Transcript Medicare Disproportionate Share

Medicare Disproportionate
Share Update
HFMA January 26, 2008
Presented by: Felicia Viselli President, HealthQuest Consulting, Inc.
DSH Formula
 Comprised of 2 components
 Supplemental Security Income(SSI) Ratio +
Medicaid Ratio
 Increases in either component increases the
total DSH payment
SSI Ratio
Federal Fiscal YR
2007
Differences
Will include HMO
Claims
Notes
Delayed
Release
2006
Excludes HMO
Claims
Under Review
Option to use 05
until reissued
2005
Re-Issued
Denominator
In Error
SSI Errors Uncovered
 Baystate v.Mutual of Omaha
 2003 & 2004 PRRB Hearings Challenged
the CMS SSI Ratio was flawed for FYE(S)
1993-1996
 PRRB renders Provider favorable decision
on March 22, 2006
SSI Errors (continued)
 SSI systemic errors noted
 Omission of inactive or “stale” records (i.e.,SSI
records of recipients whose eligibility terminated
prior to time when SSA submitted data to CMS
e.g. deceased persons)
 SSI records were deleted due to space limitations
 Omission of “forced Pay” cases (when payment
was manual as opposed to automated)
 Omission of retroactive cases
 Omission of non-cash beneficiaries
The Errors continue
 Failure to use multiple identifiers to identify SSI
recipients
 The PRRB further found that the SSI data
contained certain historical errors that were within
the control of CMS to correct
 The Administrator overturned the PRRB’s
decision and the provider proceeded to the U.S.
District court of Columbia
SSI Case Status
 On March 31, 2008 the district court held that the Secretary’s decision
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was arbitrary and capricious and ordered the case remanded to the
Secretary for further action
Subsequently, Baystate filed a motion to amend portions of the court’s
decision regarding remedy.
On November 8, 2008 the court expressly directed the Secretary to
recalculate the SSI ratios for FYE(s) 1993-1996 and pay interest
Subsequently in a joint status report before the court, Baystate
requested the court enter final judgment with respect to the Secretary’s
final decision (count one) and hold in abeyance counts two and three
concerning whether HHS or SSA has to release all of the social
security records
On December 8, 2008 the court granted Baystate’s requests
Conclusions
 The credibility of the CMS supplied SSI%
is suspect
 In light of the recent court rulings consider
the benefits of challenging CMS’
calculation
 Preserve your appeal rights by filing
protested amounts and protective appeals
List of Protested Amounts
 SSI ratio cost reporting period versus
federal fiscal year
 Total SSI days are understated (numerator)
 Total Covered days are overstated
(Denominator)
 Eligible vs. Entitled days
Medicare HMO Days & SSI
 July 2, 2007 CMS issued Transmittal 1131
Mandates Providers submit “No-Pay” bills
for Medicare Advantage Plans
 This is CMS’ attempt to capture HMO days
in the SSI fraction
 Required for FFY 07 (Explains the delay)
 Transmittal Implementation Date 1/07/08
Medicare HMO DSH Impact
 What Impact will the CMS billing requirement
have on DSH reimbursement?
 It is more advantageous to add days to the
Medicaid Fraction than the SSI fraction because
the Medicaid Denominator is fixed
 The denominator of the SSI fraction increases
with the addition of a dual-eligible days
 Low Probability that these patients will qualify for
SSI
Medicaid Fraction
 Total days for Medicaid Eligible patients
(excluding those with Part A coverage)
Divide by
 Total Acute PPS days
Medicaid Fraction Audit Issues
 Medicaid days should be based upon
discharge date (OIG report on DSH
reimbursement Methodist Hospital report
A-04-03-0203)
Medicare DSH Audit Issues
Audit Issue
Resolution
Population includes beneficiaries with
full and restricted benefits. A single
sample may result in disproportionate
audit disallowances.
Separate the population into 4 groups:
Non-restricted, Non-restricted “sameday stays”, restricted-OB & restrictedOther
Dual Eligible (State System not
complete)
Dead People Excluded
Exclude patients internally classified
Patients w/o only Part B are identified
as Part A
as Part A and/or CWF review
Run Medicare Patients through
secondary check (e.g. passport)
Same day Stays are heavily scrutinized
As potentially non-inpatient
Dr.s Formal admission constitutes an
inpatient
A room charge is not mandatory
MAC requests Remittance Advice (RA)
No RAs Available
Refuse to Provide
Audit Issues Continued
Audit Issue
MAC requests TAR
for non-restricted
days
MAC questions
Emergent nature of
Admit for RAC day
Resolution
Refer to HCFA ruling
97-2 (eligible vs. paid)
Provide proof of payment
or TAR