FI Support for Medicare-Like Rates

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FI Support for Medicare-Like Rates
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Topics for FI discussion

• Overview of system changes
• Discontinuation of pre-pricing
• Critical Access reimbursement
• Letter sent to providers from FI
• Pass Thru Rate / No Settlement
• DRG Disclosure Report
• Pends/Message codes pertinent to MLR
• EOBR examples
• Better than Medicare-Like Rates
• Question Answer

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FI System Changes

• No requirement for contracts for MLR pricing.
• Suffixes no longer used to point to a pricing
  methodology.
• Claims paying per MLR will not pend for
  signature authority
• Programming done for other PPS methodologies
  (Psych, Rehab, LTC, SNF, Home Health, Hospice,
  APC)

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Future FI programming

• To accommodate the regulation the FI is currently
  programming for the following
• Rural hospital demonstration project per section
  410 of the Medicare Modernization Act
• Childrens Hospitals and Cancer Centers
• Timely filing

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Discontinuation of Pre-Pricing

• In the past the FI has, on occasion, assisted an
  Area or Service Unit by pre-pricing a claim to
  help obligate a Purchase Order or negotiate a
  rate with an open market provider.
• With the large number of providers now paid at
  PPS rates, the FI is not staffed to continue
  pre-pricing claims.
• Online pricers are available to Service Units.
• The FI does not have a tool to pre-price APCs.

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Critical Access Reimbursement

• Per Diems are calculated using the latest settled
  cost report.
• If there isnt a settled cost report then the as
  filed report will be used.
• If there hasnt been a cost report filed, the
  Medicare FI will be contacted for the providers
  rate.
• No method 2 reimbursement related to the
  physician component.

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Provider Letter from FI

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

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Pass Thru Rate / No Settlements

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

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DRG Disclosure Report

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

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New DRG Disclosure Report Header
Pass Thru Per Day will show for MLR Pricing
Contract No. will show for Better than MLR
Contracts
Pass Thru/Settled will show for Better than MLR
Contracts
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Pends/Message Codes Pertinent to MLR

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

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EOBR Change Example
With MLR Pricing Contract No. shows MLR
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EOBR Change Example Contd
Message code M506
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Better Than Medicare Like Rates

• The regulation specifies that better than MLR
  contracts may be negotiated.
• The FI is currently testing two basic methods for
  each PPS methodology.
• Lesser of billed or Medicare
• Percent of Medicare (less than 100)
• Percentage of billed charge is not always better
  than Medicare and is not supported as a better
  than MLR contract provision.

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• Question and Answer
• Rhonda Nichols Inge Zamora
• Manager, Manager,
• Systems Reporting Prov Database Reimb