FI Support for Medicare- Like Rates. Topics for FI discussion Overview of system changes Discontinuation of pre-pricing Critical Access reimbursement.

FI Support for Medicare-FI Support for Medicare-Like RatesLike Rates

Topics for FI discussionTopics for FI discussion

Overview of system changesOverview of system changesDiscontinuation of pre-pricingDiscontinuation of pre-pricingCritical Access reimbursementCritical Access reimbursementLetter sent to providers from FILetter sent to providers from FIPass Thru Rate / No Settlement Pass Thru Rate / No Settlement DRG Disclosure ReportDRG Disclosure ReportPends/Message codes pertinent to MLRPends/Message codes pertinent to MLREOBR examplesEOBR examples““Better than” Medicare-Like RatesBetter than” Medicare-Like RatesQuestion & AnswerQuestion & Answer

FI System ChangesFI System Changes

No requirement for contracts for MLR No requirement for contracts for MLR pricing.pricing.

Suffixes no longer used to point to a pricing Suffixes no longer used to point to a pricing methodology.methodology.

Claims paying per MLR will not pend for Claims paying per MLR will not pend for signature authority signature authority

Programming done for other PPS Programming done for other PPS methodologies (Psych, Rehab, LTC, SNF, methodologies (Psych, Rehab, LTC, SNF, Home Health, Hospice, APC)Home Health, Hospice, APC)

Future FI programmingFuture FI programming

To accommodate the regulation the FI is To accommodate the regulation the FI is currently programming for the following:currently programming for the following:

Rural hospital demonstration project per Rural hospital demonstration project per section 410 of the Medicare Modernization section 410 of the Medicare Modernization ActAct

Children’s Hospitals and Cancer CentersChildren’s Hospitals and Cancer Centers

Timely filing Timely filing

Discontinuation of Pre-PricingDiscontinuation of Pre-Pricing

In the past the FI has, on occasion, assisted an In the past the FI has, on occasion, assisted an Area or Service Unit by pre-pricing a claim to Area or Service Unit by pre-pricing a claim to help obligate a Purchase Order or negotiate a help obligate a Purchase Order or negotiate a rate with an open market provider.rate with an open market provider.

With the large number of providers now paid at PPS With the large number of providers now paid at PPS rates, the FI is not staffed to continue pre-pricing rates, the FI is not staffed to continue pre-pricing claims.claims.

Online pricers are available to Service Units.Online pricers are available to Service Units. The FI does not have a tool to pre-price APCs.The FI does not have a tool to pre-price APCs.

Critical Access ReimbursementCritical Access Reimbursement

Per Diems are calculated using the latest Per Diems are calculated using the latest settled cost report. settled cost report. If there isn’t a settled cost report then the “as If there isn’t a settled cost report then the “as

filed” report will be used. filed” report will be used. If there hasn’t been a cost report filed, the If there hasn’t been a cost report filed, the

Medicare FI will be contacted for the providers Medicare FI will be contacted for the providers rate. rate.

No method 2 reimbursement related to the No method 2 reimbursement related to the physician component.physician component.

Provider Letter from FIProvider Letter from FI

Sent July 11Sent July 11th th to providers that will be to providers that will be reimbursed under MLRreimbursed under MLRBilling instructions provided for IHS/CHS facility Billing instructions provided for IHS/CHS facility claimsclaimsUB04 required for DOS on or after July 5, 2007.UB04 required for DOS on or after July 5, 2007.6 digit legacy number required in form locator 57 6 digit legacy number required in form locator 57 EMC providers to continue use of the 837-I EMC providers to continue use of the 837-I format which now requires the NPI. format which now requires the NPI. Taxonomy code required for inpatient services.Taxonomy code required for inpatient services.Questions regarding billing should be directed to Questions regarding billing should be directed to IHS/CHS FI Customer Service.IHS/CHS FI Customer Service.

Pass Thru Rate / No SettlementsPass Thru Rate / No Settlements

Regulation requires the FI to use the Regulation requires the FI to use the “interim rate” from the provider specific file “interim rate” from the provider specific file as the pass thru reimbursement. This is as the pass thru reimbursement. This is paid per day.paid per day.Prior to MLR, the pass thru was calculated Prior to MLR, the pass thru was calculated using settled cost reports and was paid using settled cost reports and was paid per discharge.per discharge.Unlike Medicare, the IHS/CHS program Unlike Medicare, the IHS/CHS program will not pay retrospective payments after will not pay retrospective payments after the cost reports are settled. the cost reports are settled.

DRG Disclosure ReportDRG Disclosure Report

DRG disclosure reports will now be available for all DRG disclosure reports will now be available for all hospitals receiving DRG reimbursement. Prior to MLR, hospitals receiving DRG reimbursement. Prior to MLR, this report was only for DRG contracted providers.this report was only for DRG contracted providers.Updated reports will be available at least twice a year -Updated reports will be available at least twice a year -after the annual DRG pricer load and/or provider specific after the annual DRG pricer load and/or provider specific file (PSF) loads.file (PSF) loads.A special run for the DRG disclosure reports will be A special run for the DRG disclosure reports will be available in August for all hospitals receiving DRG available in August for all hospitals receiving DRG reimbursement.reimbursement.Reports are available on the Report Retrieval System. Reports are available on the Report Retrieval System. Website address is Website address is https://mychsfi-reports.documentportal.comhttps://mychsfi-reports.documentportal.com. Access . Access must be approved by Area or Tribal CHSO.must be approved by Area or Tribal CHSO.

New DRG Disclosure Report New DRG Disclosure Report HeaderHeader

Contract No. will show for Better than MLR Contracts

Pass Thru/Settled will show for Better than MLR Contracts

Pass Thru Per Day will show for MLR Pricing

Pends/Message Codes Pertinent to MLRPends/Message Codes Pertinent to MLR

FI internal pends may increase while the FI internal pends may increase while the providers get used to billing IHS/CHS claims in providers get used to billing IHS/CHS claims in the Medicare format.the Medicare format.Areas and/or Service Unit pends will not change.Areas and/or Service Unit pends will not change.New provider pends may appear on the pend New provider pends may appear on the pend reports. P12G relates to APC pricing and P13G reports. P12G relates to APC pricing and P13G relates to Taxonomy codes.relates to Taxonomy codes.New message codes for EOBRs and DORs - New message codes for EOBRs and DORs - M009 or M506 which indicates payments are M009 or M506 which indicates payments are being made per MLR regulation.being made per MLR regulation.

EOBR Change ExampleEOBR Change Example

With MLR Pricing Contract No. shows MLR

EOBR Change Example Cont’dEOBR Change Example Cont’d

Message code M506

““Better Than” Medicare Like Better Than” Medicare Like RatesRates

The regulation specifies that “better than” The regulation specifies that “better than” MLR contracts may be negotiated. MLR contracts may be negotiated.

The FI is currently testing two basic The FI is currently testing two basic methods for each PPS methodology. methods for each PPS methodology.

Lesser of billed or MedicareLesser of billed or Medicare

Percent of Medicare (less than 100%)Percent of Medicare (less than 100%)

Percentage of billed charge is not always Percentage of billed charge is not always better than Medicare and is not supported better than Medicare and is not supported as a “better than” MLR contract provision.as a “better than” MLR contract provision.

Question and AnswerQuestion and Answer

Rhonda NicholsRhonda Nichols Inge ZamoraInge ZamoraManager,Manager, Manager,Manager,Systems & ReportingSystems & Reporting Prov Database & Prov Database &

ReimbReimb