Rural Hospital Revenue Opportunities

1. PPS CAH Rural Hospital Revenue Opportunities Method II DSH HPSA Module 3 – Bonus Payments PSA

2. CAH Professional Fees • Critical Access Hospital outpatient professional fees • Method I – separate billing • Method II – combined billing

3. Standard OP • Method I – (Standard) • Fee Schedule • OP services paid by carrier • Fee schedule amount Two bills Medicare Claims Processing Manual Chap 4 Section 250.1, 250.2

4. Optional OP • Method II – (Optional) • Fee schedule amount (minus deductions) x 115% • Separate line on UB with HCPCS code • Revenue codes 96x, 97x or 98x One bill

5. CRNA • Method II optional billing can be chosen for all outpatient professionals except the CRNA. • Hospital may wish to retain pass-through exemption for the CRNA. • If hospital chooses Method II option for CRNAs, it gives up pass-through payments for BOTH inpatient and outpatient CRNA services.

6. Optional OP • CAH must make election at least 30 days prior to beginning of cost report year. • Election is made annually. • Election is not automatic. • CAH must specify which physicians are covered. • CAH may be eligible to receive bonus payments.

7. HPSA Bonus • Health Professional Shortage Area • Geographically based for primary care and mental health • 10% incentive payments provided to physicians • For a CAH in HPSA, professional fees will be paid at 115% x fee schedule x 110% • Bonus is paid on a quarterly basis.

8. PSA Bonus • Physician Scarcity Area • PSA is determined by zip code. • 5% bonus payment to physicians • Payment is made on a quarterly basis. • Modifier must be attached to HCPCS code on claim: • AG – Primary Care Physician • AF – Specialty Physician

9. PPS DSH Payment • Disproportionate Share Hospital (DSH) • Available only to PPS hospitals • Add on to DRG base rate • Intended to provide additional payment to cover services to low income patients

10. SSI & Medicare A DSH Elements Medicaid Eligible w/o Part A DSH Adjustment

11. Supplemental Security Income SSI% is based on Medicare Part A beneficiaries eligible for SSI benefits divided by all Medicare Part A days.

12. The SSI% is computed for the hospitals and published each year. Until recent years, hospitals have not been able to obtain this data. There are now procedures by which a hospital can obtain the data to verify their SSI%’s. Supplemental Security Income FY 2006 IPPS Rules: For cost reporting periods that include December 6, 2004, CMS will furnish SSI data regardless of whether there is a pending DSH appeal and at no charge.

13. Medicaid Eligibility Medicaid Patients w/o Medicare Part A Medicaid % (Fraction) = Total Patients

14. DSH Payments

15. DSH Payments

16. DSH Payments DRG Rate $4,500 DSH Payment % 1.15 DRG Payment $5,175

17. Medicare Advantage • DSH payments must be negotiated with the Medicare Advantage contractor. • There will be no add-ons for this. No Medicare Advantage Add-on