JK Medicare Part A Audit & Reimbursement Update

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1 JK Medicare Part A Audit & Reimbursement Update April of 2017

2 Disclaimer National Government Services, Inc. has produced this material as an informational reference for providers furnishing services in our contract jurisdiction. National Government Services employees, agents, and staff make no representation, warranty, or guarantee that this compilation of Medicare information is error-free and will bear no responsibility or liability for the results or consequences of the use of this material. Although every reasonable effort has been made to assure the accuracy of the information within these pages at the time of publication, the Medicare Program is constantly changing, and it is the responsibility of each provider to remain abreast of the Medicare Program requirements. Any regulations, policies and/or guidelines cited in this publication are subject to change without further notice. Current Medicare regulations can be found on the Centers for Medicare & Medicaid Services (CMS) Web site at

3 No Recording Attendees/providers are never permitted to record (tape record or any other method) our educational events This applies to our Webinars, teleconferences, live events, and any other type of National Government Services educational event

4 Agenda Website Survey General Updates JK Audit Work Plan DSH/SSI Workload Update Wage Index Update National IRIS Database Q&A

5 Website Survey This is your chance to have your voice heard click on Yes, I ll give feedback when you see this pop-up so NGS can make your job easier! 5

6 Website Survey Let s Grow Together! Your feedback is valuable to NGS and CMS! This survey is a great opportunity for you to tell us about your unique experiences. We read every single comment from these surveys and develop enhancement plans based on your feedback. We would love to see more surveys from our providers, especially if you have a positive experience! Share your great experiences and ideas for new functions by completing the survey every time it pops up! 6

7 General Updates

8 Standard Mailboxes and Contact Info JK Provider Contact Center Other Contact Information on our website: Standard Boxes for JK Medicare Part A Audit & Reimbursement: Cost Report Filing JK_Cost_Report_Filing@Anthem.com Cost Report Re-openings cost.report.reopenings@anthem.com Cost Report Appeals NGSCostReportAppeal2@Anthem.com Provider Based Determinations ngsprovbaseddeterminations@anthem.com PS&R PSR@Anthem.com Hospice Caps selfreportedhospicecap@anthem.com

9 A&R JK Update Cost Report acceptance is now handled in our South Portland, Maine office Regular USPS Mail can only go to the Post Office box: National Government Services Attn: Cost Reporting Unit PO Box 9731 Portland, ME Only courier service (Fed Ex, UPS, etc.) can only go to the street address: National Government Services Attn: Cost Reporting Unit 2 Gannett Drive South Portland, ME

10 A&R JK Update Communications regarding cost report filings should be directed to the shared mailbox: Send any passwords for encrypted files to this address Bank lockbox for payments has not changed: National Government Services, Inc NY Part A Non-MSP P.O. Box Chicago, IL

11 NGS Connex Provider Portal Providers are encouraged to use the Web Portal to submit requested information to NGS electronically. Create a user account and request a user ID by registering at The Connex web site has a link to Connex User Guide which is helpful for new users Advantages of using Connex: No need to encrypt PHI/PII Submission is instantaneous Connex maintains record of all submissions and issues confirmation when received Save shipping time and cost More secure than shipping

12 NGS Connex Provider Portal Cost Report Filing - Preferred Submission: You can submit all documentation and files through Exception: Mail originally signed worksheet S to Portland (with encryption code matching the electronic files) Exception: If check is required Mail original Check to bank lock box address (include copy with regular cost report filing package submitted through Connex) Additional cost report filing guidance located on our website

13 Miscellaneous submissions GME Affiliation Agreements 42 CFR (g) 42 CFR (g) One with agreement attached to both CMS and MAC CMS: NGS: 7/1/17-6/30/18 agreements due by 7/1/17 7/1/16-6/30/17 amended agreements due by 6/30/17

14 Miscellaneous submissions Temporary teaching cap adjustment requests for displaced residents 42 CFR (h) and (i) or through Connex to: Requests to change statistical basis or order in which general service costs are allocated CMS CMS Pub Section 2312 and or through Connex to: 14

15 Passwords Passwords that NGS encrypts files with can no longer be communicated via . NGS associates will call providers with the password used. NGS letter accompanying PS&R detail reports instructs providers to call Amanda Schultz ( ) for the password. 15

16 Jurisdiction K Audit Work Plan

17 JK Audit Work Plan Option Year 4-3/1/2017 to 2/28/2018 Approximate JK inventory (NY, CT, ME, MA, NH, VT, RI) ~430 Hospitals ~2,600 Other than hospitals (i.e. freestanding: SNF, HHA, ESRD, CORF, Home Office, RHC, FQHC) Desk Reviews, Audits, Wage Index, HITECH Audits, Re-openings, Appeals, MSP Audits 17

18 JK Audit Work Plan Medicare cost report audit Workload Desk reviews (if current per provider: FY 14 and/or FY 15 cost reports) All letters notifying of intent to start with opportunity to submit changes have been issued for the hospital cost reports for this option year Letters are a courtesy, not to be relied upon and no guarantee of being issued in the future Audits (subject to change) 33 NY hospitals to complete in OY4 that were started in OY3 29 NY hospitals planned to start in OY4 HITECH Audits (18 in total 5 in NY) Final Settlements (including cases put on hold for SSI, outlier reconciliation, etc.) Wage Index/Occupational Mix Re-openings/Appeals Medicare Secondary Payer audits 18

19 JK Audit Work Plan Current list of subcontractors Figliozzi & Company CPA Kujawa & Batteau CPA Systematic Billing 19

20 DSH/SSI Update

21 DSH/SSI Update General Status FY 04 and Prior Pending final change request from CMS which applies to final settlements, appeals and re-openings Several drafts versions of the change request have been issued to date FY 14 90% of cost reports to be final settled by 10/12/17 Remaining by 4/12/18 unless other reasons to hold or are part of a separate backlog/catchup plan FY 15 Pending release of SSI and final settlement timeline

22 Change Request (CR) 9896 E ntitled Instructions to Hospitals on the Election of a Medicare-Supplemental Security Income (SSI) Component of the Disproportionate Share (DSH) Payment Adjustment for Cost Reports that Involve SSI Ratios for Fiscal Year (FY) 2004 and earlier, or SSI Ratios for Hospital Cost-Reporting Periods for Patient Discharges Occurring before October 1, 2004 Issued by CMS on 12/16/16, revised 1/27/17 Posted to NGS website 12/21/16 22

23 Change Request (CR) 9896 CMS modified Ruling 1498-R2 with the issuance of Ruling on April 22, R2 only revises the Medicare-SSI fractions for cost reports utilizing the FY 2004 SSI Ratios and earlier. This revision to the Medicare-SSI fraction addresses the data matching process issue and the issue of Medicare Part A noncovered or exhausted benefit days ( dual eligible non-covered days ). This issue was initially addressed in 1498-R dated April 28, No other component of the DSH calculation will be addressed or impacted Medicaid days (paid or eligible), total hospital days, etc. 23

24 Change Request (CR) 9896 Cost Report must be open for this CR to apply Jurisdictionally valid appeal remanded by the PRRB to the MAC Cost Report which has not had an initial Notice of Program Reimbursement (NPR) Cost Report in which the MAC has previously issued a notice of reopening specifically for the Medicare-SSI fraction issue 24

25 Change Request (CR) 9896 For each cost reporting period impacted, hospitals must elect which Medicare-SSI fraction calculation method to be used: 1. Total days - include inpatient days of a person entitled to Medicare Part A in the numerator of the hospital s Medicare- SSI fraction (provided that the patient was also entitled to SSI) and in that fraction s denominator, even if the inpatient stay was not covered under Part A or the patient s Part A hospital benefits were exhausted (that is, elect to have applied a suitably revised Medicare-SSI fraction calculated on the basis of total days ); or 2. Covered days - exclude such days where the patient s Part A hospital benefits were exhausted or otherwise were not in a covered Part A stay from both the numerator and denominator of the Medicare-SSI fraction (that is, elect to have applied a suitably revised Medicare-SSI fraction calculated on the basis of covered days ). 25

26 Change Request (CR) 9896 Hospital election must be in writing and received by the MAC within 180 calendar days of the date that instructions were posted to the MAC s website (12/21/2016) 180 calendar day window expires on June 19, 2017 Elections should be ed to the following addresses based on the status of each cost reporting period» Remanded Appeals: NGSCostReportAppeal2@anthem.com» Reopenings: Cost.Report.Reopenings@anthem.com» Awaiting initial NPR: Justin.Clark@anthem.com 26

27 Change Request (CR) 9896 Hospital election must include the following information: Provider Number Hospital Name PRRB Case Number and PRRB Remand Date (if applicable) Case Name, Docket Number (if applicable) Hospital s designated representative (if applicable) Cost Report Begin Date (YYYYMMDD) Cost Report End Date (YYYYMMDD) FFY Based on CY Begin Date (YYYY) Provider Election ( Total or Covered ) SSI ratio selected (Numerical value from CMS website) 27

28 Change Request (CR) 9896 Realignment Requests Hospitals may request to have their Medicare-SSI fraction realigned with its cost reporting period (instead of the federal fiscal year) for cost reporting periods impacted by 1498-R2. For hospitals that have not yet received an initial NPR, the hospital must appeal the issue of Medicare-SSI days to the PRRB once the NPR is issued. All previous realignment requests no longer apply since the Medicare-SSI fractions are being revised. After receiving its revised Medicare-SSI fractions, hospitals may request realignment within the normal timeframes. 28

29 Change Request (CR) 9896 Realignment Requests, cont. To request realignment, the hospital must submit a written request to the MAC, on hospital letterhead and signed by authorized hospital personnel. The request must contain: Provider number Hospital name PRRB Case Number and PRRB Remand Date (if applicable) Case Name, Docket Number (if applicable) Hospital s designated representative (if applicable) Cost Report Begin Date (YYYYMMDD) Cost Report End Date (YYYYMMDD) FFY Based on CY Begin Date (YYYY) Provider Election ( Total or Covered ) 29

30 Change Request (CR) 9896 If the hospital fails to make an election or if the hospital election does not contain the required information (from previous slide) will result in the MAC having to contact the hospital in writing. If, after the MAC attempts to contact the hospital, the hospital still does not make an election, the MAC must notify CMS and the MAC will revise the DSH adjustment using the higher of the two revised Medicare-SSI fractions ( total or covered days). Note: the items above also apply to realignment requests. 30

31 DSH/SSI Update Allina v. Sebelius - CMS instructed contractors to final settle previously held cost reports involving specific providers in this litigation Timeline issued for applicable cost reports from FY Current timeline - Settle one cost report per provider in FYE order every 4 months (first round due 6/23/17) JK 16 providers, 109 cost reports, workload began in March Revised adj. reports and cost reports will be sent to provider contacts once ready by the auditors, will then be scheduled for NPR Providers can request we accelerate the NPR timeline, must do in writing, NGS will accommodate resources permitting Direction subject to change from CMS

32 Wage Index

33 FY 2018 Wage Index Update April 5, 2017 Deadline for hospitals to appeal MAC determinations and request CMS intervention Early April 2017 Final FY 2018 wage index data compiled and sent by CMS to MACs for verification April/May 2017 Approximate date proposed rule will be published 33

34 FY 2018 Wage Index Update April 28, 2017 Release of final FY 2018 wage index and OM data on CMS website May 30, 2017 Deadline for hospitals to submit correction requests to both CMS and their MAC to correct errors due to CMS or MAC mishandling August 1, 2017 Approximate date for publication of FY 2018 final rule October 1, 2017 Effective date of FY 2018 wage index 34

35 FY 2019 Wage Index Update Occupational Mix Survey Occupational Mix filings are due 7/1/17 (applicable to payroll periods ending between 1/1/16 and 12/31/16) Filing materials: Index-Files.html Please submit supporting documentation in addition to the survey form Submit via Connex (preferred), or mail to: National Government Services Audit and Reimbursement Wage Index Attn: Sarah Starowitz 5000 Brittonfield Parkway, Suite 100 East Syracuse, New York

36 Wage Index Wage Index Hot Topics: Contract Labor-Must provide a detailed list of the types of contract services that are reported on Line 11, including associated personnel costs and paid hours. Additional documentation to be reviewed for all types of contract labor will include a copy of the contract, invoices, etc. Wage Related Costs-A frequently used allocation method is based on percent to total of salaries. An alternative allocation method would be based on FTEs. CMS s policy is that if a hospital wants to change its allocation methodology, it must inform the MAC as soon as possible, and provide a legitimate rationale for doing so, along with documentation to support the change. In addition, the MAC must agree to the change in order for the hospital to change allocation methodology for wage index purposes. Health Insurance Costs-If reviewed, MAC will verify the costs with supporting documentation-any material increases will need to be adequately explained. 36

37 Wage Index Wage Index Hot Topics (cont.): Malpractice Insurance-9/1/1994 Federal Register Pg To clarify the allowability of malpractice insurance costs for purposes of the wage index, only those policies that list actual names or specific titles (for example, President of the hospital) of covered employees may be included in the wage index. General malpractice liability coverage maintained by hospitals is not recognized as a wage-related cost for purposes of the wage index. Pension-For FY 2018 and all subsequent fiscal year wage indexes, the 3-year average will be based on pension contributions made during the base cost reporting period plus the prior 2 cost reporting years. As a result, the defined benefit pension costs used for FY 2018 are the contributions made for the CY under review and 2 preceding cost report periods unless there is an exception for short reports. 37

38 Wage Index Wage Index Hot Topics (cont.): Self-Insured Providers-CMS Pub 15-I Section 2162-If the provider is truly selfinsured, they should take the charges they are writing off times the cost to charge ratios (CCRs) for the hospital for each cost center to compute the cost of coverage. The provider is not allowed to gross up charges and then claim that imputed amount as a wage related cost. -In the scenario where they are not truly self-insured (such as claims being processed through BCBS), the administrator processes the claims at whatever contractual rate agreed upon and then sends a monthly bill to the hospital. The hospital is paying the claim at the administrator s rate and cannot gross up the charges. In this case, there will be administrative management fees but those will be directly identifiable on the GL. 38

39 39 National IRIS Database Project

40 IRIS In response to OIG recommendations, CMS has developed a national IRIS database Will be used to address overlapping rotations as well as to enhance cost report verification capabilities CMS contracted with CGI Federal to develop the system MACs and Software Vendors assisting in a consulting role with the development of this system Project began in 2015 and is ongoing

41 IRIS Process: IRIS files will be uploaded to the database as part of the cost report acceptance process (NGS began this with the FYE 12/31/15 CRs). System currently includes edits similar to IRISFIV3 edit specifications (Additional edits will be included in future pending CMS direction) Similar to current process, failure for provider to clear system edits would result in rejection of cost reports Providers should expect future edits to include enforcement of FTEs calculated from IRIS to agree to the cost report Database loaded with historical IRIS files and used for cost report auditing IRIS Vendors working with CGI to match programming specifications.

42 IRIS IRIS file naming scheme Please submit IRIS files beginning with the 12/31/15 submissions in the following file naming scheme, this a courtesy request, it is not a filing requirement but may be for future IRIS/cost report submissions M######_YYYY-MM-DD.dbf A######_YYYY-MM-DD.dbf ###### = Medicare provider number YYYY-MM-DD = IRIS/Cost Report FYE in this format (with all parts including leading zeros) Free form text is allowed after the FYE, in order to indicate amended submissions or any other such annotations Example 1 provider # FYE 6/30/2015 initial IRIS/cost report submission» M012345_ dbf» A012345_ dbt Example 2 provider # FYE 6/30/ st amended IRIS/cost report submission» M012345_ Amended 1.dbf» A012345_ Amended 1.dbf

43 IRIS Next Phase (Efforts have begun) Redesign IRIS file type.dbf file to XML+XDS file format Redesign format to match cost reporting requirements i.e. Add IPF, IRF sections, etc., etc., etc.. Rollout of new IRIS file type, format and instructions is pending CMS direction

44 Director Gene Nickerson Reimbursement Managers Christine Chamberlain Kelley Cook Audit Managers Keith Redman Sandra O Connor sandra.o connor@anthem.com Gary Lukuc gary.lukuc@anthem.com

45 Reopening Manager Kevin Glorioso Appeals Manager Kathy Hales Kyle Browning

46 Questions

10/12/2017 COST REPORTING 201. October 18, Michael K. Westerfield, CPA, FHFMA Senior Manager

10/12/2017 COST REPORTING 201. October 18, Michael K. Westerfield, CPA, FHFMA Senior Manager COST REPORTING 201 October 18, 2017 Michael K. Westerfield, CPA, FHFMA Senior Manager 1 AGENDA Cost Report 101 Review Wage Index Disproportionate Share S-10 Indirect Medical Education (IME) Graduate Medical