Hospital DSH Survey Training

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Hospital DSH Survey Training

• Kevin C. Londeen, Member
• Myers and Stauffer LC
• 11440 Tomahawk Creek Pkwy
• Leawood, KS 66211
• Phone [phone]
• Fax [phone]
• Email Londeen_at_mslc.com

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Todays Agenda

• Overview of DSH Program
• DSH Data Committee Goals
• Uses of DSH Data
• Data Elements Needed
• Hospital DSH Survey

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Overview of DSH Program

• Purpose
• Eligible Hospitals (federal criteria)
• Federal DSH Allotment
• Maximum Payments to Each Hospital

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Overview of DSH ProgramPurpose

• Requires additional payments to DSH hospitals
• Protection created when Medicaid was exempted
  from reasonable cost reimbursement
• Recognizes Medicaid shortfalls and uninsured
  costs
• Brief history of DSH

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Overview of DSH ProgramDSH Eligible Hospitals

• Must be recognized as DSH hospitals (deemed)
• Can be recognized as DSH hospitals
• Cannot be recognized as a DSH hospital

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Overview of DSH ProgramDSH Eligible Hospitals

• Must be recognized as DSH hospital (deemed)
  federal criteria
• Medicaid I/P Utilization Rate (MIUR) ? Mean 1
  Standard Deviation
• Low Income Utilization Rate (LIUR) 25
• (Medicaid Rev State/local cash sub)/Hosp. Rev
  
• (I/P Charity Chrgs I/P St/Local Cash Sub)/I/P
  Chrgs
• Total Sum
• Meets the O.B. requirement

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Overview of DSH ProgramDSH Eligible Hospitals

• Can be recognized as DSH hospital
• Medicaid I/P Utilization Rate ? 1
• Meets the O.B. Requirement

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Overview of DSH ProgramDSH Eligible Hospitals

• Cannot be recognized as a DSH hospital
• Medicaid I/P utilization rate
• Hospital does not have two or more obstetricians
  with staff privileges who provide care to
  Medicaid patients
• Note O.B. requirement does not apply to
  childrens hospitals or hospitals not offering
  non-emergency OB services in 1987. For rural
  hospitals, OB requirement can be met with any
  physicians.

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Overview of DSH ProgramFederal DSH Allotment

• Maximum amount of DSH a state can expend in a
  year.
• Georgia allotment FFY 2005
• 418,830,245 (total)
• 253,141,000 (federal)
• IMD limitation
• States may not direct more than x of DSH toward
  institutions of mental disease.

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Overview of DSH ProgramMaximum DSH Payments

• DSH payments to a hospital cannot exceed
• Medicaid cost Medicaid payment Medicaid
  shortfall
• Cost of care to uninsured Payments Net
  uninsured cost
• Maximum DSH payment
• Medicaid payments include all payments (regular
  and supplemental)

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Questions???

• Overview of DSH Program

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DSH Data Committee Goals

• Overall Principles
• Use the most recent data whenever possible
• Data accuracy is more important than timeliness
• Minimize the use of self-reported data

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DSH Data Committee Goals

• Additional Comments
• Hospitals should recognize that data may be
  audited
• Hospitals should retain documentation for five
  years
• Any data integrity issues should be resolved with
  reasonable alternatives
• Hospital contributions to community benefits
  should be captured

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Questions???

• DSH Data Committee Goals

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Uses of DSH Data

• Satisfy federal reporting requirements
• Reliable data for alternative DSH payment
  modeling
• Used to calculate DSH payments SFY 2006

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Uses of DSH DataFederal DSH Reporting
Requirements

• (Source Federal Register/Vol. 70, No. 165
  August 26, 2005)
• Hospital Name
• Medicare Provider Number
• Medicaid Provider Number
• Type of Hospital (acute, long term care, psych,
  rehab, teaching, childrens, etc.)
• Hospital Ownership
• State Government Owned
• Non-State Government Owned (i.e., public)
• Privately Owned
• Other (Indian Health Services, Tribal)

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Uses of DSH DataFederal DSH Reporting
Requirements

• (Source Federal Register/Vol. 70, No. 165
  August 26, 2005)
• Medicaid Inpatient Utilization Rate (MIUR)
• Low Income Utilization Rate (LIUR)
• DSH Payments
• Regular Medicaid Rate Payments (Inpatient and
  Outpatient)
• Medicaid MCO Payments
• Supplemental/Enhanced Medicaid Payments
• Indigent Care Revenue (Patients without 3rd Party
  Coverage)
• Transfers (IGTs)
• Total Cost of Care (Medicaid and Uninsured)
• Uncompensated Care Costs
• Medicaid Eligible and Uninsured Individuals

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Uses of DSH DataFederal DSH Reporting
Requirements

• Federal DSH Audit Requirements
• Verification No. 1 The extent to which
  hospitals have reduced their uncompensated care
  costs to reflect the total amount of DSH payments
• Verification No. 2 DSH payments to hospitals
  comply with the hospital-specific DSH limit

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Uses of DSH DataFederal DSH Reporting
Requirements

• Federal DSH Audit Requirements
• Verification No. 3 Only uncompensated care
  costs of providing inpatient and outpatient
  hospital services to Medicaid eligible and
  uninsured individuals are included in the
  hospital-specific DSH payment limit

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Uses of DSH DataFederal DSH Reporting
Requirements

• Federal DSH Audit Requirements
• Verification No. 4 The state included all
  payments under this title, including supplemental
  payments, in the calculation of hospital-specific
  DSH payment limits

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Uses of DSH DataFederal DSH Reporting
Requirements

• Federal DSH Audit Requirements
• Verification No. 5 The state has separately
  documented and retained a record of all its
  costs, expenditures and uninsured costs in
  determining payment adjustments under its DSH
  program

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Uses of DSH Data Reliable data for DSH payment
modeling

• Model alternative DSH eligibility criteria
• Model alternative DSH payment methodologies
• Document Medicaid payment shortfalls/longfalls
• Measure the cost of services to the uninsured
• Measure payment shortfalls from the underinsured
• Measure cost of free services that are charitable
  in nature

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Questions???

• Uses of DSH Data

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Data Elements Needed

• Data Sources
• Medicaid/Medicare Cost Report
• Claims Data
• State Database
• Provider Survey

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Data Elements Needed
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Data Elements Needed
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Data Elements Needed
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Data Elements Needed
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Data Elements Needed
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Data Elements Needed
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Data Elements Needed
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Data Elements Needed
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Data Elements Needed
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Data Elements Needed
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Questions???

• Data Elements Needed

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Hospital DSH SurveyGeneral Section-Instructions

• 1. Begin by selecting the Survey tab in this
  workbook. At the top of the Survey tab select
  your facility from the drop-down menu provided.
  When your facility is selected, the begin and end
  date of the cost reporting period, the Medicaid
  claims data cut-off, and the data in the General
  information will be populated.
• 2. The requested data should be provided for the
  same period as your facility's cost reporting
  period that ends in calendar year 2004.

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Hospital DSH SurveyGeneral Section-Instructions

• 3. For payment information the survey is
  requesting documentation on a modified accrual
  basis. Payments received should represent those
  payments that are received for dates of service
  within the cost reporting period, that were
  received thru the "Medicaid Claims Data Cut-Off".
  Therefore uninsured, out-of-state, and other data
  will match the service and payment period of the
  Medicaid data from the HSR.

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Hospital DSH SurveyGeneral Section-Instructions

• 4. Supporting documentation for all data elements
  must be maintained for a minimum of 5 Years. This
  supporting documentation does not need to
  remitted with your survey form, but must be
  available immediately upon request by the
  Department.
• 5. For the current period questions 5 and 6 in
  the general information have been left blank.
  This information will be obtained based upon the
  recent survey that was completed regarding he
  facility's ownership and operating structure
  requested by the Department.

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Hospital DSH SurveyGeneral Section-Survey Form

• Verify report period begin and end dates
• Note Medicaid claims data cut-off
• Review name, Medicare and Medicaid provider
  numbers
• Review hospital type
• Indicate agreement/disagreement with information
• If disagree, provide corrections

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Hospital DSH SurveySection A-Instructions

• 1. Section A of the survey document is used to
  collect Medicaid eligible days, gross charges,
  and any payments received for services provided
  to another state's Medicaid patients, or covered
  or not covered by another third party insurer.
• 2. Out-of-State data for days, payments, and
  charges must be supported by another state's
  Medicaid paid claims summary (similar to HSR),
  or a provider prepared summary of the EOB's, or
  R/A's received from the other state's Medicaid
  agency.

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Hospital DSH SurveySection A-Instructions

• 3. Out-of-State data collected or summarized must
  be for the same cost reporting period as is being
  used for in-state payment and cost report
  information. As stated above the data should be
  summarize for claims processed through the
  "Medicaid Claims Data Cut-Off" as provided in the
  header of the survey form.

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Hospital DSH SurveySection A-Survey Form

• Definitions
• Eligible days (days of care provided)
• Payments made (from all sources)
• Gross charges (excludes physician charges)
• Out-of-State Medicaid (FFS, MCO, Zero Paid and
  Medicare Crossover)
• Other (eligible but covered/not covered by 3rd
  party)
• Out-of-State DSH payments received

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Hospital DSH SurveySection B-Instructions

• 1. Report all state or local government cash
  subsidies received for patient care services. If
  the subsidies are directed specifically for
  inpatient or outpatient services please record
  the subsidies in the appropriate box. If the
  subsidies do not specify inpatient or outpatient
  services please record them in the unspecified
  column, these subsidies will be allocated between
  inpatient and outpatient based on the ratio of
  inpatient and outpatient cost. State and local
  subsidies should not include Supplemental
  Medicaid payments or Medicaid/Medicare DSH
  payments.

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Hospital DSH SurveySection B-Survey Form

• Cash subsidies from state/local sources
• Cash subsidies do not include Medicaid
  supplemental payments
• Cash subsidies (inpatient, outpatient,
  unspecified)

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Hospital DSH SurveySection C1-Instructions

• 1. Section C. 1. of the Survey form is to collect
  information on services provided to the
  uninsured. The information for this section
  should represent the services provided to
  patients with no third party coverage
  (uninsured), regardless of definitions of charity
  care, indigent care, etc. It should also include
  information for services provided to Medicaid
  recipients that are "pending" after the cut-off
  date for the Medicaid paid claims data.

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Hospital DSH SurveySection C1-Instructions

• 2. Uninsured services should also includes
  services provided to patients with third party
  insurance if the third party insurer did not
  cover the service(s) provided, or when the
  patient's insurance limits were reached resulting
  in non-insurance coverage of patient care
  services provided by the hospital.
• 3. The survey document contains separate lines
  for other hospital-based services that are not
  incidental to inpatient or outpatient hospital
  services. Each line should contain unduplicated
  information.

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Hospital DSH SurveySection C1-Instructions

• 4. See Exhibit A for example format of
  information needed to support data reported in
  section C.1. Supporting documentation should be
  maintained by facility in accordance with
  documentation retention requirements. Exhibit A
  should be run in the following sequence
• a. Select all dates of services from report
  period begin to report period end.
• b. Filter out all patients that received a third
  party payment
• c. Cut-off payments received using the date
  provided in the Medicaid Claims Data Cut-Off
• d. Sort on Service Indicator
• e. Sub-Total the charges and payments for each
  service indicator
• f. Transfer the sub-total data from the report to
  the survey form

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Hospital DSH SurveySection C1-Survey Form

• Column headers
• Unduplicated number of uninsured individuals
• Charges attributable to uninsured services
• Payments received from uninsured
• Inpatient hospital (exclude physician/include
  Medicaid pending)
• Outpatient hospital (exclude physician/include
  Medicaid pending)

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Hospital DSH SurveySection C1-Survey Form

• Physician services inpatient and outpatient
  hospital
• Hospital based clinic
• Hospital based RHC
• Hospital based FQHC
• Hospital based pharmacy services (not incidental
  to inpatient or outpatient)

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Hospital DSH SurveySection C2-Instructions

• 1. Section C. 2. of the Survey form is to collect
  information on services provided to those
  individuals that meet the facility's definition
  of charity or indigent care. This information
  will not be used in the calculation of the
  facility specific DSH limit. However the DSH data
  sub-committee has requested this data so that is
  available for potential distribution
  calculations, or for external reporting purposes.

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Hospital DSH SurveySection C2-Instructions

• 2. The survey document contains separate lines
  for other hospital-based services that are not
  incidental to inpatient or outpatient hospital
  services. Each line should contain unduplicated
  information.

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Hospital DSH SurveySection C2-Instructions

• 3. See Exhibit B for example format of
  information needed to support data reported in
  section C.2. Supporting documentation should be
  maintained by the facility in accordance with
  documentation retention requirements. Exhibit B
  should be run in the following sequence
• a. Select all dates of services from report
  period begin to report period end
• b. Filter out all patients that do not meet the
  facility's definition of charity or indigent care
• c. Cut-off payments received using the date
  provided in the Medicaid Claims Data Cut-Off
• d. Sort on Service Indicator
• e. Sub-Total the charges and payments for each
  service indicator
• f. Transfer the sub-total data from the report to
  the survey form

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Hospital DSH SurveySection C2-Survey Form

• Column headers
• Charges attributable to underinsured
• Total payments received from individual on third
  party
• Facility write-off to charity or indigent care
• Inpatient and outpatient hospital
• Physician
• Hospital based clinic, RHC, FQHC
• Pharmacy

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Hospital DSH SurveySection C3-Instructions

• 1. Section C.3. of the Survey form is to collect
  information on services your facility provided
  free to the public that are both charitable in
  nature and reported as non-allowable costs on
  your Medicare/Medicaid cost report.
• 2. For each service meeting this criteria record
  the total direct expense in column (a) (as
  reported on your cost report on worksheet A,
  column 7) and provide a brief description of the
  charitable service.

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Hospital DSH SurveySection C3-Instructions

• 3. In column (b) report the percent of these
  costs that are attributable to patients meeting
  your facility's charity/indigent care financial
  criteria.
• 4. Multiply columns (a) and (b). This amount
  should reflect the costs your facility incurred
  providing free services to charity/indigent
  patients that are charitable in nature, but
  reported as non-allowable costs on your cost
  report.

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Hospital DSH SurveySection C3-Survey Form

• Column headers
• Total non-allowable costs that are charitable in
  nature
• Percent provided to charity/indigent patients
• Example services (free lodging, free outpatient
  drugs, free transportation)

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Hospital DSH SurveySection D-Instructions

• 1. Section D of the Survey is to collect an
  unduplicated count of Medicaid Eligible
  Individuals that your hospital served during the
  reporting period. These individuals may or may
  not have received Medicaid payments for their
  services. They could include for both in-state
  and out-of-state patients FFS Medicaid, Managed
  Care Medicaid, 0-Paid Medicaid Claims, or
  Medicare Cross-Overs. Individuals who receive
  multiple services during the period or would fall
  into more than one category should be counted
  only once.

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Hospital DSH SurveySection D-Survey Form

• Unduplicated count of Medicaid eligibles served

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Hospital DSH SurveySection E-Instructions

• 1. For purposes of LIUR calculation, it is
  necessary to calculate net hospital revenue for
  patient services. This will be accomplished with
  information from your cost report along with
  information reported in sections E and F of the
  survey. Section E of the survey is requesting a
  breakdown of the contractual allowances reported
  on Schedule G-3 Line 2 of the cost report. Please
  provide the contractual allowances applicable to
  each of the lines listed for hospital and
  non-hospital services. The contractual allowance
  amounts reported should agree to your financial
  records for the period of the survey.

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Hospital DSH SurveySection E-Survey Form

• Total contractual adjustments (cost report
  section G-3, Line 2)
• This amount needs to be separated into the
  hospital and non-hospital components
• Net hospital revenue is used in LIUR calculation

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Hospital DSH SurveySection F-Instructions

• 1. Section F is simply asking for your total Bad
  Debt Expense that was written-off during the
  period of the survey, this amount will be used in
  calculating Net Hospital Revenue for Patient
  Services for the LIUR calculation.

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Hospital DSH SurveySection F-Survey Form

• Record your bad debt expense for the cost report
  period

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Hospital DSH SurveyExhibit A B-Instructions

• 1. This exhibit was prepared to share with
  hospitals an acceptable format for the
  information that should be maintained to support
  answers provided in Section C.1 and C.2 of the
  hospitals survey.
• 2. Dates of Service. All dates of service must
  fall within the facility's cost reporting period
  ending in 2004. For these services indicate the
  Gross Charges and any payments received.
• 3. Payments received information should include
  all payments received for the 2004 services that
  were received through the Medicaid paid claims
  cut-off date reflected on the top of each page of
  the survey document.

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Hospital DSH SurveyExhibit A B-Survey Form

• Dates of service must fall within the cost
  reporting period indicated on your survey
• Service indicator must be provided and separate
  services into inpatient hospitals, outpatient
  hospitals, physician (inpatient and outpatient
  hospital), clinics, RHC or FQHC

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Hospital DSH SurveyExhibit A B-Survey Form

• Charges this is the gross charges prior to any
  discounts, contractual or other adjustments
• Payments for each service, indicate the total
  payments received through the Medicaid claims
  date cut-off.

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Questions???

• Hospital DSH Survey