaid DRG applies to inpatient hospital providers only. The only exception are State Mental Hospital facilities that will be reimbursed using the Per Diem method. 7/16/13- Florida FFS Medicaid DRG applies to inpatient hospital providers only. Critical Access and Children s Cancer hospitals are included in the providers that will be paid using DRG. Federally Qualified Health Centers and Rural Health Clinics are not inpatient hospital providers and will not be paid using DRGs. Page 7

8 25 Readmission Policy Will there be a readmission policy issued by the Agency? If so, please explain the 7/22/13- There is no specific readmission policy for FFS Medicaid. For policy/provide guidance. the Medicaid fee-for-service program, most admissions require an authorization from a peer review organization to confirm medical necessity. These reviews are intended to control overpayments as a result of unnecessary admissions. The Agency looks forward to receiving feedback from FAHP s subgroup and other health plans regarding this issue. Feedback should be submitted to AHCA prior to the 7/23/13 meeting. 26 DRGs and Non-Participating Providers We understand that for our health plans (CHA and SHP), we are not REQUIRED to implement DRG Hospital Inpatient (IP) Claims payment. Please explain what the expectations are of the capitated plans who do not implement DRG payment, as it relates to the payment of NON-Participating/NON- Contracted Hospital Inpatient claims related to a hospital emergency admission. 7/16/13- Refer to the response to question 1. Can we pay non-par hospitals using a Medicaid FFS fee schedule, instead of Medicaid DRG? 27 Web Browser/DRG Calculator Access Problems: I found a computer with Internet Explorer v8, and was able to access the DRG calculator. For whatever reason, later versions are somehow barred from certain pages (but not others) of the FLMMIS website. 7/16/13- The Health Plan/user should download the DRG calculator to their PC. There should not be a browser issue. The Calculator is in Excel. If problems still persist, it may be that they are using an older version of Excel. Page 8

9 28 Non-Covered Days: The below is all that s posted about non covered days. I ve bolded the Medicare information below. We would like to know how AHCA is going to calculate when member has exhausted their Medicare part A benefits. It states below payment is prorated bases on the number of covered days in relation to the total length of stay but doesn t give examples. Will you be putting in the DRG calculator the days which Medicare didn t cover even though it may not be the date of admission? Non-covered days adjustment: A few scenarios exist in which some, but not all, of the days of a hospital stay will be covered by Medicaid fee-for-service. For these scenarios, payment is prorated based on the number of covered days in relation to the total length of stay. The non-covered day adjustment applies to the following admission scenarios: Undocumented non-citizens; Emergency services for adults who have exhausted their annual 45-day benefit limit; Medicare dual eligibles in which the recipient s Medicare Part A coverage is reached during the stay; Children enrolled in a Medicaid managed care plan and who exhaust their 45-day benefit limit during the stay; and Medically needy recipients, who gain Medicaid eligibility during the middle of a hospital stay. 7/22/13-In FFS Medicaid the particular scenario of Medicare Part A benefits exhausted for a recipient dually eligible for Medicare and Medicaid, the Florida Medicaid billing procedures are being changed to require hospitals to communicate the date Medicare Part A benefits expired. This information is communicated using occurrence code A3. The date included with this occurrence code is the last day reimbursed by Medicare (as stated in the UB-04 billing manual). If that last day is in the middle of a hospital stay, then Medicaid will consider all days following Medicare s last day of payment up until the day of discharge as Medicaid covered days (with the day of discharge not covered). In this case, the number of covered days is calculated as [(date of discharge) minus (date included with the A3 occurrence code) minus 1]. For example, if the date of admission is 8/7/2013, the date of discharge is 8/15/2013, and the date Medicare benefits exhausted is 8/10/2013, then the length of stay is 8 days and the number of Medicaid covered days is 4. Thus the Medicaid non-covered day reduction factor used in the DRG pricing calculation would be 0.5 (4 divided by 8). See also the response to Question # 3 regarding how the annual 45 day limit is calculated for Florida FFS Medicaid. With regard to children enrolled in a health plan who have exhausted their 45-day inpatient limit, there is no 45 day benefit limit for children under 21. Page 9

10 29 Non-Participating and Out-of-State Facilities After 7/16/13- See the response to Question # 1. 7/1/2013, if the Fee For Service method of reimbursement for facilities will be DRG, will the follow be true for Health Plans a. For Non Par facilities for whom we would pay 100% of Medicaid allowable, will that allowable now equate to the DRG method of reimbursement? b. For Out of State facilities for whom we would pay 100% of the Florida Medicaid allowable, will that allowable now equate the DRG method of reimbursement? 30 Contracted Provider Per Diems For our contracted facilities currently reimbursed with Per Diems, will the 1/1/2013 per diem remain in effect after 7/1/2013? a. To clarify, it is our understanding there will be no more Per Diem updates posted by the State on the website after 1/1/2013. b. If our contracted facilities wish to remain on the Per Diem method of reimbursement, again, the 1/1/2013 will be the last update and will remain in effect indefinitely Digit DRG Code To produce the 4-digit DRG code, should the 3 digit code produced by 3M be added to the 1-digit Severity Factor (SOI) produced by 3M? 32 POA Exempt Diagnosis Codes Documentation states that a POA indicator is required for primary and secondary diagnosis codes. Will the state list any diagnosis codes as exempt from the POA indicator? 7/16/13- See the response to Question # 1. 7/22/13- The first three digits are the APR-DRG produced by the 3M grouper. The fourth digit is the level of severity being either 1-4, with 1 being the least severe and 4 being the most severe case. 7/22/13- Below is the link to the CMS website where the POA exempt diagnosis codes can be found: Guidance/Guidance/Transmittals/downloads/r1019otn.pdf Page 10

11 33 Crossover Eligibility How is crossover eligibility handled? 7/22/13- When Medicare Part A is exhausted, the provider must include Based on admit/discharge/eligible days? the date the Medicare benefit exhausted on the claim with occurrence code A3. If occurrence code A3 is not included on the claim, it should deny. If A3 and its associated date is included and the benefit exhaustion date is during the hospital stay, then payment will be prorated downward because Medicare was responsible for paying for some of the stay and Medicaid is responsible for paying for another part of the stay. The part Medicaid is responsible for will be calculated as [(date of discharge) minus (date Medicare exhausted) minus 1]. The extra minus 1 is there because the date Medicare exhausted is the last date Medicare paid for. That day is not payable by Medicaid. 34 Claims for Which the POA Indicator is Not Populated We are about to engage our clearinghouse to setup edits to receive only Y or N in the POA indicator for the Principle Diagnosis and Other Diagnosis segments in the 837 Institutional claim. This edit will reject claim if those two values are not present. Is this indeed what Florida Medicaid is asking for? We are looking for confirmation as to how to handle claims for which the POA indicator is not populated. The June memo indicates that for FFS / our PSN line of business, we should ensure that providers are populating with Y or N, but the CMS documentation indicates other values as valid. Our intent was to instruct our clearinghouse to deny any claim received that lacks the Y or N per the Medicaid instruction, but we are uncertain as to whether we should only deny if the field is empty, and allow other valid, defined POA values. 7/22/13- FMMIS will accept all valid POA values, which are Y,, N, U, and W. The statement that only Y and N are valid is not correct; we are unaware of where this statement originated. The list of diagnosis codes for which a blank is accepted can be found at the following site: Guidance/Guidance/Transmittals/downloads/r1019otn.pdf. These codes are referred to as exempt from POA. Federal CMS puts out this list, and it has been added to FMMIS. Also, FMMIS is only requiring POA codes on the primary and secondary diagnoses, not on the external cause of injury diagnoses. FMMIS is coded to follow (enforce) national standard billing rules, with the exception that Florida Medicaid is not requiring POA on external cause of injury diagnoses. Page 11

12 35 FFS PSN - Claims for DOS after enrollee disenrolls from FFS plan: After July 1, 2013, how will a Hospital Inpatient (IP) 7/22/13- This item is still under discussion at AHCA for Managed Care. claims payment be handled in the case a FFS PSN member The Agency looks forward to receiving feedback from FAHP s subgroup admitted in the hospital with an admission date of 7/1 or and other health plans regarding this issue. Feedback should be after; which disenrolls from the FFS PSN and enrolls in submitted to AHCA prior to 7/23/13 meeting. (a) another FFS plan or (b) a Capitated plan while still admitted in the hospital? The discharge date would occur while enrolled in another plan. 36 FFS PSN - Changes to Another FFS Plan during same IP stay: Will Medicaid pay claim on behalf of the original FFS PSN or on behalf of other FFS plan? 37 FFS PSN - Changes to a Capitated Plan during the same IP stay: In the case where a member disenrolls to a capitated plan, will FFS Medicaid pay on behalf of the FFS Plan or will the capitated plan be expected to pay the claim? 38 FFS PSN - Changes to Another FFS Plan during same IP stay: Or, will the DRG code be applied to claim first and then payment be made on behalf of both FFS plans, accordingly? Will payment be prorated in accordance with LOS in hospital setting while enrolled in each plan? 39 FFS PSN - Changes to Capitated Plan during the same IP stay: How will this work when the member goes to Capitated plan? Page 12

13 40 FFS PSN - HCAC/Readmission Policy: After July 2013, if a member has a HCAC, is discharged and later that day or another day presents to another hospital for the treatment of the HCAC; if the plan safely transfers the patient to previous hospital where the HCAC was acquired, does that hospital have an obligation to accept patient or can hospital deny the admission, due to non-payment of the HCAC? 41 FFS PSN - Newborns: FFS PSN newborn members are not retro enrolled in the plan. Please explain how Hospital Inpatient (IP) claims will be handled for newborns born to Plan members, when an inactive newborn Medicaid ID number is not assigned previously or we have no knowledge of it. This will occur in instances where: a) The mother delivers immediately or soon after enrollment in the plan. b) The mother does not receive pre-natal care, does not advise the plan she is pregnant and plan is unable to contact member via ph (Disconnected #, wrong # provided by Agency) and/or returned mail. c) Plan submitted request to DCF for MID# and DCF has not yet provided a temp MID#. Note that DCF is taking 4-6 weeks to provide a MID #. In these cases the FFS PSN will have to prior authorize care for newborn using a temporary Identifier, a pseudo Medicaid ID # or member Number. What will happen when these babies never get enrolled in the plan because member did not make a choice for the baby. We authorized the care.but how will the hospital be paid for newborn care? 7/16/13- Newborns of mothers enrolled in FFS PSNs are not currently retroactively enrolled into the FFS PSN back to birth; therefore, for the period of time that the newborn is not enrolled in the FFS PSN, the hospitals should submit claims directly to FFS Medicaid for payment. Please note that the FFS PSNs must follow contract requirements regarding DCF notification of pregnancies and deliveries in order to ensure that enrollment of the newborn into the mother s plan occurs as soon as possible. Page 13