Transcript CPE Cost Reports, Audits and WACs

CPE Cost Reports, Audits and
WACs
What You Need to Know
September 26, 2008
10:00 AM
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Today's Speakers
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Jeff Mero, Executive Director, AWPHD
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Mary K. Bensen, Consultant
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The CPE Program – SFY 2009
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HRSA estimates that the total payments
to CPE hospitals will be $257 million
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CMS will pay $199 million of the costs
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The state will pay $58 million
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Definitions
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CMS: Centers for Medicare & Medicaid – the
federal provides the federal match from
Medicaid
HRSA: Health & Recovery Services
Administration – Medicaid state agency
OIG: Office of the Inspector General – audit
department of the federal Health and Human
Services (HHS)
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General Issues on the
Medicaid Cost Report
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The fee-for-service and state programs paid claims
are provided by the HRSA (PS & R).
Hospitals develop logs (PS & R) of paid claims for
Healthy Options (managed care) services and the
uninsured by revenue center.
The payments are to reflect the actual payments
received for the claims in the hospital developed logs.
If a hospital corrects its Medicaid cost report,
the hospital needs to submit a revised signed
certification (Schedule S1).
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Common Errors on the
Medicaid Cost Reports
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Routine charges for inpatient Medicaid, state programs,
managed care, and the uninsured are omitted (see
Schedule 1 Columns 1a, 3a, 5a, and 7a on Total
Routine line between lines 36 and 37).
Interim payments sometimes do not include actual
payments, third party, patient responsibility, and
hospitals portion of the CPE payments.
Cross walk between revenue codes and cost centers on
Medicaid cost report missing.
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Important Issues on CPE
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The CPE Medicaid program includes federal
funds and all CPE hospitals should consider
the implications by maintaining detailed
documentation.
CMS and HRSA rely on the hospital
certification that the information is true,
correct, complete and from hospital records.
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What the Federal Government
Relies on for CPE
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Hospitals certify that the Medicaid costs and costs of
the uninsured have been incurred (the costs are real
and the hospital is responsible for payment of the
costs) .
And the hospital has paid for non-federal share of the
costs without using non-allowed federal funds such
as Medicaid payments or a federal grant for another
project.
Federal regulation 42 CFR 433.51
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Audits – Audits - Audits
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HRSA conducts audits based on paid claims and will
continue for CPE hospitals after Medicaid cost reports
are final.
Timing or scope of claims audits are not determined
by the CPE program staff rather by the audit staff.
Various federal agencies can audit hospitals as the
Medicaid program relies on federal funds with no
time or scope limitation.
The federal General Accounting Office can review the
CPE program at any time – often such reviews are
part of a report to Congress.
CPE audits both on a federal and state level.
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CPE Audits are in Addition to
Ongoing Medicaid Audits
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Recent webcast provided an in depth
discussion of ongoing Medicaid audits.
The webcast “The Ins and Outs of Dealing
with Medicaid Audits” .
The webcast can be accessed at AWPHD.org
in New from AWPHD or WSHA.org in the
Webcasts and Presentation section.
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When Might the HRSA Audit
the CPE Program
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HRSA currently relies on the certification from the
Medicaid cost report and corrects obvious reporting
errors for the interim payments and settlements.
HRSA has stated that at some point in the future
hospital managed care and uninsured data on the
final Medicaid cost report may be audited - possibility
by an outside audit firm.
If HRSA elects to audit, SFY 2006, 2009 would be the
soonest.
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What the HRSA May Audit in
the CPE Program
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Continuation of HRSA audits on claims regardless of
status: CPE or non-CPE
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Audit of hospital reported data on managed care and
uninsured claims data up to a claim by claim review
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Affects DSH CAP: Uninsured cases revenue codes:
are the codes that Medicaid pays
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Affects DSH CAP: All payments for the managed care
and uninsured included
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Affects DSH CAP: Were the uninsured truly
uninsured with no third party payments
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When Might the Federal
Government Audit CPE
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HRSA staff has stated that CMS will
review CPE after the SFY 2006 final
Medicaid cost reports are settled.
CMS or the OIG or some other federal
agency can audit the CPE program at
any time.
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CPE Audit by Federal
Government (CMS or OIG)
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A federal audit is between the state and the federal
government.
If the audit is conducted by the OIG (agency other than
CMS), the findings of the audit are to CMS for any
action CMS would take with the state.
CPE hospitals may be audited to determine if the data
HRSA used are in compliance with federal requirements
and the state plan (how the state said the program is
to operate).
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What Concerns Would CMS
Have with HRSA
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CMS is a payer and pays over 50 percent of the
Medicaid program costs.
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CMS will review how HRSA came up with the billing
amount to CMS.
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CMS will look at what HRSA is including as costs.
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Is HRSA paying over the upper limit – the amount
Medicare would have paid for the services (measured
annually)?
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What a Hospital May Expect in a
Federal (CMS or OIG) CPE Audit
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Affects DSH CAP: Audit managed care and uninsured
claims data up to a claim by claim review of what is
reported on the Medicaid cost report.
Affects DSH CAP: Uninsured cases revenue codes are the codes what Medicaid pays.
Affects DSH CAP: All payments for the managed care
and uninsured included.
Affects DSH CAP: Were the uninsured truly
uninsured with no third party payments?
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What Documentation Should a
Hospital Maintain
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Managed care: patient logs including discharge date
or date of service, payer, charges by revenue center,
and payments on the claims by plan and TPL
Uninsured: patient logs including discharge date or
date of service, charges by revenue center, and
payments by patient
Documentation of how the managed care and
uninsured are identified and the retrieval
process used
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Medicaid cost report (as-filed and final)
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Revenue codes to cost center cross walk
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Records That are Updated for
Final Medicaid Cost Report
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Patient logs for the managed care and uninsured
services must be updated when the final Medicaid
cost report is prepared.
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Any additional payments on the uninsured claims
must be recorded.
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Claims that were considered insured but later found
to be uninsured would be added.
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Cross walk for revenue codes and cost centers.
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How Would State Audits Affect
CPE Hospitals
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Claims audits would probably reduce the hold
harmless if claims are disallowed or adjusted.
If the CPE did not receive a grant, the audit
items that affect the DSH CAP could result in
in the hospital returning funds to state and
the state returning funds to CMS.
If the CPE did receive a grant, the audit items
that affect the DSH CAP could result in the
state returning funds to CMS.
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How Would Federal Audits
Affect CPE Hospitals
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Any findings would be between CMS
and the state, a federal audit would not
result in a federal recoupment from the
hospital.
If there is a recoupment between CMS
and the state, the same risks apply to
the CPE hospital as with a state audit
especially for non-grant hospitals.
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Proposed State Medicaid
Regulations (WAC) - Status
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Hearing on the WAC was held
August 26, 2008
Comments were due by August 26, 2008
As of now, WACs are not shown as
adopted however, no change from the
proposed is anticipated
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388-550-4670 CPE Payment Program
– “Hold Harmless” Provision
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Hold harmless is subject to legislative
directives and appropriations.
Hospital CPE submissions are subject to
audit including the cost report
schedules.
WAC 4(b) states that the final hold
harmless calculation will be performed
after audit.
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388-550-4690 Authorization Requirements
and Utilization Review for Hospitals
Eligible for CPE Payments
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Clarifies that psychiatric admissions are
excluded from this section.
Effective August 1, 2007, CPE hospitals
are subject to the same utilization rules
as the non-CPE hospitals.
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388-550-5470 CPE Medicaid
Cost Report and Settlements
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Hospitals must send the Medicare finalized cost
report (with NPR) 30 days after receipt.
Hospitals have 30 days after receipt of HRSA updated
PS & R to complete the finalized cost report and
update the uninsured and managed care claims.
Hospitals must provide cross walks between revenue
codes and cost centers on the Medicaid cost report.
All as-filed, finalized cost reports and supplemental
data are subject to audit with no time restrictions or
limitations.
WAC 4(b) states that the final hold harmless
calculation will be performed after audit.
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Questions
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