Medicare Pricing for Indian Health Services (IHS) Under the Medicare-Like Rate (MLR) Policy

1. Medicare Pricing for Indian Health Services (IHS) Under the Medicare-Like Rate (MLR) Policy Sarah Shirey-Losso Joe Bryson

2. Objectives After this presentation, you will be able to: • Understand how MLR affects you • Know what payments fall under the MLR policy • Have a broad understanding of various Medicare payment systems • Be familiar with obtaining PPS Pricer software • Be familiar with how to navigate PC Pricer software • Understand how to enter necessary pricing inputs • Know where to go to obtain necessary pricing information

3. What payments fall under the MLR Policy? • Inpatient Acute Care Prospective Payment System (PPS) • Inpatient Psychiatric PPS • Inpatient Rehabilitation PPS • Long-Term Care Hospital PPS • Outpatient PPS • Skilled Nursing Facility PPS • Reasonable Cost Reimbursement to non-PPS hospitals

4. How can I identify claims from the various providers? • The Medicare Provider Number • also know as the OSCAR number

5. Provider Number Ranges • Acute care hospitals • XX0001-XX0879 • Psychiatric Hospitals • XX4XXX, ‘S’ or ‘M’ in the third digit • Rehabilitation hospitals • XX3025-XX3099, ‘T’ or ‘R’ in the third digit • Long Term Care Hospitals • XX2000-XX2299 • Critical Access Hospitals • XX1300-XX1399

6. Provider Number Ranges (cont.) • Skilled Nursing Facilities • XXX5XXX • Swing Beds • ‘U’, ‘W’, ‘Y’, or ‘Z’ in the third digit • Children's Hospitals • XX300-XX3399 • Cancer Hospitals • 100271, 100079, 360242, 500138, 050146, 050660, 220162, 330154, 330354, 390196, 450076

7. Instructions for Downloading and Running CMS PPS PC Pricers Joe Bryson

8. Step 1: Go to PC Pricer website Go to http://www.cms.hhs.gov/PCPricer/ to obtain all CMS PPS PC Pricer Software. Note: For illustration purposes, we have included Inpatient PPS PC Pricer screen-shots, though these the steps will be the same for downloading any PC Pricer software.

10. Step 2: Select PC Pricer

11. Step 3: Install PC Pricer version based on claim’s Through Date Double-click

12. You will receive the following window. Select “Open.” The following window will appear. Double-click on the file.

13. The following will appear. Select “Run.” The following will appear. Select “Run.”

14. The following window will appear. To unzip to the default C: drive on your PC, select “Unzip.” To unzip to another drive, first replace the “C” with the letter of the drive you wish to unzip to. Then, select “Unzip.” After a few seconds, you will receive the following window. Click “OK.”

15. Step 4: Opening the PC Pricer Go to the PC Pricer folder you extracted and saved to your PC. Below is what an idea of what the IPPS Pricer Folder looks like. Double-Click

16. The following window will appear. Select the “.exe” formatted file.

17. The following window will appear.

18. Step 5: Running the PC Pricer Type in the letter of the drive you unzipped the PC Pricer to (such as, F) to initiate the program.

19. The following PC Pricer HOME screen will appear. • Select ‘Y’ if you would like to calculate payment. • Select ‘V’ if you would like to view provider specific information • Select ‘Q’ to quit and exit the program.

20. Calculating Payment • Calculating payment is specific to each PPS • Therefore, we will provide you with specific instructions on how to enter data for calculation among the following PC Pricers • Inpatient PPS • Inpatient Rehabilitation Facility PPS • Inpatient Psychiatric Facility PPS

21. Inpatient Prospective Payment System (IPPS) Pricer Sarah Shirey-Losso

22. Background • Inpatient Acute Care Hospitals are paid under this system • Children’s Hospitals, Cancer Hospitals, Critical Access hospitals are not • For background on IPPS, see: http://www.cms.hhs.gov/AcutInpatientPPS/01_overview.asp#TopOfPage • Internet Only Manual (IOM) Pub. 100-04, Chapter 3 http://www.cms.hhs.gov/manuals/downloads/clm104c03.pdf

23. CORE ELEMENTS OF THE IPPS PAYMENT • The standardized amounts, which are the basic payment amounts • A wage index to account for differences in hospital labor costs • The DRG relative weights, which account for differences in the mix of patients treated across hospitals • An add-on payment for hospitals that serve a disproportionate share of low-income patients

24. CORE ELEMENTS OF THE IPPS PAYMENT (cont.) • An add-on payment for hospitals that incur indirect costs of medical education (IME) • An additional payment for cases that are unusually costly, called outliers • An additional payment for cases that have new technologies

25. Additional Information • The IPPS is updated annually every October • CMS has created a web-based Pricer program to calculate the claim payment • Known as the IPPS PC Pricer

26. Calculating Payment Using the IPPS PC Pricer

27. Enter ‘Y’

28. Enter the OSCAR # here

29. Enter Patient ID if desired

30. Enter From Date on claim

31. Enter Through Date on claim

32. Enter DRG

33. Enter ‘N’

34. Enter ‘N’

35. Enter ‘Y’ if Patient Status Code = 02

36. Enter ‘Y’ if PS Code is: 03, 05, 06, 62, 63, or 65

37. Enter Total Covered Charges on claim

38. Enter ‘Y’ if Procedure Code is 86.98

39. Enter ‘Y’ if Procedure Code 39.73

40. Enter ‘Y’ if Procedure Code is 84.58

41. Enter ‘Y’ if Procedure Code is 52.85

42. Enter how many times Procedure Code 52.85 is reported (max of 2)

43. Enter ‘Y’ to calculate PPS Payment

44. Total IPPS Payment

45. For additional assistance please contact: • Sarah Shirey-Losso (410)786-0187 or sarah.shirey-losso@cms.hhs.gov • Joe Bryson (410)786-2986 or joseph.bryson@cms.hhs.gov • Valeri Ritter (410)786-8652 or valeri.ritter@cms.hhs.gov

46. Inpatient Rehabilitation Facility Prospective Payment System (IRF PPS) Pricer Sarah Shirey-Losso

47. Background • Paid under the IRF PPS: • Freestanding inpatient rehab hospitals • Rehab units located in acute care hospitals • Critical access hospitals • For background, please refer to: http://www.cms.hhs.gov/InpatientRehabFacPPS/01_Overview.asp#TopOfPage • Internet Only Manual (IOM) Pub. 100-04, Chapter3, Section 140 http://www.cms.hhs.gov/manuals/downloads/clm104c03.pdf

48. Background • The IRF PPS will utilize information from a patient assessment instrument (IRF PAI) to classify patients into distinct groups based on clinical characteristics and expected resource needs • Rehab hospitals have the IRF PAI in their facility and determine the case-mix group (CMG)

49. CORE ELEMENTS of IRF PPS • The standardized amounts, which are the basic payment amounts • A wage index to account for differences in hospital labor costs • The CMG relative weights • An add-on payment to compensate hospitals for their percentage of low-income patients (LIP) • An add-on payment for hospitals located in rural areas

50. CORE ELEMENTS of IRF PPS (cont.) • An add-on payment for hospitals that incur indirect costs of medical education • An additional payment for cases that are unusually costly, called outliers • Additional adjustments are made for: • interrupted stays • short stays of less than three days • transfers (defined as less than the average length of stay for the CMG)