Transcript J. Brandon Durbin 2950-50th Street 909-18th St. Lubbock, Texas 79413 Plano, Texas 806-791-1591 469-361-0120 Fax 806-791-3974 [email protected] [email protected] Topics Medicaid & State programs Medicare issues and legislative update Medicare Group Appeals.

J. Brandon Durbin
2950-50th Street
909-18th St.
Lubbock, Texas 79413
Plano, Texas
806-791-1591
469-361-0120
Fax 806-791-3974
[email protected]
[email protected]
Topics
Medicaid & State programs
Medicare issues and legislative update
Medicare Group Appeals
Waiver Issues
Renewal
Deferral
UCC Issues
Medicaid DSH
Nursing Facility MPA (UPL)
NAIP
Payment reforms (VBP, etc)
Waiver Renewal – DSRIP
CMS
 Streamline this process
 Prototype projects for regions
 More realistic valuations
Rural Providers
 Minimum allocations
 Meaningful RURAL projects in the prototypes
Waiver Renewal – UCC
CMS does not like UCC
Florida is a case study for our renewal
 CMS back at the table for Florida
CMS is pushing “expansion”, but this is DOA
Issues are not realistic
Even with expansion we would have significant
UCC, so we must renew UCC
Florida is getting renewal of their UCC (LIP)
Waiver Renewal - UCC
Alternatives
Rural Providers have close to cost on traditional,
and if the riders pass there is very little UCC for
Medicaid. Its all about the uninsured.
Alternatives such as a provider assessment,
provider taxes, local provider fees will not provide
funds for rural providers, as this just increases the
Medicaid payments.
Funding Mechanics
The deferral was caused by CMS letter to State
Medicaid Directors
 TX position - Cannot legislate or rule make by memo
or letter
 Established this method at the inception of the
waiver
Will it Continue
 The lawyers feel that Texas is legal, and that the use
of a memo to change federal law is not applicable.
 A state wide provider tax is DOA
Funding Time Frames last of 2014
UC IGT due June 5th.
Their will be a commitment date before
 May 6th – 15th
UC paid June 30, 2015
Rural hospitals are not considered “Transferring”
 Even though you IGT.
Speeding up the process for 2015
Request participation in May 2015 for 2015
Tools in June 2015
Increasing the prepopulated data including cost
reports should help, as long as there are not too
many errors.
Local Provider Fees
Local provider fee through the County
South Texas did in 2013 – Funded $160M in UCC
2015 bills – Waco, Temple, Beaumont,
Bryan/College Station, Texarkana, Longview,
possible for Tyler.
Will fund $476M in UCC if all bills enacted
 $316M is new to program
 This will cause more stress on the system
Some markets will be disrupted
 RHP 1 & 16 will have the greatest impact
Haircuts
In 2013 this was 21.6% for those with fully
funding IGT.
In 2014 (DY3), with no other changes other
than the base decreasing this would be 31.6%
The win last year was to exempt Rider 38
hospitals from most of the cuts, projected
haircut as follows:
DY3
DY4
DY5
9.4%
14.2%
20.5%
Rider 38 Hospitals
Hospitals in counties less than
60,000 in 2010
Sole Community Hospitals
Rural Referral Hospitals
Critical Access Hospitals
Other Haircuts
Other Haircuts are very difficult to estimate,
with the new pool system. Based on PY
commitment levels, this is about 15%, but
estimates are up to 25%
With LPPF, this would increase about an
additional 10% in DY4, plus the overall
reduction in the UCC pool.
The Private programs will have the most
impact. Possible rolling back in 2015 about
15% of all community benefits.
 DSH 2015 application date is the same as the
UC tool – May 2015 for requesting the tool.
 DSH 2014 IGT date May 4th, 2015
 Payment date is May 29th, 2015
 Everything is pending the IGT.
 Two are resisting an IGT, but other 6 have
committed to take their share
 How could a District forego $20M+ net for
principle?
 DSH rules are already published
 Still issues with the transferring IGT.
 State GR for future years is (pick one)
 Nonexistent
 Iffy
 Reduced
 Certain
There is a better way to handle this
 If we look at the effect of GR on the DSH
program , the GR has about $300M net
impact.
 Rural is about $12-13M benefit
 The Outpatient and inpatient Rider is about $80M.
 The impact of $300M in GR for a supplemental
MCO payment is $700M+
Rates are better than DSH GR
 Rural DSH issues
 IGT will be on 50% of the amount, due to State GR
in 2014
 Future amounts will be based on 100% IGT, due to
no State GR.
 Pass 3 will play a small part in future years ($30M)
in total funding, with about half going to non rural
public hospitals.
 Will help on the UCC haircuts
 Will need to revise DSH estimates if Rider on
Outpatient passes
 The rider will decrease UCC cost & DSH
capacity
 Reducing haircut
 You will get more overall money, but much of
it will come in the way of claim payments
 HHSC has changed the name to Minimum
Payment Amount Program(MPAP)
 New program goes through the Managed Care
Organizations (MCO’s)
 Closed program for now, but needs to be
looked at for beyond 2016
 Need to rewrite the rules for the future
 Future program will have an emphasis on
quality programs
 Probably HHSC proscriptive projects and
managed by MCO’s
 Also need to solve some funding problems
 MCO’s have identified many issues and are
willing to help fix them
 IGT’s were based on data from 2013-14
through April of 2014
 Due to reductions in nursing home admissions,
the MCO’s will probably make a profit on this
process, which is one of the issues the MCO’s
seem willing to mitigate
 IGT funding requirements and timing on
MPAP payments are disruptive to cash flows
 The overall NH census has been reducing
about 1-3% per year in most regions, before
managed care.
 The managed care companies want to decrease
utilization and have case workers actively
working to reduce census
Minimum Payment Amount Scenario in a Declining Census Model
(Impacts Nursing Facility MPAP Payments but does not impact MCO Rate Enhancements for MPAP)
Census in
2014
Annual
Estimated MPA IGT @.4195
Actual
Census
Actual Payment Variance
A
B
50
70
2,190,000
3,066,000
918,705
1,286,187
50
68
2,190,000
2,978,400
(87,600)
C
60
2,628,000
1,102,446
62
2,715,600
87,600
D
90
3,942,000
1,653,669
87
3,810,600
(131,400)
E
40
1,752,000
734,964
37
1,620,600
(131,400)
D
85
3,723,000
1,561,799
84
3,679,200
(43,800)
7,257,770
388
16,994,400
(306,600)
395
17,301,000
 So what happens to that $306,6oo in the
example?
That becomes MCO profit.
The real number when extrapolated and without
the MCO’s reducing any census is about $9M that
will not be realized based on these assumptions.
If they are successful in reduction of residents that
number grows…
 We have met with TORCH, Kevin Reed, Kevin
Nolting and Billy Millwee (who represents the
MCO’s)
 The MCO’s are agreeable to a solution where
they will distribute the profit, as long as MCO
can mitigate any losses.
 If MCO has risk for losses, the whole process
may have bigger issues
Census
in 2014
Annual
Estimated
Actual
MPA IGT @.4195 Census
Actual
Payment Correct IGT Variance
A
50
2,190,000
918,705
50
2,190,000
918,705
B
70
3,066,000 1,286,187
68
2,978,400
1,249,439
(36,748)
C
60
2,628,000 1,102,446
62
2,715,600
1,139,194
36,748
D
90
3,942,000 1,653,669
87
3,810,600
1,598,547
(55,122)
E
40
1,752,000
37
1,620,600
679,842
(55,122)
D
85
3,723,000
1,561,799
84
3,679,200
1,543,424
(18,374)
7,257,770
388
7,129,151
(128,619)
395 17,301,000
734,964
16,994,400
-
 Also need to solve a fairness of IGT issue. The
IGT is based on historical data and this may
require an adjustment to align with actual
data.
 Program would be jointly administrated by
TORCH and TAHP (MCO Association)
 Cost should be minimal, and should more than
be covered by profits from MCO profit
distribution.
 MCO’s are also willing to make a prospective
supplemental payment, to assist in the cash
flow.
 Pay enough additional money on a quarterly
basis to solve cash flow issues
 All public providers need to participate
 This is very similar to other programs in other
states using MCO arrangements
New Program – NAIP
Network Access Improvement Program
Mini DSRIP program –less bureaucracy
Year by Year program – Not long term projects
We are working on a few projects
 School TeleMed
 TeleNICU™ through Dallas Children's
More to come on this in the coming months
Rates & Value Based Purchasing
VBP is the buzzword for payment reform
Non Emergent ED was a bad one, that hopefully
TORCH can get eliminated
Very difficult to use VBP where the hospital has no
real control over the care.
It is continuing and will grow to make up most of
your payment programs
EAPG are still being pushed for the MCO.
We need the rural rider on outpatient!!!
Telehealth
This has boomed in the last few years
Urban to rural is a traditional focus
Needs sustainability, not just referral based
Possible new programs
TeleNICU
Schools
Nursing Homes
TeleED and after hours clinics– Lots of potential
savings.
Medicare Issues
EHR payments and missing MCO data
 No Shadow bill = No payment
CAH Swing Bed Utilization requires MCO for
advantage plans be included in total.
 Will dilute SB reimbursement
 Make sure advantage is paying swing bed rates
Low Volume Group Appeal
 We have one based on using actual utilization, not
two year old data
 Average is $100K per provider
Medicare Legislation - Pending
Extension of Low-Volume Hospital Adjustment
Extension of Medicare Dependent Hospitals program
Extension of Therapy Cap Exceptions Process
Enforcement delay of Two-Midnight Policy
Medicare Ambulance Add-on Payments – Extends the
add-on payment for ground ambulance services, including
in super rural areas
Medicare Home Health Rural 3% Add-On
Questions