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Medicare 2015 IPPS Market Basket Inflationary Update = 2.9% āMarket Basket Adjustment (ACA) = (0.2%) āProductivity Adjustment (ACA) = (0.5%) āDocumentation and Coding Effect (ATRA) = (0.8%) āMS-DRG Budget Neutrality Adjustment = (0.3%) Total (With no Other Program-Based Adjustments) = 1.1% VBP, Readmissions & HAC Reductions also Applied 2% Sequestration Still in Effect Larger Than Expected Medicare DSH Cuts Increase in Outlier Threshold (From $21,748 to $24,758) Penalty for Providers That Arenāt EHR āMeaningful Usersā Overall (CMS) = Program Expenditures Reduced $756 M Wage Index Revisions Due to Revised Census Tracts Short-stay Payment Policy on Hold (for now!) 3 HFMA Central & NW Ohio Chapters Sept. 25, 2014
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The Autumn Institute
A Dual Chapter Event
OHA UpdateCharles Cataline
Vice President, Health Economics and PolicyOhio Hospital Association
September 25, 2014
Agenda ā¢ Federal o Medicare FFY 2015 IPPS Final Rule o Medicare CY 2015 OPPS Calls for More Bundling and Packagingo Medicare RAC Contract Re-bid Gets Weirder; Where is Medicaid? o OHA Working with ODM on Medicare DSH Data
ā¢ State o Update on Medicaid/Ohio Exchange Enrollment Targetso Medicaid APR-DRG Transition: Year II Yields Unexpected Results;
Whatās Left?o BWC 2015 Hospital Payment Targets
ā¢ Other Finance / PFS o 2011 Medicaid DSH Audit is Done, 2012 Kicks in o Medicaid Episodic Payment Plan Moving Forwardo SAFE Program Audits Possible Next Yearo Hospital Price & Quality Transparency Still an Issue
Sept. 25, 2014HFMA Central & NW Ohio Chapters
2
Medicare 2015 IPPSā¢ Market Basket Inflationary Update = 2.9%
ā Market Basket Adjustment (ACA) = (0.2%)ā Productivity Adjustment (ACA) = (0.5%)ā Documentation and Coding Effect (ATRA) = (0.8%)ā MS-DRG Budget Neutrality Adjustment = (0.3%) Total (With no Other Program-Based Adjustments) = 1.1%
ā¢ VBP, Readmissions & HAC Reductions also Appliedā¢ 2% Sequestration Still in Effectā¢ Larger Than Expected Medicare DSH Cutsā¢ Increase in Outlier Threshold (From $21,748 to $24,758)ā¢ Penalty for Providers That Arenāt EHR āMeaningful Usersā
Overall (CMS) = Program Expenditures Reduced $756 Mā¢ Wage Index Revisions Due to Revised Census Tractsā¢ Short-stay Payment Policy on Hold (for now!)
3HFMA Central & NW Ohio Chapters
Sept. 25, 2014
4HFMA Central & NW Ohio Chapters
Sept. 25, 2014
Medicare 2015 OPPS (Proposed)No Major Changesā¢Proposed MB Rate increase of 2.1 percentā¢Expanded Packaging/Composite APCs
ā 28 Comprehensive APCs for Device-Dependent APCsā Conditional Packaging of all Ancillaries With Geometric
Mean Cost of $100 or Less ā Prosthetic Supplies Deemed to be Part of APC
ā¢Physician Certification Only for Long Inpatient Staysā Does not Eliminate Need for Proper Physician Order
ā¢Services Furnished in Off-campus Provider-Based Departments Must be Identified on Line-Item Basis
5HFMA Central & NW Ohio Chapters
Sept. 25, 2014
Medicare RACā¢ RAC Contract Rebid Still on Hold
ā¢ New Regions Drawn to Re-Weigh Claims Volumeā¢ Existing Region B Subdivided ā at the Very Least Some States in
Region B Must Switch Contractorsā¢ CMS āPausedā Medicare RAC Activity Until New
Contracts are in Placeā¢ Feb. 21 ā Last Day a RAC can Issue Post-Payment ADRā¢ Feb. 28 ā Last Day a MAC can Issue ADR for RAC Pre-Pay Review ā¢ June 1 ā Last Day a RAC Can Send Denied Claims to MAC for Recovery
ā¢ BUTā¦ CMS Has Now Reopened Existing Contracts to a Limited (?) Number of (Mostly) Automated Reviews. ā¢ No Short-stay Reviews ā¢ No Details and/or Effective Dates Out as Yet - Stay Tuned!!
Medicare RAC Maps ā Old Vs. New
Other Medicare RAC Process āImprovementsāIn the Interim, CMS Continues to āRefineā RAC Program
ā¢ Medicare RAC Program Administrative Improvementsā¢ Expanded Services Eligible for Inpatient āPart Bā Re-Billsā¢ New Offer to Buy Out Outstanding Claims Under Appeal
ā¢ @ 68% of ānet paid amountāā¢ Not all Providers or Claims Eligible are Eligibleā¢ Formal Agreement and MAC Review of Claims Required
ā¢ Two-Midnight Ruleā¢ Proposals for IPPS āShort-Stayā Claims Payment
Whatās in it For CMS?ā¢ Fewer Appeals at ALJā¢ Settle Lawsuits, or at Least Lessen Possibility of Congressional
Action
But is it Enough?
8HFMA Central & NW Ohio Chapters
Sept. 25, 2014
CMS: Five Medicare RAC Program Improvements
9HFMA Central & NW Ohio Chapters
Sept. 25, 2014
Whatās Up With The Medicaid RAC?!ā¢ ODM/CGI Contract Ended in Julyā¢ ODM Assumed Responsibility for Outstanding
Reviews, Recoveries and Appealsā ODM Will Internally Correct Claims Recovered in
Errorā ODM will Complete any Reviews of ADRs/Medical
Records Sent to CGI Before Contract Endedā ODM Will Manage Any Requested Appeal CGI did not
Completeā¢ Interest on New Recoveries Will Only Accrue to Original
Overpayment Notification or Appeal Request
ā No Date Released for any of the Above!
10HFMA Central & NW Ohio Chapters
Sept. 25, 2014
State Update: Medicaid Expansionā¢ Background
ā¢ Started Jan 1. 2014ā¢ Electronic and Expedited Application Software available
at ābenefits.ohio.govā ā¢ Linked to Federal Data Hubā¢ No CPJFS Visit Required ā¢ Utilize MAGI Standardsā¢ No Documentation Required
ā¢ Presumptive Eligibility Now Statewideā¢ 85/85 Quality Standards yet to be enforced
ā¢ OHA āIntakeā Tool Kit Available at http://ohiohospitals.org/Policy-Advocacy/Finance-Policy/Medicaid/Medicaid-Enrollment-Toolkit.aspx
Sept. 25, 2014HFMA Central & NW Ohio Chapters
11
Medicaid Expansion Numbers1,117,407 Applied for Medicaid Through benefits.ohio.gov
ā¢ 822,807 (74%) Have Been Resolvedā¢ 592,390 Individuals Enrolled in Medicaidā¢ 230,417 Determined to be Ineligible
Expansion Population Totalsā 338,707 have enrolledā ODM Estimated 175,000 Would Sign up by June 2014ā Actuaries Estimate 563,000 Ohioans are Newly
Eligible, and 366,000 Would Sign up for Coverage by June 2015 (93% of estimate)
ā¢ This Includes 26,000 who Received Medicaid Coverage Through Metro Health Waiver
12HFMA Central & NW Ohio Chapters
Sept. 25, 2014
Sept. 25, 201413HFMA Central & NW Ohio Chapters
Sept. 25, 201414HFMA Central & NW Ohio Chapters
Health Insurance Marketplace154,668 Ohioans Have Selected Plans on the Exchange as
of May 30. 85% of Them Received Financial Assistance.
15HFMA Central & NW Ohio Chapters
Sept. 25, 2014
Age Ohio Percent
age
National Percent
age
>18 9% 7%
18-25 8% 11%
26-34 15% 17%
35-44 15% 17%
45-54 21% 22%
55-64 31% 25%
>65 0% 0%
Level Ohio Percentage
National Percentage
Bronze 25% 17%
Silver 60% 69%
1. Gold 12% 9%
Platinum 2% 4%
Catastrophic 2% 2%
Medicaid APR-DRG ConversionBackgroundā¢Year-Long Process to Determine Relative Weights, Base Rates & Payment Policies ā¢OHA Goal: Fairness and Equity Across Hospitalsā¢ODM Added Approx. $84 M / Year in FFY 2014 Inpatient Payments for In-state Hospitalsā¢Helped Rural Hospitals by Repurposing Funds From Out-of-State Hospitals ($24 M / Year)ā¢Has Three-Year Transition with Risk Corridors For Urban Hospitals to Ensure Stability and Minimize Winners & Losersā¢Preserves Most Medicaid IPPS Reimbursement Policies and Payment Logic For Now.
Sept. 25, 2014HFMA Central & NW Ohio Chapters
16
Medicaid APR-DRG ConversionIPPS Policy Shifts for SFY 2014 and Beyondā¢CMS Grouper 15 to 3M APR-DRG; New Grouper Starts Each Year with Discharges 10/1 and After ā¢Newly Calibrated Relative Weightsā¢New Base Rates & Three-Year Transition Includes Stop Loss/Stop Gain Applied to Urban Peer Groupsā¢Outliers Policy Changed to Mirror Medicareā¢Medical Education Payments Held Harmless in SFY 2014
But Itās Not Over ātill Itās Overā¢Stop Loss/Gain Threshold in Out Years of Three-Year Transition Causing Lots of Unforeseen Changes in SFY 2015ā¢ODM Proposing Revised SFY 2015 Base Rates for Transition Stop Loss/Gain Hospitals - Effective 10/1/14ā¢Additional Discussion Still to Come About Peer Groupings, Next DRG Re-base & Re-Calibration, Medical Education Payments, HAC, Other?
Sept. 25, 2014HFMA Central & NW Ohio Chapters
17
2015 BWCā¢ OHA Recommends BWC Stay With Medicare
IPPS/OPPS Methodologyā¢ Adopt Published Rates in Medicareās FFY 2015 Proposed
Rule; Includes a General Update of 2.1% ā¢ Eliminate the 1.008% Adjustment Factor to Offset the
Medicare Coding and Documentation Adjustmentā¢ Refine the BWC Payment Adjustment Factors (PAF) to
Include Separate Factors Based on Each Hospitalās Medicare Urban or Rural Classification
ā¢ BWC Fee Schedule Analysis Revealed Disparity of Payment-to-Cost Ratio at Major Teaching, Urban, Government & 400-499 Bed Hospital
ā¢ Bottom Line: as Medicare Moves so Does BWC (Down!)
18HFMA Central & NW Ohio Chapters
Sept. 25, 2014
2015 BWCā¢ BWC Proposing to Refine the Current Payment
Adjustment Factors (PAF) at the Urban and Rural Levels
ā¢ OHA Finance Committee to Review and Respond
19HFMA Central & NW Ohio Chapters
Sept. 25, 2014
Etcā¦ Etcā¦ā¢ 2015 HCAP Moving Addāl $$ to OBRA Potā¢ Medicaid Episodic Payment Plan Gaining Speed
ā¢ OHA Finance Committee Considering Responsesā¢ SAFE Program Audits Possible Next Yearā¢ FFY 2011 Medicaid DSH Program (HCAP) Audit
Results are Out. ā¢ Not Too Many Surprises (Except for OB Requirement)ā¢ FFY 2012 Audit Will Start Later This Month
ā¢ Expect Additional Scrutiny on Hospital Price and Quality Transparencyā¢ Still Waiting on CMS/HHS Final Rule for
20HFMA Central & NW Ohio Chapters
Sept. 25, 2014
State Innovation Models ā Episodic Payments
21HFMA Central & NW Ohio Chapters
Sept. 25, 2014
Questions / Comments?
Sept. 25, 2014HFMA Central & NW Ohio Chapters
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