HFMA Region IX. Novitas Solutions Steven Holubowicz, Sr. Director. November 7, Novitas Overview Medicare Cost Report Trends and Tips:

Transcription

1 HFMA Region IX Novitas Solutions Steven Holubowicz, Sr. Director November 7, 2017 Agenda Novitas Overview Medicare Cost Report Trends and Tips: OMNI Acceptance and Tentative Settlement Changes Wage Index Upcoming Dates CMS Focus Issues in Rejected! Common Reasons for Cost Report Rejections S-10 FY 2014 and 2015 Deadline to File Reopenings/Amended reports Reimbursement Issues Rate Review Facts Why Are My Payments Still Suspended Credit Balance Issue Novitas Portal, Novitasphere RAC PIP - PS&R Update New IRIS Processing (IRIS) 2 1

2 Agenda Medicare Cost Report Trends and Tips (Continued): Regulatory Update Rate Update S-10 changes Electronic Signature Volume Decrease Adjustment 3 Acronym List Acronym CMS DSH FOIA FTI NPI PHI PII Definition Centers for Medicare & Medicaid Services Disproportionate Share Hospital Freedom Of Information Act Federal Tax Information National Provider Identifier Protected Health Information Personally Identifiable Information 4 2

3 Acronym List Acronym PIP PTAN PUF SSI Definition Periodic Interim Payment Provider Transaction Access Number Public Use File Supplemental Security Income 5 Novitas Overview 3

4 Corporate Structure GuideWell Source First Coast Service Options (First Coast) Formed in 1998 as a for profit, Florida corporation (100% interest) Primarily focused on performing Medicare program administration for CMS as a Medicare Administrative Contractor (MAC) Novitas Solutions (Novitas) Formed in 2006 as a for profit, Pennsylvania corporation (100% interest) Primarily focused on performing Medicare program administration for CMS as a MAC TriCenturion (TriC) (50% interest) Formed in 1998 as a for profit, Delaware LLC (subsequently converted to a corporation) Primarily focused on performing anti-fraud work for CMS as a Program Safeguards Contractor 7 Corporate History Involved in Medicare administration since the inception of the program 50 years ago Novitas incorporated as separate subsidiary in 1998 Novitas currently serves as the Medicare Administrative Contractor (MAC) for Jurisdiction H (JH) (AK, CO, LA, MI, NM, OK, TX) and Jurisdiction L (JL) (PA, NJ, MD, DE, DC) 8 4

5 MAC Jurisdictions 9 Jurisdiction Level Statistics STATISTIC JURISDICTION L * (DC, DE, MD, NJ and PA) JURISDICTION H ** (AR, CO, LA, OK, MS, NM and TX) TOTAL Annual Claims Processed Annual Claims Payments 133 million 163 million 296 million $40 billion $50 billion $90 billion Medicare Providers 104, , ,752 Medicare Hospitals 541 1,190 1,731 Medicare Fee-For- Service Beneficiaries Percent of National Part A/B Workload 4,145,537 5,717,831 9,863, % 13.5% 24.5% * **

6 Provider Audit and Reimbursement Updates Topics OMNI Acceptance and Tentative Settlement Changes Wage Index Upcoming Date CMS Focus Issues in Rejected Cost Report Common Reasons S-10 FY 2014 and 2015 Deadline to File Reopenings and Amended Reports Reimbursement Issues Rate Review Facts Why are My Payments Still Suspended Credit Balances Novitas Portal, Novitasphere RAC PIP - PS&R Update IRIS Processing Regulatory Update Rate Update S-10 Changes and Electronic Signatures Volume Decrease Adjustment 12 6

7 OMNI Acceptance and Tentative Settlement Changes OMNI (Optimization through Modernization, Networking and Innovation) System Innovation Multi-phased innovation Acceptance of cost reports (8/2016) Tentative Settlements (12/ % of cost reports) Cost to Charge Ratios (CCR) Future Enhancements: SNF Desk Reviews (12/17) ESRD (Renal) Desk Reviews (7/21) Critical Access Hospital (CAH) Desk Reviews (12/21) Rural Health Clinic Desk Reviews (2/22) Hospital Desk Reviews (5/21) Settlement (8/20 2/21, four phases) Rate Reviews (2/19 1/20, seven phases) 13 OMNI Acceptance and Tentative Settlement Changes Automated Cost Report Acceptance: Implemented an automated acceptance process Pulls information from HFS and PS&R Eliminates many of the manual steps More complicated provider cost reports are routed out to an acceptance professional for processing Automated Tentative Settlement: Implemented an automated tentative settlement process Pulls CY and PY HFS data, PS&R, and feeds into templates, runs calculations, and prints letters in streamlined process More complicated provider cost reports are routed to TS professionals 14 7

8 Wage Index Time Table FFY 2019 Date Action Item 9/1/2017 or 10/2/17* Deadline for hospitals to request revisions to S-3 wage data and CY 2016 Occ. Mix data (request and supporting documentation). * CMS approved an extension for Texas and Louisiana providers due to Hurricane Harvey. Possibly longer extension, up to CMS. 11/4/2017 Deadline for Novitas to notify State hospital association re: hospitals that failed to respond to desk review issues 11/15/2017 Deadline for Novitas to complete all desk reviews and submit to CMS s division of acute care (DAC) 1/30/2018 First release of revised FY 2019 wage index Public Use File (PUF) 2/16/2018 Deadline for hospitals to request changes to 1/30/2018 PUF 3/23/2018 Deadline for Novitas to transmit revised wage index files to CMS and written notice to hospitals re: hospital s 2/16/2018 requests. 4/5/2018 Deadline for hospitals to appeal MAC determinations and request CMS intervention if hospital disagrees with Novitas. 15 Wage Index Time Table FFY 2019 Date April/May, 2018 Early April 2018 Action Item Approximate date proposed rule will be published; includes proposed wage index. CMS to send Novitas Final FY 2019 wage index data for verification and Novitas to notify hospitals to the availability of files 4/27/2018 Release of the final FY 2019 wage index and occupational mix data PUFs on CMS Web page. 5/30/2018 Deadline for hospitals to submit correction requests and all documentation to both CMS and Novitas for any errors related to mishandling of data posted 4/27/2018. Data that was incorrect in the preliminary or January PUF, but no correction request was received by the 2/16/2018 deadline, will not be changed. 8/1/2018 Approximate date for publication of the FY 2019 final rule 10/1/2018 Effective date of FY 2019 wage index 16 8

9 QASP - Quality Assurance Surveillance Plan Review is to ensure MAC s work meets the expected quality, quantity, and timeliness in all areas of it s operation. It is a review of the MAC s procedures and work across the enterprise in areas such as: Provider Audit & Reimbursement (AR) Customer Service Claims Processing Debt Management Medical Review Medicare Secondary Payer Provider Enrollment 17 Physician Compensation The provider must report hospital-based physician compensation on W/S A-8-2 utilizing the physician allocation agreements identifying the proper cost allocation between the following: Provider services (Part A), Professional services (Part B), and Nonreimbursable services such as research, teaching of I/Rs in a nonapproved program, etc. (Only the provider services are reimbursable on the cost report). CMS expects the physician allocation agreements (Exhibit 1 of W/S S-2, Part II) to be used to allocate the physicians compensation between the professional and provider component. In accordance with 42 CFR (f), the provider must submit a written allocation agreement to the contractor in order to receive payment for physicians compensation as a provider component. 18 9

10 Physician Compensation PRM 15-1, (C) Documentation A claim for Part B hospital costs or Part A and Part B hospital costs must be supported by the following data maintained by the hospital: A signed copy of the contract between the hospital and the physician(s) A written copy of the allocation agreement and supporting data depicting the distribution of the physician's time between services to the provider, services to individual patients and services not reimbursable under Medicare A permanent record of payments made to the physician(s) under the agreement A record of the amount of time the physician was physically present on the hospital premises to attend to emergency patients 19 CMS Focus Issues in Physician Compensation A permanent record of all patients (Medicare and non-medicare) treated by the physician, copies of all physician bills generated for such services and a record of imputed charges for services for which no billing was made by the hospital or physician. A schedule of physician charges Evidence that the provider explored alternative methods for obtaining emergency physician coverage before agreeing to physician compensation for availability services 20 10

11 B-1 Statistical Basis The statistical basis shown at the top of each column on Worksheet B-1 is the recommended basis of allocation of the cost center indicated which must be used by all providers completing Form CMS , even if a basis of allocation other than the recommended basis of allocation was used in the previous iteration of the cost report (Form CMS ) If a different basis of allocation is used, you must indicate the basis of allocation actually used at the top of the column subject to the applicable provisions of CMS Pub. 15-1, chapter 23, 2313 Simplified Cost Allocation Methodology As an alternative approach to the cost finding methods identified in CMS Pub. 15-1, chapter 23, 2306, the provider may request a simplified cost allocation methodology. 21 Simplified Cost Allocation Methodology (continued) The following statistical bases must be used for purposes of allocating overhead cost centers. There can be no deviation of the prescribed statistics and it must be utilized for all the following cost centers Buildings and Fixtures: Square Footage Movable Equipment: Square Footage Maintenance and Repairs: Square Footage Operation of Plant: Square Footage Housekeeping: Square Footage Employee Benefits: Salaries Cafeteria*: Salaries Administrative and General: Accumulated Costs Laundry and Linen: Patient Days Dietary**: Patient Days 22 11

12 CMS Focus Issues in Simplified Cost Allocation Methodology (continued) Social Service: Patient Days Maintenance of Personnel: Eliminated and moved to A&G for simplified cost finding Nursing Administration: Nursing Salaries Central Services and Supply: Costed Requisitions Pharmacy: Costed Requisitions Medical Records and Library: Gross Patient Revenue Nursing School*: Assigned Time Interns and Residents Assigned Time Paramedical Education: Assigned Time Non-physician Anesthetists: 100 percent to Anesthesiology *Contract labor is not included and is not grossed up. **If this is a meals on wheels program, a Worksheet A-8 adjustment is required. 23 Simplified Cost Allocation Methodology (continued) Once the simplified method is elected, the provider must continue to use this method for no less than 3 years, unless a change of ownership Example: Capital Related Moveable Equipment (CRME) - The provider used square feet instead of dollar value. Use of square feet distorts Medicare reimbursement to a significant degree because, CT Scan and MRI cost centers are receiving very low equipment allocations while Adult and Pediatrics cost center is getting higher allocation

13 Bad Debts In accordance with PRM 15-2, Section , a provider claiming bad debts must complete Exhibit 2 or internal schedules duplicating the documentation requested on Exhibit 2 to support the bad debts claimed 25 Working Trial Balance - Issues Worksheet A provides for the recording of trial balance expense accounts grouped to identify general service, non-reimbursable, routine, ancillary, and outpatient services CMS s review of the WTB identified the following: The Business Office was included in a separate cost center on W/S A instead of A&G. The provider should have requested and received approval to fragment the Administrative & General Services (A&G) cost center. Wellness Center cost was included in the Employee Benefits cost center. The cost should be reviewed to determine whether it is used exclusively by employees as a fringe benefit. It appears the Wellness Center may also be used by the community and serves patients as Cardiac Rehabilitation Program. Nutrition salaries and other expenses were included in the Administrative and General cost center 26 13

14 CMS s review of the WTB identified the following (continued): Marketing expenses were included in the Administrative and General cost center. Surgery salaries and other expenses were included in Adults & Pediatric cost center. In accordance with PRM-2, Chapter 40, Section 4013, Line 90, if the provider has two or more clinics which are separately costed, the provider is to separately report each clinic

15 Cost Report Reopenings Reopening requests must be very specific and include language that addresses all flow through issues: Reopen to adjust Medicaid days not sufficient Request a reopening to include additional Medicaid days from the most recent State listing and adjust the DSH amount on the cost report sufficient Include the estimated reimbursement impact of the reopening with the reopening request. 29 Nursing and Allied Health Education(NAHE) and reviewing legal operator statue: In accordance with 42 CFR (f)(1), in order to be considered the legal operator of an approved nursing/allied health educational program the provider must meet all of the following requirements: Directly incur the training costs Have direct control of the program curriculum Control the administration of the program, including collection of tuition (where applicable), control the maintenance of payroll records of teaching staff or students, or both (where applicable) and be responsible for day-today program operation 30 15

16 Nursing and Allied Health Education(NAHE) and reviewing legal operator statue (continued): Employ the teaching staff Provide and control both classroom instruction and clinical training (where classroom instruction is a requirement for program completion CMS has directed that costs be disallowed if the provider cannot document the above and reopen all available cost reports to disallow costs Absent evidence to the contrary, the provider that issues the degree, diploma, or other certificate upon successful completion of an approved education program is assumed to meet all of the criteria set forth above and to be the operator of the programs 31 Contractor Audit Selection Process: CMS requesting more issues and more time on the audit. No longer going to focus on one or two issues May result in fewer audits, but the approved audits will be more intensive CMS actively involved in the selection process 32 16

17 Rejected! Common Reasons for Cost Report Rejection Common Cost Report Rejection Reasons: A wet signature is still required on the settlement summary page of all as-filed cost reports. The signature must be from an officer of the provider who can legally bind the provider and the settlement amount should agree with the E series settlement amount. Incorrect FY period Frequently occurs after a CHOW Missing required data on S-2 Worksheet S-2, line 145, column 2 is blank Invalid PS&R run date on S-2, line 10 is invalid. Date format is incorrect. Meant to enter 02/15/2017 but it is incorrect in the file, CMS level one edit. 33 Rejected! Common Reasons for Cost Report Rejection Common Cost Report Rejection Reasons: Rejected due to a level I edit for MAC ID on S-2 Pt I line 141, the provider entered It must be 9 numbers. Missing an IRIS disc (Interns and Residents Information System) that will pass all IRIS edits. ECR fails to pass all Level 1 edits 34 17

18 S-10 FY 2014 and FY Reopening and Amended Cost Reports Use of S-10 Data to Determine Uncompensated Care Payments In the FY 2018 (IPPS) notice of proposed rulemaking, CMS proposed to begin using data from Worksheet S-10 in conjunction with low income insured days to determine uncompensated care payments for FY 2018 In response to this proposed rule, IPPS hospitals expressed interest in revising the Worksheet S-10 submitted with their FY 2014 cost reports (that is, cost reports starting on or after October 1, 2013 and prior to October 1, 2014) For these revised data to be available for potential use in rulemaking for FY 2019, it is essential for MACs to accept amended cost reports due to revisions to Worksheet S-10 submitted by hospitals CMS later included FY 2015 cost reports as well The initial deadline had been extended until October 31, S-10 FY 2014 and FY 2015 Reopening and Amended Cost Reports FY 2014 and FY 2015 S-10 Revisions (continued): On October 20, 2017 CMS issued updated guidance Requests for reopenings or amended cost reports must be received by January 2, 2018 Requests for Amended FY 2014 or 2015 cost reports due to revised or initial submissions of Worksheet S-10 must be received by MACs on or before January 2, Providers must follow the current requirements for Electronic submission of cost reports found at 42 CFR (f)(4), which includes submitting: Hard copy of a settlement summary Statement of certain worksheet totals found within the electronic file Statement signed by its administrator or chief financial officer certifying the accuracy of the electronic file or the manually prepared cost report 36 18

19 S-10 FY 2014 and Reopening and Amended Reports FY 2014 and FY 2015 S-10 Revisions (continued): Requests to amend or submit FY 2014 worksheet S-10 for changes unrelated to UCP factors, received after September 30, 2017, will still be accepted under normal timelines and procedures Revisions to Worksheet S-10 from other fiscal years, revisions to other worksheets of the FY 2014 cost reports, or revisions to Worksheet S-10 by non-ipps hospitals are not subject to this instruction Requests for reopenings received on or before December 1, 2017 will be finalized by December 31, 2017 Requests for reopenings received between December 2, 2017 and January 2, 2018 will be finalized by January 31, 2018 Desk Review Steps for S-10 CMS has not published the desk review steps at this time 37 Reimbursement Issues - Rate Review Facts Rate Reviews Per Year: Hospital cost-based PIP requires four reviews per year Hospital PPS PIP at least two reviews per year (provider can request additional) Critical Access Hospitals PIP require four reviews per year Non-PIP require two reviews per year Other rates in 42 CFR (c) specifically reference old capital (cost reports prior to 10/1/91) and GME. It notes that at least two per year are required. Organ Acquisition requires two per year Other reviews can always be completed if additional information is provided that would warrant an additional review 38 19

20 Why Are My Payments Still Suspended Credit Balance Issue Payment Suspension: Failure of a provider to file a timely cost report Payments will be suspended if not received within seven days of due date Novitas will accept the cost report within 30 days of filing Provider must cure any missing documents or be subject to suspension Exceptions can be granted in the case of a Federally declared natural disaster Credit Balance Report Missing Failure to file a quarterly report will result in payment suspension Report is due 30 days after quarter end If you are repaying the credit balance by check, the check and supporting documentation must be mailed in. All other submissions should be via fax. Most reports are received and logged without an issue, but problems can occur with fax submissions so it is recommended that you utilize the selfservice feature to check your credit balance report status 39 Why Are My Payments Still Suspended Credit Balance Issue Credit Balance Report Missing Check your status by going to Novitas-solutions.com link is below Use this tool to check your credit balance status using just your PTAN and a calendar date For zero balance submissions, please allow two days before checking status For submissions with a credit balance, please allow 10 business days, before checking status Enter your six digit PTAN number Quarter Date - Key the quarter END date in using MM/DD/YYYY format. Only one year of history is kept. Press "Submit Query" Results - Each result will tell you: Which Plan (A or B), Received Date, Total Credit Balance Amount, and a Status Open or Closed). Still a problem contact barbara.cataldi@novitas-solutions.com 40 20

21 Novitas Portal Novitasphere Portal Submissions 41 Novitas Portal Novitasphere Provider Portal Topics: Portal Benefits Gaining Access Novitasphere Portal Features Document Types for Portal Submissions Cost Report Submission Walkthrough Miscellaneous Documentation Submissions Walkthrough Future Enhancements User Manual & Reference Material 42 21

22 Novitasphere Portal Benefits Time Security Cost Reduction Process Streamlining 43 Novitasphere Gaining Access Step 1: Enroll for Novitasphere via the Novitasphere Portal Enrollment form Step 2: Create an EIDM account after enrollment form has been processed Step 3: Request Novitasphere Role under your EIDM profile 44 22

23 Novitasphere Document Types for Portal Submissions Submit A Cost Report: Used for submitting As-Filed, Amended, and Low/No Utilization Cost Reports Reopening: Used for Submission of reopening Requests for a cost report after it has been settled Appeals: Used for the submission of supporting documents for cost reposts that are under appeal SSI Realignment Request (DSH): Used to request an update to a provider s disproportionate share statistics Provider-Based Determination: Used to request initial setup or change in a unit s provider-based status Wage Index/Occupational Mix: Used to upload documentation for the yearly wage index and occupational mix audits New document type for CRNA submissions Desk Review/Audit Additional Documentation: Used to upload documentation requested by the Novitas audit staff during the time of a desk review and/or audit Submit FOIA Request: Used to submit a Freedom of Information Act request for Medicare cost reports Submit PS&R Request: Used to submit a Provider Statistical & Reimbursement report request for fiscal years not covered on the CMS PS&R online system. Providers may utilize this selection if they are currently experiencing PS&R access issues as well General Correspondence: Used to submit documentation for items not covered in the above-mentioned table selections; such items include: Request for Interim Rate Change Request for Tentative Settlement Change TEFRA Exception Request SCH Low Volume Request Request for Change in Statistical Basis CMS Tie-In-Notice Bankruptcy Other Supporting Documentation 50%Reduction Request 45 RAC PIP PS&R Update RAC PIP PS&R: 1/9/17 CMS notified all MACs - correction to PS&R release 4.06 Novitas was holding most hospital PIP provider s NPR due to improper reporting of payments due to RAC If settled as is, providers would have been underpaid CMS issued clarifying instructions in early August to MAC s to settle cost reports and provided a timeline to complete: NPR all cost reports that were on hold must be finalized no later than early February, Cost reports that were final settled and not held need to have a new PS&R run to determine if there are material variances and applying reopening thresholds. For those cost reports that exceed thresholds and require a reopening, a Notice of Reopening must be issued by 10/2/17 and they must be finalized by May 2,

24 Sample of New PS&R report (cont.): 47 RAC PIP PS&R Update RAC PIP PS&R: The amount to be reported on the cost report is the Actual Claim Payment for PIP reported on the PS&R. The other PIP label fields reported on the Additional Information Section of the PS&R is to show the amount of the RAC adjustments

25 RAC PIP PS&R Update RAC PIP PS&R: 49 IRIS Processing Interns and Residents Information System: Effective April 17, 2017, CMS created a new national IRIS database housed in the System for Tracking Audit and Reimbursement (STAR) This system was developed to address the need for a national database of IME/GME FTE s to address GAO/OIG findings on Interns/Residents reporting more than 1 FTE for a given resident Hospitals reporting remains unchanged, required to report IRIS data to the MAC when filing cost reports. However, MACs now have a requirement to feed the hospitals reported self-reported IRIS data into this new national IRIS database housed in STAR. Future direction and additional reconciliation is pending Potential to have a requirement for the submitted cost report to tie to the national IRIS database 50 25

26 Regulatory Update IPPS Final Rule Issued August 2, 2017: CMS arrived at an incremental rate of 1.2 percent Charity care and non-medicare bad debt: S-10 line 20 reporting revised such that charity care to be reported based on date of write-off, not based on service date (consistent with GAAP) Electronic signature: Effective for cost reporting periods ending on or after December 31, 2017 Elect to submit the cert and settlement summary page with an electronic signature of the administrator or CFO Hard copy not required to be mailed Must check the electronic signature checkbox or the signature cannot be accepted Volume Decrease Adjustment SCH or MDH experiences decrease of >5% in discharges 51 IRIS Processing IPPS Final Rule - Continued: Volume Decrease Adjustment Effective cost reporting periods beginning on or after 10/01/17 Current calculation (VDA payment limited to the CAP), inconsistency New Payment Calculation (No CAP limitation or staffing adjustments) (Fixed costs/total costs) x DRG revenue = M/C fixed cost payment (b) Medicare inpatient costs x fixed cost % = M/C inpatient fixed cost (a) VDA = (a) (b) 52 26

27 Thank You Questions? Contact information: Or Mounir Kamal, Director JH Audit 53 27