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  1. Miscellaneous Issues / Questions Jim Flowers / Roger Barnes / Chuck Smith, CPA DMA / Clifton Gunderson LLP November 9, 2006

  2. Certified Registered Nurse Anesthetists (CRNAs) • CRNAs are reimbursed based on a fee schedule as incident to provider services prior to 1995 and allowed for direct enrollment and billing in 1995. • “Fees for certified registered nurse anesthetists (CRNA’s) are established at 90% of Anesthesiology rates. For DMA approved procedures (CPT and HCPCS) CRNA’s will be reimbursed the same as physician services, which are based on the current Physician Medicaid Fee Schedule.” • NC State Plan, Attachment 4.19-B, Section 17, Page 1, (17B) effective 6/1/1995. TN 95-13

  3. Certified Registered Nurse Anesthetists (CRNAs) • Costs and charges for Professional Services, including CRNAs must be excluded from the Medicaid cost report. • “Charges for non-covered services and services not reimbursed under the inpatient DRG methodology (such as professional fees) shall be deducted from total billed charges.” • NC State Plan, Attachment 4.19-A, Page 5, Section (g)(2). TN 05-015. Same language dates back to TN 94-33 effective 10/1/1995

  4. Certified Registered Nurse Anesthetists (CRNAs) • Reminder of Medicaid policy is identified on the DMA website and cost report filing instructions. • Professional fees may not be included in the 2552 cost reports used to support the current DSH plan; this was a component requirement of CMS approval.

  5. Changing Allocation Basis • Medicaid cost reports are filed independently from Medicare cost reports as evidenced by DMA direction in FY2004 and FY2005 to file cost reports in absence of delayed Medicare PS&Rs. • Providers requesting to change an allocation basis in their Medicaid cost report shall follow guidance outlined in the Provider Reimbursement Manual (CMS 15-1), Chapter 23 and submit the request to DMA.

  6. Changing Cost Report Period • Although less common than a request to change an allocation basis, providers requesting to change their cost report period for their Medicaid cost report shall follow guidance outlined in the Provider Reimbursement Manual (CMS 15-1), Chapter 24 and submit the request to DMA.

  7. Zero Paid Claims • Currently Zero Paid Claims are excluded from charges and payments in calculation of outpatient settlements as well as desk reviews and field audits. • To exclude Zero Paid Claims precludes the risk of private or non-Medicaid payments in excess of cost being applied to Medicaid recipient costs in cost settlement.

  8. Critical Access Hospitals • Effective with State Plan Amendment 05-015, with the effective date of 10/1/2005, Critical Access Hospitals will be settled to 100% of reasonable and allowable costs in accordance with North Carolina State Plan and the Provider Reimbursement Manual (CMS 15-1)

  9. Critical Access Hospitals • SPA 05-015 for DSH & Supplemental Payments changed cash flow for CAH. • Interim (quarterly) cost reports will not be filed. • Outpatient Services Ratio of Costs to Charges has been changed to 97%. • DMA will perform a tentative settlement based on the annual filed cost reports subject to a 10% retainage pending a full scope field audit. • Collection / Recoupments of payments in excess of costs will follow DHHS Cash Management Plan. • Clifton Gunderson LLP contract Year 5 will perform full scope field audits on all public hospitals claimed for CPE and on all CAHs.

  10. Regulatory Guidance • Medicaid Participation Agreement • Comply with federal and state laws, regulations, state reimbursement plan and policies governing the services authorized under the Medicaid Program and this agreement (including, but not limited to, Medicaid provider manuals and Medicaid bulletins published by the Division of Medical Assistance and/or its fiscal agent). • North Carolina State Plan • Provider Reimbursement Manual

  11. QUESTIONS ?