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FI Support for Medicare-Like Rates

FI Support for Medicare-Like Rates. Topics for FI discussion. Overview of system changes Discontinuation of pre-pricing Critical Access reimbursement Letter sent to providers from FI Pass Thru Rate / No Settlement DRG Disclosure Report Pends/Message codes pertinent to MLR EOBR examples

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FI Support for Medicare-Like Rates

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  1. FI Support for Medicare-Like Rates

  2. Topics for FI discussion • Overview of system changes • Discontinuation of pre-pricing • Critical Access reimbursement • Letter sent to providers from FI • Pass Thru Rate / No Settlement • DRG Disclosure Report • Pends/Message codes pertinent to MLR • EOBR examples • “Better than” Medicare-Like Rates • Question & Answer

  3. FI System Changes • No requirement for contracts for MLR pricing. • Suffixes no longer used to point to a pricing methodology. • Claims paying per MLR will not pend for signature authority • Programming done for other PPS methodologies (Psych, Rehab, LTC, SNF, Home Health, Hospice, APC)

  4. Future FI programming To accommodate the regulation the FI is currently programming for the following: • Rural hospital demonstration project per section 410 of the Medicare Modernization Act • Children’s Hospitals and Cancer Centers • Timely filing

  5. Discontinuation of Pre-Pricing In the past the FI has, on occasion, assisted an Area or Service Unit by pre-pricing a claim to help obligate a Purchase Order or negotiate a rate with an open market provider. • With the large number of providers now paid at PPS rates, the FI is not staffed to continue pre-pricing claims. • Online pricers are available to Service Units. • The FI does not have a tool to pre-price APCs.

  6. Critical Access Reimbursement • Per Diems are calculated using the latest settled cost report. • If there isn’t a settled cost report then the “as filed” report will be used. • If there hasn’t been a cost report filed, the Medicare FI will be contacted for the providers rate. • No method 2 reimbursement related to the physician component.

  7. Provider Letter from FI • Sent July 11th to providers that will be reimbursed under MLR • Billing instructions provided for IHS/CHS facility claims • UB04 required for DOS on or after July 5, 2007. • 6 digit legacy number required in form locator 57 • EMC providers to continue use of the 837-I format which now requires the NPI. • Taxonomy code required for inpatient services. • Questions regarding billing should be directed to IHS/CHS FI Customer Service.

  8. Pass Thru Rate / No Settlements • Regulation requires the FI to use the “interim rate” from the provider specific file as the pass thru reimbursement. This is paid per day. • Prior to MLR, the pass thru was calculated using settled cost reports and was paid per discharge. • Unlike Medicare, the IHS/CHS program will not pay retrospective payments after the cost reports are settled.

  9. DRG Disclosure Report • DRG disclosure reports will now be available for all hospitals receiving DRG reimbursement. Prior to MLR, this report was only for DRG contracted providers. • Updated reports will be available at least twice a year -after the annual DRG pricer load and/or provider specific file (PSF) loads. • A special run for the DRG disclosure reports will be available in August for all hospitals receiving DRG reimbursement. • Reports are available on the Report Retrieval System. Website address is https://mychsfi-reports.documentportal.com. Access must be approved by Area or Tribal CHSO.

  10. New DRG Disclosure Report Header Pass Thru Per Day will show for MLR Pricing Contract No. will show for Better than MLR Contracts Pass Thru/Settled will show for Better than MLR Contracts

  11. Pends/Message Codes Pertinent to MLR • FI internal pends may increase while the providers get used to billing IHS/CHS claims in the Medicare format. • Areas and/or Service Unit pends will not change. • New provider pends may appear on the pend reports. P12G relates to APC pricing and P13G relates to Taxonomy codes. • New message codes for EOBRs and DORs - M009 or M506 which indicates payments are being made per MLR regulation.

  12. EOBR Change Example With MLR Pricing Contract No. shows MLR

  13. EOBR Change Example Cont’d Message code M506

  14. “Better Than” Medicare Like Rates • The regulation specifies that “better than” MLR contracts may be negotiated. • The FI is currently testing two basic methods for each PPS methodology. • Lesser of billed or Medicare • Percent of Medicare (less than 100%) • Percentage of billed charge is not always better than Medicare and is not supported as a “better than” MLR contract provision.

  15. Question and Answer Rhonda Nichols Inge Zamora Manager, Manager, Systems & Reporting Prov Database & Reimb

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