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CMS UpdatesHFMAWestern Region Symposium
January 2019
You Give Healthcare a Band‐Aid
Presented by:
Shar Sheaffer, CPA, Owner
Outline
• Legislative outlook
• Budget Act
• 2018/2019 IPPS/OPPS/MPFS changes
• Uncompensated care calculation
• Miscellaneous
• OIG work plan
2
Budget Issues
• No budget
• Government shut downs (2-3 in 2018)
• Lower income taxes
• Increased spending
• Three states with successful measures to expand Medicaid (Idaho and Utah)
• Democratic-led House
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Trump’s Budget
• Backs changes “close to Graham-Cassidy”
• Decrease Medicare bad debts to 25%
• Remove excepted off-campus provider-based locations
• Decrease in GME payments
• Continue Medicaid DSH reductions
• Cap state’s supplemental payments to cost
• Modify UCC payments
• Repeal the Independent Payment Advisor Board (IPAB)
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2018 BUDGET ACT
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Budget Act
• Insurance premiums
No marketplace stability
• Funds community health centers
$3.8 billion in 2018
$4 billion in 2019
Instructs CHCs to improve care coordination with local hospital and reduce emergency visits
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Non-CAH Changes
• Extended and changed low-volume add on through 2022
• Extended Medicare-dependent hospitals through 2022
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Ambulance
• Five-year extension of ambulance add-on
Urban: 2%
Rural: 3%
Super rural: 22.6% (based on originating zip code)
Expires December 31, 2022
• Reduction for non-emergency basic life support transports of ESRD patients for dialysis
Was 10 percent – now 23 percent
Effective October 1, 2018
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Rural Home Health
• Rural home health add-on—three types of Counties
Six or fewer per square mile
• 2019-2022: 4-1% add-on
Rural counties in highest quartile (home health episodes per 100 Medicare eligible)
• 2019-2020: 1.5-.5% add-on
All other rural counties
• 2019-2021: 3-1%
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Other Extenders
• Physician geographic floor of 1
Expired December 31, 2017
Extended through December 31, 2019
• Removed therapy caps beginning 2018
• Non-enforcement of physician supervision for small rural hospitals through 2017
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Other Hospital Changes
• Allows for less stringent EHR measures
• ACA decreases to Medicaid DSH pushed out and increased years 2021-2025
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Telehealth Changes
• Dialysis Monthly clinical assessments beginning 1-1-19
Requires face-to-face assessment monthly for first three months and at least once every three months thereafter
• Stroke victims Mobile stroke units
CMS to find additional originating locations for stroke victims—“looking for comments!”
• New sites cannot bill a facility fee
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Other Physician Changes
• MIPS—more gradual weighting of resource use
Was zero in 2019 (2017 reporting)
Was set to be 30% in 2021 (2019 reporting)
Changed from 3 year phase into a 5 year
• Changes 2019 base increase from .5% to .25%
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Other Physician Changes
• MIPS adjustments applied to all covered service
• Now: to covered professional services
• Includes payment and low volume calculation
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Other Non-physician Changes
• Physician assistants to provide services for hospice patients on or after 1-1-19
Initial certification must still be physician
• Mid-level supervision beginning 1-1-24
Cardiac rehab
Intensive cardiac rehab
Pulmonary rehab
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IPPS, OPPS, MPFS
Final Rules
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Cost Report Filings
• Can submit electronically (12-31-17 cost reports and on)
• Same portal as your PS&R
• Signed PDF of worksheet S sufficient
There is a new box for you to check
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Cost Report Acceptance—CAH and PPS
• Medicare bad debts must be Submitted with the cost report
In the proper form
Match the amount claimed
• Allocating costs from home office or chain organization Must submit home office cost report
Costs must match home office cost report
Can be rejected –OR–
Costs could be disallowed
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Cost Report Acceptance (PPS)
• DSH hospitals
Medicaid eligible days
Charity and uninsured discounts
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Physician Certification
• Rule: physician certify and recertify inpatient necessity
Prior: state where backup for decision is in file
Now: documents in file must support decision, but they do not have to be cross-referenced
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Price Transparency Not as Easy as It Sounds
• Must be in machine-readable format
• On website by January 1, 2019
• Update at least annually
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Price Transparency Not as Easy as It Sounds
• CMS is seeking input on how best to report standard charges on your website Upload charge master?
List CPTs generally billed together?
What type of information is meaningful to patient?
Should providers be required to tell of out-of-pocket costs before service is provided?
Should providers give patients what Medicare pays for a particular service?
What changes would you all need to make to be able to do these things?
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Price Transparency CMS FAQs
• Format: machine readable – PDF does not count
• Applies to all items and services
Including those not provider-based
Including those for which there is a zero charge
Includes your nursing home, ALF, RHC, free-standing clinic, DME, or whatever you may provide
• CAHs: yes, you must comply
• Online state transparency sufficient: NO
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OPPS Comments Requested
• Use of prior authorization
• Why hospital-based clinics should be paid more
• Utilization management tools
• Exemption for rural areas
• Potential effects on Medicare population
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2019 MPFS
• Beginning January 1, 2021
• Combined E&M payment amounts for levels 2-4
• Separate pricing Level 1 established (99211)
Level 1 new (99202)
Level 2-4 established (99212-99214)
Level 2-4 new (99202-99204)
Level 5 established (99215)
Level 5 new (99205)
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2019 MPFS
• Will bill with appropriate CPT code
• For levels 2-4, only need to code to level 2
• RHC implications
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Radiology Assistant Supervision
Current
• Personal supervision
Proposed
• Direct supervision
Registered radiology assistants (RRA)
Radiology practitioner assistants (RPA)
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Technology Based—Not Telemedicine
• G2012—brief communication technology based (virtual check-in)
5-10 minutes of medical discussion
Verbal consent required
Must be established patient
Cannot be related to any E/M services within the prior seven days
If an E/M is scheduled for the next day or next available appointment, the amount cannot be charged
• G2010—remote evaluation of recorded video or images submitted by the patient
Follow-up can be via the phone, email, secure text, audio video, or patient portal
Must be established patient
Cannot be related to any E/M services within the prior seven days
If an E/M is scheduled for the next day or next available appointment, the amount cannot be charged
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Technology Based—Not Telemedicine for RHCs and FQHCs
• At least a five minute check-in
• Must be established patient
• Paid separately if no encounter
Seven days prior –OR–
Within 24 hours (or next available appointment
• Otherwise part of all-inclusive rate
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MIPS Eligible Clinicians
• Physicians
• Physician assistants
• Nurse practitioners
• Clinical nurse specialist
• Certified registered nurse anesthetist
• Groups that contain such clinicians
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Additional Clinicians
• MIPS allowed for more starting with 2021
• Reporting for 2021 began 1-1-19
Physical therapist
Occupational therapist
Speech therapist
Clinical psychologist
Audiologist
Registered dietician or nutrition professional
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Low-volume Eligible Clinicians
• 200 or fewer Medicare beneficiaries
–or–
• $90,000 or less Medicare reimbursement
–or–
• 200 or fewer covered professional services
Miss one of these and they can opt-in
• Log-in to Quality Patient Portal and chose “opt-in”
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MIPS Weights and Performance Period
• 2019
12 months
• Quality performance—45%
• Cost performance—15%
90 days
• Promoting interoperability—25%
• Improvement activities—15%
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WORKSHEET S‐10Uncompensated Care
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• Includes
Charity care
• Charges for days exceeding a length-of-stay limit
Financial assistance policy/uninsured discount policy
Non-Medicare bad debts
Non-reimbursed Medicare bad debts
• Excludes – discounts not in the above policies
Uncompensated Care Costs
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• 501r discounts Must be approved by the board
Should be on website and “one click away”
• Bankruptcies
• Discounts to out-of-network individuals
• Noncovered service provided to Medicaid (or other indigent program) beneficiaries
• What are we discounting that is not included in these policies Put it in said policy
Financial Assistance Policy/Uninsured Discount Policy
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Charity Care Reported Before
• Cost report periods beginning before 10-1-16
• Uninsured—total charge
• Insured—total deductible or coinsurance
• Written off based on dates of service
• FAP in effect when amount was written off
• Must report partial payments
Total charge $35,000 – patient qualifies for 50% charity and pays $10,000
• Total charge of $35,000 reported
• Payment of $10,000 reported
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Charity Care Reported After
• Cost report periods beginning after 10-1-16
• Uninsured—total amount written off
• Insured—portion of deductible or coinsurance written off
Move Medicare to bad debt
Double-check for those with insurance but no payment• Move to uninsured bucket
• Claim based on writeoff date
• FAP in effect when amount was written off
• Payments should be minimal or zero
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Bad Debts
• Claimed based on writeoff date
• Can claim while in collections
Yes, different than Medicare bad debts
• Include Medicare bad debts in the total
Including those written off under charity care policy
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Some Technicalities
• Charity changed: cost reports beginning on or after October 1, 2016
• Payments only reported if related to charity claimed (CMS expects payments to be close to zero)
• Can claim bad debt while in collections
• FAP in effect when the amount was written off
• Claim in year written off (now)
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Reporting Requirements—DSH Hospitals• Detail-level report must be submitted with MCR
Patient name/identifier
Primary insurance
Secondary insurance
Revenue code
Payment
Deductible
Coinsurance
Copay
Amount written off to charity
Dates of service
Date written off
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The Math
Charges Times CCR
• Uninsured charity or FAP
• Non-Medicare bad debts
Charges at Face Value
• Medicare bad debts
• Unpaid portion of Medicare bad debts
• Insured charity or FAP
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The Math
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Overall CCR - line 1.00 0.480000
Amount Amount of
Reported Cost
Uninsured charity $ 100,000 $ 48,000
Insured charity 50,000 45,000
Charges for patient days beyond
the allowed days 5,000 2,400
Total bad debts 500,000
Medicare bad debts claimed 100,000
Medicare bad debts paid 65,000 35,000
Net bad debts 400,000 192,000
Total UCC cost $ 322,400
It is a Hospital Cost Report
• Include hospital inpatient and outpatient services
• Exclude physicians services
Detail with revenue code does charges
You do the math for payments
• Generally – if included on C, include
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New S-10 Guidance
• First year of new guidance
September 30 YE – 2017
December 31 YE – 2017
April 30 YE – 2018
June 30 YE – 2018
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S-10’s Effect
• PPS—used in uncompensated care calculation
• Not-for-profit hospitals—it is compared to the IRS Form 990
• States Some are considering using for base of DSH type
programs (Texas is the first)
Other will follow suit
• It is looked at to see if you all should be paid more or less. Just saying.
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MISCELLANEOUSAND PITFALLS
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DSH Rule
• State DSH payments
• Paid up to total uncompensated care costs
Uninsured
Medicaid eligible
• Medicare primary
• Insurance primary
• Holding decision up in court is fun
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CAH Physician Certification
• Conditions of Participation
Average length of IP stay must be less than 96 hours
• Conditions of Payment
MD must certify patients will be discharged or transferred within 96 hours
Does not have to be transferred or discharged
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CAH Physician Certification
• October 1, 2017 – “not priority for review”
• What does it all mean?
lol
• Ensure you have the proper certification
• Work with state hospital association to get legislative fix
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CAH Off-campus Locations
• Cannot provider-based if location does not meet CAH distance requirements
PPS can be provider-based, but payment is flat
CAH cannot be provider-based – it puts their CAH status in jeopardy
Grandfathered as of 1-1-08
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CAH Bed Counting
• Hospital-type beds
In nursing
Areas adjacent to nursing
Labor and delivery where mother remains after birth
Sick baby in basinet
Hospice under arrangement
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2018 EHR Promoting Interoperability
• Any continuous 90-day period
January 1 through December 31
2018
2019
2020
• 2015 certification required starting 2019
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OIG WORKPLAN
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OIG Workplan
• Review of inpatient hospital billing
• Involuntary transfers or discharges in nursing homes
• Review of post-operative services provided during the global period
• Medicaid nursing home supplemental payments
• Review of Medicare payments for telehealth services
• Review of EHR security
• Medical assistance days claimed
• Comparison of provider-based and free-standing clinics
• Duplicate GME payments
• Review of hospital wage data utilized in wage index
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Questions
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Contact Information
Shar Sheaffer, CPA, OwnerDingus, Zarecor & Associates PLLC
12015 East Main AvenueSpokane Valley, Washington 99206
Email: [email protected]
Phone: 509.321.9485
www.dzacpa.com
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