Transcript Slide 1

September 2014
Healthcare Financial Management
Association (HFMA)
Western Michigan Chapter
Grand Rapids
Great Lakes Chapter
Traverse City
Vickie R. Kunz
Senior Director, Health Finance
Michigan Health & Hospital Association
1
Who is the MHA?
• Advocacy organization representing all hospitals in
Michigan.
• Activities include:
– State advocacy and policy on Medicaid funding and
policy issues
– Federal advocacy and policy on Medicare and
Medicaid issues
– MHA Keystone Center – Quality Improvement and
Patient Safety Initiatives
– BCBSM Contract Administration Process
• Unique to Michigan
2
Payer Issues
• The role of the MHA is to assist in resolving
systematic payer issues.
• Individual hospital contracts determine terms and
conditions and take precedence.
• Communicate issues to Marilyn Litka-Klein
([email protected]) or Vickie Kunz
([email protected]) at the MHA.
3
Examples of MHA Involvement in Other Issues
• Other activities identified by/for the MHA membership
– Maximize federal funding in state Quality Assurance
Assessment Program (QAAP)
– Medicaid implementation of Critical Access Hospital
takeback that included “reject” vs “no-pay”, impact on
Medicare reimbursement
– Michigan Managed Care Rebid process
– Medicaid implementation of MI Health Link (formerly
dual eligible project)
– HFMA/MPAA/ACMA, etc. outreach
– BCBSM DRG Validation Audits
4
CMS RAC Appeals Settlement Proposal
• Administrative Law Judge (ALJ) appeals back log –
CMS proposes 68% of funds due if hospital
withdraws all pending appeals.
• Hospitals must submit request for settlement by
Oct. 31, 2014.
– CMS to provide payment 60 days after CMS acceptance
• No timeframe for CMS to accept
– PPS hospitals and CAHs are eligible- Rehab and Psych
Hospitals are not eligible.
• See Sept. 15 MHA Monday Report Article which
includes a link to CMS’ Sept. 9 presentation.
5
CMS ALJ Settlement Proposal – cont.
• These claims would not be counted for Medicare GME and
other cost report reimbursement purposes.
• Many hospitals that have appealed to the ALJ have had
positive outcomes, therefore diminishing the value of this
proposal.
• Due to the significant backlog at the ALJ, it may be years
before a hospital receives a positive decision and its payment
under the current appeals process.
• Hospitals are encouraged to carefully evaluate
whether to request settlement.
6
IPPS 2015 Final Rule
7
Uncompensated Care Pool
-$1.40
Billion
8
2 Midnight Rule & Short-Stay Payment Policy
• No changes adopted for two-midnight policy finalized in
FY 2014 IPPS rule.
• CMS will continue seeking input on short stay payment
methodology.
– No consensus in comments received
9
Reporting of Hospital Charges
• ACA provision requires hospitals to make public a list of
standard charges for items/services, including a list of
charges for services by MS-DRGs.
• No deadline for compliance but sets expectation that
hospitals should update the information at least
annually, or more often as appropriate.
• CMS states that hospitals should either make public a list
of their standard charges or their policies for allowing the
public to view a list of charges in response to an inquiry.
– Can use charge master
10
IME and GME
• Finalized proposal to pay the Medicare Advantage
IME add-on amount to SCHs paid at the hospitalspecific rate.
• IME adjustment factor remains at 1.35.
11
FY 2015 CBSAs
• CMS finalized use of the 2010 census data which
results in status changes for hospitals located in five
Michigan counties:
– Ionia – Changes from Grand Rapids/Wyoming CBSA to Rural
– Newaygo – Changes from Grand Rapids/Wyoming CBSA to Rural
– Midland – From Rural to Midland CBSA
– Montcalm – From Rural to Grand Rapids/Wyoming CBSA
– Ottawa – From Holland/Grand Haven CBSA to Grand
Rapids/Wyoming CBSA.
12
Wage Index Development
• CMS accelerated the timeline for developing the
Medicare wage index starting with the FY 2016 AWI.
• Request for changes to hospital wage and
occupational mix data are due to WPS/NGS Oct. 6.
– Changes for FY 2017 AWI due in early September 2015.
• Feb. 13, 2015 – CMS to release revised FY 2016 wage
and OM public use files.
• March 2 – Deadline for hospital requests to correct
CMS/MAC processing errors.
• April 15 – Deadline for hospital appeals
13
Occupational Mix Survey
• Survey identical to 2010 but collected calendar year
2013.
– Due to WPS or NGS July 1, 2014.
• Will be used to adjust FY 2016, 2017, and 2018 AWI.
• Preliminary PUF released mid-July.
• Non-responding hospitals are encouraged to
complete and submit survey now before annual
“data scrub” period ends Oct. 6.
14
PRRB Appeals
• As a result of comments received, CMS did not finalize its
proposal to eliminate the current requirement that a hospital
either claim reimbursement on its cost report for a specific
item or self disallow and file its CR under protest.
• CMS will likely address these provisions in future rulemaking.
15
Overview – Value-Based Purchasing
Program
• Mandated by ACA starting in FY 2013, funded by 1% withhold
from all IPPS hospital payments, increasing by 0.25% to 2% in
FY 2017 and future years.
• Hospitals can earn more or less than their contribution
amount or break even.
• Nationally, this program is budget-neutral; however, it will
redistribute approximately $1.4 billion in IPPS payments in FY
2015.
• Michigan VBP incentive payments estimated to be $700,000
lower than VBP program contribution amount.
16
Value-Based Purchasing Program
Hospital
Contribution %
1.25%
1.5%
1.75%
2%
Domain Scoring
FY 2014
(VBP Year 2)
FY 2015
(VBP Year 3)
FY 2016
(VBP Year 4)
Finalized
FY 2017
(Year 5)
Clinical Processes
45 percent
20 percent
10 percent
5 percent
Clinical Outcomes
25 percent
30 percent
40 percent
25 percent
30 percent
30 percent
25 percent
25 percent
N/A
20 percent
25 percent
25 percent
N/A
N/A
N/A
20 percent
Patient
Experience
Efficiency/Cost
Reduction
Safety
17
General VBP Program Trends
• Continuously evolving program
–
–
–
–
Addition of new domains/measures over time
National Quality Strategy (NQS)-based domains beginning FY 2017
Measure complexity
Hospital Eligibility
18
Readmissions Reduction Program Overview
• First payment adjustment was applied Oct. 1, 2012 (FY 2013)
• At risk: Hospital-specific IPPS payment penalty of up to:
– 1% in FY 2013
– 2% in FY 2014
– 3% in FY 2015 and subsequent program years
• Hospitals remain whole or lose and CMS gains
• Payment adjusted for hospitals with excess readmissions
rates (risk-adjusted hospital rates higher than risk-adjusted U.S. average)
FY = Federal Fiscal Year
19
Hospital Readmissions Reduction Program
• Five readmission conditions for FY 2015 up from three
conditions for FY 2013 and FY 2014:
–
–
–
–
Acute Myocardial Infarction (AMI);
Heart Failure (HF);
Pneumonia (PN);
New for FY 2015:
• Chronic Obstructive Pulmonary Disease (COPD);
• Elective Total Hip Arthroplasty (THA); and Total Knee Arthroplasty (TKA)
• CMS will calculate the FY 2015 excess readmissions ratios and
the payment adjustment based on data from the 3-year time
period of July 1, 2010 to June 30, 2013.
20
Hospital Readmission Reduction Program – Cont.
• Payment adjustment factor will increase from 2% to 3% in
FY 2015 as mandated.
• Nationally, program is expected to reduce IPPS payments by
$424 million in FY 2015, up from $227 million in FY 2014.
– Michigan impact estimated at $22 million reduction in FY 2015.
• No changes for FY 2016 program
– Based on same 5 conditions as FY 2015
• Addition of one condition area to FY 2017 program:
– 30 Day All-Cause Unplanned Readmission Following Coronary Artery
Bypass Graft (CABG)
• Currently in NQF review for endorsement
– Same general measure methodology as other program measures
21
HAC Reduction Program Overview
• First payment adjustment will be applied during FY 2015
• At risk: 1% payment penalty applied to Medicare IPPS
payment
– National impact $369 million cut in FY 2015.
– Michigan impact $14 million cut in FY 2015.
• Hospitals remain whole or receive payment penalty.
• Payment adjusted for hospitals with total HAC score in top
quartile (worst performing quartile)
• Rules adopted for FY 2015; measures adopted through
FY 2017
22
General Program Themes
• Increased financial exposure each year (max exposure shown below)
HAC = Hospital Acquired Condition (HAC) Reduction Program; RRP = Readmission Reduction Program; VBP = Value
Based Purchasing Program
23
IPPS 2015 Final Rule Summary
System Component
Change
Update Factor
1.1% net rate increase (net of all rate adjustments) after budget neutrality for
hospitals that meet meaningful use (MU) and IQRP requirements.
Wage Index
Redefined CBSAs based on 2010 census – besides direct wage index implications,
may impact other programs or special designations. Impacts 5 Michigan counties
Value Based Purchasing
(VBP) Program
1.5% rate reduction with chance to earn back amount withheld or more; increasing
by 0.25% annually to 2% in FY 2017 and after.
Readmissions
Keep pace with national average or subject to up to 3% reduction for FY 2015
Hospital Acquired
Conditions (HAC)
Hospitals in top quartile (the worst performing) will be penalized 1% - Reduction
applies to operating payments and add-ons (DSH, IME, etc)
IME/GME
Changes in new hospital established programs and how rural hospitals are paid for
new programs.
DSH
25% of traditional formula calculation; remaining 75% pooled for all DSH hospitals,
reduced by uninsured reduction factor and then redistributed to hospitals as
uncompensated care (UCC) pool based on low income patient days . – No major
changes from FY 2014 final rule but UCC pool $1.4 billion less than in FY 2014.
Low-Volume Adjustment
Loosened criteria through March 31, 2015
MDH (Medicare Dependent
Hospital)
Extended through March 31, 2015
LTCH
1.1% rate increase
24
Medicare Payment Challenges
• Absent Congressional action, 2% sequestration across-theboard cut continues through FY 2024.
• Reduction to annual MB update if hospital fails to comply
with IQRP and MU program requirements.
• Readmissions Reduction Program – Hospitals at risk for up to
3% in FY 2015.
• Value Based Purchasing Program – 1.5% payment withhold,
hospitals can earn back that amount, earn more or earn less.
– withhold increases to 2% for FY 2017 and beyond
• Hospital Acquired Condition (HAC) reduction program – 1%
reduction to nearly 25% of hospitals nationally.
– Begins in FY 2015
25
Medicaid
26
FY 2015 Budget
• New $11 million OB Stabilization Pool – Funded by GF and
Federal $.
• Maintained GME Funding
– Restored $4.3 million
• Continued Rural Access Pool - $35.6 million – Funded by GF
and Federal $.
• New tax-funded $85 Million DSH Pool
– $70 Million to be distributed to Large/Urban Hospitals
– $15 Million to be distributed to Small/Rural Hospitals
• More aligned with hospital provider tax paid to support these payments.
27
Hospital Reimbursement Reform Initiative
• 2013 meetings with hospitals, MSA steering committee
finalizing areas to implement
• Representatives include small, medium, and large hospitals
and CAHs
• Several ideas discussed:
· statewide inpatient rate with hospital adjustors,
· APR-DRG for inpatient
· Increase in outpatient payments financed with reduced inpatient
rates
· Medicaid OPPS rates are 53% of Medicare OPPS rates
· DSH methodology changes
· HRA methodology changes
· GME methodology changes
28
FY 2011 DSH Audits
• Early-to-Mid October, Myers and Stauffer
expected to distribute hospital-specific
worksheets.
– Hospitals will have 2 weeks to notify M&S
of errors
• Sept. 30 draft report due to MSA.
• Dec. 31 final report due to CMS.
29
FY 2014 & 2015 DSH Payments
• FY 2014 Step 1 review occurred in early August, with hospitals
having until Aug. 20 to return DSH feedback form to MSA.
• FY 2014 DSH payments distributed mid-to-late September.
• FY 2015 DSH eligibility form released early September.
Hospitals must complete and return to the MSA by Oct. 2 in
order to be eligible for FY 2015 DSH payments.
– Failure to do so will result in hospital being deemed ineligible for DSH
payments
30
Newborn Claim Requirements
•
•
•
•
•
•
Dates of service Oct. 1, 2014 and after
Type of admission/visit
Birth weight
C-section/inductions related to gestational age
Both FFS & HMO claims
Informational edits, but will be required effective Jan. 1, 2015.
31
Healthy Michigan Plan
• Enrollment as of Sept. 16 was 385,000
• Statewide $53 million in HRA payments
• No QAAP tax associated with these payments
• All counties have achieved enrollment
• Additional appropriation required for FY 2015 as
enrollment has exceeded budget
• Despite 100% federal funding, there may be
some resistance in the legislature to pass the
additional funding bill
32
Continued, Healthy Michigan Plan
• CMS confirmed that HMP inpatient days should be
included for Medicare DSH calculations.
• HRA payments (April – Aug.) = approx. $53 million
• No QAAP tax associated with these payments.
• Hospital registration staff encouraged to use
CHAMPS to determine which patients are HMP
versus regular Medicaid.
• Can use 270/271 batch transactions
• Hospitals required to report both FFS and HMO HMP
33
data separately on MMF.
BCBSM DRG Validation
• Consultant found BCBSM erred in removing codes for BMI
and cerebral edema
• Other audit areas for improvement
• Sept. 24 education session, webinar available
• 2014 audits will be reviewed for compliance with consultant
findings
• MHA advocated for retroactive adjustment
– BCBSM has not finalized retroactive policy
34
Nov. 4 Voters Will Decide….
•
•
•
•
•
•
U.S. Senate (1 seat, open)
U.S. House of Representatives (14 seats, 4 open)
Governor
Attorney General
Secretary of State
State Supreme Court (2R incumbents, 1 open
seat)
• State Senate (38 seats, 10 open seats)
• State House of Representatives (110 seats, 41
open seats)
35
Michigan Loses Seniority
• U.S. Senate
– Sen. Carl Levin
(35 yrs)
• U.S. House of Representatives
–
–
–
–
–
Rep. John Dingell
Rep. Dave Camp
Rep. Mike Rogers
Rep. Gary Peters
Rep. Kerry Bentivolio
(59 yrs)
(23 yrs)
(13 yrs)
(5 yrs)
(2 yrs)
Total experience + seniority lost = 137 years
36
General Election 2014 - State Legislature
• Senate – 38 seats
– 10 open seats
– First election since 2011 redistricting
– Majority Leader Randy Richardville is term limited
• House of Representatives – 110 seats
– 41 open seats
– 70 lawmakers will have no more than 2 years of
legislative experience
– Speaker of the House Jase Bolger is term limited
37
Legislative Issues to Watch: Federal
Level
Likelihood That Congress Will Consider Key Legislation
Likely to
Consider
Uncertain
Legislation
Unlikely to
Consider
Before
Elections
In LameDuck Session
In 114th
Congress
Budget and Appropriations
Appropriators are unlikely to finish funding bills before the new fiscal year in October, but will probably
pass a continuing resolution, pushing broader budget negotiations into a lame-duck session and beyond
Debt Ceiling
The federal debt ceiling is currently suspended through March 15, 2015; the 113th Congress is unlikely to
propose any hike or extension, but the 114th Congress is certain to consider the issue
Export-Import Bank
The bank’s charter expires on Sept. 30th, but Congress could reauthorize the institution through a bill in
the lame-duck session
Tax Extenders
Expired and expiring tax provisions may not see action before the midterms, but after the elections,
Congress could consider a larger taxation bill
Affordable Care Act
If Republicans win the Senate, they are certain to vote to repeal the ACA; if Dems hold the chamber,
Congress could pass legislation to address the law’s perceived deficiencies
Immigration Reform
The Senate immigration bill is almost certainly dead, but Congress could move limited immigration
legislation in a lame-duck session, or more likely in a new Congress
•Analysis
•The fact that both parties hope to be in a stronger negotiating position post-elections may mean that Republicans and Democrats wait until 2015 to act
on major legislation, gambling on a more favorable composition of the other chamber
Sources: Billy House, “Time is Running Out for Big Bills,” National Journal, Apr. 13, 2014; National Journal Research, 2014 .
Election 2014 — Call to Action
• Meet your candidates for state House and Senate, and
candidates for Congress
• Use MHA election tools available on the MHA election web
page
• http://www.mha.org/mha/elections.htm
–
–
–
–
–
Election Materials (table tent, posters, brochure)
Election Snapshot
Candidate Listing
Redistricting Information
Non-partisan sources
39
Dates to Remember
• Last day to register for general election: Oct. 6
• General election: Nov. 4
40
Objective & Useful Information
www.MIVote.org
• Non-partisan guide to candidates and issues
Secretary of State- michigan.gov/vote
• Elections in Michigan website
www.MichiganTruthSquad.com
• Non-partisan website providing analyses of campaign ads and
literature from candidates for Gov., state Legislature and Congress
www.mha.org (click on election logo)
• MHA election web page containing candidate information and
election information pertinent to hospital community
41
MHA Resources
•
Monday Report is available FREE to anyone and is distributed via email each
Monday morning.
– Go to website and select “Newsroom”, then Monday Report
•
MHA Monday Report – electronic publication issued weekly
•
Request password if you don’t have one.
– Email Donna Conklin at [email protected] to obtain MHA member ID
number
•
Advisory Bulletins – Extensive communications available only to MHA
members, as needed. (Require password to obtain from website).
•
Hospital specific mailings as needed for various impact analyses, etc.
•
Periodic member forums
•
See mha.org for other resources.
•
Monthly Financial Survey (MFS) provides free benchmarking of financial and
utilization statistics.
42
???Questions???
Vickie Kunz
Senior Director, Health Finance
Michigan Health & Hospital Association
110 West Michigan Avenue, Suite 1200
Lansing, MI 48933
Phone: (517) 703-8608
email: [email protected]
43
DRG Operating Rate – 2015 Final Rule
• Labor and Non-Labor Related Standard Rates
Hospitals with a Wage Index
Greater than 1 (69.6% Labor
Share/30.4% Non-Labor Share)
Hospitals with a Wage Index Equal
to or Less than 1 (62% Labor
Share/38% Non-Labor Share)
Full Update
Labor
Non-Labor
Related
Related
$3,780.13
$1,651.09
$3,367.36
$2,063.86
44
Rate Update with Meaningful Use and
Inpatient Quality Reporting
PASSES
BOTH
MU
AND
IQR
• Incentives ending for many;
penalties starting up
• Connects IQR and MU Programs to
update factor for PPS hospitals
• Creates 4 update scenarios going
forward
• MU exposure increases over 3 years
beginning 2015; IQR holds constant
(MU = 25%; 50%; 75% | IQR = 25%)
• CAHs = cost-based payment
reduced; exposure increases over 3
years beginning 2015 (-0.33%; -0.66%; -1.0%)
FY 2015
Market Basket Rate-of-Increase
Adjustment for Failure to
Submit Quality Data under
Section 1886(b)(3)(B)(viii) of
the Act
Adjustment for Failure to be a
Meaningful EHR User under
Section 1886(b)(3)(B)(ix) of the
Act
MFP Adjustment under Section
1886(b)(3)(B)(xi) of the Act
Statutory Adjustment under
Section 1886(b)(3)(B)(xii) of the
Act
Proposed Applicable
Percentage Increase Applied to
Standardized Amount
FAILS
MU
FAILS
BOTH
MU
AND
IQR
FAILS
IQR
Hospital
Hospital
Hospital
did NOT
Hospital submitted did NOT
submit
submitted quality data submit quality data
quality data and is NOT quality data and is NOT
and is a
a
and is a
a
meaningful meaningful meaningful meaningful
EHR user EHR user EHR user EHR user
2.9
2.9
2.9
2.9
0.0
0.0
−0.725
−0.725
0.0
−0.725
0.0
−0.725
−0.5
−0.5
−0.5
−0.5
−0.2
−0.2
−0.2
−0.2
2.2
1.475
1.475
0.75
45
Cost Outlier Threshold & Capital Rates
• Final FY 2014 threshold:
$21,748
• Final FY 2015 threshold:
$24,758
• Represents a 13.8 percent increase in the cost outlier threshold,
resulting in fewer cases being eligible for outlier payments.
• Threshold is adjusted annually based on CMS’ projections for total
outlier payments so that total outliers payments approximate 5.1
percent of total IPPS payments.
• Final FY 2015 federal capital rate of $434.26, up from the current
$429.31
– 1.15 percent increase
46
MS-DRGs
― See Table 5 in final rule for file containing weights.
MS-DRG
470 – Major Joint Replacement W/O MCC
871 – Septicemia W/O MV 96+ Hrs W MCC
392 – Esophagitis W/O MCC
292 – Heart Failure & Shock W CC
291 – Heart Failure & Shock W MCC
194 – Pneumonia W CC
690 – Kidney and Urinary Infection W/O MCC
683 – Renal Failure W CC
190 – COPD W MCC
193 – Simple Pneumonia & Pleurisy W MCC
Total
Number of
Discharges
Final
2014
Weight
Final
2015
Weight
Percentage
Change
435,351
395,147
197,891
196,728
2.1463
1.8527
0.7395
0.9938
2.1137
1.8072
0.7388
0.9824
-1.52%
-2.46%
-0.09%
-1.15%
193,972
179,988
173,875
153,012
151,963
145,156
1.5031
0.9771
0.7693
0.9655
1.1708
1.4550
1.5097
0.9688
0.7794
0.9512
1.1743
1.4491
0.44%
-0.85%
1.31%
-1.48%
0.30%
-0.41%
47
DSH Payments
• CMS is required by the ACA to reduce hospital DSH
payments based on the expectation that there will be a
decreased number of uninsured individuals.
• Based on the 2014 final rule and 2015 final rule:
― Hospitals will receive 25% of the DSH amount calculated under the
traditional formula.
― The remaining 75% reduced to reflect the impact of insurance
expansion under the ACA and redistributed to hospitals as a new and
separate uncompensated care (UCC) payment based on each
hospital’s UCC ratio relative to the total for all DSH-eligible hospitals.
48
Continued, DSH Payments
• Distributing the uncompensated care (UCC) payment
pool:
Use low-income patient days as proxy
• Medicaid days + Medicare SSI days (based on 2011/12 data)
• Numerators of traditional DSH % calculation
• CMS cites unreliable data on Worksheet S-10 as hospitals
are not consistent in reporting bad debt and charity care in
terms of hospitals’ costs (% of charges) vs. payment from
government or other payors.
Calculate uncompensated care payment factor
• Hospital's low-income patient days relative to all DSH
hospital low-income patient days
49
Continued, DSH Payments
• Review the cost report split between the traditional
methodology and the revised methodology.
• Ensure the hospital is continuing to identify additional
Medicaid eligible days.
• Review the data reflected on S-10 for accuracy as this will
likely be used in the future for distribution of the 75% pool.
• In the final rule, CMS stated its commitment to making the
necessary revisions and S-10 clarifications.
• Prepare the DSH worksheets for all PPS hospitals for each
year even if hospital has not qualified historically.
• Review the calculation for 340B Drug Program benefit.
50
Two-Midnight Policy
• Finalized in FY 2014 IPPS rule.
• Under the two-midnight rule, CMS will generally
consider hospital admissions spanning two midnights
as appropriate for payment under the IPPS.
• Hospital stays or less than two midnights will be
generally be considered outpatient cases, regardless
of clinical severity.
– CMS reiterates that there may be rare and unusual circumstances not
yet identified that justify IP admission and payment absent an
expectation of care spanning two midnights. CMS continues to
encourage comments at [email protected], with
“Suggested Exceptions to the Two-Midnight Benchmark” in the
subject line.
51
FY 2015 Quality Payment Adjustment Factors
• VBP Program – Proxy factors on CMS Table 16 are unreliable
since they are based on FY 2014 program performance and fail to
take into account the new measures, domains, and domain
weighting rules.
• Readmissions Reduction Program – CMS proxy factors on Table
15A are believed to be pretty solid since based on data for all
measures and from correct time
• HAC Reduction program – CMS did not release updated “penalty
flags” but Table 17 from IPPS proposed rule is believed to be
fairly reliable.
• CMS to release final tables for all adjustments by Oct. 1.
52
Final Rule Tables
• Table 1A-1E
• Tables 2-4
• Table 5
• Table 14
•
•
•
•
Table 15A
Table 16A
Table 17
Table 18
Operating & Capital Rates
CBSA Delineations & Wage Index
Values
MS-DRG Weights
List of Hospitals with <1,600 Medicare
Discharges (used for Low Volume
Adjustment)
Readmission Factors
VBP Program Proxy Factors
Hospital-level HAC Reduction Program
Medicare DSH Uncompensated Care
Payment Factor
53
OPPS 2015 Proposed Rule
54
OPPS Comment Topics
• Tracking services provided in off-campus provider-based
departments.
• Comprehensive APCs
• Packaging proposals for Ancillary Services, Prosthetic Supplies and
Add-on Code APCs
• The reduction in partial hospitalization program payments
• Modification of process for accepting new and revised CPT codes.
• Hospital OQRP changes
• Final rule expected by Nov. 1 effective Jan. 1, 2015
55
Michigan Health Link (Dual Eligibles)
• Phased-in implementation of pilot project expected
to begin January 1, 2015.
• Hospitals responsible to negotiate payment
parameters in their contracts.
• Nine plans in Macomb/Wayne, two in 8 SW counties,
one in UP
• No guarantee of Medicare rates for I/P & O/P
• Ambiguity in rate for SNF payments
56
Revised DSH Policy
• Based on its final policy released October 2012,
MSA adopted a multiple-step DSH process
beginning with FY 2011 DSH payments:
– Step 1: Initial DSH calculation
– Step 2: Interim DSH settlement – 2 years after
payment
– Step 3: Final DSH audit-related redistribution –
3 years after payment
57
DSH Payments and Audits
• Beginning with FY 2011 DSH payments:
• payments will be recalculated and redistributed using
actual hospital data during Step 2. (Key change
from past)
• hospitals subject to DSH payment recoveries if
audits indicate DSH payments exceeded their
actual DSH limits.
• Audit reports available on MSA’s website for
FY 2010 and prior years.
• FY 2011 draft report due to MSA by Sept. 30.
58
DSH Audits – Cont.
• All Medicaid DSH payments must be considered
included in the calculation including:
– $45 million regular DSH pool
– $60 million tax funded OP Uncomp DSH pool
– Gross-payments not net
– Indigent Care Agreement (ICA) DSH
– Governmental hospital DSH
59
Summary of Hospital QAAP
• Available in MHA Advisory Bulletin # 1353 dated 11/25/13.
• Provides overview regarding payment allocation for each of
the four programs.
– Medicaid Access to Care Initiative (MACI) - FFS
– Hospital Rate Adjustment (HRA) - HMO
– Outpatient Uncompensated Care DSH
– Inpatient Psych HRA
• The same tax base is used for all four programs.
• Data updated annually for both payments and tax.
– Can result in change in hospital net benefit/loss.
60
ICD-10 Business-to-Business Testing
• Despite implementation delay to Oct. 1, 2015, MDCH testing
efforts continue.
• MHA strongly encourages hospitals to test ICD-10 claims
processing with all payers.
• MDCH offering ICD-10 compliant B2B testing for providers
pursuing CMS Level II compliance.
• Providers should test ICD-10 claims and inquiry transactions
using the CHAMPS B2B system.
– Work with clearinghouses or billing agents
– Submit claims using Michigan’s Single Sign-on (SSO) process
61
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Medicare Advantage Plans
• As of July 2014, 30 plans in Michigan, with 564,000 or
approximately 31% of Michigan’s 1.8 million Medicare
beneficiaries enrolled.
− Up to 21 plans in some counties.
• Review MA payment rate for all plans.
• CAH entitled to Medicare cost reimbursement.
• Each MA plan may determine own utilization model and is
not required to maintain electronic transactions.
• Many MA have instituted “RAC-like” utilization programs.
• Matrix of MA plans by county available at MHA website –
updated quarterly, with MHA Monday Report article.
− Aug. 11 MHA Monday Report.
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