Disproportionate share hospital (DSH) Reporting schedule Preparation DSH Year 2010

1. Disproportionate share hospital (DSH) Reporting schedule PreparationDSH Year 2010

2. Presented by: • David McMahon, Senior Manager • Michael Horoho, Manager

3. Agenda Items • Recap of Final Rule • Hospital documentation and how it corresponds to preparation of Disproportionate Share Reporting Schedule • Issues & results of 2009 data

4. Reason for the DSH Audit Rule • To ensure that the hospital specific DSH limits have not been exceeded. • Hospital specific DSH limit is uncompensated costs incurred during the year of furnishing hospital services by the hospital to individuals who either are eligible for medical assistance under the State plan or have no health insurance (or other source of third party coverage) for services provided during the year.

5. 42 CFR 447.299(c) Reporting Requirements • Applies to State Fiscal Year 2005 and after • Reports must be created by State Medicaid Agency with the following information for each hospital receiving DSH payments: • Hospital Name • Estimate of Hospital Specific DSH Limit • Medicaid Inpatient Utilization Rate • Low Income Utilization Rate • State Defined DSH Qualification Criteria • IP/OP Medicaid Fee For Service (FFS) Basic Rate Payments

6. 42 CFR 447.299(c) Reporting Requirements • Reports must be created by State Medicaid Agency with the following information for each hospital receiving DSH payments: • IP/OP Medicaid Managed Care Organization Payments • Supplemental/Enhanced Medicaid IP/OP Payments • Total Medicaid IP/OP Payments • Total Cost of Care for Medicaid IP/OP Services. • Total Medicaid Uncompensated Care • Uninsured IP/OP Revenue

7. 42 CFR 447.299(c) Reporting Requirements • Reports must be created by State Medicaid Agency with the following information for each hospital receiving DSH payments: • Total Applicable Section 1011 Payments • Total Cost on IP/OP Care for Uninsured • Total Uninsured IP/OP Uncompensated Care Costs • Total Annual Uncompensated Care Cost • Disproportionate Share Hospital Payments • States must report DSH payments to all hospitals under the authority of the approved Medicaid State Plan.

8. 42 CFR 447.299(c) Reporting Requirements • States must report all 17 fields of data for payments to in-state hospitals. • States can report a minimum of the following fields for out-of-state hospitals: • Hospital Name • Estimate of Hospital Specific DSH Limit • Medicaid Inpatient Utilization Rate • Low Income Utilization Rate • State Defined DSH Qualification Criteria • IP/OP Medicaid Fee For Service (FFS) Basic Rate Payments • Supplemental/Enhanced Medicaid IP/OP Payments • Total Medicaid IP/OP Payments • Disproportionate Share Hospital Payments

9. Hospital documentation needed in order to populate the Disproportionate Share Reporting Schedule (DRS)

10. Reporting Periods • Certain documentation is needed by cost reporting period in order to verify requirements by MSP rate year • Medicaid State Plan (MSP) rate year • Audits must be completed with information on the MSP rate year §447.299(c) • MSP rate year October 1-September 30 • If the hospital cost report period does not coincide with the MSP year, then documentation needed may be two or more cost reports

11. Actual Cost Determination For Hospital With Fiscal Year Not Corresponding to MSP Rate Year • Medicaid State Plan rate year is 9/30/2010. • Hospital cost reporting period end June 30th. • Hospital’s cost report for 6/30/10 and 6/30/11 are obtained. • MMIS data and hospital data is separated as follows: 10/1/09-6/30/10 and 7/1/10-9/30/10. • Charges and payments applied to specific cost report for actual payment calculation.

12. OB Requirement • Request list #1 • 2 obstetricians with staff privileges and are Medicaid approved physicians and UPIN numbers • Exceptions to OB requirement • Rural facilities may have two physicians with staff privileges at the hospital that have agreed to perform non-emergency obstetrics • Patients are predominately under (18) years of age • Facility did not offer non-emergency obstetric services as of December 22, 1987 • Hospital must meet the OB requirements to qualify for DSH under §455.304(d)

13. MIUR (Medicaid Inpatient Utilization Rate) • MIUR must not be less than 1% • Medicaid inpatient days / total inpatient days • Sub-provider days are included • Swing beds SNF days are not be included in calculation

14. Working Trial Balance • Request list #2 • Cost report period • If the cost report period does not coincide with the MSP rate year, two or more trial balances will need to be provided that fall within the MSP rate year • Required to be submitted with Medicare Cost Report

15. Audited Financial Statements • Request list #3 • Cost report period • Identify possible source of revenue needed to offset cost of care • Required to be submitted with Medicare Cost Report

16. Expenses and Revenue Mapping to Worksheets A & C of Medicare cost report • Request list #4 • Cost report period • Used in conjunction with the trial balance to ensure proper matching of cost and charges are reported on the Medicare cost report • Cost to charge ratios are used to determine costs for both Medicaid and Uninsured • If already shown on submitted WTB then this is N/A

17. Transplant Providers • Request list #5 • List of Useable Organs within MSP period • Medicaid by organ • Uninsured by organ • Payment information • Medicaid FFS • Out of State (FFS, Dual Eligible, MCO) • Dual Eligible • Individuals with no source of third party insurance

18. Crosswalks • Request list #6 (Medicaid) and #7 (Self-Pay) • Used to map revenue codes included in patient detail requests to cost centers of cost report • Provide crosswalks in excel format by cost report period • If crosswalk is not provided/useable then charges are allocated on a percent to total of charges reported on the cost report

19. .ecrFIle • Request list #8 • Current version of CMS form 2552-96 or 2522-10 • Cost to Charge ratios adjusted to include CRNA • GME included

20. Provider Payer/Insurance Code Listing with Descriptions • Request list #9 • MSP rate year • Listing needed to determine what codes are self pay, insurance, or other payers. • Any payer/insurance codes included in patient detail request must correspond to the payer code listing.

21. Detail Listing of Self-Pay Payments • Request list #10 • Payment Date during the MSP year • Payments should be on a cash basis and agree to the MSP rate year, regardless of the date when charges were incurred • Compared to Uninsured Data to limit to collections on Uninsured Accounts only

22. Out of State Medicaid Agencies Patient Detail • Request list # 11 • Inpatient and Outpatient Medicaid FFS, MCO, Dual Eligibles related to Out of State Medicaid Beneficiaries • Discharge Dates within MSP year • Used in calculation of Medicaid Uncompensated Care

23. Out of State Medicaid Agencies Patient Detail (continued) • Detailed log of: • Inpatient or Outpatient • Account number • Medical record number • Patient name • Admit and Discharge Date • Charges • Payments • Payer Code • Revenue Code

24. Medicaid Dual Eligible Patient Detail • Request list #12 • Inpatient and Outpatient Accounts where Alabama Medicaid is Secondary Payer • Discharge Dates within MSP year • Medicare Bad Debt Log • Used in calculation of Medicaid Uncompensated Care

25. Medicaid Dual Eligible Patient Detail (Continued) • Detailed log of: • Inpatient or Outpatient • Account number • Medical record number • Patient name • Admit and Discharge Date • Charges • All Payments • Payer Code • Revenue Code

26. Medicaid Maternity Waiver Patient Detail • Request list # 13 • Inpatient and Outpatient Medicaid Maternity Waiver • MCO • Discharge Dates within MSP year • Used in calculation of Medicaid Uncompensated Care

27. Medicaid maternity waiver Patient Detail (continued) • Detailed log of: • Inpatient or Outpatient • Account number • Medical record number • Patient name • Admit and Discharge Date • Charges • Payments • Payer Code • Revenue Code

28. Out of State Supplemental/Enhanced/DSH Payments • Request list #14 • Any Supplemental or Enhanced Medicaid Payments and Medicaid DSH Payments received from Out of State Medicaid Agencies during MSP rate year • Used to offset Medicaid Costs in Uncompensated Care Calculation

29. Medicaid eligible Not Billed patient detail • Request list #15 • Discharge Dates within MSP year • Used in calculation of Medicaid Uncompensated Care • Medicaid not billed is usually when hospitals have not billed because of: • Exhausted days (Over 16 Days) • Liability exceeds charges

30. Medicaid eligible Not Billed patient detail (continued) • Detailed log of: • Inpatient or Outpatient • Account number • Medical record number • Patient name • Admit and Discharge Date • Charges • Payments • Payer Code • Revenue Code

31. Uninsured Patient detail • Request list #16 • Individuals with no source of third party insurance • Discharge Dates within MSP year • Detail is tested and used to calculate Uninsured Uncompensated Care

32. Uninsured patient detail (continued) • Detailed log of: • Inpatient or Outpatient • Account number • Medical record number • SSN (Last four digits) • Patient name • Admit and Discharge Date • Charges • Payments • Payer Code • Revenue Code

33. Credit and Collection Policy • Request list #17 • Required to verify that hospitals attempt collection efforts for all self pay patient balances and that all collection effort recoveries received during the MSP year are recorded to patient specific accounts and offset for DSH limit

34. Uninsured Cleaning “Cleaning” analysis to be performed • Is the claim a duplicate entry • Is the claim outside of the fiscal period being tested • Does the SSN and name on the claim match the Medicaid Eligibility Listing received from the State of Alabama Medicaid Agency for the period under review. In addition, does the date of service or discharge date fall during the recipients eligibility period • Does the account number on the claim match the account number on the listing of Dual Eligible, Out of State, Maternity Waiver, Medicaid Not Billed Residents received from the Hospital

35. Uninsured Cleaning (Continued) • Is the insurance code for a claim a code for credible third party insurance • For claims that matched in step e., is the insurance workers compensation and if so was there a payment made by this insurance • Does any payment that was received for the claim exceed 40% of the total charge • Were any payments received on a claim with no charges

36. Uninsured vs. Underinsured • Eligibility for credible coverage is determining factor • Uncompensated – provider does not receive payment for charges – self pay/no pay, exceeds coverage, co-pays, coinsurance, deductibles not met. • Uninsured – no coverage from any outside source • Underinsured – health insurance does not cover services

37. Uninsured vs. Underinsured • Auto Insurance and Worker’s compensation • If claim is denied and zero amount is paid, patient is considered uninsured • If any payment is made, patient is considered insured by third party • Charity Care • Not considered insurance • Patients are required to meet certain criteria based on hospital’s written policy • Accounts will not be sent to collections for recovery, but written off to bad debt • Any payments from patients should still be offset and submitted as self-pay uninsured

38. Non-Traditional Services Documentation

39. Hospital based Physicians • Request #18 • Dates of Service within MSP • Listing of physicians with cost removed for professional fees on WS A-8 and A-8-2 of Medicare Cost Report. • Include relative value units or charges for each physician • Include total payments received from Medicaid and on behalf of individuals with no source of third party insurance

40. Hospital based CRNA and non-professional or Other physician Services • Requests #19 and #20 • Dates of Service within MSP • Non-Professional or Other Physician can Include: • Nurse Practitioner • Physician Assistants • Dentists • Certified Nurse Midwives • Clinical Social Workers • Clinical Psychologists • Optometrists

41. Hospital based CRNA and non-professional or Other physician Services (Cont.) • Total amount of charges excluded from Worksheet C • Costs Removed for these services on A-8 • Include total payments received from Medicaid and on behalf of individuals with no source of third party insurance

42. Hospital based Ambulance, dme, prescription pharmacy • Request #21, #22, #23 • Dates of Service within MSP Year • Submit charges and payments for Dual Eligible, Out of State Medicaid, Medicaid Eligible not Billed, and accounts with no source of third party insurance

43. Hospital based Home Health Agency • Request #24 • Dates of Service within MSP Year • Patient account detail for home health visits and charges (Exclude Medical Social Services) • Include Dual Eligible, Out of State Medicaid, MCD eligible but not billed, and accounts with no source of third party insurance

44. Hospital based Hospice • Request #25 • Dates of Service within MSP Year • Patient account detail for billed unduplicated days and payments • Include Dual Eligible, Out of State Medicaid, MCD eligible but not billed, and accounts with no source of third party insurance

45. Hospital based Rural Health Clinic and Federally qualified health center • Requests #26 • Dates of Service within MSP Year • RHC and FQHC visits and payments received • Include Dual Eligible, Out of State Medicaid, MCD eligible but not billed, and accounts with no source of third party insurance

46. Hospital based Renal Dialysis • Request #27 • Dates of Service within MSP Year • Patient account detail of renal dialysis treatments, and payments • Include Dual Eligible, Out of State Medicaid, MCD eligible but not billed, and accounts with no source of third party insurance

47. Provider Documentation Issues • Patient Detail Unavailable (Data Storage Vendor) • Useable crosswalks • Self pay data submitted based on Discharge Date not Payment Date • Patient detail with charges but no payments • No response on OB request

48. Request List • One single excel file template will be provided • Do not send PHI (protected health information) via e-mail • FTP sites – Terms of Use Agreement • Electronic format is preferred • Do not submit detailed logs in .pdfformat or hardcopy • If unable to use template provided, identify documentation by corresponding number on request list • Please submit all documentation by April 15th, 2013

49. Findings From SFY 2009 DSH Audit • 46 hospitals exceeded the DSH Limit due to lack of documentation from hospitals. • 10 hospitals did not provide sufficient documentation to determine the hospital was DSH eligible.

50. Final Comments Moving Forward For SFY 2010 • Lack of documentation can severely impact the Alabama Medicaid Agency’s claiming of certified public expenditures for SFY 2010 • Potential disallowance of undocumented CPE which will impact Medicaid funding of other services during SFY 2014