HOSPITAL MEETING Friday, November 3, 2017 9:00 AM 12:00 PM - - PowerPoint PPT Presentation
HOSPITAL MEETING Friday, November 3, 2017 9:00 AM 12:00 PM Location: The Department of Health Care Policy & Financing, 303 East 17 th Avenue, Denver, CO 80203. 11 th Floor Rooms A&B. Conference Line: 1-877-820-7831 Passcode: 294442# For
1
Location: The Department of Health Care Policy & Financing, 303 East 17th Avenue, Denver, CO 80203. 11th Floor Rooms A&B. Conference Line: 1-877-820-7831 Passcode: 294442# For more information contact: Elizabeth Quaife at elizabeth.quaife@state.co.us
2
Colorado Department of Health Care Policy and Financing
3
4
hospital
conversation, so please don’t:
hear you and it is being recording)
5
6
The agenda for upcoming meetings will be available on our external website in advance of each meeting. https://www.colorado.gov/hcpf/inpatient- hospital-payment 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
7
Meetings will be moved to 303 East 17th Avenue, Denver Conference Room 7B & 7C
Engagement Meeting Dates for 2018
01/12/2018 07/13/2018 03/02/2018 09/07/2018 05/04/2018 11/02/2018
Matt Haynes Special Finance Projects Manager
8
9
10
4
How the Department of Health Care Policy and Financing is Driving Improved Health Care Delivery and Payment Systems in Colorado
Payment Reform Models Taxpayers Clients
H
FQHCs PCPs
1 2
WHY? Because almost one of four Coloradans is covered by Health First Colorado, HCPF has the ability to move the market.
3
WHO? HCPF partners with key stakeholders.
4
HOW? HCPF works with stakeholders to build a value-based system.
5
DESTINATION? System Transformation.
Quadruple Aim
L TSS Specialists RAEs
Desired Outcome
1 2 3 4
13 FY15-16 data 6
2019 for an 1115 waiver focusing on adding value into our delivery system.
in to provide adequate time for us to work in partnership.
7
15
toward adding value into the system over time.
goal of HCPF.
9
integration of care across settings;
ensuring appropriate care in appropriate settings;
costs through reductions in avoidable hospital utilization and increased effectiveness and efficiency in care delivery;
readiness for value-based payment; and
17
The HTP envisions transforming care across the following six priority areas:
11
Colorado’s hospitals have a critical role to play in the HTP, and will be asked to:
12
August, 2017 – October, 2018 – Planning period
with urban and rural providers to finalize the HTP.
system for input and feedback that will inform program development
processes for engaging with their communities.
13
October, 2018 – October, 2019 – Ramp-up period
with the provider fee year to establish critical relationships and identify HTP initiatives.
process to further determine the needs of the community and the roles hospitals can play to support those needs.
application
14
October 1, 2019 – HTP implementation
forward with an 1115 Waiver with an implementation date beginning October 1, 2019.
15
11/3/2017
23
24
25
26
Can you look at Claim number XXXXXXXXX. The information is vague and we are having to do a full analysis with the claim or go back and forth with Provider to get more information on what is going on. This is taking up Analyst’s and Provider’s time
Adjustments or writing of Transmittals.
Can you help me with EAPGs Questions on claims or system should go through DXC first prior to escalation with few exceptions. DXC Provider Services Call Center: 1-844-235-2387
27
Escalate Claims if:
DXC rep or State and DXC rep, obtain CTNs (call tracking number)
representative specified for topic
denial has occurred and reporting back to Department results of Mass Adjustment.
to correct Department)
**Note: If escalated to Rates Department, issue may be forwarded to a different department to obtain resolution if outside of Rates’ knowledge. Example: Issues with the Portal will be forwarded to Systems**
28
When escalating a claim make sure to:
escalating the same claim/question
vs what should have been paid. OR Denial codes received OR Steps taken to resolve previously escalated claim with new denial code(s)/reason(s) for re-escalation
29
Can you help me with Claim XXXXXXXX. I contacted DXC, CTN YYYYYYYYY, they do not know why the claim was denied. Denial reason EOB 1234 and EOB 5678. Thank you for any assistance. Why this is helpful: Providing complete information allows timely responses/investigation from the Department. Can pull the claim, review issues and review resolutions. When appropriate, Department will then forward information to DXC for additional training opportunities to assist with future calls. Can you help me with Claim XXXXXXXX. I contacted DXC, CTN YYYYYYYYY, they said the claim was paid correctly. We were paid $1234.56 I calculated our payment at $4567.89 using the following methodology …. It appears to have grouped correctly but I am not sure why the payment
30
Would like to meet with most LTACs and Rehabs at least
Specialty Hospital Engagement Meetings 10/06/2017 (1pm-3pm) 11/3/2017 (1pm-2pm) 12/01/2017 (1pm-2pm)
31
**Implementation Goal July 1, 2018**
Step Down Per Diem Rate Using Blanket Calculated Service Days and 5% Stepdown:
Q1 $ Q2 $ Q3 $ Q4 - starts $ LTAC 0-21 $2,084.02 22-42 $1,979.82 43-77 $1,880.83 78 $1,786.79 REHAB 0-21 $1,082.20 22-42 $1,028.09 43-77 $976.69 78 $927.85 CRAIG 0-21 $3,070.13 22-42 $2,916.62 43-77 $2,770.79 78 $2,632.25
Moving Forward with Proposed Per Diem Rates Thank you to the Specialty Providers participating in our meetings and will continue conversations about next steps and feedback at our 1pm meeting today.
➢ A list of all CCs/CCECs your hospital owns/operates ➢ Identify claims from these locations
▪ Either ICN/TCNs, Client/DOS, or other unique identifiers
➢ Other data to help us assess cost and utilization at
these locations
32
33
found in the Inpatient/Outpatient Billing Manual.
(procedure and diagnosis codes) are billed on one claim as one stay. Services should be billed on the mother’s claim until the time the mother is discharged.
stay, they should only appear on the mother’s claim. They should not appear on the newborn’s claim after the mother was
deny.
age or gender restriction are currently encountering errors. The Department is working on a solution to this problem.
Admit/From Date
34
Per UB-04: IP and OP Billing Manual All of the conditions must be met in order for the claim to qualify for Interim Billing: 1. Health First Colorado must be the Primary Payer. If recipient has other medical insurance including Medicare and private insurances. They do not qualify for Interim Billing 2. Each request must reach a payable amount from Health First Colorado of $100,000 3. Claim must be in an outlier status (not documented in current manual but will be in updated manual coming soon) 4. Can only use Bill types 112, 113 or 114.
35
Type of Bill 112: First Interim Claim
➢ First bill submitted by the hospital for the services
performed from the admission date through the billing date. Type of Bill 113: Continuous Interim Claim
➢ Billed when the services have exceeded an additional
$100,000 from the first interim claim
➢ Must be billed using the admission date through billing
date Type of Bill 114: Last Interim Claim
➢ Billed after the patient has been discharged from the
hospital and billed using the admission date through discharge date.
36
37
2017 Meetings, Conference Room 11B & 11C, 2:00pm-4:00pm 11/17/2017 12/01/2017
38
2018 Meetings, Conference Room 7B, 2:00pm-4:00pm 01/12/2018 01/26/2018 02/09/2018 03/02/2018 03/16/2018 03/30/2018 04/13/2018 05/04/2018 05/18/2018 06/01/2018 06/15/2018 06/29/2018
Please Note: Future 2018 Meetings will be held at 303 E. 17th Ave Denver Conference Room 7B
39
ICD-10 10/1/2017 Update: The APR-DRG Version 33 Software was updated to reflect the ICD-10 10/1/2017 Update on 10/3/2017. DXC checked and no claims required mass adjustment as a result of this update.
40
Claim Status Claim Type Count % % Claim Status Paid Inpatient Xover Claims 2048 9.90% Paid Inpatient Claims 18141 88.10% 98.00% Suspended Inpatient Xover Claims 102 0.50% Suspended Inpatient Claims 311 1.50% 2.00% 20602 100.00%
41
42
CMS approval for FY2017-18 rates is received 7/1/2017 Mass Adjustment of all claims back to 7/1/2017 to reflect FY2017-18 CMS approved base rates and Adjusted Birth DRG weights as proposed. ~October 2017 Mass Adjustment of Claims with correct coding will receive payment for IPP-LARCs at this time CMS approval for IPP- LARCs State Plan change is received and Adjusted Birth DRG weights are instituted. ?
Please Note: The State has no control over when CMS approves State Plan changes.
TBD
43
DRG-SOI Affected Birth DRGs FY2015-16 Weight w/ LARCs Weight w/LARCs removed Difference in Weights
540-1
3,277 0.5893 0.5853 0.0040
540-2
less than 30 0.9434 0.9394 0.0040
540-3
less than 30 1.3456 1.3416 0.0040
540-4
141 3.1956 3.1916 0.0040
542-1
1,238 0.3787 0.3747 0.0040
542-2
less than 30 0.5629 0.5589 0.0040
542-3
less than 30 1.0438 1.0398 0.0040
542-4
9,286 4.8252 4.8212 0.0040
560-1
719 0.4795 0.4755 0.0040
560-2
6,850 0.5601 0.5561 0.0040
560-3
99 0.7559 0.7519 0.0040
560-4
1,718 2.2333 2.2293 0.0040 23,393
44
Immediate Post-Partum Long-Acting Reversible Contraceptives (IPP-LARCs / IUDs and Implants) prior to hospital discharge is efficacious in preventing unintentional follow-up pregnancies.
through the APR-DRG system.
been developed and will be submitted to CMS for approval.
July 1, 2017 TBD provided that approval is received from CMS.
45
Partum LARCs (Long Acting Reversible Contraceptives)
DIAGNOSIS CODES JCODE MODIFIER NDC Z30.430 J7298 FP 5041942101 Z30.49 J7307 FP 00052027401 DIAGNOSIS CODES JCODE MODIFIER NDC Z30.430 J7298 5041942101 Please note, The Department is only recommending what needs to appear on a claim in order to receive credit for inserting an IPP-LARCs
LARCS SUPPLEMENT PAID REQUIREMENTS FOR INPATIENT HOSPITAL IPP-LARCS CLAIMS LARCS SUPPLEMENT NOT PAID
ANY CLAIMS SUBMITTED WITHOUT THE FP MODIFIER OR ANY OTHER REQURIED CODES WILL NOT RECEIVE PAYMENT FOR THE LARCS SUPPLEMENT
46
Count of ICN_NBR Column Labels Row Labels ICD10_oldsystem ICD10_wrongversion LVP_3hosp Transfer_Claims Grand Total HealthOne 50 3 1 54 HealthOne North Suburban Medical Center 8 8 HealthOne Presbyterian/St. Luke's Medical Center 7 1 8 HealthOne Rose Medical Center 6 2 8 HealthOne Sky Ridge Medical Center 4 4 HealthOne Spalding Rehabilitation Hospital 1 1 2 HealthOne Swedish Medical Center 9 9 HealthOne The Medical Center of Aurora 15 15 HealthSouth 5 1 15 21 HealthSouth Littleton Rehabilitation 3 6 9 HealthSouth Rehabilitation Hospital of Colorado Springs 2 1 9 12 SCL Health 50 50 Exempla Good Samaritan 4 4 Exempla Lutheran Medical Center 14 14 Exempla Saint Joseph Hospital, Inc. 23 23 Platte Valley Medical Center 3 3
6 6 UC-HEALTH 50 6 56 Memorial Hospital 18 2 20 Poudre Valley Hospital 10 10 University of Colorado Hospital 22 4 26 YAMPA 7 39 46 Yampa Valley Medical Center 7 39 46 Grand Total 162 10 39 16
227
Numbers are subject to change due to adjustments made by Providers or Department staff
InterChange Claims w/discharge dates on or after 3/1/2017:
errors Next Steps:
dates on or after 3/1/2017 that should process correctly.
test Legacy Xerox claims with detail dates & Medicare payment dates present to see if those claims can be processed without harming providers.
10/1/2016 - 2/28/2017
722 claims CMS Rural Demonstration Hospitals – LVP restored, paid dates >= 7/1/2016 & <= 5/5/2017
20
214 Claims processed after 3/1/2017 using wrong DRG version 111 LTAC/ Rehab Transfer Claims 3/1/2017 – 5/2/2017
*Numbers are subject to change due to adjustments made by Providers or Department staff
*Numbers are subject to change due to adjustments made by Providers or Department staff
▪ Form Locator 15, Source of Admission (04 = Transfer from a Hospital (different facility)) ▪ Form Locator 17, Patient Discharge Status (02, 05, 62, 63, 66, 69, 82, 85, 90, 91, or 94)
New coding instituted 3/1/2017 with new InterChange system.
PATIENT STATUS/DISCHARGE CODES:
02 Discharged/transferred to another short term hospital √ 05 Discharged/transferred to another type institution √ 62 Discharged/transferred to an inpatient rehabilitation hospital. √ 63 Discharged/transferred to a Medicare certified long term care hospital. √ 66 Transferred/Discharged to Critical Access Hospital CAH √ 69 Discharged/Transferred to Designated Disaster Alternative Care Site. √ 82 Discharged/transferred to a Short Term General Hospital for Inpatient Care with A Planned Acute Care Hospital Inpatient Readmission √ 85 Discharged/transferred to a Designated Cancer Center or Children’s Hospital with a Planned Acute Care Hospital Inpatient Readmission √ 90 Discharged/transferred to an Inpatient Rehabilitation Facility (IRF) including Rehabilitation Distinct Part Units of a Hospital with a Planned Acute Care Hospital Readmission √ 91 Discharged/transferred to a Medicare Certified Long Term Care Hospital (LTCH) with a Planned Acute Care Hospital Readmission √ 94 Discharged/transferred to a Critical Access Hospital (CAH) with a Planned Acute Care Hospital Readmission √
√ Triggers Transfer Pricing (LTAC and Rehab Hospitals are exempt).
53
“Costs associated with professional services by salaried physicians are included in the hospital's rate structure and cannot be billed separately to the Health First Colorado. Do not bill professional fees (revenue codes 0960-0989) for emergency and outpatient services as an 837 Institutional (837I) electronic transaction or on the UB-04 claim form. Professional fees for services provided in the emergency room by contract physicians must be billed by the physician as an 837 Professional (837P) electronic transaction or on the CMS 1500 claim form using the appropriate HCPCS codes. The Health First Colorado payment is made to the physician.”
54
➢ Prevent double billing ➢ Increase transparency ➢ Consistency across hospitals
➢ Being paid for services rendered ➢ Etc.
55
56
57
58
Ana Lucaci Hospital Policy Specialist Ana.Lucaci@state.co.us Raine Henry Hospital Policy Specialist Raine.Henry@state.co.us Melanie Reece Family Planning Policy Specialist Melanie.Reece@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 Hospital Rates Analyst Diana.Lambe@state.co.us Andrew Abalos Hospital Rates Analyst Andrew.Abalos@state.co.us Elizabeth Quaife Specialty Hospital Rates Analyst Elizabeth.Quaife@state.co.us