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Teaching Hospitals
Jackson Health System
Mount Sinai
Medical Center
Orlando Health
UF Health Shands Hospital
UF Health Jacksonville
Tampa General Hospital
Public Hospitals
Halifax Health
Lee Memorial Health System
Memorial Healthcare System
Broward Health
Sarasota Memorial
Health Care System
Children’s Hospitals
All Children’s Hospital
Miami Children’s Hospital
Anthony Carvalho
President
www.safetynetsflorida.org
Safety NetHospital Alliance
of Florida
SNHA
Regional Perinatal IntensiveCare Center
Sacred Heart Health System
GRR MEETING & TELECONFERENCE
Holland & Knight Law Firm 315 S. Calhoun Street (Bank of America Bldg), 6th Floor
Tuesday, March 17, 2015 12:00 p.m. – 1:00 p.m. EST
Call-In: (888) 684-4447 Conference ID: 8504255685
AGENDA Welcome
1. AHCA Rate Litigation Letter: 21 Day Opportunity to Challenge of Audited Rates
2. ACA Coverage Expansion: SB 7044, 3/17/15, Sen. HHS Appropriations
3. Appropriations:
a. Supplemental Payments & 1115 Waiver: Update
b. GME Funding: $20M Request
c. Pediatric DRG High Outlier: FACH Request
4. Key SNHAF Bills:
a. SB 322 by Stargel: Medicaid Rate Setting Litigation
b. HB 999/SB 1394 by Fitzenhagen/Gibson: ASC & RCCs
c. SB 516/HB 681 by Bean/Trujillo: Balance Billing (Commercial Ins)
5. Key Public Hospital Bills:
a. HB 953 by Costello: 10 Year Public Reauthorization Vote
b. PCB by M. Gaetz: Taxing Authorized ONLY if Claim Denials Within 10%
6. SNHAF Level 1 Trauma Survey: Update
7. Other Issues
Adjourn
Upcoming Meetings:
March 24, 2015: GRR Meeting SNHAF Hospital Day’s in the Capitol: April 13th-‐14th
From: SNHAF Subject: FYI: AHCA 21 Day Rate Notice Letter Date: March 11, 2015 at 9:34:48 AM EDT
Hi Everyone -‐
As promised during today's government relation’s teleconference, attached is a Question & Answer document produced as the result of discussions between AHCA’ s General Counsel and SNHAF. These answers serve as clarification to outstanding questions generated by the “Notice of Agency Action: Historical Medicaid Inpatient and Outpatient Hospital Reimbursement Rates” (21 day rate letter).
If you have hospital specific questions, please feel free to contact us or the agency directly.
Your SNHAF Team,
Jan, John, Mike, Mark, Tony and Lindy
From: Williams, Stuart [mailto:[email protected]] Sent: Tuesday, March 10, 2015 3:04 PM Subject: Q & A Please see responses to your questions. Feel free to give me a call if you have additional questions or need further clarification. Best Regards, Stu Stuart F. Williams General Counsel Agency for Health Care Administration Office of the General Counsel 2727 Mahan Drive, Building 3, MS #3 Tallahassee, FL 32308 Telephone: (850) 412-3669 Fax: (850) 921-0158 Email: [email protected] Note: Florida has a very broad public records law. Most written communications to or from state officials regarding state business are public records available to the public and media upon request. Your e-mail communications may therefore be subject to public disclosure.
Question 1.
If the rate listed in Exhibit A of the Notice of Agency Action Letter (“Agency Letter”) mailed to
hospital providers is unaudited and the Agency subsequently changes the rate based on an
audited Medicaid cost report will the hospital have the opportunity to challenge the audited
rate or request a reopening of the Medicaid audited cost report.
Note that this question is referencing audited rates issued by the Agency subsequent to
February 2015.
Answer.: Yes. The Agency Action Letter does not constitute agency final action in regard to
unaudited rates and was not intended to be a point of entry in regard to same. In regard to
unaudited cost reports, when the audits are subsequently completed the Agency will issue a
new notice of agency final action and notice of hearing rights to the affected hospital for rates
set based on subsequently audited cost reports and rates set pursuant to same -- thereby
providing the affected hospital a new point of entry; the hospital will then have 21 days from
that new notice to petition for hearing.
For audited rates published on or before the Feb 2015 Agency Letter, the Agency reserves the
right to deny an otherwise timely request to reopen which asserts as its basis errors or mistakes
that the hospital was on notice of prior to issuance of the Agency Letter; the validity of requests
to reopen will be assessed by the Agency on a case-by-case basis pursuant to the operative
state plan and governing law.
Question 2.
As noted in the second section of the first paragraph of the Agency Letter
“Effective October 1, 2013, for cost reports received prior to October 1, 2003, all desk or
onsite audits of these cost reports shall be final and not subject to reopening”
If the Agency currently has original Medicaid audits for cost report periods prior to October 1,
2003 that have not been processed and the Agency processes the Medicaid audits and notices
the hospital of the audited rates, will the hospital be allowed to request a reopening of the
audits to correct any errors in the Medicaid audits. Will the Agency deem Medicaid audits for
cost reports received prior to 2003 as final even though a revised rate based on the Medicaid
audit has never been issued by the Agency.
Example: The Agency has an original Medicaid audit for a hospital’s fiscal year 2001 and the
Agency revises the hospital’s unaudited Medicaid rate based on the Medicaid audit in February
2015, will the hospital have the right to challenge the audited rate or reopen the audited cost
report to correct any errors.
Answer. See response to Question 1. The Agency Action Letter does not constitute notice of
agency final action in relation to unaudited rates; this is true regardless of whether the
unaudited rates were for a rate semester prior to October 1, 2003. In this scenario, because “a
revised rate based on the Medicaid audit has never been issued by the Agency,” the provider
would have “three years [from] the date that the audit adjustments are noticed through a
revised per diem rate completed by the Agency” to request re-opening, in accordance with the
controlling language in the Inpatient Plan and governing law.
Question 3.
For any cost report received on or after October 1, 2003, for which a Medicaid cost report audit
is conducted and a revised rate based on the audit is issued by the Agency will the hospital only
have three years and twenty-one days from the date the audited Medicaid rate is noticed to
request a reopening of the Medicaid audited cost report or challenge the audited rate.
Answer
See response to Question 1. For a cost report received on or after October 1, 2003, the
provider would have 21 days from “the date that the audit adjustments are noticed through a
revised per diem rate completed by the Agency” to challenge the accuracy of the revised per
diem rate. It would have three years from that date (not three years + twenty-one days) to
request reopening of the cost report; whether the agency will grant a request to reopen will be
judged on a case-by-case basis dependent upon the grounds asserted in the request and
governing law.
Question 4.
If a hospital has been issued a Medicaid rate based on a Medicaid audited cost report and it is
within the allowed time for requesting a reopening of the Medicaid audit will the Agency allow
the Medicaid audit to be reopened to correct errors made by the Agency or the Agency’s
auditor or in cases where the provider did not include certain Medicaid allowable cost in the
original filed cost report.
Answer.
See response to Question 1. Requests to re-open will be judged on a case-by-case basis.
However, generally: for a cost report received on or after October 1, 2003, the provider would
have twenty-one days from “the date that the audit adjustments are noticed through a revised
per diem rate completed by the Agency” to challenge the accuracy of the revised per diem rate.
It would have three years from that date to request reopening of the cost report; whether the
agency will grant a request to reopen will be judged on a case-by-case basis dependent upon
the grounds asserted in the request, the operative state plan, and governing law.
Question 5.
For any hospital where the Agency has issued a revised Medicaid rate based on an audited
Medicaid cost report and it has been more than three years since the audited rate was noticed
to the hospital, but the hospital has requested a reopening (that was made beyond the three
year time period) by the Agency, will the Agency allow the reopening.
Answer. No.
Question 6.
How is the language in 409.905 (5) (c) 2., F.S and at paragraph I.O. in the Reimbursement Plan
reconcile to the ability of a hospital to reopen a Medicaid audit within three years from the
date the audited rate is noticed.
Statutory Language:
“…However, the agency may not make any adjustment to a hospital’s reimbursement more than
5 years after a hospital is notified of an audited rate established by the agency. The prohibition
against adjustments more than 5 years after notification is remedial and applies to actions by
providers involving Medicaid claims for hospital services….”
Plan Language:
“Effective July 1, 2011, the Agency may not make any adjustment to a hospital’s reimbursement
rate more than 5 years after a hospital is notified of an audited rate established by the agency.
The requirement that the agency may not make any adjustment to a hospital’s reimbursement
rate more than 5 years after a hospital is notified of an audited rate established by the agency is
remedial and shall apply to actions by providers involving Medicaid claims for hospital
services…”
Answer. The Agency interprets the five year limitation language quoted above to be an absolute
bar to the adjustment of any hospital’s reimbursement more than five years after a hospital is
notified of an audited rate established by the agency, regardless of the bases for the
adjustment.
Question 7.
Does the Agency Letter give hospitals a point of entry to challenge or reopen any audited rate
included in Exhibit A if that challenge is made within 21 days of the hospital receiving the letter.
Answer. It gives a point of entry to challenge any audited rate included in Exhibit A on any
grounds. Each challenge will be judged on its individual merits. For example, if a hospital wants
to request that a cost report be re-opened more than three years after an audit-adjusted rate
has been issued by the Agency, that request should be made within the twenty-one day
window, but the Agency would likely deny that request based on the applicable limitations set
forth in the Inpatient Plan.
Teaching Hospitals
Public Hospitals Halifax Health Lee Memorial Health System Memorial Healthcare System Sarasota Memorial Health Care System
Broward Health Jackson Health Mount Sinai Medical Center Orlando Health UF Health Shands Hospital UF Health Jacksonville Tampa General Hospital
Children’s Hospitals All Children’s Hospital Miami Children’s Hospital
www.safetynetsflorida.orgRegional Perinatal IntensiveCare Center
Sacred Heart Health System
101 N. Gadsden StreetTallahassee, FL 32301
Office: 850.201.2096 Fax: 850.201.2078Teaching Hospital Council
GME Startup Bonus
FLORIDA MUST EXPAND GRADUATE MEDICAL EDUCATION TO MEET FUTURE HEALTH CARE NEEDS
GROUNDBREAKING NEW STUDY: FLORIDIANS FACE CRITICAL DOCTOR SHORTAGE
FUNDING REQUEST: $20 million recurring general revenue
FEDERAL MATCH AVAILABLE: $30 million (60% federal match for $50 million total program)
FUNDING ALLOCATION: GME Startup Bonus Program will provide a one-‐time startup bonus of $100,000 for each newly created (and filled) residency slots in the 20 physician specialties in deficit.
KEY POINTS:
! New study shows Florida needs 7000 new physicians in 19 different specialties
! Florida has a shortage of physicians and now has definitive information on which physician specialties are in the most severe shortages.
! GME is the best way to attract and retain physicians in Florida
! 81% of doctors who complete their residency training in Florida stay here
! Unfortunately, Florida keeps only 34% of the medical school graduates due to a lack of in-‐state residency slots.
Any unspent startup program funds remaining at the end of each fiscal year would be proportionally reallocated to all existing residency slots in the 20 shortage areas. This allocation to all shortage slots would be in addition to the Statewide Medicaid Residency Program (SMRP) formula allocation that provides funds to all residency slots regardless of specialty. Thus, the $80 SMRP would be maintained at current levels and slots in shortage specialties would receive a retention incentive allocation on top of their baseline SMRP allocation following their year one $100,000 start up bonus.
Note: This new program is eligible for the 60% federal Medicaid match. Thus, a $20 million state investment in a new GME Startup Bonus Program in shortage specialties would produce a $50 million head start in reducing Florida’s physician shortage.
GME$Startup$Bonus$Program$50$M$Total$($20M$GR$request$with$$30M$Federal$Match)$
3/16/15 a_SFY2014C15_GME_SMRP_calculation.xlsx
100 10,000,000$ Amount to Allocate 40,000,000$ 1 2 3 4
Provider County Medicaid ID
Hospital Total Residents (from SMRP file) __
Residents in Supply/Demand
Shortage
Percent to Total (column 2 / Total
column 2)
Allocation (column 3 * total Amount to
Allocate) 1 Alachua 100030 Shands Teaching Hospital 472.9 275.3 14.72991% 5,891,963$ 2 Broward 100129 Broward General Hospital 94.9 27.9 1.49229% 596,917$ 3 Broward 120405 Broward Health Coral Springs 2.1 1.0 0.05565% 22,259$ 4 Broward 102202 Cleveland Clinic Hospital 72.4 17.9 0.95703% 382,813$ 5 Broward 100200 Memorial Hospital 34.2 17.0 0.90821% 363,286$ 6 Broward 112801 University Hospital & Medical Center 17.0 17.0 0.90961% 363,844$
Total Broward 220.6 80.8 1,729,118$ 7 Dade 116483 Anne Bates Leach Eye Hospital 24.8 21.8 1.16465% 465,859$ 8 Dade 120375 Aventura Medical Center 15.2 3.2 0.17042% 68,167$ 9 Dade 100366 Cedars Medical Center, Inc. 103.4 59.9 3.20314% 1,281,254$
10 Dade 100421 Jackson Memorial Hospital 559.0 331.2 17.71873% 7,087,490$ 11 Dade 120138 Kendall Regional Medical Center 22.8 12.3 0.65866% 263,466$ 12 Dade 120057 Larkin Hospital-Miami 197.6 113.9 6.09394% 2,437,575$ 13 Dade 100609 Miami Children's Hospital 116.3 3.7 0.19666% 78,663$ 14 Dade 100463 Mt. Sinai Medical Center 132.1 46.8 2.50308% 1,001,233$ 15 Dade 104604 Palmetto General Hospital 72.5 19.0 1.01662% 406,649$ 16 Dade 100471 University of Miami Hospital and Clinic 41.9 15.6 0.83503% 334,011$ 17 Dade 32265 West Kendall Baptist Hospital 7.6 7.6 0.40879% 163,516$ 18 Dade 100625 Westchester General Hospital 29.8 25.0 1.33766% 535,064$
Total Dade (Miami-Dade) 1,323.0 659.9 14,122,948$ 19 Duval 100641 Baptist Medical Center 46.7 18.2 0.97593% 390,371$ 20 Duval 100722 Mayo Clinic Florida 111.1 61.8 3.30660% 1,322,640$ 21 Duval 101931 Memorial Medical Center 1.5 1.5 0.07812% 31,248$ 22 Duval 100676 Shands Jacksonville Med Cntr 251.7 125.4 6.70791% 2,683,162$ 23 Duval 100731 St. Vincent's Hospital 29.3 29.3 1.56560% 626,239$
Total Duval 440.2 236.1 5,053,659$ 24 Escambia 100765 Sacred Heart Hospital 52.5 15.0 0.80260% 321,038$ 25 Hernando 120073 Oak Hill Hospital 9.8 - 0.00000% -$ 26 Hillsborough 120324 Moffitt Cancer Center 118.3 50.0 2.67281% 1,069,122$ 27 Hillsborough 100994 Tampa General Hospital 247.1 110.6 5.91513% 2,366,053$ 28 Hillsborough 100943 Univ Community Hosp Carrollwood 1.2 1.2 0.06685% 26,739$ 29 Hillsborough 101028 Univ Community Hosp-Tampa 5.5 3.9 0.20846% 83,382$
Total Hillsborough 372.1 165.6 3,545,296$ 30 Lee 101109 Lee Memorial Hospital 12.0 12.0 0.64208% 256,831$ 31 Leon 101133 Tallahassee Memorial Rgnl Med Cntr 59.8 33.8 1.80584% 722,336$ 32 Manatee 101168 Manatee Memorial Hospital 42.6 11.0 0.58857% 235,428$ 33 Marion 101389 Osceola Regional Medical Center 16.5 4.0 0.21403% 85,610$ 34 Orange 101290 Florida Hospital 157.8 88.2 4.71819% 1,887,278$ 35 Orange 40876 Nemours Childrens Hospital 0.5 0.5 0.02442% 9,769$ 36 Orange 101338 Orlando Regional Medical Center 234.2 71.0 3.80118% 1,520,474$
Total Orange 392.5 159.7 3,417,521$ 37 Palm Beach 101401 Bethesda Hospital 8.1 - 0.00000% -$ 38 Palm Beach 101419 Boca Raton 21.2 - 0.00000% -$ 39 Palm Beach 120308 Columbia Hospital 19.5 - 0.00000% -$ 40 Palm Beach 101460 Columbia JFK Medical Center 51.8 7.3 0.39006% 156,025$ 41 Palm Beach 120090 Delray 8.0 - 0.00000% -$ 42 Palm Beach 101443 Lakeside Medical Center 13.0 13.0 0.69558% 278,233$ 43 Palm Beach 120260 Palm West Hospital 18.5 - 0.00000% -$ 44 Palm Beach 102130 Wellington Regional Medical Center 17.2 - 0.00000% -$
Total Palm Beach 157.2 20.3 434,258$ 45 Pasco 119881 Regional Medical Center Bayonet Point 6.9 - 0.00000% -$ 46 Pinellas 101516 All Children's Hospital 46.7 13.7 0.73465% 293,860$ 47 Pinellas 101567 Bayfront Medical Center 39.0 38.0 2.03388% 813,553$ 48 Pinellas 119741 Largo Medical Center 110.9 43.9 2.34894% 939,578$ 49 Pinellas 101583 Morton F. Plant Hospital 25.4 23.0 1.23188% 492,751$ 50 Pinellas 115193 Northside Hospital 32.6 1.9 0.10353% 41,414$ 51 Pinellas 120103 St. Petersburg General Hospital 43.2 26.9 1.43879% 575,515$
Total Pinellas 304.7 147.5 3,156,670.6 52 St. Lucie 119971 St. Lucie Medical Center 43.0 16.0 0.85610% 342,441$ 53 Volusia 101842 Halifax Medical Center 32.0 32.0 1.71220% 684,882$
Totals (Medicaid Allowable (1), Shortage Wtd (2)) 3,951.3 1,868.9 100.00000% 40,000,000$
Direct Payments to Hospitals Projection of GME Resident Funding after
Assumption of 100 New Resident Slots Generated
GME Startup Bonus Allocation Flowchart
3/16/15
Key
Year 1 Year 2 Year 3
alt 100
$50M Shortage Slots: $50M Shortage Slots: $50M Shortage Slots:100 New Slots @ $100k = $10M 200 New Slots @ 100k = $20M 300 New Slots @ $100k = $30M
Allocation Formulas:SMRP - Medicaid volume and number of GME residents.
GME Bonus - $100k per newly created shortage slot and unspent funds proportionally allocated to all shortage slots.
FUNDING REQUEST: $20 million recurring general revenueFEDERAL MATCH AVAILABLE: $30 million (60% federal match for $50 million total) FUNDING ALLOCATION: GME Startup Bonus Program will provide a one-time startupbonus of $100,000 for each newly created residency slot in the 20 physician specialties indeficit. Any unspent startup bonus funds remaining at the end of the third quarter of eachfiscal year would be proportionally allocated to all existing residency slots in the 20 shortagespecialtes. This allocation to shortage slots would be in addition to the Statewide MedicaidResidency Program (SMRP) allocation that provides funds to all residency slots regardless ofspecialty. The $80 SMRP would be retained for all residency slots.
$80M All Slots: 4000 slots @ approx $20k per slot $80M All Slots: 4100 slots @ approx $19.5k per slot $80M All Slots: 4300 slots @ approx $18.6k per slot
Statewide Medicaid Residency Program (SMRP)
Scenario: $50M GME Startup Bonus with Annual Growth in Number of New Shortage Slots Created
Scenario - GME Bonus growth in newly created slots is not cumulative. Bonus is one-time for brand new slots.
2100 Existing Shortage Slots $20M remaining = $9.5k per slot
$100k Bonus: First Allocations to Newly Created Shortage Slots
$100k Bonus: First Allocations to Newly Created Shortage Slots
1800 Existing Shortage Slots $40M remaining = $22.2k per Slot
1900 Existing Shortage Slots $30M remaining = $15.8k per slot
$100k Bonus: First Allocations to Newly Created Shortage Slots
1800
Bonus New
Shortage Specialty Slots SMRP
All Speciali6es All Slots
SMRP Shortage
Specialty Slots
100 New Slots
4000 Slots 4100 Slots
1900 100
200 New Slots
200
4300 Slots
2100
300 New Slots
Increases next year's slots
Increases next year's slots
Increases next year's slots
DRG Pediatric Outlier Policy Adjustment
Reviewed by the FACH Executive Committee on March 4
Currently Under Discussion by the FACH Board of Directors
Hi SNHAF GRRs,
In order to fine tune our GME funding proposal, we need to gather information that only you will have access to. Please let us know if your hospital is applying, or planning to apply, to the ACGME or OPTI for additional slots or a new program in one of the physician specialties listed below.
Name of Program ACGME or OPTI
New or Existing Program
Number of New Slots
Anticipated Month (?) / Year
for New Slots
Example: Name of Your Hospital
Name of Program ACGME or OPTI
New or Existing Program
Number of New Slots
Anticipated Month (?) / Year
for New Slots Neurology ACGME Existing 5 2016 OB/Gyn ACGME New (2016) 6 2016 OB/Gyn ACGME New (2017) 8 2017
IM - Endocrinology ACGME Existing 10 7/2015
Physician specialties and subspecialties, adult and pediatric, that are in statewide supply/demand deficit:
Allergy/ Immunology Infectious Diseases* Psychiatry
Anesthesiology Neurological Surgery Pulmonary*/ Critical Care
Cardiology* Neurology Radiology
Endocrinology* Obstetrics / Gynecology Rheumatology*
Family Medicine Ophthalmology
Thoracic Surgery
General Surgery Orthopedic Surgery Urology
Hematology* /
Oncology
Otolaryngology
*Specialty programs with an asterisk are secondary specialties under Internal Medicine as the primary program description.
