Transcript No Slide Title

Slide 1
Western Michigan HFMA Meeting
September 24, 2014
WPS Medicare Audit Update
Paul Hula
Chris Severson
Slide 2
Agenda
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SSI/Cost Report Settlements
Contractor Update
Wage Index
Audit Issues
Cost Report Software Update
Sequestration
MDH/Low Volume
EHR Update
Questions
Slide 3
SSI Settlements – 2006-2009
• At the time of the J8 transition, WPS was tasked with completing the
final settlement on nearly 500 hospital cost reports that utilized the
2006 – 2009 SSI ratio
• The number of hospital audits conducted by WPS was adjusted to
account for this workload
• By the end of August 2013, WPS had completed 480 final settlements
on J8 hospital cost reports
Slide 4
Status of SSI 2010 and 2011 Settlements
• WPS has been issuing final settlements for cost reports that use the
2010 and 2011 SSI ratios i.e. cost reporting periods beginning on or
after 10/1/09 and before 10/1/11
• The CMS requirement is to have at least 90% of these final
settlements completed by November 1, 2014
• WPS has over 300 J8 cost reports that utilize the 2010 and 2011 SSI
ratio that can be finalized, and over 215 have been settled to date.
We will have in excess of 90% finalized by November 1, 2014
Slide 5
Status of SSI Settlements
• Cost reports that use the 2012 SSI ratio i.e. cost reporting periods
beginning on or after 10/1/11 and before 10/1/12 – CMS has recently
published the 2012 SSI ratios
• We are awaiting final instructions from CMS on the timeframes for the
final settlement of cost reports that use the 2012 SSI
• Priority is completing the final settlements on the 2010 and 2011 SSI
reviews, which are due by November 1, 2014
Slide 6
Cost Report Settlements
• CMS requirement – for non-audited cost reports, the FI/MAC must
complete a Notice of Program Reimbursement (NPR) within 365 days
from cost report acceptance
• For cost reports with 2012 Fiscal Year Ends, contractors have 18
months to complete the review. This was recently extended to the
2013 Fiscal Year End cost reports as well
• Acute and rehab hospitals which utilize the SSI ratio have had
separate settlement instructions issued
Slide 7
Contractor Update
• CMS had intended to consolidate Jurisdictions 8 and 15 to form JI, in
2015-2016, and Jurisdictions 5 and 6 to form JG, in 2016-2017
• CMS announced last spring a postponement of up to 5 years in the
consolidation of these two jurisdictions
Slide 8
Contractor Update
• Reasons for the delay:
1) Uncertain cost benefits
2) Potential performance issues
3) Home Health and Hospice
4) Evolving Business Environment
CMS wants additional time to evaluate all these issues
Slide 9
Wage Index
• CMS is significantly changing the Wage Index Development
Timetable for FY2016.
• The FY2016 IPPS Wage Index will be calculated based on Federal
Year 2012 hospital cost reports – those that have fiscal year begin
(FYB) dates of on or after October 1, 2011 and on or before
September 30, 2012
Slide 10
Wage Index
• The major changes include an earlier provider deadline for
submission of revisions to the Worksheet S-3 wage data and
occupational mix data (early October vs. late November/early
December)
• The corresponding timeframe for contractors to perform their annual
wage index desk reviews is also now earlier
Slide 11
Wage Index
• October 6, 2014 - provider deadline for submission of revisions to the
Worksheet S-3 wage data and occupational mix data. MACs must
receive the revision requests and supporting documentation by this
date
• October 15, 2014 – only for hospitals with FY2012 cost reporting
periods that begin on or after August 15, 2012 – deadline for
providers to request revisions to their defined benefit pension plan
data only. MACs must receive the revision requests and supporting
documentation by this date
Slide 12
Wage Index
• Note that the October 15, 2014 date only applies to pension plans
that are classified as defined benefit pension plans. Requests to
revise data of all other types of pension plans (such as defined
contribution plans) must be received by the MACs no later than
October 6, 2014
Slide 13
Wage Index
• December 16, 2014 – deadline for MACs to complete all desk
reviews for hospital wage index and occupational mix data and
transmit revised S-3 wage data to CMS
• February 13, 2015 – release of the revised FY2016 wage index and
occupational mix PUFs on the CMS website
• March 2, 2015 – deadline for hospitals to submit requests (including
supporting documentation) for corrections to errors in the PUF or
revisions of desk review adjustments to their wage index as included
in the February PUF
Slide 14
Wage Index
Tips for the Wage Index Desk Review Process:
• For providers who utilize Health Financial Systems (HFS) software –
please include an HFS auditor file (.auditor) that contains the
requested wage index revisions
Slide 15
Wage Index
Tips for the Wage Index Desk Review Process:
• For providers that do not use HFS software, an Excel template is on
the WPS Medicare website that will facilitate this process:
www.wpsmedicare.com/j8macparta/departments/audit_reimbursement
Slide 16
PHI and the Cost Report
• The safeguarding of PHI is a high priority for the Centers for
Medicare & Medicaid Services (CMS) and WPS Medicare
• We ask providers that submit documentation containing PHI, e.g., a
bad debt listing, with their "as submitted" cost report or at the time of
desk review or audit, to do so in an electronic format on a compact
disc (CD)
• The CD should be encrypted and the password communicated to the
WPS Audit Supervisor responsible for your facility. This provides a
level of protection not available with paper
Slide 17
Audit Issues – Medicare Website
WPS Medicare Website, under the Audit & Reimbursement Department
section, has detailed information on:
• Bad Debts (Collection Agency Referrals, Collection Efforts/Must
Bill Policy for Dual Eligible, Documentation Needed at Desk
Review and Audit
• CAH – Physician Compensation
• Claims Calculations/Rates
• DSH – L&D Days, Dual Eligible Patients, Documentation Needed
at Desk review and Audit
• EHR – Q&As, Required Documentation
Slide 18
Audit Issues – Medicare Website
WPS Medicare Website, under the Audit & Reimbursement Department
section, has detailed information on:
• Wage Index
• Organ Acquisition – including Time Study Requirements, and
Documentation Needed at Desk Review and Audit
• Low Volume
• Provider-Based Attestations
• PS&R
• FAQs … and much more
Slide 19
Hospital Cost Report Update – T6 (proposed)
Proposed Items:
• Worksheet S-2 - New instructions for uncompensated care,
Medicaid days
• Worksheet S-3 - Medicaid managed care discharges
• Worksheet D - Updated for new children’s and cancer hospitals
• Worksheet D-4 - Eliminated other organ
• Worksheet D-5 - Added lines to follow A-8-2 and apply RCE to
teaching providers for FYEs on or after 6/30/14
• Worksheet E-3, Part 5 – instructions for new children’s and
cancer hospitals
Slide 20
Hospital Cost Report Update – T6 (proposed)
Worksheet E, Part A:
• Line 20 – IME ratio
• Line 35.03 – prorated share of uncompensated care
• Line 41.01 – ESRD discharges
• Line 49 – MDH calculation extended
• Lines 70.96 -70.98 – Low Volume Adjustment extended
We anticipate T6 getting approved and released in the near
future
Slide 21
J8 Michigan Contacts – Omaha, NE
Paul Hula, Director, Audit
(402)995-0382
[email protected]
Paul Beach, Audit Supervisor
(402)995-0433
[email protected]
Scott Ferrin, Senior Auditor
(402)995-0432
[email protected]
Slide 22
J8 Michigan Audit Contacts – St. Louis, MO
Cost Report Audits:
Mike Connelly, Field Audit Manager
(314)997-6626 ext. 222
[email protected]
HITECH Audits:
Scott Fontana, Field Audit Supervisor
(314)997-6626 ext. 232
[email protected]
Slide 23
Audit Topics – Sequestration
• In general, Medicare fee for service claims with dates-of-service or
dates-of-discharge on or after April 1, 2013, will incur a 2 percent
reduction in Medicare payment. Claims for durable medical
equipment (DME), prosthetics, orthotics, and supplies, including
claims under the DME Competitive Bidding Program, will be reduced
by 2 percent based upon whether the date-of-service, or the start
date for rental equipment or multi-day supplies, is on or after April 1,
2013.
Slide 24
Audit Topics – Sequestration
• The claims payment adjustment shall be applied to all claims after
determining coinsurance, any applicable deductible, and any
applicable Medicare Secondary Payment adjustments.
• Though beneficiary payments for deductibles and coinsurance are not
subject to the 2 percent payment reduction, Medicare’s payment to
beneficiaries for unassigned claims is subject to the 2 percent
reduction.
Slide 25
Audit Topics – Sequestration
• Transmittal 4 for the Hospital Cost Report incorporated the
sequestration.
• Transmittal 5 for the SNF Cost Report incorporated the sequestration.
Slide 26
Audit Topics – Medicare Dependent Hospitals
• MDH was set to expire on 10/01/2012 - extended one year by ATRA
and CR 8214
• MDH then expired effective 10/01/2013
– Existing MDH Hospitals reverted to Acute Care Status
– Pending any legislative changes by Congress…….
Slide 27
Audit Topics – Medicare Dependent Hospitals
• ….Like this one
• MDH reinstated retroactive to 10/01/13 by the Pathway for SGR
Reform Act of 2013
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Only reinstated through 4/1/14
Automatic reinstatement for providers that were previously MDH on 9/30/13
Claims reprocessed by June 30th
Notification letters were sent out as well
Slide 28
Audit Topics – Medicare Dependent Hospitals
• MDH reinstated again by the Protecting Access to Medicare Act of
2014 Act
• Seamless transition from previous 3/31/14 extension. Extends
through 3/31/15.
– No documentation needed for extension through 9/30/14
– Request will be needed for extension from 10/1/14 – 3/31/15 (FFY 15
Proposed and Final Rule)
– FFY 2015 Final Rule
• New table of discharges
Slide 29
Audit Topics – Low Volume
• 42 CFR 412.101
• Low volume eligibility expanded 10/01/2010 (2 years) (ACA)
– Expired 09/30/12
– Criteria
• Original - Less than 200 total discharges and more than 25 road miles from
nearest like hospital
• Amended – Less than 1,600 Medicare discharges and more than 15 miles from
the nearest like hospital
• Revised eligibility extended one more year (ATRA & CR 8214)
– Expired 09/30/13
Slide 30
Audit Topics – Low Volume
• Cost Report
• Worksheet S-2 Line 39
Slide 31
Audit Topics – Low Volume
• Cost Report - E Part A Exhibit 4
Slide 32
Audit Topics – Low Volume
• Add on to all Inpatient PPS DRG-Based Payments
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DRG
Outlier
IME
DSH
High % ESRD
SCH/MDH Hospital Specific
Capital DRGs
New Technologies
• Add on percentage found in CMS table in each year’s Federal
Register
Slide 33
Audit Topics – Low Volume
• Low volume payment will be reconciled at final settlement
• Claims reprocessing (individual claims)
– For 10/1/13 – 3/31/14 (by June 30th)
– For 4/1/14 through about 7/7/14 (by 9/30/14 per CMS Change Request 8761.)
– 7/7/14 and on claims are being paid properly
Slide 34
Audit Topics - EHR/HITECH
• Subsection (d) Hospitals & Critical Access Hospitals
• That properly attest they have met the criteria for “meaningful use” of
“certified EHR technology” in the applicable stage that corresponds to
their payment year.
• Attestation must be made for any year provider wants an EHR
incentive
– Regardless of whether MU stage has changed
Slide 35
Audit Topics-EHR/HITECH
• MACs responsible for reviewing and calculating incentive payments
• Payment made by a single contractor - Payment File Development
Contractor (PFDC)
• Separates incentive payments from the rest of the Medicare trust
fund.
Slide 36
Audit Topics-EHR/HITECH
Overview of Payment Process - Subsection (d) Hospitals:
• Hospital registers
• Hospital attests as a Meaningful User
• Any registration/attestation questions must go to the EHR Information
Center (1-888-734-6433)
– MACs have no access to any information until after the provider successfully
attests.
Slide 37
Audit Topics-EHR/HITECH
Overview of Payment Process - Subsection (d) Hospitals:
• Monthly “trigger file” sent from NLR to obtain FISS/Medicare Share
information for those who attested that month. (Third Thursday night
of each month.)
– MAC has already preloaded that data based on most recent cost report
• Payment information sent to Payment File Development Contractor
(PFDC)
Slide 38
Audit Topics-EHR/HITECH
Overview of Payment Process (continued):
• PFDC prepares the file
• Payments are distributed to providers by EFT or check (towards the
end of the month after the trigger file.)
• Adjustments will be made at final settlement through the cost report
desk review/audit/final settlement process.
– Medicare share data adjusted to “proper” cost report period (now final settled.)
• CR period beginning in the Federal Fiscal Year that was attested to.
Slide 39
Audit Topics-EHR/HITECH
Overview of Payment Process - CAH:
• CAH registers
• CAH attests as a Meaningful User
– Submit questions to EHR Information Center
• CAH supplies “cost” documentation to their MAC
– Reminder letter is only sent after first year of attestation
– Submission process is the same for all future years or revisions
– Separate costs by cost reporting period
Slide 40
Audit Topics-EHR/HITECH
Overview of Payment Process - CAH:
• MAC reviews costs and enters allowable amount and Medicare
Share into FISS.
– MAC enters that Medicare Share data based on most recent cost report
• Monthly “trigger file” sent to obtain FISS/Medicare Share information
for those who attested that month (third Thursday night of each
month.)
Slide 41
Audit Topics-EHR/HITECH
Overview of Payment Process - CAH (continued):
• Payment information sent to PFDC
• PFDC prepares the file
• Payments are distributed to providers by EFT or check (towards the
end of the month after the trigger file.)
• Adjustments will be made once the cost report is settled (desk
review/audit/final settlement process.)
– Medicare share data adjusted to “proper” cost report period (now final settled.)
• CR period beginning in the Federal Fiscal Year that was attested to.
– CAH cost data adjusted to final settled amount.
– Payment will be made 4-8 weeks after settlement.
Slide 42
Audit Topics-EHR/HITECH
Website and email information:
• http://www.wpsmedicare.com/j5macparta/departments/audit_reimbur
sement/cah-incentive-documentation.shtml
– (CAH EHR Info)
• http://www.wpsmedicare.com/j5macparta/departments/audit_reimbur
sement/_files/cah-incentive-sample.xls
– (CAH EHR Template to submit)
• http://www.wpsmedicare.com/j5macparta/departments/audit_reimbur
sement/acute-cah-ehr-qanda.shtml
– FAQs
Slide 43
Audit Topics-EHR/HITECH
WPS contact for Hospital/CAH EHR (including submission of EHR
Payment Requests):
• [email protected]
Slide 44
Details of Payment Timing
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Payment Year (Federal Fiscal Year)
– (First) 10/01/2010-9/30/2011
– (Second)10/01/2011-9/30/2012
– (Third) 10/01/2012-9/30/2013
– (Fourth) 10/01/2013-9/30/2014
– (Fifth) 10/01/2014-9/30/2015
– (Sixth) 10/01/2015-9/30/2016
Which FFY did you attest in?
90 day period for provider’s first attestation period (regardless of what payment year it falls
in)
– FFY 2011 attestation due date was 11/30/2011
Full FFY attestation period for remaining 3 years (attestation always due between 10/1 and
11/30 each year.)
– Exception for FFY 2014 due to revised certification standards. All providers must attest to
any standard quarter (Oct-Dec, Jan-March, etc.) in FFY 2014.
Slide 45
Details
• EHR Reporting Period (aka EHR Attestation Period)
– (90 days, 1 Quarter, or 365 days within a FFY)
– Auditors will need documentation of this for cost report
Slide 46
Details
• EHR Reporting Period (aka EHR Attestation Period)
– (90 days, 1 Quarter, or 365 days within a FFY)
– Auditors will need documentation of this for cost report
Slide 47
Details
• “Payment Year” = Federal Fiscal Year
Slide 48
Details
• “Cost Report Period Beginning in the Payment Year” = Cost Report
this will be settled on.
– If less than 365 days, the Medicare share data will be pulled from the next 12
month cost reporting period.
• Potential for “reopenings”
– If there is no later 12 month period, look backwards for one.
Slide 49
Details
• Excerpt from 42 CFR 495.104(c)(2) Interim and final payments.
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“CMS uses data on hospital acute care inpatient discharges, Medicare Part A acute
care inpatient bed-days, Medicare Part C acute care inpatient bed-days, and total
acute care inpatient bed-days from the latest submitted 12-month hospital cost
report as the basis for making preliminary incentive payments. Final payments are
determined at the time of settling the first 12-month hospital cost report for the
hospital fiscal year that begins on or after the first day of the payment year, and
settled on the basis of data from that cost reporting period. In cases where there is
no 12-month hospital cost report period beginning on or after the first day of the
payment year, final payments may be determined and settled on the basis of data
from the most recently submitted 12-month hospital cost report.”
Slide 50
Details
• Initial Payment vs. Final Payments
– Initial – Most recent 12-month cost report data available at time
• No adjustments to payment until settlement and reconciliation of applicable cost
report
– Exception for first year CAHs, may use short period for initial payment
– Final payments must be twelve months
• If no 12 month period going forward (termed provider), go backwards.
Slide 51
Payment Reductions for Late or No MU Attestation
• Beginning 10/1/2014 (FFY 2015)
– CMS currently working on implementation
– Acutes subject to claims reprocessing
– CAHs subject to cost report reconciliation
Slide 52
HIT Cost Report Changes
• Worksheet S (Settlement Summary)
Slide 53
HIT Cost Report Changes
• Worksheet S-2
Slide 54
HIT Cost Report Changes
• Worksheet E-1 Part II
Slide 55
HIT Cost Report Changes
• Worksheet A-8
Slide 56
CAH Assets for EHR Incentive
• From CMS FAQs
• “The reasonable costs for which a CAH may receive an EHR
incentive payment are the reasonable acquisition costs for the
purchase of certified EHR technology to which purchase depreciation
(excluding interest) would otherwise apply.”
Slide 57
CAH Assets for EHR Incentive
• Cost of Assets subject to “purchase depreciation”
– Certified Technology
– Computer Hardware and Software “necessary to administer” certified
technology
• Capital Leases allowed, but Operating Leases not allowed
• Interest (capital or otherwise) specifically disallowed by Statute
• Medical imaging devices (e.g. MRI, CAT Scans, X-Rays) not allowed,
regardless of the fact that they feed into the EHR system.
Slide 58
CAH Assets for EHR Incentive
• Undepreciated value (i.e. remaining net book value) as of the
beginning of the applicable cost reporting period that begins in “a”
payment year.
– Only eligible for EHR cost reimbursement that year if your attestation related to
that FFY.
– Payment Year vs. Eligible Payment Year
– Costs will continue to be depreciated until you are eligible for a payment year
(and thus the cost reporting period beginning in that payment year.)
Slide 59
CAH Assets for EHR Incentive
Slide 60
CAH Assets for EHR Incentive
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Reasonable Implementation Costs Allowed
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Computer Hardware and Software “necessary to administer” certified technology
– Must be computer hardware or software
– Must be “necessary to administer”
• Subject to judgment and further CMS policy clarifications
– Examples of non-allowable items
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HVAC or plumbing for computer room or training room
Desks for computers
Backup power systems
Electrical and infrastructure upgrades
Other items that are not computer hardware or software and would normally be depreciated
as separate items
Slide 61
CAH Assets for EHR Incentive
• More examples of non-allowable items
– End User Training not normally depreciable under GAAP or Medicare
– Data Conversion (the process) not normally depreciable under GAAP or
Medicare
• Conversion software/hardware allowable
• Adjustment for percentage of non-EHR use
– Remaining portion of asset will continue to be depreciated as normal
– Reasonable allocation methodology
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Information from vendor
Activity reports
Storage space comparison
Etc.
Slide 62
CAH Assets for EHR Incentive
• Chains purchasing assets for their components
– Allowable in each components’ cost report ONLY if cost is directly or
functionally allocated to each component through Home Office Cost Report.
• No Pooled Allocations allowed. (Total costs)
– (Total patient days may be considered “functional” for this purpose)
Slide 63
CAH Assets for EHR Incentive
• Additional questions should be emailed to:
• [email protected]
• Questions need to be in writing for tracking and because further
research and potentially communication with CMS may be needed
• Submissions of asset listings/documentation can be mailed or
emailed.
Slide 64
Submission Template
Slide 65
Tentative and Final Settlements
• Based on cost that has been “initially” reviewed.
– Amount on cost report is not used for this payment. It is automatically adjusted
to the amount that has already ben approved
– If you have amendments (additions, deletions, etc.) to your listing, it must go
through the initial review process to be captured at tentative settlement, final
settlement, or reopening.
Slide 66
Tentative and Final Settlements
• Cost disallowed during initial review may impact A-8 adjustments.
• If you carved out depreciation on A-8 for an asset that was ultimately disallowed as
EHR
• MAC has no way of knowing what the A-8 impact would be.
• If you would like to revise your A-8 adjustment based on a disallowance or revision
of EHR costs, you must either submit an amended cost report, work with the
auditor performing the desk review, or request a reopening
– Be sure to provide documentation (i.e. depreciation schedules and
reconciliations, etc.)
Slide 67
FAQs
• Acutes Converting to CAH mid-program
– Treated as separate providers, can get separate payments
– Assets purchased under Acute not eligible, because CAH did not purchase
them. Can still report depreciation.
Slide 68
FAQs
• CAH EHR Incentive
– Source of funds doesn’t matter (e.g. grants, etc.)
– Must “purchase” the asset.
Slide 69
FAQs
• CAH costs related to Psychs or IRFs are excluded from incentive
– Costs related to other provider-based units are allowed.
– Except for RHC’s, which are separately certified areas per CMS
Slide 70
FAQs
• Submission of year 2 or later assets
– Can submit and be reimbursed under year 1 attestation for initial payment
purposes
– Allowability at final settlement dependent on successful year 2 attestation
– Costs must be split between the cost reporting periods they were purchased in.
Slide 71
Audit Findings
• Charity Care –
– Listings being submitted without all required information requested at audit.
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Name of patient
Dates of service
Patient account number
Name of health insurer (public or private), Medicare, or uninsured status
Total gross charges for the services
Charity care charges – see PRM-II, Section 4012, Line 20
– Did not separate out patient payments for charity care (S-10 Line 22)
– Did not separate out insured and uninsured charity care charges on S-10 Line
20
– For uninsured, did not include non-contracted insurance plans as required by
cost reporting instructions.
Slide 72
Audit Findings
• CAH EHR Assets–
– Use template on website to submit assets
– Documentation must contain at least all of those items
– Inclusion of questionable assets not required for EHR software…more for
patient care or medical services themselves.
Slide 73
• Any questions?