Friday, March 1, 2019 9:00 AM 12:30 PM Location: The Department of - - PowerPoint PPT Presentation

1

Friday, March 1, 2019 9:00 AM – 12:30 PM

Location: The Department of Health Care Policy & Financing, 303 East 17t h Avenue, Denver, CO 80203. 7t h Floor Rooms B&C. Conference Line: 1-877-820-7831 Passcode: 294442# Topic Suggestions, due by close of business one week prior to the meeting. S end suggestions to Elizabeth Quaife at elizabeth.quaife@ state.co.us

2

Welcome & Introductions

• Thank you for participating today!
• We are counting on your participation to

make these meetings successful

[Poll]

3

• WE WILL BE RECORDING THIS WEBINAR.
• ALL LINES ARE MUTED. PRESS *6 IF YOU WISH TO UNMUTE.

PARTICIPANTS CAN ALSO UTILIZE THE WEBINAR CHAT WINDOW

• If background noise and/ or inappropriate language occurs all

lines will be hard muted.

• Please speak clearly when asking a question and give your

name and hospital

4

Overview of the Day

• Hospital Engagement Meeting

9:00-12:30

• Coffee Break

TBA

Colorado Department of Health Care Policy and Financing

5

6

Dates and Times for Future Hospital Stakeholder Engagement Meetings in 2019

The agenda for upcoming meetings will be available on our external website on a Monday the week of the meeting. https:/ / www.colorado.gov/ pacific/ hcp f/ hospital-engagement-meetings

Dates of Meetings Meeting Time January 11, 2019 12:30 p.m. – 4:00 p.m. March 1, 2019 9:00 a.m. – 12:30 p.m. May 3, 2019 9:00 a.m. – 12:30 p.m. July 12, 2019 12:30 p.m. – 4:00 p.m. S eptember 13, 2019 12:30 p.m. – 4:00 p.m. November 1, 2019 9:00 a.m. – 12:30 p.m.

Please note the offset dates and times to work around holidays AND Medical Services Board

Topics Provided For Engagement Meetings

We great ly appreciat e feedback and t opics provided prior t o t he Engagement Meet ings as request ed. To encompass t hese more effect ively, st art ing on May 3rd, slide(s) will be dedicat ed at t he beginning of each appropriat e sect ion of t he meet ing t o include t he quest ion from t he S t akeholder and Department ’ s response when possible. Example: A quest ion regarding EAPG/ Out pat ient will be at t he beginning of t he EAPG/ Out pat ient designat ed sect ion of t he meet ing. Followed by t he response or st at us. An individual response back t o t he Provider will st ill occur but t his will allow all Providers t o see t he t opics and responses submit t ed.

7

Topics Provided For Engagement Meetings

Topics for the Engagement Meetings can be sent to Elizabeth Quaife anytime from the day after the recent Hospital S takeholder Engagement Meeting up to the Friday before the next Hospital S takeholder Engagement Meeting. All topics and whom they originated from are tracked.

8

Upcoming Topics/Discussions

May 3, 2019 Hospital S takeholder Engagement Meeting

• UB-04: IP and OP Billing Manual Update

9

Webpage Updates

10

Webpages were required to be reviewed and updated by January 31, 2019. The following changes have been made: Inpatient Hospital Rates Page

• Long Term Acute Care Hospitals, Rehabilitation Hospitals,

Spine/Brain Injury Treatment Hospitals and Psychiatric Hospitals APR-DRG rates were removed and moved to Inpatient Hospital Per Diem Reimbursement page Outpatient Hospital Rates Page

• Old EAPG survey link was removed
• Added September 7, 2018 and November 2, 2018 Provider

Summaries

• Awaiting new link to the 3M Definitions Manual. Link is currently

disabled Inpatient Hospital Per Diem Reimbursement Page

• APR-DRG Rate page updated to include new hospital: Vibra

Rehabilitation Hospital

• Per Diem Rate Page updated to include new hospital and correct

terminology

Webpage Updates (cont.)

11

Hospital Stakeholder Engagement Meeting Page

• Old meeting information can only be posted for two years (current

calendar year and previous year)

• To request meeting documents for calendar year 2017,

please send an email to Elizabeth Quaife

• Meeting Summaries uploaded
• Hospital Stakeholder Engagement Meeting Summary,

November 2, 2018

• Per Diem Hospital Engagement Meeting Summary,

November 2, 2018

• During the quality check, it was found the Hospital Stakeholder

Engagement Meeting PowerPoint for January 12, 2018 was

• incorrect. Correct PowerPoint has been uploaded
• The 2019 Meeting schedule dates and times has been uploaded

Status Update for SCRs

12

Department SCR prioritization is re-evaluated every two weeks. The Department

considers factors such as:

• financial risk,
• impact on providers,
• relative magnitude, etc.

The Department is committed to moving forward with these important changes, and will continue to provide updates as they are available.

SCR Prioritization Medicare Crossover Claims Priority #2, on hold until Inpatient PAR is implemented IPP-LARCs Priority #7, on hold until Inpatient PAR is implemented Per Diem Hospital Rates (LTACs/Rehabs) Priority #24 Observations over 24 hours/24-48 hours Not Yet Prioritized JW Modifier Not Yet Prioritized

Part B Only and Part A Exhaust Workaround

13

The Department is working on a method to reprocess Part B Only and Part A Exhaust claims. Please send Part B Only and Part A Exhaust Inpatient ICNs by March 8, 2018 to Raine.Henry@state.co.us We will be prioritizing claims with DOS and Paid Dates prior to April 1, 2017.

Community Clinic and Community Clinic and Emergency Center (CC/CCEC) Reminder

14

CC/ CCECs previously enrolled as a hospital provider type and/ or billing through their main hospital ID need to enroll as and bill under the CC/ CCEC provider type for dates of service beginning December 1, 2018, going forward. Details on enrolling as in the CC/ CCEC provider type can be found on the Information by Provider Type page under Community Clinic.

Inpatient Hospital Review Program (IHRP)

• Information regarding IHRP authorization requirements can be found on

eQHealth’ s website: http:/ / www.coloradopar.com/ Inpatient.aspx

• Additional information regarding S

B 18-266 Controlling Medicaid Costs Initiatives can be found here: https:/ / www.colorado.gov/ pacific/ hcpf/ controlling-medicaid-costs- initiatives

• Please see https:/ / www.colorado.gov/ hcpf/ provider-news for regular

provider updates and to sign up for the IHRP Newsletter email list

• For questions and/ or comments please email:

HospitalReview@ hcpf.state.co.us

15

16

• S

till working on base rate development for this year and working toward having a first look available by sometime in April.

• Diana will be unavailable during the month of March

to finish building FY2019-20 hospital base rates. For emergency requests – please contact Kevin Martin.

FY2019-20 Hospital Base Rates

17

• After rates are built, the S

tate provides a 30-day review period during which hospitals can request their rate calculations for review and ask specific questions about how their rate was created.

• We wholeheartedly encourage hospitals to ask for their

calculations since despite our quality checks, we do manage to find data entry issues. The data we receive from the hospital intermediaries is in print format and cannot be uploaded to a spreadsheet and therefore requires a lot of data entry.

• Every year as part of the rate building process, documents are

prepared to send calculations to any hospital that requests them.

30-day Review Period

18

• We continue to find that some hospitals are unaware when the 30-

day review period starts and ends.

• Current Communication consists of:

1. Provider Bulletin 2. Emails to list of individuals entered on Hospital Engagement Meeting email list 3. Notice given during Hospital Engagement Meetings 4. Rates Loaded to Inpatient Hospital Payment webpage 5. Ideas on other ways to get the word out?

• How can we improve that communication?

30-day Review Period

19

Separating Baby from Mother’s Claim

To make t he change, t he Depart ment has been working on a plan t o present t o hospit als which will consist of t he following universe of Delivery & Neonat al DRGs:

DRG APR-DRG DESCRI PTI ON

540 Cesarean delivery 560 Vaginal delivery 541 Vaginal delivery w complicating procedures exc sterilization &/ or D&C 542 Vaginal delivery w sterilization &/ or D&C

DRG APR-DRG DESCRI PTI ON

589 Neonate bwt < 500g or GA < 24 weeks 634 Neonate, birthwt > 2499g w resp dist synd/ oth maj resp cond 630 Neonate birthwt > 2499g w major cardiovascular procedure 588 Neonate bwt < 1500g w major procedure 593 Neonate birthwt 750-999g w/ o major procedure 612 Neonate bwt 1500-1999g w resp dist synd/ oth maj resp cond 602 Neonate bwt 1000-1249g w resp dist synd/ oth maj resp or majanom 591 Neonate birthwt 500-749g w/ o major procedure 640 Neonate birthwt > 2499g, normal newborn or neonate w other problem 625 Neonate bwt 2000-2499g w other significant condition 614 Neonate bwt 1500-1999g w or w/ o other significant condition 639 Neonate birthwt > 2499g w other significant condition 607 Neonate bwt 1250-1499g w resp dist synd/ oth maj resp or majanom 631 Neonate birthwt > 2499g w other major procedure 633 Neonate birthwt > 2499g w major anomaly 609 Neonate bwt 1500-2499g w major procedure 622 Neonate bwt 2000-2499g w resp dist synd/ oth maj resp cond 611 Neonate birthwt 1500-1999g w major anomaly 583 Neonate w ECMO 608 Neonate bwt 1250-1499g w or w/ o other significant condition 621 Neonate bwt 2000-2499g w major anomaly 626 Neonate bwt 2000-2499g, normal newborn or neonate w other problem

20

Separating Baby from Mother’s Claim

Proposed st eps involved in est imat ing change in payment :

• 1. Use National DRG Weights, Average Length Of S

tay and TrimPoint for delivery and neonate DRGs since the standard in the US is to separate Mother’s delivery and Baby birth claims.

• We

must use the National DRG Weights since Colorado weights currently combine mother and baby on delivery claims.

• Data Source:

3M Non-HS RV National DRG Weight Table version 33.

• An excerpt
• f

this table will be posted on our website containing information on Delivery & Neonate DRGs after receiving approval from 3M.

21

Policy Adjustments

S t eps involved in est imat ing change in payment :

2. Apply Policy Adj ustments before scaling to CO Weights.

DRG-SOI DRG DESCRI PTI ON POLI CY ADJUSTMENTS

540-1 CESAREAN DELIVERY Equal to weight for Vaginal Delivery 560-1 560-1 560-2 560-3 560-4 589-1 589-2 589-3 589-4

2/3 of old CO weight or New National Weight, whichever is higher

Weight increased by 10% for all severities VAGINAL DELIVERY NEONATE BWT < 500G OR GA < 24 WEEKS

22

Separating Baby from Mother’s Claim

Steps involved in estimating change in payment:

3. Remove claims where a solid payment cannot be reasonably estimated. Claims Used for Analysis 3/ 1/ 2017 - 2/ 28/ 2018 CLAI M COUNT

DELI VERY DRGs 22,524 NEONATE DRGs

(5,734 - 21 = 5,713 claims) Removed 21 Neonate claims where birthdate = 1/ 1/ 1900 or mother's birth date

5,713

TOTAL 28,237

23

Separating Baby from Mother’s Claim

S t eps involved in est imat ing change in payment :

• 4. Estimate number of claims for babies born who did not stay

after Mother left – we currently have no claims for these since they are combined with Mother’s delivery claim.

• 22,524 Delivery Claims
• Removed remaining 5,713 neonate claims (baby admitted

after mother left hospital)

• Results in estimate of 16,811 missing well-baby birth claims.
• We assume these births will be assigned to a low severity

Neonate DRG (DRG-S OI = 640-1) to cover normal births.

24

Separating Baby from Mother’s Claim

S t eps involved in est imat ing change in payment :

5. Estimate payments for S ick Newborns who stay after their Mother leaves the hospital. We will take Neonate DRGs and use birth date to re-calculate the full stay for these claims.

CLAI M UNI VERSE COVERED DAYS BASED ON ADMI T DATE FOR BABY AFTER MOTHER LEAVES HOSPI TAL NEW COVERED DAYS CALC USI NG BRTHDATE DI FFERENCE

NEONATE DRGS: 580-640 57,575 67,276 9,701

25

Separating Baby from Mother’s Claim

Steps involved in estimating change in payment:

• 6. Prepare a comparison of the old payments (current state) vs.

new payments by DRG grouping.

CLAI M TYPE CLAI M COUNT OLD PMT EST NEW PMT DI FFERENCE

Delivery DRGs 22,524 $$$$$ $$$$$ Neonate DRGs 5,713 $$$$$ $$$$$ Estimated Missing Well- Baby Claims using 640-1 and FY19 Rates 16,811 $0 $$$$$

TOTAL 45,048 $$$$$ $$$$$ $0

26

Separating Baby from Mother’s Claim

• Is DRG-SOI 640-1 the right DRG-SOI to assume newborns will be assigned

to? Or do we need different DRGs for each weight range?

DRG-SOI DRG Description DRG-SOI DRG Description

580-1 603-1 580-2 603-2 580-3 603-3 580-4 603-4 581-1 608-1 581-2 608-2 581-3 608-3 581-4 608-4 589-1 614-1 589-2 614-2 589-3 614-3 589-4 614-4 591-1 626-1 591-2 626-2 591-3 626-3 591-4 626-4 593-1 640-1 593-2 640-2 593-3 640-3 593-4 640-4 NEONATE BWT 1250-1499G W OR W/ O OTHER SIGNIFICANT CONDITION NEONATE BWT 1500-1999G W OR W/ O OTHER SIGNIFICANT CONDITION NEONATE BWT 2000-2499G, NORMAL NEWBORN OR NEONATE W OTHER PROBLEM NEONATE BIRTHWT > 2499G, NORMAL NEWBORN OR NEONATE W OTHER PROBLEM NEONATE, TRANSFERRED < 5 DAYS OLD, NOT BORN HERE NEONATE, TRANSFERRED < 5 DAYS OLD, BORN HERE NEONATE BWT < 500G OR GA < 24 WEEKS NEONATE BIRTHWT 500-749G W/ O MAJOR PROCEDURE NEONATE BIRTHWT 750-999G W/ O MAJOR PROCEDURE NEONATE BIRTHWT 1000-1249G W OR W/ O OTHER SIGNIFICANT CONDITION

EAPG Module Updates

• GPS

v2019.1.0 S cheduled March 28, 2019

• EAPG Grouper will recognize 4/ 1/ 2019 quarterly update to

CPT/ HCPCS

• Version 3.10 remains in use
• Estimated Installation – first week of April 2019
• Maj ority of DXC 1/ 1/ 2019 CPT/ HCPCS

updates completed in February

• No planned changes for any upcoming S

ervice Packs released during this quarter

• In rare circumstance of an interim update, communication

will be released as soon as possible

27

EAPG Observation Payment Clarification

• interChange and EAPG software functioning as

designed for Observation payment

• Considered as an item for prioritization in EAPG

S urvey

28

EAPG Survey Results

0.00 1.00 2.00 3.00 4.00 5.00 6.00 EAPG Base Rat e Development Nat ional Weights Modifier 25 - Medical Visit s S pecialt y Drugs Observat ion Policy Mult iple S ame Day Visit Payment Non-Packaged Drug Carveout Priorit izat ion S core

29

EAPG Survey Plans

30

• Re-distribution of EAPG Survey
• Wider range of feedback, obtain responses more reflective of
• rganizations rather than individuals
• Extend reach to more than 17 hospitals
• Provide greater confidence that payment reform efforts moving

in right direction

• Re-written descriptions to better describe impacts of various

payment reform efforts

• Any further modifications to consider?
• Intend to distribute in March 2019

Questions, Comments, & Solutions

31

BHO/RAE Representative Q&A

32

33

34

35

36

37

38

39

HMS Audit Representative Q&A

40

Resource Links

• Inpatient Hospital Rates Webpage Link
• Outpatient Hospital Rates Webpage Link
• Hospital Engagement Meeting Webpage Link
• UB-04: IP and OP Billing Manual Webpage Link
• Inpatient Per Diem Reimbursement Group Webpage

Link

41

42

Thank You!

Melissa Eddleman Behavioral Health Unit S upervisor Melissa.Eddleman@ state.co.us David S mith Benefits Coord. S ection Mgr David.S mith@ state.co.us Ashley Dirienzo Third Party Liability & Recovery Officer Ashley.Dirienzo@ state.co.us S hane Mofford Payment Reform S ection Mgr S hane.Mofford@ state.co.us Kevin Martin Fee for S ervice Rates Mgr Kevin.Martin@ state.co.us Diana Lambe Inpatient Hospital Rates Analyst Diana.Lambe@ state.co.us Andrew Abalos Outpatient Hospital Rates Analyst Andrew.Abalos@ state.co.us

Inpatient Hospital Review Team HospitalReview@ hcpf.state.co.us

Elizabeth Quaife S pecialty Hospital Rates Analyst Elizabeth.Quaife@ state.co.us Raine Henry Hospital and S pecialty Care Unit Manager Raine.Henry@ state.co.us Rob Edwards Hospital Policy S pecialist Robert.Edwards@ state.co.us Jeremy Oat Operations S ection Manager Jeremy.Oat@ state.co.us