HOSPITAL ENGAGEMENT MEETING Friday, March 2, 2018 9:00 AM 12:00 PM - - PowerPoint PPT Presentation

1

HOSPITAL ENGAGEMENT MEETING

Friday, March 2, 2018 9:00 AM – 12:00 PM

Location: The Department of Health Care Policy & Financing, 303 East 17th Avenue, Denver, CO 80203. 7th Floor Rooms B&C. Conference Line: 1-877-820-7831 Passcode: 294442# For more information contact: Elizabeth Quaife at elizabeth.quaife@state.co.us

2

Overview of Meetings

• General Hospital Meeting

9:00-10:00

• Break

10 min.

• General Hospital Meeting cont’d

10:10-12:00

• Lunch Break

12:00-1:00

• Specialty Hospital Meeting

1:00-2:00

• EAPG Engagement Meeting

2:00-4:00

Colorado Department of Health Care Policy and Financing

3

4

GROUND RULES FOR WEBINAR

• WE WILL BE RECORDING THIS WEBINAR
• ALL LINES ARE MUTED. PLEASE UTILIZE WEBINAR CHAT

WINDOW

• Please speak clearly when asking a question and give your

name and hospital

• If you wish to utilize the conference line for speaking, please

submit the request through webinar chat window. We will temporarily mute the microphones and activate the conference line. This may take a few moments.

5

Welcome & Introductions

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

make these meetings successful

6

• 1/12/2018
• 3/2/2018
• 5/4/2018
• 7/13/2018
• 9/7/2018
• 11/2/2018

Dates for Future Hospital Engagement Meetings in 2018

The agenda for upcoming meetings will be available on our external website in advance

• f each meeting.

https://www.colorado.gov/pacific/hcpf/hos pital-engagement-meetings Registration links for each session during the day will also be available prior to the meeting. Just click on the links to register for each session and you will receive the link to connect to the webinar. Meetings will now begin at 9am starting with 11/3/2017 meeting

Specialty Hospital Meetings

7

• Updates on Budget Neutral Proposal
• Updated goals and Timelines

Specialty Hospital Engagement Meetings 1/12/2018 1pm-2pm CANCELED 2/2/2018 1pm-2pm CANCELED 3/2/2018 1pm-2pm 4/6/2018 1pm-2pm

Escalation Process

8

• Escalated Claims should include a Call Tracking Number (CTN)
• If a CTN is not included in an escalation, Provider may be referred back to

DXC Call Center

• Requesting Providers to use channels currently open to them.
• Established Provider and Department meetings
• Engagement Meetings
• Escalating to correct team

Escalating to correct team after utilizing DXC call center:

• Rates Team: inquiries where the reimbursement is incorrect related to

base rate or Provider calculated reimbursement is different then

• received. Provide calculation and difference when escalating if DXC is

unable to assist.

• Operations: Escalate claim examples when requested by

representative

• Policy: Escalate claim examples when requested by representative

Escalations Continued

9

• If a claim is raised to a Department team, please do not escalate it to other

Department groups

• Multiple escalations of same claim can result:
• In different solutions
• Different solutions may cause a conflict with another solution
• Multiple requests for same issue with same fix can create multiple

work orders which delays the correction process.

• Department is still receiving multiple escalations for the same claim/issue from

multiple representatives within a Provider community. Examples include:

• Escalation of claim/issue from multiple people to one Department member
• Escalation of claim/issue to multiple Department members on the same

team by an individual or multiple personnel AND/OR

• Escalations of same claim/issue to multiple Department members on

different teams. All of the above examples can cause delay in response, action and removes resources from Projects and normal operations.

Escalations Continued

10

If unsure whom to escalate a claim to, please email potential Department representatives on one email. Do not send individual emails to each

• representative. A single email will allow the Department to assign the escalation

to the appropriate person and prevent duplicate emails from being sent. If a claim or issue has been escalated and a response has not been received and it is being escalating to a new individual within the Department, please include the original representative the claim/issue was escalated to. This allows the new representative to reach out to the original representative to check if it is being worked on. If an escalation has been sent, please proceed as follows: Follow up with the Department Representative the claim was escalated to OR If forwarded to a different Department Representative to assist with the claim, please follow up with the new Representative working on the claim.

Medicare Crossovers – Part A or Part B Only

11

Inpatient Medicaid with Medicare Part B only*

• Part B causing error code to bill Medicare first even though

Inpatient claim is not eligible for Part B services (outpatient

• nly)
• Department is aware and already has several examples of

the issue. Rates is currently working with multiple teams to correct Inpatient claims from bumping against Medicare Part B only Outpatient Medicaid with Medicare Part A only*

• Part A causing error code to bill Medicare first even though

Outpatient claim is not eligible for Part A services (Inpatient

• nly)
• Systems sent correction and completed Dec/Jan. Mass

adjustment has been completed. *Please do not escalate any additional claim examples

Reminder for Filing Medicare Crossover Claims

12

• Utilize the appropriate Crossover Claims option and enter correct

data into each applicable field

• Do not add Medicare Payment into Third Party Liability (TPL) or

Other Government Insurance box. This results in deduction of Medicare Payment twice. Other Government Insurance Third Party Liability

Type of Bill 12X

• Inpatient Hospital (Medicare Part B only)
• Initial Department plan to pay these claims using

crossover claim payment policies

• Part B Only (TOB 12X) – assessing variety of

solutions with attention to complexity / timeliness

• f implementation

▪ Denying 12Xs Not Feasible option for proper reporting ▪ Solutions being assessed – minimum 6 months

13

Transportation at Discharge

If a member requires Non-Emergent Medical Transportation (NEMT) at discharge, plan ahead to help prevent extended waiting times or denial of services. The Department will be issuing a Provider Bulletin Article in the near future.

14

Admin Date/From Date

• From Date or Procedure code date is before Admit

Date (24- hour Bundling policy)

• EOBs: 1730, 1731, 1393, 1395, 1920, 1930 and 1702.
• Issue has been resolved and claims that denied for these

EOBs have been reprocessed.

➢ A small amount of claims are still waiting to be reprocessed

because of the circumstances that had a 48-hour stay for Observation.

15

Pending Additional Research and/or Actions

The following items have been discussed at previous meetings and are pending while additional research and/or processes are being completed

• Exhausted Medicare Benefits on Crossovers
• IPP-LARCs
• Interim Billing
• Professional Fees

16

EAPG Monthly Meetings

17

2018 Meetings, Conference Room 7B, 2:00pm-4:00pm

03/02/2018 03/30/2018 05/04/2018 06/01/2018

Please Note: Future 2018 Meetings will be held at 303 E. 17th Ave Denver Conference Room 7B

NOTE: There are no meetings in April

Agenda for EAPG Meeting

• Drug Payments in EAPGs

➢ Upcoming Rule Change – Details at

https://www.colorado.gov/pacific/hcpf/outpatient-hospital- payment

• EAPG Grouper Version

➢ New set of Payer Exceptions not functioning correctly ➢ Impacts claims using X Modifiers

18

Agenda for EAPG Meeting

• Mass Adjustment Updates

➢ Testing 12,900 claims for EAPGs processed in Xerox system ➢ Aiming for March / April completion, depending on results

• Policy clarification regarding Recurring Visits
• Questions and comments regarding EAPG payments,

billing, etc.

19

Recurring Visits Clarification and ED/Observation Billing

• Emergency Room visits should not be included on
• utpatient claims describing recurring visits (regularly

scheduled visits for ongoing treatment, such as physical therapy or oncology treatment). Emergency Room visits should be billed separately in order for the EAPG grouper to calculate payment appropriately per claim and visit. Recurring visits which may include Observation services should have each visit billed separately to avoid unintended bundling during payment calculation.

20

21

Newborn/Live Birth Diagnosis Codes

Two Issues:

• 1. Three Newborn/Live Birth Diagnosis codes disallowed as

Principal/Primary Diagnosis on interChange system.

a) Claims from 3/1/2017 – present with a primary diagnosis code of Z381, Z384, or Z387 were mass adjusted mid-February. If you still see problems, please contact diana.lambe@state.co.us.

• 2. 3M APR-DRG Grouper limits allowance of Newborn/Live

Birth Diagnosis Codes as the primary diagnosis based on age in days of child upon admission.

22

Newborn/Live Birth Diagnosis Codes

23

Newborn/Live Birth Diagnosis Codes

MDC 15 Newborns and other neonates with conditions originating in the perinatal period All Patient Refined Diagnosis Related Groups (APR DRG) Classification System defines MDC (Major Diagnostic Category) 15 as: Overall, the approach of the classification system is to include newborns and other neonates with problems arising at or shortly after birth in MDC 15, and to place older neonates who are generally readmissions from home and treated in different patient care units, to more disease specific groups in the other body system specific MDCs.

This is the APR-DRG Website that 3M provides for non-clients. Website: www.aprdrgassign.com Login: COHosp Passwd: aprdrg001

24

Newborn/Live Birth Diagnosis Codes

Demonstration of 3M APR-DRG Grouper, Version 33:

Admit & Principal Diagnosis = Z3801 Age in Days (Admit Date – Birth Date): 7 days Groups to APR-DRG 633-3 Neonate birthwt>2499g w/major anomaly

25

Newborn/Live Birth Diagnosis Codes

Demonstration of 3M APR-DRG Grouper, Version 33:

Admit & Principal Diagnosis = Z3801 Age in Days (Admit Date – Birth Date): 8 days Groups to APR-DRG 955: Principal diagnosis invalid as discharge diagnosis

Baby on Mom’s Claim

For claims in which the mother and baby are both eligible for Medicaid, the baby’s first services, which include the birth, is included on the mother’s claim. If the baby stays after the mother is discharged, the baby will start their own claim based on the reason that they are staying past the mother's discharge. Using a newborn/live birth diagnosis code (Z38, Z38X or Z38XX) as primary diagnosis on the baby’s independent claim may cause the claim to be ungroupable and result in appropriate denial.

UB 04: IP and OP Billing Manual page 6

26

Baby on Mom’s Claim Moving Forward

Multiple groups within the Department are currently working on separating the baby from the mother’s

• claim. Currently working on:
• System updates
• Timeline for system implementation
• Recalibration of weights
• Rule & Policy changes
• Provider Fee

The anticipated timeline and process will be communicated with Providers in future meetings.

27

28

Bi-Partisan Budget Act of 2018 passed 2/9/2018

• Sec. 50204. Extension of increased inpatient hospital payment

adjustment for certain low-volume hospitals.

https://www.congress.gov/bill/115th-congress/house-bill/1892/text

• Extension of the Medicare low-volume hospital payments through 2022
• Current low-volume payments would continue unchanged requiring less

than 1,600 discharges during the fiscal year to qualify.

• 2019 – 2022: less than 3,800 discharges during the fiscal year to

qualify.

• 2023 – beyond: less than 800 discharges during the fiscal year to

qualify.

FY 2018 Medicare Base Rate - Low Volume Payment (L VP) Adjustment

29

• According to a 2/28/2018 mlnconnects newsletter, CMS will

be re-issuing Table 14 at some point.

• Hospitals must be in contact with their MAC to receive

LVP this year: For hospitals that qualified for the low- volume adjustment in fiscal year 2017, this written verification could be a brief letter to the MAC stating that the hospital continues to meet the low-volume hospital distance criterion as documented in a prior low-volume hospital status request.

• The State will have to request updated DRG Disclosures from Novitas

& WPS in order to officially grant LVP to hospitals not participating in the CMS Rural Community Hospital Demonstration.

Current Developments 2/28/2018

30

Inpatient Base Rate Reform

• Using the Medicare Base Rate as our starting point for

Medicaid Base Rates will continue to put us at risk of changes implemented at the Federal level.

• The Department will present other base rate options at

future meetings but we welcome feedback on potential alternatives.

Questions, Comments, & Solutions

31

The final poll is now an external survey to provide anonymity, please take a few moments to complete it. Thank you

32

Thank You!

Ana Lucaci Hospital Policy Specialist Ana.Lucaci@state.co.us Raine Henry Hospital Policy Specialist Raine.Henry@state.co.us Elizabeth Reekers-Medina Contract Compliance Specialist Elizabeth.Reekers- Medina@state.co.us Andrew Larson CC/CCEC Rates Analyst Andrew.Larson@state.co.us Shane Mofford Payment Reform Section Manager Shane.Mofford@state.co.us Kevin Martin Fee for Service Rates Manager 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 Elizabeth Quaife Specialty Hospital Rates Analyst Elizabeth.Quaife@state.co.us