10/12/2017 COST REPORTING 201. October 18, Michael K. Westerfield, CPA, FHFMA Senior Manager
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1 COST REPORTING 201 October 18, 2017 Michael K. Westerfield, CPA, FHFMA Senior Manager 1
2 AGENDA Cost Report 101 Review Wage Index Disproportionate Share S-10 Indirect Medical Education (IME) Graduate Medical Education (GME) 3 COST REPORTING 101 REVIEW What is a cost report 4 2
3 REVIEW Worksheet S Series Worksheet A Series Worksheet B Series Other Miscellaneous 5 S SERIES S - Settlement summary S-2 - Provider information S-3, Part I - Provider statistics S-4 - Home health statistics S-8 -RHC data S-10 Uncompensated care 6 3
4 A SERIES A -Costs A-6 - Reclassifications A-8 - Adjustments A Related organizations A Physician costs 7 A SERIES (CONT.) 8 4
5 A SERIES (CONT.) 9 A SERIES (CONT.) A -Costs A-6 - Reclassifications A-8 - Adjustments A Related organizations A Physician costs 10 5
6 A-8 11 A SERIES (CONT.) Examples of non-allowable expense Alcoholic beverages Lobbying expenses Gifts and donations Promotional items Sports and other tickets Advertising to increase patient utilization Marketing salary and related costs Physician recruitment & guarantees Gift shops & vending machines Cost of travel related to non-patient care Cost of drugs sold to other than patients Personal use of autos Surety bonds Patient telephones and televisions Physician clinics Barber and beauty shops Country club dues Costs associated with reorganizations, mergers & acquisitions Fines & penalties Costs of catering & guest meals 12 6
7 A SERIES (CONT.) A -Costs A-6 - Reclassifications A-8 - Adjustments A Related organizations A Physician costs 13 B SERIES B, Part I Cost step-down B, Part II Capital step-down B-1 Statistics for step-down B-2 Post step-down adjustments 14 7
8 OTHER FORMS C Series D Series E Series G Series 15 OTHER FORMS (CONT.) 16 8
9 OTHER FORMS C Series D Series E Series G Series 17 S-3 PART II (WAGE INDEX INFORMATION) This worksheet provides for the collection of hospital wage data which is needed to update the hospital wage index applied to the laborrelated portion of the national average standardized amounts of the PPS. 18 9
10 WAGE INDEX Five major components of a wage index Salaries Hours Contract Labor Physicians Wage related costs 19 SALARIES & HOURS Salaries From Worksheet (WS) A data Should include Vacation Holiday Sick pay Paid time off Severance Bonus Do you know what is taxed to your employees and is it always recorded in salary accounts? 20 10
11 SALARIES & HOURS Hours Include Regular hours Paid overtime at 1.0 factor Holiday pay Vacation & sick leave Paid time off Hours associated with severance Exclude On-call hours Bonus pay hours Pay in lieu of time-off hours 21 SALARIES & HOURS Salaries & Hours Read the cost report instructions for the time period under review or preparation Not all of the guidelines are intuitive e.g., Accrued dollars & paid hours Consider the impact of: Worksheet A grouping of expenses Worksheets A-8 & A-8-1 treatment of adjustments & related parties 22 11
12 SALARY & HOUR TIPS Meet with payroll & see what is taxed on W-2 AND where it is recorded on the G/L Get actual payroll hours by paycode (key codes have errors) Test impact of groupings & structure of organization 23 CONTRACT LABOR Categories Category Worksheet S-3,Part II Line Patient Care Line 11 Management & Administrative Line 12 Administrative & General Line 28 Housekeeping Line 33 Dietary Line 35 Labor component & related hours with a contract Contract labor is a broad term, not a general ledger term 24 12
13 CONTRACT LABOR TIPS Vendor listing review, not just G/L review Contact vendors early & be persistent Put in a gatekeeper in Accounts Payable: Missing info = No payment 25 TURNING TIPS INTO ACTIONS Do: Set Minimum Vendor Thresholds Do: A Review of Invoices for Fees & Hours Do: Follow the Information Trail Do: Contact Other Hospitals within your CBSA Do: Gain Rapport with your Vendors Do: Verify all Chain Hospitals are Reporting Fees & Hours for the same Vendors Do: Include as many Fees & Hours on the asfiled Cost Report 26 13
14 TURNING TIPS INTO ACTIONS X Don t: Forget Home Office A&G Contract Labor X Don t: Forget to Keep Support for Fees & Hours X Don t: Wait Until the Last Minute to Find Contract Labor! 27 PHYSICIANS Part A physician time included in the WI Salaried Contract Varying degrees of acceptable information by each MAC Examples of Part A time include medical directorship & administrative duties 28 14
15 PHYSICIAN TIPS When possible, update the employment agreement or the contract to state dollars & hours specifically If time studies are required, implement a gatekeeper Ask your MAC what support is needed 29 TURNING TIPS INTO ACTIONS Physicians Do: Search for employed physicians using a pay code report Do: Develop a contract matrix to track all physicians Do: Review contracts for determination of services provided, Part A or Part B Do: Review invoices for physician fees, hours & completed time studies Do: Ask your MAC about time study & other documentation requirements Do: If time studies are not feasible, specify Part A hours in contract Do: Include as many fees & hours on the as-filed Cost Report 30 15
16 TURNING TIPS INTO ACTIONS X Don t: Forget to Keep Support for Fees & Hours X Don t: Wait Until the Last Minute to Find Physician Contract Labor! 31 WAGE-RELATED COSTS Wage-related costs Wage related cost lines should match salary lines E.g., Part B physician s/h Part B physician WRC Not every line is used in setting the wage index Core, Other, Physician Part A used Commonly omitted Mental health component of employee assistance program (EAP) Employee health expenses 32 16
17 WAGE-RELATED COSTS TIPS Meet with HR and/or review your website re: benefits offered & compare to G/L Look at the allocation basis & alignment of the WRC Evaluate your selfinsurance for reasonableness & discount compared to other payers 33 DISPROPORTIONATE SHARE HOSPITAL (DSH) Medicare Disproportionate Share Hospitals (DSH) receive an additional Medicare inpatient payment for treating a disproportionate share of low income patients The Medicare DSH payment is an add-on to the hospital s inpatient DRG payment Designed to compensate hospitals for the higher cost of treating low income patients 34 17
18 DISPROPORTIONATE SHARE HOSPITAL (DSH) Disproportionate patient percentage of 15.0% or more determined by the sum of two ratios: Medicaid Ratio: Patient days that are eligiblefor Medicaid & not entitledto Medicare Part A divided by total patient days Medicare/SSI Ratio: Total patient days that are entitledto Medicare Part A benefits & federal supplemental security income (SSI) benefits divided by patient days entitledto Medicare Part A benefits 35 DSH & UNCOMPENSATED CARE Effective October 1, 2014, there are two components in determining Medicare DSH payments Traditional Medicare DSH 25% (Empirical) Uncompensated Care Costs (UCC) 75% Created big winners and losers and shifted previous DSH reimbursement between hospitals Only hospital who qualify for DSH, qualify for the uncompensated care payment 36 18
19 UNCOMPENSATED CARE Medicare UCC payment factors Factor 1 75% of the estimated traditional total Medicare DSH payments for the current Federal fiscal year (FFY) Factor 2 The change in the uninsured percent for individuals under 65 from FFY 2013 to the current FFY Factor 1 multiplied by Factor 2 determines the total Medicare UCC pool payments available 37 UNCOMPENSATED CARE Medicare UCC payment factors Factor 3 Hospital specific Determined based upon a hospital s uncompensated care as a percentage of the total uncompensated care for all Medicare DSH hospitals Determined based upon Medicaid days and SSI ratios for FFY 2014 to FFY 2017 The hospital specific Factor 3 is multiplied by the total Medicare UCC pool payments available 38 19
20 UNCOMPENSATED CARE Factor 3 Low income proxy Three year transition to use Worksheet S-10 uncompensated care cost to determine the low income proxy instead of Medicaid days and SSI ratios FFY 2018 low income proxy calculation Average of the three percentages below Individual hospital s FFY 2012 cost report Medicaid days and FFY 2014 SSI ratios as a percentage of all qualifying Medicare DSH hospitals Individual hospital s FFY 2013 cost report Medicaid days and FFY 2015 SSI ratios as a percentage of all qualifying Medicare DSH hospitals Individual hospital s FFY 2014 Worksheet S-10 charity care and bad debt expense data as a percentage of all qualifying Medicare DSH hospitals FFY 2020 would be the first year to use only Worksheet S-10 data to determine the low income proxy (FFYs 2014, 2015 and 2016) 39 WHY WORKSHEET S-10 MATTERS? Greater focus, transparency & emphasis on charity care provided by hospitals Compare charity care reported across all publicly available documents for consistency Publicly available data Worksheet S-10 IRS Form 990 Schedule H Community benefit reporting Increased scrutiny of hospital tax-exempt status from a 501(R) perspective 40 20
21 WHY WORKSHEET S-10 MATTERS? Senator Grassley (IA) Nonprofit hospitals should spend at least 5% of the their patient revenue on charity care Charity care and bad debt trends Growth of high deductible plans Medicaid expansion EHR incentive payments Unknown future uses Medicare uncompensated care payments beginning FFY WORKSHEET S-10 HOSPITAL UNCOMPENSATED AND INDIGENT CARE DATA Provider CCN: Period From: 01/01/2016 To: 12/31/2016 Worksheet S Uncompensated and indigent care cost computation 1.00 Cost to charge ratio (Worksheet C, Part I line 202 column 3 divided by line 202 column 8) Uninsured patients Insured patients Total (col. 1 + col. 2) Charity care charges for the entire facility (see instructions) 53,004,534 9,523,321 62,527, Cost of patients approved for charity care (line 1 times line 20) 14,615,947 2,626,046 17,241, Partial payment by patients approved for charity care 164, , , Cost of charity care (line 21 minus line 22) 14,451,806 2,131,939 16,583, Total bad debt expense for the entire hospital complex (see instructions) 58,683, Medicare bad debts for the entire hospital complex (see instructions) 639, Non-Medicare and non-reimbursable Medicare bad debt expense (line 26 minus line 27) 58,043, Cost of non-medicare and non-reimbursable Medicare bad debt expense (line 1 times line 28) 16,005, Cost of uncompensated care (line 23 column 3 plus line 29) 32,589,
22 WORKSHEET S-10 Cost reporting periods beginning prior to October 1, 2016 Line 20, Column 1 Charity Care Charges Uninsured Patient Total initial payment obligations (measured at full charges) of the patients who are given a full or partial discount, based on the hospital s charity care criteria for care delivered during the cost reporting period for the entire facility Line 20, Column 2 Charity Care Charges Insured Patient Deductible and coinsurance payments required by the payer for insured patients covered by a public program or private insurer with which the provider has a contractual relationship that were written off to charity care 43 WORKSHEET S-10 Cost reporting periods beginning on or after October 1, 2016 Line 20, Column 1 Charity Care Charges Uninsured Patient Actual or portion of the total charge amount for the entire facility In accordance with the hospital s charity care policy Written off to charity care during the cost report period Charge amount the patient is not responsible to pay after discount Includes patients with coverage from an entity that does not have a contractual relationship with the hospital Line 20, Column 2 Charity Care Charges Insured Patient Deductible and coinsurance payments required by the payer for insured patients covered by a public program or private insurer with which the provider has a contractual relationship that were written off to charity care 44 22
23 WORKSHEET S-10 Line 20, Column 1 & 2 Do NOT include Charges of uninsured patients that do not meet the hospital s charity care policy Physicians and other professional services Non-covered services Charges for patients given courtesy allowances who do not meet the hospital s charity care criteria Medicare deductible or coinsurance amounts 45 WORKSHEET S-10 Line 26 Total Facility Bad Debts Total bad debt expense written off during the cost report period Excludes physicians and other professional services 46 23
24 S-10 ISSUES, CHALLENGES & OPPORTUNITIES The increase in the FFY 2018 Factor 1 mask the impact of using Worksheet S-10 uncompensated care data The Medicare UCC payment pool is budget neutral Utilizing Worksheet S-10 data will create winners and losers Hospitals may not be able to rely upon an annual $800 million increase in the Medicare UCC payment pool amount in future periods 47 S-10 ISSUES, CHALLENGES & OPPORTUNITIES Complying with Worksheet S-10, Transmittal 10 instructions and definitions Receiving the Medicare UCC DSH payments you are entitled to Ensuring charity care charges comply with the hospital s charity care policy Creating and implementing procedures for accumulating charity care and bad debt expense amounts Projecting charity care charges and total bad debt expense changes on future Medicare UCC payments 48 24
25 S-10 ISSUES, CHALLENGES & OPPORTUNITIES Avoiding significant Medicare UCC payment reductions based upon audit findings Maintaining auditable documentation for charity care and bad debt amounts on Worksheet S-10 for cost reports beginning on or after October 1, 2016 (9/30/2017, 12/31/2017, 3/31/2018, 6/30/2018) Considering amending FFYs 2014 and 2015 Worksheet S-10 data by October 31, INDIRECT MEDICAL EDUCATION IME, E, PART A Section 1886(d)(5)(B) of the Act provides that prospective payment hospitals that have residents in an approved graduate medical education program receive an additional payment for a Medicare discharge to reflect the higher patient care costs of teaching hospitals relative to nonteaching hospitals. The IME adjustment factor is calculated using a hospital's ratio of residents to beds, which is represented as r, and a multiplier, which is represented as c, in the following equation: c x [(1 + r).405-1]
26 DEFINITION OF A BED The bed count is notyour licensed or staffed beds Available Beds is based on 42 CFR (b) For purposes of this section, the number of beds in a hospital is determined by counting the number of available beddays during the cost reporting period and dividing that number by the number of days in the cost reporting period. 51 DEFINITION OF A BED Available bed days excludes Beds in a unit or ward that are otherwise occupied that could not be made available for inpatient occupancy within 24 hours for 30 consecutive days Beds used for: Outpatient observation services (admitted observation patients count as available bed days) Skilled nursing swing-bed services Ancillary labor/delivery services 52 26
27 GRADUATE MEDICAL EDUCATION GME, E-4 Graduate Medical Education Per resident amount Weighted FTE 53 QUESTIONS? 27
28 THANK YOU! FOR MORE INFORMATION Michael K. Westerfield, CPA, FHFMA Senior Manager BKD, LLP 400 W. Capitol Avenue, Suite 2500 P.O. Box 3667 Little Rock, AR Office: Fax:
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