medicare ehr payment & medicare advantage patient days
TRANSCRIPT
Medicare EHR/ Meaningful Use &
Medicare AdvantageBe sure you receive your full payment
What is Medicare EHR/Meaningful Use• A program that provides financial incentives to eligible acute
care hospitals that are meaningful users of certified Electronic Health Records (EHR) technology.
• The Centers for Medicare & Medicaid Services (CMS) were authorized by the American Recovery and Reinvestment Act of 2009 to provide incentive payments to eligible professionals and hospitals that adopt, implement, upgrade, or demonstrate meaningful use of certified EHR technology.
• Eligible hospitals must adopt, implement or upgrade to certified EHR
Medicare EHR/Meaningful Use• Eligible Hospitals could begin receiving Medicare
EHR incentive payments in any year from 2011 to 2015
• Incentive payments for hospitals will be reduced to those that begin receiving payments after 2013
• Hospitals that are not meaningful users of certified EHR technology as of October 1, 2015 will begin to have their payment reduced
HOSPITALS THAT ARE NOT
MEANINGFUL USERS OF
CERTIFIED EHR TECHNOLOGY
AS OF OCTOBER 1, 2015 WILL BEGIN TO HAVE THEIR
PAYMENT REDUCED
Medicare Advantage
• Medicare Advantage claims are submitted to the Medicare Advantage plan carrier for payment
• CMS requires that a separate “no pay” (aka “shadow bill”) be sent to Medicare via the hospital’s Medicare Administrative Contractor (MAC) to receive additional payments (i.e. IME, GME and NAHE) and record utilization data
• Medicare Advantage data will appear on the PS&R report as type 118
Medicare Advantage & Medicare EHR• All hospitals, teaching and non-teaching, should have a thorough
process in place to identify patients registered under a Medicare Advantage plan and to ensure the “no pay” claims are submitted to CMS
• Medicare Advantage patient days are included in the Medicare Share calculation of the Medicare EHR incentive payment calculations
How Problems Can Occur• Many hospital billing systems are setup to
automatically trigger a shadow bill when the patient is recognized as a Medicare Advantage patient at registration.
• When the Medicare Advantage plan is not recognized, the patient’s Medicare HIC may not be collected.
• The HIC number can often be difficult to track down later and the potential underpayments are significant.
THE MEDICARE HIC IS REQUIRED FOR
SUBMISSION OF THE
SHADOW BILL
Example “No Pay” claim issuePatient is a member of an Aetna Medicare HMO plan
Patient arrives at the hospital and is mistakenly registered under a different Aetna plan
“No pay” bill is not triggered in billing system
Bill is sent to registered Aetna plan and is denied
Main claim is resubmitted manually to the correct Aetna Medicare HMO plan
“No pay” bill falls through the cracks
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Additional benefits of capturing Medicare utilization
• Beyond the benefits of proper reimbursement, correctly capturing Medicare utilization days have added benefits:• Higher GME and Nursing Allied Health (NAHE)
reimbursement at the time of Medicare cost report settlement
• Additional Medicare beneficiary days used in the DSH calculation for both teaching and non-teaching facilities
• Higher Medicare share for Medicare EHR incentive payments
Timely Filing Issues• “No pay” bills are subject to timely filing deadlines
• The timely filing limit for “no pay” claims is 12 months
THE TIMELY FILING
LIMIT FOR “NO PAY” CLAIMS IS 12 MONTHS
Medicare EHR Incentive Payment Calculation and the impact of Additional Medicare Advantage Patient DaysHospital A
Total Discharges for 2014 = 7,500
Total Inpatient Part A Days for 2014 = 10,200
Total Inpatient Part C Days (Medicare Advantage Days) for 2014 = 2,250
Total Bed Days for 2014 = 36,500
Charity Care Charges for 2014 = $5,000,000
Total Charges for 2014 = $625,000,000
Hospital A began receiving Medicare EHR Incentive Payments in 2014
Medicare EHR Incentive Payment Calculation and the impact of Additional Medicare Advantage Patient Days
Hospital A 2014 Incentive Payment Calculation
Hospital A 2014 Incentive Payment Calculation with an
Increase of 250 Inpatient Part C Days
Base Payment $2,000,000 $2,000,000Additional Per Discharge Payment $1,270,200 $1,270,200Total Initial Payment $3,270,200 $3,270,200
Inpatient Part A Days 10,200 10,200Inpatient Part C Days 2,250 2,500Total Medicare Days 12,450 12,700
Total Bed Days 36,500 36,000Total Charges Excl. Charity/Total Charges
0.99 0.99
Medicare Share .3438 .3508
Medicare Share of Initial Payment $1,124,447 $1,147,027
Transition Factor for FY 2014 .75 .75
Total Medicare Incentive Payment for 2014$843,336 $860,270
Impact of Increasing Inpatient Part C Days by 250 patient days
$16,934
Payment Increase per day $67.74
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