Annette Guilford, Senior Manager Carl Williams, Senior Accountant

Transcription

1 Annette Guilford, Senior Manager Carl Williams, Senior Accountant

2 Review of DSH Exam Regulations/Policy OH DSH Exams in Review Common Reporting Issues in 2015 Exam Statewide 2015 Exam Results 2016 DSH Exam Timeline 2016 DSH Exam Data Requirements Patient-Level Data Templates Walk-Through Myers and Stauffer DSH FAQ 2

3 Federal Register Vol. 73, No. 245, Friday, Dec. 19, 2008 Medicaid Reporting Requirements 42 CFR (c) Independent Certified Audit of State DSH Payment Adjustments 42 CFR Purpose 42 CFR Definitions 42 CFR Conditions for Federal Financial Participation (FFP) 3

4 Federal Register Vol. 79, No.232, Wednesday, December 3, 2014 / Final Rule Additional Information on the DSH Reporting and Audit Requirements additional-info-on-dsh-reporting-and-auditing.pdf Additional Information on the DSH Reporting and Audit Requirements - Part 2 (published April 2014) additional-info-on-dsh-reporting-and-auditing.pdf General DSH Audit and Reporting Protocol 4

5 Conditions for Federal Financial Participation (42 CFR ) Specific Requirements: Verification No. 1: Each hospital in the state that qualifies for a DSH payment is allowed to retain that payment to offset its uncompensated costs. Verification No. 2: DSH payments made to each qualifying hospital comply with the hospital-specific DSH payment limit. The DSH payments made in the audited Medicaid state plan year must be measured against the actual uncompensated care cost (UCC) in that same plan year. Verification No. 3: Only uncompensated care costs of furnishing inpatient and outpatient hospital services to Medicaid and uninsured individuals are eligible for inclusion of the hospitalspecific DSH limit. 5

6 Specific Requirements (continued): Verification No. 4: For purposes of the hospital-specific DSH limit, Medicaid payments that are in excess of Medicaid costs must be applied against the uncompensated care costs. Verification No. 5: Any information and records of all of a hospital s Medicaid inpatient and outpatient and uninsured service costs have been separately documented and retained by the state. Verification No. 6: The information in Verification No. 5 includes a description of the methodology for calculating each hospital s payment limit under Section 1923(g)(1). 6

7 Exams are to be performed in accordance with the Federal DSH Rule, not an exam of compliance with the State Plan DSH Audit Protocol as issued by CMS & Prescribed Additional Sources 7

8 DSH Exam Year 2013, Due to CMS 12/31/16 DSH Exam Year 2014, Due to CMS 12/31/17 DSH Exam Year 2015, Due to CMS 12/31/18 DSH Exam Year NOW 8

9 Patient logs were not submitted in accordance with Myers and Stauffer template. Ensure days are on routine revenue code lines. Payor plans should be appropriate for the Log. Should be no mismatches between Logs and corresponding data. Ensure payments are broken out as requested on the Myers and Stauffer template. 9

10 7 = Total Number of Providers with DSH payments exceeding the adjusted Uncompensated Care Costs (UCC); may result in recoupments 154 = Total Number of Providers with adjusted UCC exceeding DSH payments; no recoupments will be necessary 161 = Total Number of Providers subject to the 2015 Review 10

11 Data Obtained From ODM Mid-August 2018 DSH Providers/Payments MMIS Claims Data and Other Medicaid Payments Medicare and Medicaid Cost Reports that Encompass 10/1/15 9/30/16 Data Obtained From Hospitals October 2018 Non-MMIS Patient Level Detail to Support Reported Costs and Payments (e.g., Sch F series - Uninsured, Sch I Managed Care, Sch J series Crossover, My Care, Other Medicaid Eligibles & Out-of-State) Revenue Code Crosswalk DSH Payment Certification 3 rd Party Disclosure Form 11

12 Desk Review Procedures Performed Begin Oct 2018 Providers Selected for on-site reviews Mar-April 2019 Selection Criteria includes (but not limited to): DSH Payment Amount Proximity of DSH Payment to the UCC Prior Year Selections 12

13 Statewide Calculations Performed Apr-May 2019 Costs and Payments from Medicaid Cost Reports are Populated into our Statewide Database and Pro-rated to the State Plan DSH Rate Year Hospital Medicaid and Uninsured Uncompensated Costs Compared Against Corresponding DSH Payment Quality Reviews Performed 13

14 Exam Result Notifications to Providers May/Jun 2019 Exam reports due to the Ohio Department of Medicaid: June 30,

15 Ohio DSH Examination Results for 2016 DSH UCC Cost & Payment Summary Review Results Provider Name Mcaid Provider Number Mcare Provider Number In order to comply with the December 19, 2008 federal regulation regarding disproportionate share hospital (DSH) payments, Ohio Medicaid Cost Reports and supporting data were submitted by all facilities that received DSH payments during the 2016 state DSH year. Reviews have been completed and below are the results of those reviews. We are supplying you with the adjusted uncompensated care calculation (UCC) and DSH payment for the 2016 state DSH year. Medicaid DSH Examination Uncompensated Care Cost (UCC) For State Fiscal Year: 10/1/2015 9/30/2016 (A) (B) (C) (D) (E) Cost Report Year Begin Cost Report Year End Adjusted DSH Uncompensated Care Cost (UCC) % of Year Applicable Totals Cost Report Year 1 UCC: - X 0.00% = $ - Cost Report Year 2 UCC: - X 0.00% = $ - Cost Report Year 3 UCC: - X 0.00% = $ - Sub-Total: $ - **Total Uncompensated Care Calculation (UCC): $ - Out-of-State DSH Payment: $ - DSH Payment: $ - DSH Payment In Excess of UCC: $ - Non-Compliant Findings: 1. Log 1 Uninsured Patient Level Detail not Submitted 2. Log 3 MCO Patient Level Detail not Submitted 3. Log 5 OOS FFS Patient Level Detail Submitted in Non-Compliant Format 15

16 2016 Exam (10/1/15-9/30/16) Applicable State Fiscal Year Cost Reports SFY 2016 (7/1/15-6/30/16) SFY 2017 (7/1/16-6/30/17) NA 9/30/ mo 10/31/2015-1mo 10/31/ mo 11/30/2015-2mo 11/30/ mo 12/31/2015-3mo 12/31/2016-9mo 3/31/2016-6mo 3/31/2017-6mo 6/30/2016-9mo 6/30/2017-3mo 16

17 DSH Exam Compliant Versions of the SFY 2016 Ohio Medicaid Cost Reports Should already have been submitted to ODM (Myers and Stauffer will obtain from ODM) Myers and Stauffer Data Request Letter Certification Signature (DSH Payments Retained) Will not be sent to providers until November 2018 Revenue Code Crosswalk 3 rd Party Disclosure Form Patient-Level Detail (using data templates) Subject to Further Guidance from CMS Logs will be rejected if not reported in accordance with Myers and Stauffer Patient Log Templates 17

18 Cost Report Schedule/Section Schedule C-2 Schedules F1-F4 Schedule J1 Schedule J2 Schedule J3 Schedule J4 Schedule J5 Schedule J6 Reason To report Uninsured & Medicaid managed care routine costs in accordance with Medicare costing principles (per diems) To report Uninsured costs/payments in accordance with Medicare costing principles (by cost center) To report out-of-state DSH payments To report In-State MCO crossover costs/payments To report out-of-state Medicaid costs/payments To report out-of-state crossover costs/payments To report MyCare Ohio Program costs/payments To report Other Medicaid Eligibles costs/payments 18

19 Patient Log Log 1 - Uninsured Charges Ties to C/R Schedules Schedules F1 F4 Log 2 - Self-Pay Payments (All) Log 3 - In-State Medicaid Managed Care Log 4 - In-State Medicaid Managed Care Crossovers Log 5 - Out-of-State Medicaid FFS Log 6 - Out-of-State Medicaid Managed Care Log 7 - Out-of-State Medicaid FFS Crossovers Log 8 - Out-of-State Medicaid Managed Care Crossovers Log 9 MyCare Ohio Program Schedules F and F1 F4 Schedules C-2 and I Schedules J1 and J2 Schedules J1 and J3 Schedules J1 and J3 Schedules J1 and J4 Schedules J1 and J4 Schedules J1 and J5 Log 10 Other Medicaid Eligibles Schedules J1 and J6 19

20 Schedule F series charges for patients without insurance must reflect services (discharges) incurred during the hospital cost report year regardless of financial category (<100% FPL, >100% FPL) Claim Status (Column K) is the same as the prior year need to indicate if Exhausted/Non-Covered Insurance claims are being included under the December 3, 2014 final DSH rule. 20

21 Hospitals can report services if insurance is fully exhausted or if the service provided was not covered by insurance. The service must still be a hospital service that would normally be covered by Medicaid. If exhausted/non-covered insurance services are included on Log 1, then they must be included on Log 2 for patient payments. 21

22 Note: Uninsured Charges must be based on Discharges incurred during the cost report period. Patient Identification Number (PCN) Patient Name Admit Date Discharge Date Service Indicator (IP hospital / OP hospital) Revenue Code Gross Charges* Routine Days Total Patient Payments Received ** Total Private Insurance Payments Received Claim Status (Exhausted or Non- Covered Service ***, if applicable) Doe, Jane 3/1/2010 3/11/2010 Inpatient 110 $ 4, $ Doe, Jane 3/1/2010 3/11/2010 Inpatient 200 $ 4, $ Doe, Jane 3/1/2010 3/11/2010 Inpatient 250 $ 5, $ Doe, Jane 3/1/2010 3/11/2010 Inpatient 300 $ 2, $ Doe, Jane 3/1/2010 3/11/2010 Inpatient 360 $ 15, $ Doe, Jane 3/1/2010 3/11/2010 Inpatient 450 $ 1, $ Jones, James 6/15/2010 6/15/2010 Outpatient 250 $ $ Exhausted Jones, James 6/15/2010 6/15/2010 Outpatient 450 $ $ Exhausted Smith, Mike 8/10/2010 8/10/2010 Outpatient 450 $ 1, $ - Non-Covered Service Log Type (>100%FPL / <100%FPL) * All charges for non-hospital services should be excluded. ** These amounts are used for examination purposes only and should reflect all patient payments received to date on the account; please note this log should only contain charges and payments for uninsured claims. *** Report services not covered under the patient's insurance package as a "Non-Covered Service" (NOTE - the service must be covered under the state Medicaid plan). The determination of an individual's status as having a source of third party coverage must be a service specific coverage determination. The service specific coverage determination can occur only once per individual per service provided and applies to the entire service, including all elements as that service, or similar services, would be defined in Medicaid (42 CFR (c)(1)). The intent is that the hospital will generally determine that an individual is either insured or not insured for a given hospital stay, and will not separate out component parts of the hospital stay based on the level of payment received (79 Federal Register 71691, dated December 3, 2014). **** It is reasonable to expect a certain amount of variance compared to the Ohio Medicaid Cost Report due to the timing differences of running the data. Reasonable variances will usually be accepted. If a variance appears to be greater than expected we will contact you to confirm the amounts. 22

23 Self Pay Payments must be reported on a cash basis (payments received during the hospital cost report year) regardless of financial category (<100% FPL, >100% FPL), and regardless if such payments are applicable to a prior period. This Log should capture Self Pay Payments for all patients regardless of Insurance Status. Please note the column to indicate if the cash collection is a 1011 payment. These payments of the Medicare Prescription Drug Improvement Act of 2003 provide federal reimbursement for emergency health services furnished to undocumented aliens. If your hospital participates in this program these payments must be reported on the Ohio Medicaid Cost Report, Schedule E, line 7b. Additional information on Section 1011 can be found at: Network-MLN/MLNProducts/downloads/Section_1011_Fact_Sheet.pdf 23

24 Note: Must represent ALL self-pay payments received during the cost report period (Regardless of Insurance Status) Patient Identification Number (PCN) Patient Name Admit Date Discharge Date Cash Collection Date Payments Received Indicate if Service Collection Indicator is a 1011 (IP hospital Payment* / OP ** hospital ) Total Hospital Charges* Total Physician Charges Total Other Nonhospital Charges ** Insurance Status* (Insured / Uninsured) Claim Status (Exhausted or Non- Covered Service ****, if applicable) Jones, Anthony 7/12/1995 7/14/1995 1/1/2010 $ No Inpatient $ 10, $ $ - Insured Jones, Anthony 7/12/1995 7/14/1995 2/1/2010 $ No Inpatient $ 10, $ $ - Insured Jones, Anthony 7/12/1995 7/14/1995 3/1/2010 $ No Inpatient $ 10, $ $ - Insured Jones, Anthony 7/12/1995 7/14/1995 4/1/2010 $ No Inpatient $ 10, $ $ - Insured Smith, John 9/21/2000 9/21/2000 9/30/2009 $ No Outpatient $ 2, $ - $ Insured Exhausted Smith, John 9/21/2000 9/21/ /31/2009 $ No Outpatient $ 2, $ - $ Insured Exhausted Smith, John 9/21/2000 9/21/ /30/2009 $ No Outpatient $ 2, $ - $ Insured Exhausted Cliff, Heath 12/31/2009 1/1/2010 5/15/2010 $ No Inpatient $ 15, $ 1, $ - Uninsured Cliff, Heath 12/31/2009 1/1/2010 5/31/2010 $ No Inpatient $ 15, $ 1, $ - Uninsured Johnson, Joe 9/1/2005 9/3/ /12/2010 $ No Inpatient $ 14, $ $ Insured Non-Covered Service * Charges and insurance status will be the same when listing multiple payments for the same patient and dates of service. ** Other non-hospital charges should include RHC, FQHC, Pharmacy, etc. *** If Section 1011 (undocumented Alien) payments are applied at a patient level, include these payments in the cash collection column. **** Report services not covered under the patient's insurance package as "Non-Covered Service". (NOTE - the service must be covered under the state Medicaid plan) ***** It is reasonable to expect a certain amount of variance compared to the Ohio Medicaid Cost Report due to the timing differences of running the data. Reasonable variances will usually be accepted. If a variance appears to be greater than expected we will contact you to confirm the amounts. Log Type >100%FPL / <100%FPL 24

25 Note: Data must be based on Discharges incurred during the cost report period * All charges for non-hospital charges should be excluded. ** Include charges and payments for the following: 1) Ohio Medicaid MCO is primary, 2) the Ohio Medicaid MCO is secondary to other insurance and a payment was received from both or only the primary, and the claim was reported as "paid" on the Ohio Managed Care Plan remittance advice. Please refer to the Ohio Medicaid Cost Report instructions for Schedule I, Title XIX HMO Cost Calculations. *** If a situation exists where private insurance is primary and Medicaid is secondary (regardless if Medicaid makes a payment), include in this Log even if not originally reported on Schedule I of the Ohio Medicaid Cost Report. **** It is reasonable to expect a certain amount of variance compared to the Ohio Medicaid Cost Report due to the timing differences of running the data. Reasonable variances will usually be accepted. If a variance appears to be greater than expected we will contact you to confirm the amounts. ***** Payments should reflect all payments received through the present. 25

26 Note: Data must be based on Discharges incurred during the cost report period * All charges for non-hospital charges should be excluded. ** Include charges and payments for the following: 1) Medicare is primary and the Medicaid MCO is secondary, 2) the Ohio Medicaid MCO is secondary to other insurance and a payment was received from both or only the primary, and the claim was reported as "paid" on the Ohio Managed Care Plan remittance advice. Please refer to the Ohio Medicaid Cost Report instructions for Schedule J2, Title XIX In-State Medicare/Medicaid Crossover Cost Calculations. *** If a situation exists where private insurance is primary and Medicare is secondary (regardless if Medicaid makes a payment), include in this Log regardless if not originally reported on Schedule J2 of the Ohio Medicaid Cost Report. **** It is reasonable to expect a certain amount of variance compared to the Ohio Medicaid Cost Report due to the timing differences of running the data. Reasonable variances will usually be accepted. If a variance appears to be greater than expected we will contact you to confirm the amounts. ***** Payments should reflect all payments received through the present. 26

27 Note: Data must be based on Discharges incurred during the cost report period * All charges for non-hospital charges should be excluded. ** Include charges and payments for the following: Medicaid program of another state is primary. Please refer to the Ohio Medicaid Cost Report instructions for Schedule J3, Title XIX Out-of-State Medicaid Cost Calculations. *** It is reasonable to expect a certain amount of variance compared to the Ohio Medicaid Cost Report due to the timing differences of running the data. Reasonable variances will usually be accepted. If a variance appears to be greater than expected we will contact you to confirm amounts. **** Payments should reflect all payments received through the present. 27

28 Note: Data must be based on Discharges incurred during the cost report period * All charges for non-hospital charges should be excluded. ** Include charges and payments for the following: Medicaid Managed Care program of another state is primary. Please refer to the Ohio Medicaid Cost Report instructions for Schedule J3, Title XIX Out-of-State Medicaid Cost Calculations. *** It is reasonable to expect a certain amount of variance compared to the Ohio Medicaid Cost Report due to the timing differences of running the data. Reasonable variances will usually be accepted. If a variance appears to be greater than expected we will contact you to confirm the amounts. **** Payments should reflect all payments received through the present. 28

29 Note: Data must be based on Discharges incurred during the cost report period * All charges for non-hospital charges should be excluded. ** Include charges and payments for the following: Medicare program of another state is primary and Medicaid program of another state is secondary. Please refer to the Ohio Medicaid Cost Report instructions for Schedule J4, Title XIX Out-of-State Medicare/Medicaid Crossover Cost Calculations. *** It is reasonable to expect a certain amount of variance compared to the Ohio Medicaid Cost Report due to the timing differences of running the data. Reasonable variances will usually be accepted. If a variance appears to be greater than expected we will contact you to confirm the amounts. **** Payments should reflect all payments received through the present. 29

30 Note: Data must be based on Discharges incurred during the cost report period * All charges for non-hospital charges should be excluded. ** Include charges and payments for the following: Medicare program of another state is primary and Medicaid program of another state is secondary. Please refer to the Ohio Medicaid Cost Report instructions for Schedule J4, Title XIX Out-of-State Medicare/Medicaid Crossover Cost Calculations. *** It is reasonable to expect a certain amount of variance compared to the Ohio Medicaid Cost Report due to the timing differences of running the data. Reasonable variances will usually be accepted. If a variance appears to be greater than expected we will contact you to confirm the amounts. **** Payments should reflect all payments received through the present. 30

31 Note: Data must be based on Discharges incurred during the cost report period * All charges for non-hospital charges should be excluded. ** Include the following: MyCare Ohio program or Integrated Care Delivery System program of another state. Please refer to the Ohio Medicaid Cost Report instructions for Schedule J5, MyCare Ohio and Out-of-State Integrated Care Delivery System Cost Calculations. *** It is reasonable to expect a certain amount of variance compared to the Ohio Medicaid Cost Report due to the timing differences of running the data. Reasonable variances will usually be accepted. If a variance appears to be greater than expected we will contact you to confirm the amounts. **** Payments should reflect all payments received through the present. 31

32 Other Medicaid Eligibles Medicaid-eligible patient services where Medicaid did not receive the claim or have any cost sharing may not be included in the state s data. The hospital must submit these eligible services on Log 10 for them to be eligible for inclusion in the DSH uncompensated care cost (UCC). If no log 10 data is submitted, please provide an explanation for the omission in the cover letter to Myers and Stauffer. This includes patients with private insurance who are dually eligible for Medicaid. (CMS Additional Information on the DSH Reporting and Audit Requirements, FAQ #33, January 2010) 32

33 Note: Data must be based on Discharges incurred during the cost report period * All charges for non-hospital charges should be excluded. ** If a Medicaid FFS or Medicaid FFS Crossover claim is not submitted to ODM, it should be reported in this Log since M&S will adjust to the MMIS claims data and will also utilize this Log to capture any Medicaid-eligible non-claim submissions for these patient populations. *** Include charges and payments for the following: Other Medicaid Eligibles. Please refer to the Ohio Medicaid Cost Report instructions for Schedule J6, Other Medicaid Eligibles. Schedule J6 is a new schedule for the SFY2017 Medicaid Cost Report. Please note, if a Medicaid FFS or Medicaid FFS Crossover claim (including zero-pays) has been submitted to ODM, these services will be included in the paid claims data received from the State (and therefore would not be included in this Log). For In-state Medicaid Managed Care patients (non-crossover), if a situation exists where private insurance is primary and Medicaid is secondary (and the claim was not submitted to ODM), include in this Log. Otherwise, include the claim in Log 3 - Medicaid Managed Care regardless if not originally reported on Schedule I of the Ohio Medicaid Cost Report. Additionally, if a situation exists where private insurance is primary and Medicare is secondary (and the claim was not submitted to ODM), include in this Log. Otherwise, include the claim in Log 4 - Medicaid Managed Care Crossovers regardless if not originally reported on Schedule J2 of the Ohio Medicaid Cost Report. **** It is reasonable to expect a certain amount of variance compared to the Ohio Medicaid Cost Report due to the timing differences of running the data. Reasonable variances will usually be accepted. If a variance appears to be greater than expected we will contact you to confirm the amounts. ***** If no Log 10 data is submitted please provide an explanation for the omission in the cover letter to Myers & Stauffer. ****** Payments should reflect all payments received through the present. 33

34 Log Description Also Use Log 10? When Log 10 is applicable N/A - Obtained Traditional FFS Medicaid (non-crossover) Maybe FFS Medicaid eligible (non-crossover) claim is NOT submitted to ODM. For from MMIS example, many providers historically have not submitted claims to ODM for Medicaid-eligible patients when a 3rd party payer paid more than what Medicaid would pay (i.e., no Medicaid liability). These and similar nonsubmissions for Medicaid-eligible patients, including instances in which no Medicaid liability exits should be included on log 10. N/A - Obtained from MMIS Traditional FFS Medicaid crossover Maybe FFS Medicaid eligible crossover claim is NOT submitted to ODM. For example, many providers historically have not submitted claims to ODM for Medicaideligible patients when Medicare paid more than what Medicaid would pay (i.e., no Medicaid liability). These non-submissions for Medicaid-eligible patients should be included on log Uninsured Charges No 2 Self-pay payment No 3 IN-State Medicaid Managed Care (Non-Crossover) Maybe IN-State Medicaid Managed Care (Non-Crossover) where Medicaid is primary use log 3. If a situation exists where private insurance is primary and Medicaid is secondary (regardless if Medicaid makes a payment), include on EITHER log 3 OR log 10 (not both). 4 IN-State Medicaid Managed Care Crossover Maybe IN-State Medicaid Managed Care (Crossover) where Medicare is primary use log 4. If a situation exists where private insurance is primary and Medicare is secondary (regardless if Medicaid makes a payment), include on EITHER log 4 OR log 10 (not both). 5 OOS Medicaid FFS No 6 OOS Medicaid Managed Care (Non-Crossover) No 7 OOS Medicaid FFS Crossover No 8 OOS Medicaid Managed Care Crossover No 9 MyCare Ohio No 10 Other Medicaid Eligibles N/A See "Maybe" scenarios above. 34

35 This is now a specific item listed in the Provider Data Request letters that were sent out earlier this month. Revenue Code Crosswalks are required for every payor type in order to allocate days and charges for each revenue code included in the Patient Logs to the appropriate cost centers. A template is provided in the Ohio Patient Log Templates work book. Log templates were updated on ODM s website August 29,

36 Crosswalk: One-to-One Allocation A one-to-one crosswalk should be utilized when each revenue code is allocated to a single cost center. Provider Revenue Code (A) Provider CCID (B) % % % % % % % % % Percentage Allocation (C) 36

37 Crosswalk: One-to-Many Allocation A one-to-many crosswalk should be utilized when individual revenue codes are allocated to multiple cost centers. Provider Revenue Code (A) Provider CCID (B) Percentage Allocation (C) % % % % % % % % % 37

38 1. What is the definition of uninsured for Medicaid DSH purposes? Uninsured patients are individuals with no source of third party health care coverage (insurance) for the specific inpatient or outpatient hospital service provided. Prisoners must be excluded. On December 3, 2014, CMS finalized the proposed rule published on January 18, 2012 Federal Register to clarify the definition of uninsured and prisoners. Under this final DSH rule, the DSH examination looks at whether a patient is uninsured using a service-specific approach. Based on the 2014 final DSH rule, the survey allows for hospitals to report fully exhausted and insurance non-covered services as uninsured. 38

39 1. What is the definition of uninsured for Medicaid DSH purposes? (Continued from previous slide) Excluded prisoners were defined in the 2014 final DSH rule as: Who are inmates in a public institution or are otherwise involuntarily held in secure custody as a result of criminal charges. These individuals are considered to have a source of third party coverage. Prisoner Exception If a person has been released from secure custody and is referred to the hospital by law enforcement or correction authorities, they can be included. The individual must be admitted as a patient rather than an inmate to the hospital. The individual cannot be in restraints or seclusion. 39

40 2. What is meant by Exhausted and Non-Covered in the uninsured Logs 1 and 2? Under the December 3, 2014 final DSH rule, hospitals can report services if insurance is fully exhausted or if the service provided was not covered by insurance. The service must still be a hospital service that would normally be covered by Medicaid. 40

41 3. What categories of services can be included in uninsured? Services that are defined under the Medicaid state plan as a Medicaid inpatient or outpatient hospital service may be included in uninsured. (Auditing & Reporting pg & Reporting pg ) There has been some confusion with this issue. CMS attempts to clarify this in #24 of their FAQ titled Additional Information on the DSH Reporting and Audit Requirements. It basically says if a service is a hospital service it can be included even if Medicaid only covered a specific group of individuals for that service. EXAMPLE : A state Medicaid program covers speech therapy for beneficiaries under 18 at a hospital. However, a hospital provides speech therapy to an uninsured individual over the age of 18. Can they include it in uninsured? The answer is Yes since speech therapy is a Medicaid hospital service even though they wouldn t cover beneficiaries over

42 4. Can a service be included as uninsured, if insurance didn t pay due to improper billing, late billing, or lack of medical necessity? No. Improper billing by a provider does not change the status of the individual as insured or otherwise covered. In no instance should costs associated with claims denied by a health insurance carrier for such a reason be included in the calculation of hospital-specific uncompensated care (would include denials due to medical necessity). (Reporting pages & 77913) 42

43 5. Can unpaid co-pays or deductibles be considered uninsured? No. The presence of a co-pay or deductible indicates the patient has insurance and none of the co-pay or deductible is allowable even under the 2014 final DSH rule. (Reporting pg ) 6. Can bad debts be considered uninsured? Bad debts cannot be considered uninsured if the patient has third party coverage. The exception would be if they qualify as uninsured under the 2014 final DSH rule as an exhausted or insurance non-covered service (but those must be separately identified). 43

44 7. Can a hospital report services covered under automobile polices as uninsured? Not if the automobile policy pays for the service. We interpret the phrase who have health insurance (or other third party coverage) to broadly refer to individuals who have creditable coverage consistent with the definitions under 45 CFR Parts 144 and 146, as well as individuals who have coverage based upon a legally liable third party payer. The phrase would not include individuals who have insurance that provides only excepted benefits, such as those described in 42 CFR , unless that insurance actually provides coverage for the hospital services at issue (such as when an automobile liability insurance policy pays for a hospital stay). (Reporting pages & 77916) 44

45 8. How are patient payments to be reported on Log 2? Cash-basis! Log 2 should include patient payments collected during the cost report period (cash-basis). Under the DSH rules, uninsured cost must be offset by uninsured cash-basis payments. 9. Does Log 2 include only uninsured patient payments or ALL patient payments? ALL patient payments. Log 2 includes all cash-basis patient payments so that testing can be done to ensure no payments were left off of the uninsured log. 45

46 10. Can Physician services be included in the UCC? Physician costs that are billed as physician professional services and reimbursed as such should not be considered in calculating the hospital-specific DSH limit. (Reporting pg ) 11. Do dual eligibles (Medicare/Medicaid) have to be included in the Medicaid UCC? Yes. CMS believes the costs attributable to dual eligible patients should be included in the calculation of the uncompensated care costs, but in calculating the uncompensated care costs, it is necessary to take into account both the Medicare and Medicaid payments made. In calculating the Medicare payment, the hospital should include all Medicare adjustments (DSH, IME, GME, etc.). (Reporting pg ) 46

47 12. Does Medicaid MCO and Out-of-State Medicaid have to be included? Yes. Under the statutory hospital-specific DSH limit, it is necessary to calculate the cost of furnishing services to the Medicaid populations, including those served by Managed Care Organizations (MCO), and offset those costs with payments received by the hospital for those services. (Reporting pages & 77926) 13. Do Other Medicaid Eligibles (Private Insurance/Medicaid) have to be included in the Medicaid UCC? Days, costs, and revenues associated with patients that are dually eligible for Medicaid and private insurance should be included in the calculation of the Medicaid inpatient utilization rate (MIUR) for the purposes of determining a hospital eligible to receive DSH payments. Section 1923(g)(1) does not contain an exclusion for individuals eligible for Medicaid and also enrolled in private health insurance. Therefore, days, costs and revenues associated with patients that are eligible for Medicaid and also have private insurance should be included in the calculation of the hospital-specific DSH limit. (January, 2010 CMS FAQ 33 titled, Additional Information on the DSH Reporting and Audit Requirements ) 47

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49 When submitting data via the secure M&S FTP site, and you have questions, please contact Kevin Weingartner or Crissy Gallion or at the following number: The secure M&S FTP site is located at: Note: ALL Patient-Level Detail Logs 1-10 include protected health information and must be sent accordingly (No ). For all other questions, please contact Carl Williams at or