FQHC Cost Reporting

1. FQHC Cost Reporting CEO and CFO working together June 22, 2012

2. Who do we have in the room? CFOs and Accountants CEOs, COOs, and non-accountant types

3. Non-accountants Gap is a store, not generally accepted accounting principles (GAAP). Fast bees are something to avoid, not the Financial Accounting Standards Board (FASB)

4. CEOs: What happens when you hear… • The cost report is due • Our cost rate has gone down • We owe Medicare or Medicaid • Other concerns??

5. CFOs: Once every year cost report • The time for the annual cost reporting exercise arrives, what thoughts start to crowd your mind? • New accounting staff or managers have not coded transactions appropriately • Trial balance from the auditors is still not ready • What else….. • Remember even if you have been a CFO for 20 years, that is only 20 cost reports. Unlike financial statement preparation at once per month for 20 years or 240 chances to get it right.

6. Goal of cost reporting: To align payments with reasonably efficient FQHCs’ costs of furnishing care, thereby helping to ensure beneficiaries’ access to high-quality services. Cost report is to accurately reflect the costs to provide FQHC-covered services to Medicare and Medicaid beneficiaries.

7. Where Are We Going Today? • Why it matters to have it right? (Hint: ACA 2014) • The gut check: a quick formula • Learning how to count visits & FTE • “Book ‘em, Danno” – your accounting staff’s coding behavior is very important • HR plays a part in cost reporting. No, they really do. • The Biggest Mistakes & Growing a backbone • How can the visionary CEO help the down-to-earth CFO with cost report and operational analysis?

8. Your Future, Your Cost Report Thanks to the Affordable Care Act: Medicare is going PPS In 2011 FQHCs have been transmitting Medicare claims with CPT/HCPCSdetail Probably 2013-14 year will be the base year for Medicare PPS calculation

9. Baby Boomers & FQHCs • The Medicare program generally the second best payer after state Medicaid • Payer mix goal for community health centers • Growing percentage of Medicare beneficiaries served as population ages. • If Medicaid is block granted, Medicare may become the BEST payer

10. Projections What percent of your current patients are Medicaid or dual eligible? In 5 years you project X? 10 years?

11. The formula Costs/Visits (Costs divided by visits)

12. Homework • Take one month of medical expenses and divide by the medical provider visits for the month • Back out your dental, pharmacy and other non-primary medical care expenses • 2012 Medicare Ceilings: • Urban: $ 126.98 • Rural: $109.90 • Where are you compared to these limits? If you are more efficient and doing for less, great, but most of are struggling to keep our heads above water with costs at and above $150 per visit. • My story: $54 per visit

13. This is simple division. Right? NO!! Determining allowable DIRECT costs takes the entire leadership and management team (as well as staff) Counting visits is never straightforward

14. Visits • Problems: • Many practice management systems count visits from the appointment table, not the charge table • Canned reports from the vendors are RARELY accurate, usually over counting visits, inflating encounters(Misys and HC) • IT staff writing visit reports usually do NOT understand the definition of a FQHC visit.

15. Too Many Visits – is that a problem? UDS Visits are NOT Medicare/Medicaid FQHC visits Medicare Visit: Face-to-face encounter between the patient and a physician, physician assistant, nurse practitioner, certified nurse midwife, visiting nurse, clinical psychologist or clinical social worker during which an FQHC service is rendered. Only one visit per day (An exception: patient suffers an illness/injury subsequent to the first encounter requires additional diagnosis/treatment.)

16. Visits NEVER accept the first report or analysis as definitive. Run detail reports and analyze it

17. How to Count (1 of 3) • Generate a report from the CLAIMS system (not the appointment system) with the following fields: • Patient name, • Patient account, • Date of service, • Insurance, • Claim id (unique to each claim), • CPT code • Run a frequency distribution by CPT code • Analyze which CPT codes are being billed.

18. How to Count (2 of 3) • Determine which CPT codes are FQHC visits and which are not. • Most E/M codes are FQHC visits, except for nursing visits (99211) • Venipunctures and Urinalysis are not. • Flag the CPT codes that are FQHC visits Who is best equipped to do this analysis? • Not necessarily the CFO. It might be better to have a provider work with finance staff.

20. How to Count (3 of 3) • Using a relational database, link the CPT code table with the claim detail table • Remove duplicate entries so that for each date of service one, and only one, claim exist for each patient.

22. CEOs listen up • Give your CFOs and Medical Directors what they need for financial and clinical analysis: • Analytics • You need one person who is proficient with relational databases. • The power of the “what if” analysis

24. Sidebar: Productivity Screens • It is important for providers to accurately track their time because it WILL affect the cost report. • FTEs are an important part of the cost report. • If you over count FTEs you may be “dinged” for not meeting productivity floors. • UDS FTEs are NOT Medicare/Medicaid FQHC FTEs • Again – providers, HR and accounting staff must make sure that there is an accurate record of provider time.

25. The number of full time equivalent employees (FTE) of each type (i.e., physician, physician assistant, or nurse practitioner) is determined by the following formula. • Divide the total number of hours per year worked by all employees of that type by the greater of: • The number of hours per year for which one employee of that type must be compensated to meet the clinic/center’s definition of an FTE. (If the clinic/center is open on a full time basis, the usual definition of an FTE is 2,080 hours per year, 40 hours per week for 52 weeks); or • 1,600 hours per year (40 hours per week for 40 weeks).

26. Medicare guidelines state that a provider’s FTE must be reduced by all administrative and non-worked days (vacation, sick, personal, etc.) for reporting purposes. • Vacation hours • Sick hours • Holiday hours • CME hours • Administrative Duties • Total Non-Work Hours

27. Booking: Accounting Staff • Cost report is affected by how transactions are coded by staff/management and booked in the accounting system • FQHC costs are one of three: • Direct Medical • Overhead • Non-Covered Services

28. Direct costs: • salary and benefits for medical and behavioral health providers, • medical supplies, etc. • Overhead: • administrative salaries, • utilities, • Non-covered costs: • marketing, • laboratory, etc.

29. Why does it matter which cost? • If costs are in the Direct Medical Cost classification, every penny spent is captured • Overhead/Administrative costs are allocated over the Direct Medical Costs and the Non-Covered Costs • As such, if you misclassify a Direct Medical Cost as administrative costs, a portion of the costs will not be captured in the FQHC cost rate • Accurate coding in accounting is FUNDAMENTAL

30. But it is not so clear cut… • Electronic medical/health records: • NGS and Palmetto try to classify as administrative overhead • Patient education materials • Electronic access to HealthWise • Diabetes, Hypertension paper handouts • Staff • Triage nurses working at the call center • Medication assistance staff • Intake staff when part of the job is preventive health screening

31. Accounting and Coding • The CEO and Medical Director authorize the mass production of 30,000 full-color hypertension education handouts • Accounting receives the invoice from the print company and codes it as follows: • G/L: Printing Supplies • Dept: Medical • When the trial balance is sent to the intermediary this expense will be re-classed as administrative. • OUCH!!

32. Other examples from the audience?

33. Human Resources • Job Descriptions are important • For positions where job crosses two cost centers (Direct Medical and Administrative costs) • Intake staff who do PHQs • Do time studies to justify % Direct Medical and % Administrative

34. Growing a backbone • Question intermediary disallowances and adjustments • Do not accept. Just because the auditor disallows/reclasses it does not mean that should be. • Examples: • Changing depreciation basis • Requesting copies of BPHCCHC grant and NGAs • Medical nutrition, social services • Question assumptions • Medicaid story: CFO and CEO working together

35. Know how to argue with the rules Read Cost Principles & Medicare FQHC: https://www.cms.gov/Center/Provider-Type/Federally-Qualified-Health-Centers-FQHC-Center.html?redirect=/center/fqhc.asp

36. Top Ten Mistakes (Source: BKD, LLP - CPA) No reclassifications and/or adjustments reported to align costs properly Not properly listing clinic locations which may affect per-visit payment limit(s) No tracking & reporting of influenza & pneumococcal vaccines and/or other Part B billing issues No reporting of Medicare bad debts - reclaim it, but prove you tried to collect

37. Lack of review of intermediary proposed adjustments during settlement process FQHC provider number issues No reconciliation of expenses reported on cost report with total expenses per the audited financial statements

38. Not reporting expenses correctly in the proper “buckets” Incorrect computation of FTEs & related productivity standard Inaccurate reporting of visits

39. General rules of thumb UDS full-time equivalency (FTE) on Table 5 are almost always higher than Medicare and Medicaid FTE UDS Provider Visits on Table 5 are usually higher than FQHC visits Always question visits – never accept the first pass. Costs – ask questions about coding of expenses Give your finance and clinical staff a database expert Grow a backbone – question the intermediary’s determination.

40. Questions? Resources? Brian O. Harris brian.harris@rhgnc.org 252-536-5796