This entry is important to any hospital that operates or has operated a Rural Health Clinic. Throughout the history of Medicare and no matter what the payment system, the availability of exceptions to the payment rules has been a constant. While some exceptions become well known and eventually become an annual procedure for the hospitals for which they apply (i.e. SNF and TEFRA), other exceptions seem to remain outside of the realm of “common knowledge.” They remain hidden in the details, unknown to most hospitals and their cost report preparers, and underutilized.

As we review hundreds of Medicare/Medicaid cost reports per year, we come across these underutilized exceptions. One of these exceptions is the waiver of the RHC productivity standard, also referred to as a guideline. The Medicare cost report and the applicable instructions specifically reference the fiscal intermediary’s authority to waive the RHC productivity guidelines at a hospital’s request. All a hospital has to do is “reasonably justify” why they have not meet the guideline. It is right there in black and white, but we have seen very few hospitals that have been limited by the guideline actually make such a request. The few waiver requests that we have seen filed have all been accepted by the hospital’s FI and resulted in additional reimbursement to the hospital.

As we studied this opportunity, we wondered just how many hospitals might benefit from this exception/waiver. We analyzed cost reporting data and determined that about 400 small and mid-size hospitals may be able to benefit from this exception. There are over 50 hospitals that could benefit by in excess of $100,000, if they submitted a request and it was accepted.

Hospital executives are always rightfully concerned about any downside risk that could be associated with such a request. What is the downside to requesting this exception? If an exception is requested and denied by the FI, you are right back where you started. The hospital will just have to apply or continue to apply the productivity guidelines. The Hospital loses nothing by making the request.

If your hospital has an RHC, have you been or will your payments be materially limited by the RHC productivity standards? If so, take the time to request an exception or call us we will be happy to help you with the filing. Your hospital may have a lot to gain and nothing to lose by making the request.

I hope this and all future blog entries help you identify the most important reimbursement issues and new developments in the field for you.

Sincerely,

Kendall Quisenberry
President
Reimbursement Counselors
(972) 403-9910

This entry is important to any hospital that is contracting out its annual Medicare/Medicaid cost report preparation. We have noticed an increasing number of the accounting/consulting firms that are providing cost report preparation services are not providing their clients with a complete set of cost report preparation workpapers and an electronic cost report file at the completion of the preparation project.

I highly recommend including language, in any contracts for this service, that requires the preparer to provide a complete set of workpapers at the completion of the project. This is not to much to ask of the preparer and it will halt their efforts to tie themselves forever to your hospital while simultaneously making your job more difficult. At a minimum, hospital’s should require copies of any workpapers provided to the Fiscal Intermediary as a part of the submission process.

I also recommend language that requires the preparer to provide the hospital with the Medicare/Medicaid cost report in electronic form, known as the ECR file. While the hospital may not have the software to run the ECR file, obtaining the ECR file upfront could save the hospital substantial fees should they choose to utilize a different accountant or consultant that has the required software for future cost reports or other special projects.

While including the above language in the contract is certainly helpful, hospital management must also make sure that their accountants and/or consultants comply with the terms of the contract by actually providing the data to them at the completion of the project.

In most instances, reputable accounting and consulting firms will provide both the workpapers and ECR files upon the request of a current or former client, but often the data is not produced in a timely fashion and occasionally a fee is attached to the provision of the data. The worst case would be the accountants going out of business (if it can happen to Arthur Anderson- it can happen to your firm), losing the workpapers or being upset with a hospital’s subsequent change in accounting firms. In these cases, the hospital may have no way to get their own workpapers that support their cost report. Getting the data up front as a part of the required deliverable is always a good idea!

I hope this and all future blog entries help you identify the most important reimbursement issues and new developments in the field for you.

Kendall Quisenberry
President
Reimbursement Counselors
(972) 403-9910

]]> http://www.reimbursementcounselors.com/2010/cost-report-workpapers-get-them-up-front/feed/ 0 http://www.reimbursementcounselors.com/2009/geographic-service-area-expansion/ http://www.reimbursementcounselors.com/2009/geographic-service-area-expansion/#comments Fri, 13 Nov 2009 17:41:29 +0000 Kendall Quisenberry http://www.reimbursementcouncelor.com/?p=63 Continue reading →]]> After serving mostly the Hospitals of our home State of Texas for nine years, we decided to expand our geographic service area in 2009.

The expansion has proved to be a great success. In 2009, we recovered a cumulative total in excess of half a million dollars of lost reimbursement for four Hospitals located in the State of Georgia. We have also recovered smaller dollar amounts, from $10,000 to $120,000 each, for Hospitals located in Colorado, Maine, New York, Oklahoma, West Virgina, Wisconsin and Wyoming.

During this time, we have also initiated relationships with Hospitals or Hospital Corporations located in Arkansas, Florida, Idaho, Louisiana, Mississippi, Missouri, New Mexico, Nebraska, Oregon and Tennessee.

This entry is important to any hospital receiving Disproportionate Share payments for a fiscal year beginning during Federal Fiscal Year 2005. CMS posted updated SSI Ratios for Federal Fiscal Year 2005 on the website on September 3, 2008. Click Here to go to the CMS post.

Upon review of the data, you will find that most hospitals were helped marginally by the SSI Ratio changes. It will be up to hospital personnel and their consultants to determine if the additional amount of reimbursement is worth pursuing.

There will be some big winners. Eighty three facilties had increases of over one percent. One percent in DSH can result in hundreds of thousands of additional reimbursement dollars. I my opinion some of the data seems unreasonable and will unquestionably lead to further questions regarding the validity of the data and processes used to arrive at the numbers.

If your facility received DSH payments for a fiscal year beginning in FFY 2005, checking out these numbers is a must. It may result in an unexpected windfall. I wish you all the best!

I hope this and all future blog entries help you identify the most important of reimbursement issues and new developments in the field for you.

Sincerely,

Kendall Quisenberry
President
Reimbursement Counselors
(972) 403-9910

This entry is important because it will inform you of due dates for the Medicare Occupational Mix Survey that will be applied to Hospital’s Medicare Wage Index from FY 2010 to FY 2012. Anything that effects the wage index is vitally important to PPS reimbursed Hospitals. If it effects the wage index for three consecutive years, then….

The 2007-2008 Occupational mix survey will collect hospital specific wages and hours data by type of clinician (RN, LVN, Aide, Etc.). The completed survey must be submitted to FI by September 1, 2008. The survey is available on CMS’ website. To see the survey click here.

The interesting note about the Occupational Mix Survey is that the financial impact of the survey is somewhat counter-intuitive. Most would think that a higher mix of staff would mean added reimbursement. In reality, when a close look at the mechanics of the calculation is done, the lower the skill mix of staff that is reported on the survey the more reimbursement a hospital will receive. This may be as good a time as any to recheck those clinicians credentials to make sure your “RN’s” and “LVN’s” have competed all the requirements to keep their credentials (i.e. continuing education, etc.). It would also be a good idea to get Nursing Administration’s input into the contents of the survey. They may be privy to recent developments with regard to a clinicians status that have not found their way to personnel or the applicable information systems.

The preliminary, unaudited 2007-2008 Occupational Mix Survey data should be released by CMS in early October 2008.

I hope this and all future blog entries help you identify the most important of reimbursement issues and new developments in the field for you.

Sincerely,

Kendall Quisenberry
President
Reimbursement Counselors
(972) 403-9910

Periodically, I hope to provide you with key insights, tips, and little nuggets of information you can use to help your facility achieve its goals. We invite you to take a moment and subscribe to the blog through the link at the bottom of this page.

This entry is important because it will inform you of important dates for the FFY 2009 wage index and other recent wage index related developments.

CMS Posts FFY 2009 Wage Index Development Time Table

On October 9, 2007, CMS posted the FFY 2009 Wage Index Development Time Table on their website. The preliminary wage data files were released on October 5, 2007. The most important date on the Time Table from a hospital manager’s prospective is December 7, 2007. This is the deadline for hospitals to submit requests for a revision to their Worksheet S-3 wage data. The request for revision must be accompanied by documentation to support each requested revision. FI’s will be allowed until February 13, 2008 to complete all desk reviews for wage data and transmit the revised data to CMS.

If your facility has not begun the process of reviewing its wage index data or engaged an outside consultant to do so, now is the time to act. This is particularly important for hospitals that make up a significant portion of their CBSA and are reimbursed based upon a prospective rate, but the effect of the wage index should not be underestimated by any hospital adminstrator. Small adjustments to the wage data can produce large swings in the amount of Medicare reimbursement ultimately received.

CMS Includes Additional Contract Labor in Wage Index

The FFY 2008 Final Rule was published on August 22, 2007. The Final Rule stated that contract labor for Administrative & General, Dietary, Housekeeping and management contracts would be included in the FFY 2008 wage index. Since this data has been included in the FFY 2008 wage index, hospital administrator’s should ensure Worksheet S-3, Part II, Line 9.03, 22.01, 26.01 and 27.01 are properly completed for the FFY 2009 wage index.

While the inclusion of Dietary and Housekeeping contract labor may actually decrease a facility’s average hourly rate, the Administrative & General and management contracts have the potential to increase the average hourly rate significantly. In any event, the goal should be to get it right (i.e. compliant) regardless of the impact. For those facilities with current management contracts in place, steps should be taken to ensure the the number of labor hours that are associated with the payments can be identified. If the hours cannot be identified, the hospital should make changes to the contract or billing procedures to ensure that the hours can be identified for future periods. If the hours cannot be identified, the payments will not be able to be included in the wage index. Another proactive step that should be considered by management is to implement an electronic method to accumulate contract labor hours throughout the fiscal year. This can save hours of your staff’s time or reduce the amount of consulting fees paid.

I hope this and all future blog entries help you identify the most important of reimbursement issues and new developments in the field for you.

Sincerely,

Kendall Quisenberry
President
Reimbursement Counselors
(972) 403-9910

Welcome to the first official entry into my Reimbursement Blog! Reimbursement Counselors is a consulting firm that offers a full line of services to our healthcare clients. Periodically, I hope to provide you with key insights, tips, and little nuggets of information you can use to help your facility achieve its goals. We invite you to take a moment and subscribe to the blog through the link at the bottom of this page.

Our Mission is to help our clients to better serve the healthcare needs of their communities by providing them with best-in-class advice and service through our team of experienced and innovative consultants

We invite your comments, feedback and questions regarding the issues discussed in the blog. Our first issue is a very important one and is included below.

Medicare Bad Debt Policy Change

TrailBlazer Health Enterprises has institued a new policy with regards to Medicare Bad Debts. The policy requires that Medicare Bad Debts be returned from any collection agencies that are utilized prior to inclusion on the Medicare Cost Report. This means that, if you write-off a Medicare Bad Debt after 120 days and then send to a collection agency, the bad debt can not be claimed at the write off date under the new policy. If you are not having accounts returned from your agencies timely, now is the time to request the agencies return those accounts periodically to you. Please note that Medicare and non-Medicare accounts of like amounts should always be treated the same; therefore, the frequency of the return of the accounts from the collection agency should be consistent across payor classes.

The knowledge of this new policy change will be particularly important for hospitals with upcoming year ends from 9/30 to 12/31 that currently are not having accounts returned from their agencies. If you want to claim Medicare Bad Debts on your 2007 cost report, you must obtain confirmation of the return of the account by the last day of your fiscal year; otherwise, the accounts will not be allowable until they are returned which may fall in the 2008 fiscal year or later.

This new policy should not effect duel-eligible (Medicare/Medicaid) patient claims where Medicaid has not paid the full amount of the deductible and coinsurance. The duel eligible patients with unpaid deductible and coinsurance amounts should be deemed indigent under your indigent policy upon receipt of the Medicaid RA. These accounts should not be sent to a collection agency. They are eligible to be claimed as a Medicare Bad Debt on the date the patient account is adjusted to reflect the indigency determination.

The new policy is posted on TrailBlazer Health Enterprises web site. To see the post click here. You will also need to click on “I Accept” at the bottom of the page.

We have developed new strategies that may help you recover any reimbursement lost due to the implementation of this new policy. Some of these strategies do have strict filing deadlines (i.e. statutes of limitation), so it is important to act quickly upon action by TrailBlazer Health Enterprises or other Fiscal Intermediaries.

Thanks for taking the time to view this first entry. We sincerely hope this information helps you. Please do not forget to subscribe via the link at the bottom of the page to ensure you get future entries timely.

Sincerely,

Kendall Quisenberry
President
Reimbursement Counselors
(972) 403-9910

Their 2006 report was prepared to a well respected accounting firm that specializes in small and mid-size facilities. Over the course of our review, we found several material opportunities in each of the areas within the scope of the project. We project an increase in reimbursement of approximately $140,000 for the FYE 2007 Medicare/Medicaid Cost Report .

Our client has also ask us to go back and collect the reimbursement that was lost due to these errors in prior years through the cost report reopening process. Our fee for the initial review, including expenses, was less than $7,500, so the return-on-investment for our client on this project will be outstanding.

It will include our recent success stories and Kendall Quisenberry’s new blog. We hope the site will likely became a valued resource for CEO’s, CFO’s, Director’s of Reimbursement and others in the health finance field.