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Year-end reimbursement planning issues

December 15, 2015 Article 10 min read

As we close out the end of 2015, we wanted to remind you of a few reimbursement planning issues that will be helpful for year-end close, cost reporting, and revenue enhancements:

1. Set accurate bad debt receivable/liability

Over the next two weeks, we recommend that you review all your Medicare bad debt claims and compare them to any pass-through and lump sum payments received during the year in order to determine if your Medicare Bad debt receivable/liability is booked accurately. This will also help you avoid any surprises when your Medicare cost report is filed by May 2016. Note: What will be different this year is understanding how MyCare Ohio is treating co-insurance. Unfortunately, each plan may be different, which causes some plans to be more favorable than others. Also, since CGS has not taken into account MyCare prepayment of bad debt, we feel the current pass-through payments will be larger this year than in the past.

Action items

Know how bad debt is treated for all your Medicare days. This section has commentary and helpful tips from ECS Solutions/ECS Billing & Consulting South:

  • For patients covered under traditional Medicare but Medicaid MyCare Ohio
    All five MyCare Ohio plans have the same process when a patient has opted out for Medicare but is covered under MyCare Ohio for Medicaid. The facility bills the plan, awaits a remit they hope will be acceptable by Medicare auditors, and then the coinsurance can be written off as allowable Medicare bad debt reported on the annual Medicare cost report. Some helpful tips:
    • The paid at zero remit has to be dated on or before 12/31/15 to be claimed on the 2015 Medicare cost report.
    • The intermediary will be paying close attention to reason codes on MyCare remits and will request to see the page of the remit with reason code definitions.
    • Claim Adjustment Reason Codes 190 and 45 have verbiage that seems acceptable to CGS.
    • Remittance cannot be in DENIED status but must be in PAID status in order to be claimed on the 2015 Medicare cost report.
  • For dually enrolled patients in Medicare and Medicaid MyCare
    • Buckeye
      This plan will process bad debt like Medicare Part A. after 20 days it tracks unpaid coinsurance and in 2016 will pay a percentage of coinsurance back to the facility based on Medicare bad debt in a lump sum for 2015 coinsurance. Provider should submit one claim—plan will track the coinsurance and pay bad debt on coinsurance in a lump sum using a report that the plan will send to providers in 2016. Payment is based on Medicare coinsurance percents for that period. For calendar year 2015, it most likely will be 65 percent.
    • Caresource
      This plan was paying at Medicare RUGs for all covered skilled days without a deduction for coinsurance, thus there was no coinsurance calculation. However, there was a change during 2015 even though the contract did not specify a change. Per CareSource representative, “At this time CareSource is not reimbursing the Medicare Skilled Nursing Facility co-insurance above the Medicaid allowable (i.e., the bad debt). CareSource is currently reviewing this process internally and we plan to publish a communication in the near future.” Verbally ECS was told while it stopped paying with no coinsurance around August, CareSource intends to pay the coinsurance at 65 percent for the claims that paid 0% toward coinsurance. To date, ECS has not seen these adjustments.
    • Molina
      This plan increases payments for all SNF claims by 1 percent and, if accepted, should have been effective as early as September 1, 2014. Note: A contract amendment had to be signed to receive this extra payment. This is Molina’s way of paying bad debt for coinsurance for members who are dually enrolled in Molina. It deducts coinsurance from days 21-100 and pays a 1 percent add-on to all claims, Medicare, or Medicaid custodial.
    • Aetna
      This plan increases payments for skilled dual eligible claims by 2 percent to cover coinsurance and bad debt. Again, a contract amendment had to be signed to receive this extra payment. Aetna will deduct coinsurance from days 21-100 — compensate by adding 2 percent to the rate it pays for all Medicare primary skilled stays — does not apply to Medicaid custodial payments.
    • UHC
      Paying at Medicare RUGs for all covered skilled days without deduction for coinsurance.

For traditional Medicare patients, make sure your Medicare bad debt log is up to date. This includes making sure all bad debts are written off in your general ledger in accordance with your Bad Debt Policy. Any write-off dates outside of the cost reporting period will not be allowed by CGS.

For dually enrolled patients in Medicare and Medicaid MyCare Ohio, we think you should also keep track in a separate bad debt log all bad debt claims associated with Buckeye, CareSource, Molina, and Aetna. While we cannot claim any of these bad debts on the 2015 Medicare cost report, these logs will assist in the following:

  • Will provide you with an amount due from Buckeye, which is paid in 2016. Coinsurance receivable should be 2015 Buckeye coinsurance claims times 65 percent.
  • Will provide you with an amount due from CareSource. Coinsurance receivable should be for all coinsurance days that were paid at zero during 2015. These days times allowable coinsurance amount should be reimbursed at 65 percent.
  • Assuming you signed the contract amendment with Molina and Aetna, we recommend you set up a separate revenue account (i.e., Molina and/or Aetna Medicare Bad Debt) and place the respective 1 or 2 percent payments into this revenue account. Next, compare this revenue account to your separate logs to determine if Molina or Aetna is truly covering your coinsurance bad debt similar to a traditional Medicare payer. This information can be shared with the associations as a way to argue that all plans should be paying the same as traditional Medicare. Note: if the contract amendment was not signed, you most likely lost your chance to recover coinsurance bad debt under these two plans.
  • Clearly, United Healthcare is the most advantageous option to reimburse Medicare coinsurance.

Determine a final traditional Medicare Bad Debt receivable. Take your traditional Medicare bad debt for Medicaid Co-Insurance plus your Medicare bad debt for private pay coinsurance and multiply by 65 percent and again by 98 percent for sequestration. Compare this amount to your pass-through and lump sum payments to determine the receivable or liability.

Account for all bi-weekly pass-through payments and lump sum payments received. If you are not sure, we suggest that you find or obtain the interim rate letter from your fiscal intermediary that typically was mailed in the summer. Note this is from a 6/30 provider and your letter will reflect calendar year dates. Please review and see if you agree with your intermediary’s documentation.

Lastly, for census tracking, we also recommend keeping track of each plan’s Medicare and Medicaid days separately from traditional Medicare and Medicaid days, and other Managed Medicare and Medicaid days. Below is a snap shot of the new Medicaid cost report and how ODM wants census reported on a monthly basis.

The only difference that we would recommend is under column 3 and 10, keep a yearly total for each plan. For example, say a provider is in Toledo and reports 15,000 days under column 3, we will ask to see from the 15,000 MyCare Medicaid days how many days were under Aetna and how days were under Buckeye in total (not by month).

2. Access your PS&R

Since the Provider Statistical and Reimbursement (PS&R) report typically does not tie to your monthly Medicare revenue, we find that providers do not actively retrieve this report. However, we believe it is a critical management tool for accessing billing practices. In fact, we use the PS&R as one of our audit tests for Medicare revenue recognition and for completing Medicare cost reports. The system accumulates data applicable to the processed and finalized Medicare Part A claims for SNFs, home health, and hospice.

Action items

Make sure you or your authorized representative can access the PS&R. While we would like to take this burden off your hands, Plante Moran or other consultants cannot do this on your behalf. In fact, the intermediaries are becoming less helpful and are denying requests to send PS&R reports to providers. We have developed new specialized instructions that we can send you upon request.

After you are successful with your login, we recommend that you log into the PS&R system quarterly, at a minimum, to ensure your username and password remain active.

For cost reporting purposes, obtain the most recent PS&R report for the cost report filing period with pay dates through the date you are requesting the report – most likely will be in the months of March through May 2015.

3. Determine if de-licensing beds by YE is beneficial

If you have debated whether to de-license beds due to current and projected census levels, you have until December 31 to notify ODH in order to potentially increase your future reimbursement and save provider taxes. Below are the considerations under each scenario:

  • De-license beds to change peer group from large to small for each peer group
    The Ohio Department of Medicaid (ODM) will determine FY 2017 Medicaid peer group based upon licensed beds reported on your 12/31/2015 Medicaid cost report. Also, if you’re able to de-license beds as of 12/31/2015, your provider tax will be reassessed as of 1/1/2015. Based upon 2014 census with licensed beds at 100 to 110, it appears there are 136 facilities that have a potential to decrease beds in order to increase reimbursement.

    Other considerations: Before making this change, providers need to consider the fact the beds are gone forever unless you rebuy them, the bed value you would be giving up, restrictions from loans, bond covenants, HUD agreements, and lessors. Furthermore, while ODM’s history has shown it rebases every 10 years, there is always a chance through “re-basing” prices that this current price differential could change if ODM chooses to rebase sooner.

Action items

Please call us if you have specific questions regarding bed right sizing to determine if this is an opportunity for your organization. We can assist with bed value and proper notifications.

4. Complete your PELI for all SNF in-house residents as of 12/31/2015

At this time, the new quality payment system works as follows:

  • Each facility will have $1.79 per day curved out of its rate on 7/1/2016.
  • Each facility has the chance to earn back $0 to $4.10 per day based on 5 new quality points.
  • Each point is worth $0.82 per day so, to be ahead, providers need to earn 3 points.

A summary of the new quality points are as follows:

  1. Staff retention
    75th percentile; reported as actual individuals (not FTEs as reported in the past) and based on the last 6 months data reported on the 12/31/2015 cost report.
  2. Antipsychotics
    25th percentile on both short and long stay federal quality measures; based on the third and fourth quarter of 2015 results.
  3. Pressure ulcers
    25th percentile on both short and long stay federal quality measures; based on the third and fourth quarter of 2015 results.
  4. Potentially preventable admissions (PPAs)
    Ratio of 1.0 or lower; ratio is calculated as the actual PPAs to expected PPAs based on data from the last 6 months of 2015.
  5. Preferences for everyday living inventory (PELI)
    Facility will receive this quality point if they use the tool (we recommend at least the short form).

Action items

Please call us if you have specific questions regarding your PELI. It’s the best way to ensure one earned quality point. Below on attachment 8 of the Medicaid cost report is how ODM plans to certify that providers completed their PELI,

5. Make sure you have all the correct reimbursement rates loaded in your billing systems

Part A rates

On August 4, 2015, the Centers for Medicare and Medicaid (CMS) issued the final rule for federal Fiscal Year 2016 Medicare skilled nursing facility PPS rates. The SNF PPS Rates will be effective October 1, 2015, through September 30, 2016.

Note, we do understand CGS has been paying incorrect rates but we feel this will be corrected soon.

Co-insurance, Part B premium and deductibles

  • Medicare Part A Co-Insurance is $161.00 per day for days 21 through 100 each qualified benefit period.
  • Medicare Part B Premium for 2016 for those "held harmless" from any increase in premiums is $104.90. Beneficiaries not subject to the "hold harmless" provision will pay $121.80.
  • Medicare Part B Deductible for 2016 is $166.00

Therapy caps

  • Physical therapy (PT) and speech language pathology (SLP) combined: $1,960
  • Occupational therapy (OT): $1,960

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