5/3/2016 L oc al He alth De par tme nt Cost Re por t a nd Se - - PDF document

5/3/2016 1

L

• c al He alth De par

tme nt Cost Re por t a nd Se ttle me nt

By: Ste ve n W. Ga rne r

Me dic a id Re g ula tions

• CMS Pro vide r Re imb urse me nt Ma nua l 15-1
• 2300. Princ iple :
• “Pro vide rs re c e iving pa yme nt o n the b a sis o f

re imb ursa ble c o st must pro vide a de q ua te c o st da ta b a se d o n fina nc ia l a nd sta tistic a l re c o rds whic h c a n b e ve rifie d b y q ua lifie d a udito rs.”

Me dic a id Re g ula tions Continue d

Sta te Pla n Ame ndme nt (SPA) Atta c hme nt 4.19-B Se c tio n 9 sta te s:

“T

• a ssure pa yme nts do no t e xc e e d the uppe r

pa yme nt limits se t fo rth a t 42 CF R447.321, He a lth De pa rtme nt se rvic e s re imb urse d unde r a fe e sc he dule a nd furnishe d to Me dic a id re c ipie nts will b e c o st se ttle d a nnua lly to Me dic a id a llo wable c o st.

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Ac tua l T ime Re ports 4 Prima ry a re a s of c ost re porting F ina nc ia ls

A B C

Sta tistic a l Re ports

D

7 Ste p Cost Se ttle me nt Proc e ss

Yo ur Ge ne ra l L e dg e r must re fle c t c o st a ssig ne d a ppro pria te ly to the pro g ra m whe re e xpe nse d.

• A. Cost Re porting F

ina nc ia ls

• Ac c o unt 4A is Administra tive Co st
• He a lth Dire c to r/ Administra tive Sta ff
• Me dic a l Dire c to r
• Ac c o unt 4B is Clinic al Administra tive Co st
• Nursing Dire c to r/ Supe rviso rs a nd L

e a d Nurse s

• Pha rma c ists, I

nte rpre te rs, Clinic a l Billing Sta ff

• Ac c o unt 4C is Clinic al Co st
• - F

a mily Pla nning, Ma te rna l He a lth, Child He a lth,

• - De nta l, I

mmuniza tio ns, T B, ST D, Co mmunic able Dise a se

• Ac c o unt 4D is No n Re imb ursable Co st
• E

nviro nme ntal He a lth, CC4C, OBCM, Ho me He a lth, Bio te rro rism,

• WI

C, He a lth Pro mo tio n, Anima l Co ntro l, o the r Gra nt pro g ra m a c tivity

Sta nda rd Cha rt of Ac c ounts – Ca te g o rize Co st

• A. Cost Re porting F

ina nc ia ls Cont.

All 4B c o st a re a llo c ate d to c linic a l c o st a c tivity o nly All 4A c o st a re Ge ne ra l Admin. c o st a llo c a te d to a ll c o st c a te g o rie s 4D c o st a re re mo ve d fro m yo ur c la ima b le c o st 4C c o st inc lude a ll Clinic a l Dire c t Se rvic e Ac tivity c o st

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• All Sta ff tha t a re e mplo ye d b y the

He a lth De pa rtme nt a nd re po rts to the He a lth Dire c to r must b e inc lude d

• n the Pe rso nne l Re po rt
• E

a c h E mplo ye e is a ssig ne d to a c o st po o l c a te g o ry a s a ppro ve d b y CMS

• T

he Pe rso nne l Re po rt must b a la nc e b a c k to the Sa la ry a nd F ring e Re po rte d o n the Ge ne ra l L e dg e r

• A. Cost Re porting F

ina nc ia ls Cont.

• 1. Pe rsonne l Re port – Assig ning Sta ff
• 1. Most a ppropriate c ost a pplic ation:
• I

de ntify a ll sta ff a nd pro g ra m c o st unde r Huma n Se rvic e Mo de l. T his inc lude s:

• He a lth Ac tivity
• DSS Ac tivity
• Othe r De pa rtme nt Ac tivity
• 2. Impa c t of Huma n Se rvic e s Mode l Admin Alloc a tion
• Co st Re po rt a llo c a te s a dministra tive c o st b a se o n a

full c o st me tho do lo g y. CMS do e s no t a llo w a dministra tive c o st a llo c a tio n b a se d o n F T E fo r c o st re po rt purpo se s.

• He a lth De pa rtme nts sho uld a llo c a te b a se o n the ir

se le c te d me tho do lo g y.

• A. Cost Re port F

ina nc ia ls Cont.

Huma n Se rvic e Mo de l

• Sta ff tha t c o mple te s a time re po rt:

1. 100% o f time must b e re po rte d o n the time re po rt. 2. 100% o f time must b a la nc e b a c k to c o unty time she e t. 3. Nursing Dire c to r/ Supe rviso rs a nd L e a d nurse s must b e e xc lude d fro m the a c tua l time re po rt.

• B. Ac tua l T

ime Re porting Proc e ss

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• Nurse s:
• I

nc lude Nurse s a nd Nursing Assista nt Po sitio n.

• Do no t inc lude

Nurse Dire c to r o r Nurse Supe rviso rs.

• Soc ial Wor

ke r s:

• L
• o king fo r so c ia l

wo rke rs tha t ma y pe rfo rm a ny type o f c linic a l a c tivity.

• 100% CC4C a nd

PCM ma y b e e xc lude d a nd re po rte d to 510 if no c linic a l a llo c a tio n.

• He a lth E

duc a tion a nd Nutrition

• L
• o king fo r He a lth

E duc a to rs a nd Nutritio nists tha t pe rfo rm c linic a l se rvic e a c tivity.

• WI

C sho uld b e e xc lude d a nd re po rte d to 510.

Ac tua l T ime Re porting Proc e ss

Whic h E mplo ye e s Pa rtic ipa te in the a c tua l time re po rt

• C. Sta tistic a l Re porting

T ime F ra me for Re porting / Billing Se rvic e s

• Ac c o rding to the ne w Sta te Pla n Ame ndme nt (SPA), I

nte rim Co st Re po rts a re to b e sub mitte d to Me dic a id 8 mo nths a fte r the c lo se o f the fisc a l ye a r.

• Me dic a id ha s 12 mo nths a fte r yo ur c o st re po rt is file d to

re vie w the re po rt a nd pre pa re a fina l c o st re po rt.

• L

HD’ s ha ve 12 mo nths to b ill c la im a nd 18 mo nths to re b ill de nie d c la ims.

• I

t is impo rta nt to sta y o n to p o f yo ur b illing a nd ma ke sure a ll c la ims a re sub mitte d in a time ly ma nne r to a vo id la g c la ims b e ing e xc lude d fro m yo ur se ttle me nt.

• C. Sta tistic a l Re porting Cont.

How Billing a nd F unding c a n a ffe c t Se ttle me nt

• Cla ims no t e nte re d prio r to sub mitting yo ur inte rim c o st

re po rt will re sult in the fo llo wing :

• I

na ppro pria te c a lc ula tio n o f yo ur Me dic a id sta tistic . (Cla ims e xc lude d fro m the c o st re po rt c o uld po te ntia lly o ve rsta te Me dic a id c o st.)

• I

na ppro pria te o ffse t o f Me dic a id pa yme nts. (Adding a dditio na l pa yme nt a fte r filling the inte rim se ttle me nt wo uld re sult in a pa yb a c k a t time o f fina l se ttle me nt c a lc ula tio n.)

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• C. Sta tistic a l Re porting Cont.

Me dic a id Popula tion Sta tistic Re quire d by DMA

Adjudic ate d Me dic aid Charge s (Nume rator ) T

• tal Charge s (De nominator)

= Me dic aid Statistic

• I

n o rde r to impro ve the Me dic a id sta tistic , the fo llo wing re po rta b le o nly se rvic e type s will b e ide ntifie d a nd e xc lude d fro m the T

• ta l Cha rg e s (De no mina to r):
• Co de s a sso c ia te d with OB Pa c ka g e c o de
• Co de s a sso c ia te d with He a lth Che c k Pa c ka g e c o de s
• Sta te Supplie d Va c c ine s
• C. Sta tistic a l Re porting Cont.

Me dic a id E lig ible Not Pa id Re port

• One o f the la rg e st ne g a tive impac ts to c o st se ttle me nt funds

inc lude se rvic e s pro vide d to pa tie nts e lig ib le to re c e ive Me dic aid b e ne fits o n the da te the se rvic e wa s re nde re d b ut no t pa id b y Me dic aid. T he impac t o f the se type o f se rvic e s inc lude :

• 1. Yo u re c e ive no fe e fo r se rvic e funding fo r the se c la ims.
• 2. T

he c ha rg e s fo r the se se rvic e s a re c o nside re d pa rt o f the no n Me dic aid po pulatio n a nd the re fo re re duc e the pe rc e ntag e o f Me dic aid c o st tha t c o uld b e se ttle d.

• As pa rt o f the c o st re po rting pro c e ss b e g inning with SF

Y 2015, a re po rt will b e a va ilable fo r e a c h L HD to ide ntify tho se c la ims tha t c o uld po te ntially b e pa id b y Me dic aid b ut ha ve no t b e e n a djudic ate d thro ug h the Me dic aid MMI S syste m.

• C. Sta tistic a l Re porting Cont.

De te rmining a Cha rg e Sc he dule Our g o a l is to a lso a ssist lo c a l he a lth de pa rtme nts in de te rmining a fe e sc he dule b a se d o n a c tua l c o st. It is o ur inte ntio n to a dd a c ha rg e sc he dule re po rt to the list o f sta nda rd c o st re po rts. Ba se o n a Re la tive Va lue Unit Me tho do lo g y, a c tua l c o st will b e a ssig ne d to e a c h se rvic e a s a ra te o r fe e pe r se rvic e . T

• ta l c o st will o nly b e a ssig ne d to c o ve re d de fine d

se rvic e s.

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T he 7 Ste p Cost Se ttle me nt Proc e ss

Ste p 1: T he Me dic a id po pula tio n fro m a c ha rg e b a se d me tho do lo g y is a pplie d to to ta l c linic a l c o st to ide ntify to ta l a llo wa b le Me dic a id c o st. Ste p 2: A se c o nd c ha rg e b a se d me tho do lo g y is use d to disting uish Me dic a id a llo wa b le c o st b e twe e n F a mily Pla nning a nd No n F a mily Pla nning . Ste p 3: All Me dic a id pa yme nts a re a pplie d a s a n o ffse t to to ta l c linic a l c o st. Ste p 4: T he diffe re nc e b e twe e n yo ur to ta l c linic a l c o st a nd pa yme nt o ffse t is yo ur se ttle me nt. Ste p 5: T he F e de ra l F unds Pa rtic ipa tio n Ra te (F F P) is a pplie d. F a mily Pla nning re c e ive s 90% a nd c urre ntly No n F a mily Pla nning is a ppro xima te ly 65%. No n F a mily Pla nning ra te c ha ng e s ye a rly. Ste p 6: He a lth De pa rtme nts a re pa id the F F P sha re o f the se ttle me nt. DMA withho lds 10% fro m the inte rim pa yme nt. Ste p 7: DMA pe rfo rms a de sk a udit a nd pre pa re s a fina l se ttle me nt within 12 mo nths fro m the file d inte rim c o st re po rt. T he re sult will b e pa id to o r c o lle c te d fro m the he a lth de pa rtme nt.

T hank You!

Ste ve n W. Ga rne r 919- 909- 4625 sg a rne r@nc a pha.org