Transcript FI Support for Medicare Like Rates

FI Support for MedicareLike Rates
Topics for FI discussion
Overview of system changes
Discontinuation of pre-pricing
Critical Access reimbursement
Letter sent to providers from FI
Pass Thru Rate / No Settlement
DRG Disclosure Report
Pends/Message codes pertinent to MLR
EOBR examples
“Better than” Medicare-Like Rates
Question & Answer
FI System Changes
No requirement for contracts for MLR
pricing.
Suffixes no longer used to point to a
pricing methodology.
Claims paying per MLR will not pend for
signature authority
Programming done for other PPS
methodologies (Psych, Rehab, LTC, SNF,
Home Health, Hospice, APC)
Future FI programming
To accommodate the regulation the FI is
currently programming for the following:
Rural hospital demonstration project per
section 410 of the Medicare Modernization
Act
Children’s Hospitals and Cancer Centers
Timely filing
Discontinuation of Pre-Pricing
In the past the FI has, on occasion, assisted an
Area or Service Unit by pre-pricing a claim to
help obligate a Purchase Order or negotiate a
rate with an open market provider.
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With the large number of providers now paid at PPS
rates, the FI is not staffed to continue pre-pricing
claims.
Online pricers are available to Service Units.
The FI does not have a tool to pre-price APCs.
Critical Access Reimbursement
Per Diems are calculated using the latest
settled cost report.
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If there isn’t a settled cost report then the “as
filed” report will be used.
If there hasn’t been a cost report filed, the
Medicare FI will be contacted for the providers
rate.
No method 2 reimbursement related to the
physician component.
Provider Letter from FI
Sent July 11th to providers that will be
reimbursed under MLR
Billing instructions provided for IHS/CHS facility
claims
UB04 required for DOS on or after July 5, 2007.
6 digit legacy number required in form locator 57
EMC providers to continue use of the 837-I
format which now requires the NPI.
Taxonomy code required for inpatient services.
Questions regarding billing should be directed to
IHS/CHS FI Customer Service.
Pass Thru Rate / No Settlements
Regulation requires the FI to use the
“interim rate” from the provider specific file
as the pass thru reimbursement. This is
paid per day.
Prior to MLR, the pass thru was calculated
using settled cost reports and was paid
per discharge.
Unlike Medicare, the IHS/CHS program
will not pay retrospective payments after
the cost reports are settled.
DRG Disclosure Report
DRG disclosure reports will now be available for all
hospitals receiving DRG reimbursement. Prior to MLR,
this report was only for DRG contracted providers.
Updated reports will be available at least twice a year after the annual DRG pricer load and/or provider specific
file (PSF) loads.
A special run for the DRG disclosure reports will be
available in August for all hospitals receiving DRG
reimbursement.
Reports are available on the Report Retrieval System.
Website address is https://mychsfireports.documentportal.com. Access must be approved
by Area or Tribal CHSO.
New DRG Disclosure Report
Header
Pass Thru Per Day will show
for MLR Pricing
Contract No. will show for Better
than MLR Contracts
Pass Thru/Settled will show for Better than MLR
Contracts
Pends/Message Codes Pertinent to MLR
FI internal pends may increase while the
providers get used to billing IHS/CHS claims in
the Medicare format.
Areas and/or Service Unit pends will not change.
New provider pends may appear on the pend
reports. P12G relates to APC pricing and P13G
relates to Taxonomy codes.
New message codes for EOBRs and DORs M009 or M506 which indicates payments are
being made per MLR regulation.
EOBR Change Example
With MLR Pricing
Contract No. shows MLR
EOBR Change Example Cont’d
Message code
M506
“Better Than” Medicare Like
Rates
The regulation specifies that “better than”
MLR contracts may be negotiated.
The FI is currently testing two basic
methods for each PPS methodology.
Lesser of billed or Medicare
Percent of Medicare (less than 100%)
Percentage of billed charge is not always
better than Medicare and is not supported
as a “better than” MLR contract provision.
Question and Answer
Rhonda Nichols
Manager,
Systems & Reporting
Reimb
Inge Zamora
Manager,
Prov Database &