Hospital Cost Report Data

1. 12th Annual Medicare/Medicaid Statistics and Data Analysis Conference Hospital Cost Report Data Data Mining for Benefit Integrity Presenters: Greg Dobbins, Jane Grover and Marcus Israel

2. Presentation Sections • Background • Relational Database Structure of Cost Reports • Programming and SAS Basics • Analysis Methodology • Results • Contact Information

3. Background • Program Vulnerabilities Identification • Discover Specific Facilities and Take Action • Reconnaissance and Collaboration with Other: • Program Safeguard Contractors (PSCs) • Medicare Administrative Contractors (MACs) • Fiscal Intermediaries (FIs)

4. Western Integrity Center (WIC)Program Safeguard Contractor MT (A/B) WA (A/B) ND (A/B) MN (A) SD (A/B) OR (A/B) ID (A/B) WY (A/B) IA (B) AK (A/B) NV (B) UT (A/B) CO (B) AZ (A/B) HI (B) • American Samoa (B) • Guam (B) • Northern Mariana Islands (B)

5. Background • Law Enforcement Suggestions for Proactive Analysis • Cost Report Data Supplements Claims Data • Collaborate with FI/MACs to Focus on Important Vulnerabilities • Cost Reports are Certified by Officer or Administrator of Provider(s)

6. Organ Acquisition Costs Bad Debts Intern and Residents Medical Education Disproportionate Share Hospitals (DSH) Outlier Payments – Inpatient and Outpatient New Technology Critical Access Hospitals Children’s Hospitals Specialty Hospitals Cancer Hospitals Wage Index Medicare Dependent Hospitals Areas Where Cost-Based Reimbursement is Settled through the Cost Report

7. Cost Report Certification – Worksheet S, Part I

8. Cost Report Certification – Worksheet S, Part I Misrepresentation or falsification of any information contained in this cost report may be punishable by criminal, civil, and administrative action, fine, and/or imprisonment under federal law. Furthermore, if services identified in this report were provided or procured through the payment directly or indirectly of a kickback or where otherwise illegal, criminal civil, and administrative action, fines and/or imprisonment may result. Certification by Officer or Administrator of Provider (s) I HEREBY CERTIFY that I have read the above statement and that I have examined the accompanying electronically filed or manually submitted cost report and the Balance Sheet and Statement of Revenue and Expense prepared by …..and that to the best of my knowledge and belief, it is a true, correct and complete statement prepared from the books and records of the provider in accordance with applicable instructions, except as noted. I further certify that I am familiar with the laws and regulations regarding the provision of health care services and that the services identified in this cost report were provided in compliance with such laws and regulations.

9. Predication for Critical Access Hospital Analysis • Homogeneous Population of Facilities • 25 Beds • 4 day Average Length of Stay • 25% of CAHs Nationwide are within WIC Jurisdiction • Over Past Several Years CMS and Rural Healthcare Lobbyists have Increased CAH Reimbursement Rates • Prior Complaints and Referrals based on Increased Financial Consultant Activity

10. Cost Report Worksheet SpecificationsSample of Specifications for Worksheets S, A, B, C

11. Cost Report Worksheet SpecificationsSample of Specifications for Worksheets C, D, and E

12. Cost Report Worksheet SpecificationsSample of Specifications for Worksheets E, E-2, and E-3

13. Cost Report Worksheet SpecificationsSample of Specifications for Worksheets G, H, L, and M

14. Multi-disciplinary Approach • Data and Statistical Analysts • Healthcare Fraud Investigators • Audit and Reimbursement Accountants • Medical Director • Program Management

15. Cost Report Relational Database Structure • There are three main tables in the CMS Hospital Cost Report Information System (HCRIS) Relational Database (RDB) • The report table • Alpha numeric table • Numeric table

16. Alpha Numeric Table (Character and Numeric Data) Report Record Number (FK) Worksheet Code Column Number Line Number Item or Data Value (Text) Report Table (Control Information) Report Record Number (PK) Provider Number Provider Control Type FY Begin Date FY End Date Process Date FI Receipt Date Numeric Table (Numeric Data) Report Record Number (FK) Worksheet Code Column Number Line Number Item or Data Value (Number) Relational Database Structure • There are three main tables in the HCRIS RDB

17. Alpha Numeric Table (Character and Numeric Data) Report Record Number (FK) Worksheet Code Column Number Line Number Item or Data Value (Text) Report Table(Control Information) Report Record Number (PK) Provider Number Provider Control Type FY Begin Date FY End Date Process Date FI Receipt Date Numeric Table (Numeric Data) Report Record Number (FK) Worksheet Code Column Number Line Number Item or Data Value (Number) Relational Database Structure • The Report Table • Control Information • Report Record Number • Primary Key or Linking field

18. Relational Database Structure • The Alpha-Numeric table • Alpha-numeric data • Hospital name, address, etc. • Text response to questions, i.e. urban or rural classification, teaching hospital or not, etc. Alpha Numeric Table(Character and Numeric Data) Report Record Number (FK) Worksheet Code Column Number Line Number Item or Data Value (Text) Report Table (Control Information) Report Record Number (PK) Provider Number Provider Control Type FY Begin Date FY End Date Process Date FI Receipt Date Numeric Table (Numeric Data) Report Record Number (FK) Worksheet Code Column Number Line Number Item or Data Value (Number)

19. Relational Database Structure • The Numeric Table • Numbers only • Medicare inpatient days • Medicare cost • Cost to charge ratios, Alpha Numeric Table (Character and Numeric Data) Report Record Number (FK) Worksheet Code Column Number Line Number Item or Data Value (Text) Report Table (Control Information) Report Record Number (PK) Provider Number Provider Control Type FY Begin Date FY End Date Process Date FI Receipt Date Numeric Table(Numeric Data) Report Record Number (FK) Worksheet Code Column Number Line Number Item or Data Value (Number)

20. What Facilities Appear in These Reports? • A hospital cost report is submitted yearly by all hospitals. It is a kind of analog for what we know on an individual basis as “filing our income tax return.” • The distribution of hospitals that submit hospital cost reports is given in the Table below.

21. Programming basics using SAS • Download • Import tables as *.CSV files • Merge by report record number • Report table • Alpha numeric table • Numeric table • Get data fields of interest

22. Programming basics using SAS • Some code details /*Worksheet S2 data*/ if ws='S200000' then do; if line='03003' and col='0100' then ambulance=item; if line='00200' and col='0100' then HOSPNAME=item; end; • This example is relevant to a later section related to an analysis of CAH Ambulance billing.

23. Analysis Methodology and Results to Date • Cost Per Diem Analysis. This analysis identified Critical Access Hospitals with a surge in cost per diem during the four year cost reporting period 2003 – 2006. • Financial records from one Northwest Facility are under review. • Critical Access Hospital Ambulance Claims Analysis. This analysis identified hospitals which were inappropriately claiming cost reimbursement for ambulance services • WIC has submitted a vulnerability report, caused one hospital to reprocess claims, and is determining the appropriate action for another hospital. • Financial Analysis. The objective of financial analysis is to examine and develop relationships between assets, expenses, bad debt and Medicare costs that are “normally” true in hospital cost reports. • Once these patterns are developed then “outliers” can be identified and investigated.

24. Cost Per Diem Analysis Methodologies • Cost Per Diem was calculated using CAH Inpatients Cost Report Data from the CMS website. In order to look for trends, four years of cost report data was considered: 2003, 2004, 2005 and 2006. • We flagged the facilities having reports for all four years and such that the following outlier criterion is satisfied. The outlier criterion is: • the inpatient cost per diem average for the last two years (2005, 2006) be at least 50% greater than the same average for the first two years (2003, 2004).

25. Cost Per Diem Data • To get this data, the cost reports were downloaded from the CMS site. • Workbook 255296_S contained the necessary information. Table below gives the details of the data acquisition.

26. Cost Per Diem Analysis • Six Facilities Identified • One Under Investigation

27. CAH Ambulance Analysis • Issue • Part A Data – TOB 85, Rev Code 054X, Condition Code B2 • Cost Report Data – Worksheet S-2, Line 30.03 • Part B Data - Ambulance • Geographic analysis • Detective work • Putting it all together

28. CAH Ambulance Analysis • Issue • Paid on Reasonable Cost or Ambulance Fee Schedule • 35 mile driving distance requirement • Code of Federal Regulations, Title 42, Chapter IV, Part 413.70 • Definitions • Condition Code B2: “Attestation by Critical Access Hospital that it meets the criteria for exemption from the Ambulance Fee Schedule” • Cost Report Worksheet S-2, Line 30.03: If this facility qualifies as a CAH is it eligible for cost reimbursement for ambulance services (12/21/00s). Enter a “Y” for yes or a “N” for no. If yes, enter in column 2 the date eligibility determination was issued. (See 42 CFR 413.70(b)(5))

29. CAH Ambulance Analysis The two items, condition code B2 on the claims and a “Y” on the cost report, should be in sync with each other. Either they should both be used or No condition code B2 should be used on the claim and an “N” should be entered on the cost report. Both are used to indicate eligibility or non-eligibility for cost reimbursement based on the 35-mile driving distance requirement.

30. CAH Ambulance Analysis Vulnerabilities – where the 35-mile criteria is NOT met • Vulnerability #1 – CAH billing with condition code B2 on its claims and a “Y” on Line 30.03 of the cost report • Vulnerability #2 – CAH billing with condition code B2 on its claims and an “N” on Line 30.03 of the cost report • Vulnerability #3 – CAH billing without condition code B2 on its claims but using a “Y” on Line 30.03 of the cost report • Effect of Condition Code B2 on Beneficiary Co-Pay

31. CAH Ambulance Analysis Data Analysis • Part A Claims Data • Find all CAHs billing for ambulance service • Determine which are billing with condition code B2 • Part A Cost Report Data • Find which providers of ambulance service are entering a “Y” on Line 30.03 of Worksheet S2 • Part B Ambulance Claims Data and Provider Data • Find active providers of ambulance service • Determine physical location (data system, MCS, phone calls) • Need to know where the Part B provider “parks” its ambulance vehicles

32. CAH Ambulance Analysis Detective Work • Compare Part B Ambulance locations with CAH locations billing ambulance on a cost reimbursement basis (either condition code B2 OR “Y” on the cost report) • Use longitude and latitude • Use program to determine distance from center of one zip to center of another zip code • Printed maps • On line mapping programs, e.g., Mapquest • Check mileage using odometer • Don’t forget to compare a CAH to other CAHS in the vicinity which also bill for ambulance

33. CAH Ambulance Analysis • Findings – Washington and Oregon • Hospital A billed with a “Y” on the cost report and no condition code B2. It was NOT eligible for cost reimbursement. Total overpayment for four years = $406,402. • Hospital B billed with a “Y” on the cost report and condition code B2. It was NOT eligible for cost reimbursement. Total overpayment for two years = $157,812. • Hospital C billed with an “N” on the cost report but used condition code B2 on its claims. Cost report handled correctly but beneficiary copays were too high. Provider has been asked to submit claim adjustments. • Hospital D billed with a “Y” on the cost report and condition code B2. It does not appear to be eligible for cost reimbursement. In process of referral or cost report adjustment or both. Also seeking CMS clarification. • Hospital E billed with a “Y” on the cost report and condition code B2. Situation referred to CMS

35. CAH Ambulance Analysis • Outcome to Date – two states • Cost Report Adjustments by the FI for two providers • One provider adjusting all claims • Clarification being sought from CMS (now at the Rural Health Council, CMS Central Office) • One provider (Hospital D) may be either a referral or cost report adjustment or both • Vulnerability Report submitted to CMS • CAH Ambulance providers in other WIC states being reviewed

36. Financial Analysis • Bad debt process for analysis • Facilities identified for further investigation

37. Financial Analysis • The objective of financial analysis is to examine and develop relationships between assets, expenses, bad debt and • Medicare costs that are “normally” true in hospital cost reports. Once these patterns are developed then “outliers” can be identified and investigated. Several “outliers” are identified for further investigation.

38. Financial Methodology Hypothesis:Medicare Bad Debt is positively correlated with Medicare Inpatient Days r= 0.287 P-Value = 0.000

39. Financial Methodology Hypothesis:Total Medicare Bad Debt is positively correlated with Medicare Cost. High bad debt and lower cost is not the usual pattern. r = 0.469 P-Value = 0.000

40. Financial Methodology Hypothesis:Total Medicare Bad Debt is positively correlated with facility size. High bad debt and lower facility size is not the usual pattern. r = 0.157 P-Value = 0.001

41. Financial Methodology Hypothesis:Rapid expansion may involve construction kickbacks

42. Hospital Cost Report Data – Summary • Can compare cost reports across provider, line by line, year by year • FIs or MACs usually do not have this capability • Outliers can be identified • Significant changes from one year to the next can be observed • Opportunity to work with Audit staff at FI or MAC • Ask about suspicious trends • Request at least one full hard-copy cost report to verify download accuracy • ZPICs • Will have more emphasis on cost reports

43. Contact Information Marcus Israel, PMP, MHSA WIC Operations Manager 443.436.6651 israelm@admedcorp.com Greg Dobbins, PhD WIC Senior Scientist 410.763.6293 dobbinsg@dfmc.org Jane Grover WIC Investigator/Data Analyst 425.357.8874 jgrover2@csc.com

44. References • http://www.cms.hhs.gov/CostReports/

45. References • http://www.costreportdata.com

46. References • http://www.resdac.umn.edu/