medicare pricing for indian health services (ihs) under the medicare-like rate (mlr) policy
DESCRIPTION
Medicare Pricing for Indian Health Services (IHS) Under the Medicare-Like Rate (MLR) Policy. Sarah Shirey-Losso Joe Bryson. Objectives. After this presentation, you will be able to: Understand how MLR affects you Know what payments fall under the MLR policy - PowerPoint PPT PresentationTRANSCRIPT
Medicare Pricing for Indian Health Services (IHS) Under
the Medicare-Like Rate (MLR) Policy
Sarah Shirey-LossoJoe Bryson
Objectives
After this presentation, you will be able to:
• Understand how MLR affects you• Know what payments fall under the MLR policy• Have a broad understanding of various Medicare
payment systems• Be familiar with obtaining PPS Pricer software• Be familiar with how to navigate PC Pricer software• Understand how to enter necessary pricing inputs• Know where to go to obtain necessary pricing
information
What payments fall under the MLR Policy?
• Inpatient Acute Care Prospective Payment System (PPS)
• Inpatient Psychiatric PPS • Inpatient Rehabilitation PPS• Long-Term Care Hospital PPS• Outpatient PPS• Skilled Nursing Facility PPS• Reasonable Cost Reimbursement to non-PPS
hospitals
How can I identify claims from the various providers?
• The Medicare Provider Number – also know as the OSCAR number
Provider Number Ranges
• Acute care hospitals– XX0001-XX0879
• Psychiatric Hospitals– XX4XXX, ‘S’ or ‘M’ in the third digit
• Rehabilitation hospitals– XX3025-XX3099, ‘T’ or ‘R’ in the third digit
• Long Term Care Hospitals – XX2000-XX2299
• Critical Access Hospitals – XX1300-XX1399
Provider Number Ranges (cont.)
• Skilled Nursing Facilities– XXX5XXX
• Swing Beds– ‘U’, ‘W’, ‘Y’, or ‘Z’ in the third digit
• Children's Hospitals– XX300-XX3399
• Cancer Hospitals– 100271, 100079, 360242, 500138, 050146, 050660, 220162,
330154, 330354, 390196, 450076
Instructions for Downloading and Running CMS PPS PC
PricersJoe Bryson
Step 1: Go to PC Pricer website
Go to http://www.cms.hhs.gov/PCPricer/
to obtain all CMS PPS PC Pricer Software.
Note: For illustration purposes, we have included Inpatient PPS PC Pricer screen-shots, though these the steps will be the same for downloading any PC Pricer software.
Step 2: Select PC Pricer
Step 3: Install PC Pricer version based on claim’s
Through Date
Double-click
The following window will appear. Double-click on the file.
You will receive the following window. Select “Open.”
The following will appear. Select “Run.”
The following will appear. Select “Run.”
The following window will appear.
To unzip to the default C: drive on your PC, select “Unzip.” To unzip to another drive, first replace the “C” with the letter of the
drive you wish to unzip to. Then, select “Unzip.”
After a few seconds, you will receive the following window. Click “OK.”
Step 4: Opening the PC Pricer
Go to the PC Pricer folder you extracted and saved to your PC. Below is what an idea of what the IPPS Pricer Folder looks like.
Double-Click
The following window will appear. Select the “.exe” formatted file.
The following window will appear.
Step 5: Running the PC PricerType in the letter of the drive you unzipped
the PC Pricer to (such as, F) to initiate the program.
The following PC Pricer HOME screen will appear. 1. Select ‘Y’ if you would like to calculate payment.2. Select ‘V’ if you would like to view provider specific
information3. Select ‘Q’ to quit and exit the program.
Calculating Payment• Calculating payment is specific to each
PPS
• Therefore, we will provide you with specific instructions on how to enter data for calculation among the following PC Pricers– Inpatient PPS– Inpatient Rehabilitation Facility PPS– Inpatient Psychiatric Facility PPS
Inpatient Prospective Payment System (IPPS) Pricer
Sarah Shirey-Losso
Background• Inpatient Acute Care Hospitals are paid under
this system • Children’s Hospitals, Cancer Hospitals,
Critical Access hospitals are not • For background on IPPS, see:
http://www.cms.hhs.gov/AcutInpatientPPS/01_overview.asp#TopOfPage
• Internet Only Manual (IOM) Pub. 100-04, Chapter 3 http://www.cms.hhs.gov/manuals/downloads/clm104c03.pdf
CORE ELEMENTS OF THE IPPS PAYMENT
• The standardized amounts, which are the basic payment amounts
• A wage index to account for differences in hospital labor costs
• The DRG relative weights, which account for differences in the mix of patients treated across hospitals
• An add-on payment for hospitals that serve a disproportionate share of low-income patients
CORE ELEMENTS OF THE IPPS PAYMENT (cont.)
• An add-on payment for hospitals that incur indirect costs of medical education (IME)
• An additional payment for cases that are unusually costly, called outliers
• An additional payment for cases that have new technologies
Additional Information
• The IPPS is updated annually every October
• CMS has created a web-based Pricer program to calculate the claim payment– Known as the IPPS PC Pricer
Calculating Payment Using the IPPS PC Pricer
Enter ‘Y’
Enter the OSCAR # here
Enter Patient ID if desired
Enter From Date on claim
Enter Through Date on claim
Enter DRG
Enter ‘N’
Enter ‘N’
Enter ‘Y’ if Patient Status Code = 02
Enter ‘Y’ if PS Code is: 03, 05, 06, 62, 63, or 65
Enter Total Covered Charges on claim
Enter ‘Y’ if Procedure Code is 86.98
Enter ‘Y’ if Procedure Code 39.73
Enter ‘Y’ if Procedure Code is 84.58
Enter ‘Y’ if Procedure Code is 52.85
Enter how many times Procedure Code 52.85 is
reported (max of 2)
Enter ‘Y’ to calculate PPS Payment
Total IPPS Payment
For additional assistance please contact:
– Sarah Shirey-Losso (410)786-0187 or [email protected]
– Joe Bryson (410)786-2986 or [email protected]
– Valeri Ritter (410)786-8652 or [email protected]
Inpatient Rehabilitation Facility Prospective Payment System
(IRF PPS) PricerSarah Shirey-Losso
Background
• Paid under the IRF PPS:– Freestanding inpatient rehab hospitals– Rehab units located in acute care hospitals– Critical access hospitals
• For background, please refer to: http://www.cms.hhs.gov/InpatientRehabFacPPS/01_Overview.asp#TopOfPage
• Internet Only Manual (IOM) Pub. 100-04, Chapter3, Section 140 http://www.cms.hhs.gov/manuals/downloads/clm104c03.pdf
Background
• The IRF PPS will utilize information from a patient assessment instrument (IRF PAI) to classify patients into distinct groups based on clinical characteristics and expected resource needs
• Rehab hospitals have the IRF PAI in their facility and determine the case-mix group (CMG)
CORE ELEMENTS of IRF PPS
• The standardized amounts, which are the basic payment amounts
• A wage index to account for differences in hospital labor costs
• The CMG relative weights • An add-on payment to compensate hospitals for
their percentage of low-income patients (LIP) • An add-on payment for hospitals located in rural
areas
CORE ELEMENTS of IRF PPS (cont.)
• An add-on payment for hospitals that incur indirect costs of medical education
• An additional payment for cases that are unusually costly, called outliers
• Additional adjustments are made for:– interrupted stays– short stays of less than three days– transfers (defined as less than the average
length of stay for the CMG)
Additional Information
• IRF PPS is updated annually in October
• The following slides demonstrates the IRF PPS PC Pricer
Calculating Payment Using the IRF PPS PC Pricer
Enter ‘Y’
– Sarah Shirey-Losso (410)786-0187 or [email protected]
– Joe Bryson (410)786-2986 or [email protected]
– Valeri Ritter (410)786-8652 or [email protected]
For additional assistance please contact:
Inpatient Psychiatric Facility Prospective Payment System
(IPF PPS) PricerSarah Shirey-Losso
Inpatient Psychiatric Facility PPS
• Who is paid under the IPF PPS?– Freestanding inpatient psychiatric hospitals– Psych units located in acute care hospitals– Critical access hospitals
• Unlike IPPS, IRF, and LTCH, IPFs are paid on a per diem methodology at discharge
CORE ELEMENTS of IPF PPS
For background on IPF PPS, refer to:http://www.cms.hhs.gov/InpatientPsychFacilPPS/
01_overview.asp#TopOfPage
Pub. 100-04, Chapter 3, Section 190 http://www.cms.hhs.gov/manuals/downloads/
clm104c03.pdf
CORE ELEMENTS of IPF PPS
• Under the IPF PPS, the Federal per diem rate includes inpatient operating and capital related costs (including routine and ancillary services) and is adjusted by:– Geographic factors– Patient characteristics: Age, Presence of
specified comorbidities– Facility characteristics: rural adjustment and
indirect teaching – Services provided: Diagnosis Related Group
(DRG) classification, Length of stay
CORE ELEMENTS of IPF PPS (cont.)
• Additional payments are provided for the following:– Patients treated in IPFs that have a qualifying
emergency department receive a higher payment for the first day of the stay
– The number of Electroconvulsive Therapy (ECT) treatments furnished; and
– Outlier payments for cases that have extraordinarily high costs
CORE ELEMENTS of IPF PPS (cont.)
• The per diem base rate excludes pass-through costs such as bad debts and graduate medical education (GME)
• Release Schedule for the IPF PPS:– annual release occurs in July– updates are made in October for
comorbidities and DRGs
Calculating Payment Using the IPF PPS Pricer
Enter ‘Y’
For additional assistance please contact:
– Sarah Shirey-Losso (410)786-0187 or [email protected]
– Joe Bryson (410)786-2986 or [email protected]
– Valeri Ritter (410)786-8652 or [email protected]
Long Term Care Hospital PPS
Sarah Shirey-Losso
LTCH PPS: Definition
• Certified under Medicare as short-term acute-care hospitals and for the purpose of Medicare payments in general
• Defined as having an average inpatient length of stay of greater than 25 days
• DRG based payment system (like IPPS); called LTC-DRGs
LTCH PPS: Background
For background on IPF PPS, refer to:http://www.cms.hhs.gov/
LongTermCareHospitalPPS/01_overview.asp
IOM Pub. 100-04, Chapter 3, Section 150http://www.cms.hhs.gov/manuals/downloads/
clm104c03.pdf
CORE ELEMENTS OF THE LTCH PPS PAYMENT
• The standardized amounts, which are the basic payment amounts
• A wage index to account for differences in hospital labor costs
• The LTC-DRG relative weights, which account for differences in the mix of patients treated across hospitals. LTC-DRGs are weighted to account for resources used for more medically complex patients
CORE ELEMENTS OF THE LTCH PPS PAYMENT (cont.)
• An additional payment for cases that are unusually costly, called outliers
• Adjustments for short stay cases, interrupted stays, and co-located providers
LTCH PPS Does Not Include
• Bad Debts
• DME
• Blood Clotting Factors
Additional Information
• The LTCH PPS is updated annually every July
• DRGs are updated in October of each year
Additional Information (cont.)
CMS has created a web-based Pricer program to calculate the claim payment.
Training Guide and Implementation instructions are located at:
http://www.cms.hhs.gov/PCPricer/07_LTCH.asp#TopOfPage
For additional assistance please contact
• Sarah Shirey-Losso (410) 786-0187, [email protected]
• Joe Bryson, (410) 786-2986, [email protected]
• Valeri Ritter, (410) 786-8652, [email protected]
Skilled Nursing Facility Prospective Payment
System (SNF PPS) Pricer
Joe Bryson
SNF PPS: Background
• SNF and Swing Bed (SB) facilities are paid under this system
• Critical Access Hospital Swing Beds are not
SNF PPS: Background (cont.)
For background on SNF PPS, see: http://www.cms.hhs.gov/center/snf.asp
Pub. 100-04, Chapter 6:http:///www.cms.hhs.gov/manuals/downloads/
clm104c06.pdf
Pub. 100-04, Chapter 7:http://www.cms.hhs.gov/manuals/downloads/
clm104c06.pdf
CORE ELEMENTS OF THE SNF PPS PAYMENT
• Unadjusted federal per diem rate (basic payment amount)
• Wage index to account for differences in area wage levels (Note: Hospital wage data is used)
• Case-mix relative weights, which account for differences in the mix of patients treated across SNFs and SBs
• Add-on payment for patients with AIDS, made after all other adjustments (wage and case-mix)
CORE ELEMENTS OF THE SNF PPS PAYMENT (cont.)
• The SNF PPS is updated annually every October
• CMS has created a web-based Pricer program to calculate the claim payment– Training Guide and Implementation
instructions are located at: http://www.cms.hhs.gov/PCPricer
The Outpatient Prospective Payment System (OPPS) Pricer
Joe Bryson
Introduction to OPPS: Coverage
The Outpatient PPS covers the following:– Hospital outpatient services – Certain Part B services furnished to
inpatients with no Part A benefits– Partial hospitalization services furnished by
Community Mental Health Centers (CMHCs)– Certain vaccines – Splints, casts and antigens for Hospice
patients
Introduction to OPPS:Coverage (cont.)
– Services provided from a clinic/unit ONLY if the clinic/unit is billing under the hospital’s Medicare provider number (i.e., OSCAR) and the services were billed on a 13x Type of Bill (TOB)
– Professional services and professional components are NOT covered under MLR
Introduction to OPPS: Key Terms
• Healthcare Common Procedure Coding System (HCPCS): – Code that is billed on the claim to represent a
procedure, item or service. Each HCPCS is mapped to an APC for payment
• Ambulatory Payment Classification (APCs): – Payment group for services that are clinically
similar and require similar resource use• Coinsurance:
– Amount of patient responsibility taken out of the total APC payment.
• Reimbursement: – Amount paid to hospital minus all applicable
coinsurance and deductibles
Introduction to OPPS: Payment Adjustments
• Packaging: – A bundling of items and services that are
considered to be an integral part of another billed service paid under the OPPS. No separate APC payment is made for packaged services
• Discounting: – Reduction in APC payment due to multiple
procedures on the same day or due to a terminated procedure
Introduction to OPPS: Payment Adjustments (cont.)
• Outlier: – Additional payment made for
extraordinarily high cost services
• Geographic: – Wage adjustment to account for
differences in wages across geographical areas. Sixty percent of the total OPPS payment is wage-adjusted by multiplying payment by the hospital’s wage index
Introduction to OPPS: Manual Reference
To view detailed claim processing instructions, go to Publication 100-04 (Claims Processing), Chapter 4 at:
http://www.cms.hhs.gov/manuals/downloads/clm104c04.pdf
OPPS Pricing: Background
The OPPS Pricer determines payment by using inputs from the following:
• Hospital claim data
• Outpatient Code Editor (OCE) output
• Provider specific data (pulled from the Outpatient Provider Specific File)
OPPS Pricing: Outpatient Code Editor (OCE)
Two major functions of the OCE:
1. Edit claim data to identify errors
2. Set payment flags to direct the OPPS Pricer on how to price a particular claim
OPPS Pricing: Pricer• There is no OPPS PC Pricer• Pricer Files
– Are posted at: http://www.cms.hhs.gov/PCPricer/08_OPPS.asp#TopOfPage
– Consist of: • pricing logic
• APC rates
• wage indices
• payment adjustment tables
• provider specific information
– Can assist in manual pricing
OPPS Pricing: Pricer FilesBelow are the filenames and descriptions of the
Pricer files that can be downloaded:
– Baseapc – readable APC table– Basewinxv – readable MSA table– Basewnxcv – readable CBSA table– Devred – list of devices for device reduction– Oppsacpc – compressed APC table– Oppscal – pricer calculation logic– Oppsof – compressed list of devices for offsetting– Oppswinxcv – compressed MSA table– Oppswnxcv – compressed CBSA table– Psfall – Provider-Specific Data
OPPS Pricing: Obtaining Software
• Contact a vendor/contractor to obtain OPPS pricing software or to simply contract this work out
• Selection of a vendor is based on your individual tribe’s preference and resources. Vendor information can be obtained via the internet
OPPS Pricing: References
• Outpatient Code Editor - Information regarding the OCE can be found at the following website: http://www.cms.hhs.gov/OutpatientCodeEdit/01_Overview.asp#TopOfPage
• OPPS Pricer - OPPS Pricer files can be obtained by selecting the applicable quarterly link at the following site and downloading the files: http://www.cms.hhs.gov/PCPricer/08_OPPS.asp#TopOfPage
Reasonable Cost Reimbursement
Joe Bryson
Reasonable Cost Providers
• Critical Access Hospitals (CAHs)– Medicare provider number (also known
as OSCAR) range: xx1300 – xx139
• TEFRA – Children’s Hospitals
• Provider number range: xx3300 – xx3399
– Cancer Hospitals– Territory Hospitals
Cost Reimbursement under IHS/CHS
• No cost report settlement under IHS/CHS
• Apply the hospital’s Cost-to-Charge Ratio (CCR) to the billed “covered” charges on the claim
How do I obtain a hospital’s Cost-to-Charge Ration (CCR)?
• Contact the servicing hospital’s Medicare Fiscal Intermediary (FI)
Reasonable Cost: TEFRA Payment Example
– Children’s Hospital– LOS 7/1/07 – 7/5/07 – Total Covered Charges = $12,000.00– CCR = 0.62
Multiply total covered charges by CCR: $12,000 x .62 = $7,440.00
Reasonable Cost: CAH Payment Example
– CAH– LOS 7/1/07 – 7/3/07– Total Covered Charges = $2,935.60– CCR = .62
1. Multiply total covered charges by CCR: $2,935.60 x .62 = $1,820.07
2. Multiply Cost by 101%:$1,820.07 x 101% = $1,838.28
***Same formula applies to outpatient CAHs
The End