Category: IP CAH

From: CMS FY 2015 Final Rules Table – 11/19/14

AHA News

The Centers for Medicare & Medicaid Services has released a list of critical access hospitals in counties that lost their rural status and became classified as urban as of Oct. 1, 2014. To maintain their CAH status, these hospitals must apply for reclassification as rural through one of two channels by Sept. 30, 2016. The first is by determination of a Rural-Urban Commuting Area Code of 4 or larger. The second is by mandate from either state law or regulation that defines the hospital as rural. Documentation should be sent in a letter from the CEO to the CMS regional office. The regional office will review it and send a notice within 60 days that the reclassification is effective as of their application date. This process is not to be confused with wage index requests, which should be submitted to the Medicare geographic reclassification review board for processing. CMS will discuss the redesignation process during its Rural Open Door Forum tomorrow, Nov. 20 at 2 p.m. ET.

Critical Access Hospitals Located in Counties That Will Lose Rural Status and Become Urban FY 2015

From: Office of Inspector General – 10/7/14

OIG Summary:

WHY WE DID THIS STUDY 

The Critical Access Hospital (CAH) certification was created to ensure that rural beneficiaries would have access to hospital services. Medicare reimburses CAHs at 101 percent of their “reasonable costs,” rather than at the predetermined rates set by the Outpatient Prospective Payment System (OPPS). The system that Medicare uses to calculate outpatient coinsurance amounts for beneficiaries who receive services at CAHs differs from that used for beneficiaries who receive services at acute care hospitals. Beneficiaries who receive services at CAHs pay coinsurance amounts based on CAH charges, whereas beneficiaries who receive services at acute care hospitals pay coinsurance amounts based on OPPS rates. CAH charges are typically higher than the reasonable costs associated with CAH services or the OPPS rates that acute-care hospitals receive.

HOW WE DID THIS STUDY

We used 2009 and 2012 claims data to calculate the percentages and amounts of coinsurance that Medicare beneficiaries paid toward the costs for outpatient services at CAHs. Additionally, we calculated the percentages and amounts of coinsurance that beneficiaries would have paid at acute-care hospitals for 10 outpatient services that were frequently provided at CAHs.

WHAT WE FOUND

Because coinsurance amounts were based on charges, Medicare beneficiaries paid nearly half the costs for outpatient services at CAHs. In 2012, beneficiaries paid approximately $1.5 billion of the estimated $3.2 billion cost for CAH outpatient services. Additionally, the average percentage of costs that beneficiaries paid in coinsurance for these services increased 2 percentage points between 2009 and 2012. Finally, for 10 frequently provided outpatient services at CAHs, beneficiaries paid between 2 and 6 times the amount in coinsurance that they would have for the same services at acute-care hospitals.

WHAT WE RECOMMEND 

Because coinsurance amounts were based on charges, Medicare beneficiaries paid a higher percentage of the costs in coinsurance for outpatient services received at CAHs than they would have paid at hospitals under OPPS. Further, the percentage of costs that Medicare beneficiaries paid in coinsurance for outpatient services at CAHs has increased in recent years. To reduce the percentage of costs that Medicare beneficiaries pay in coinsurance, we recommend that the Centers for Medicare & Medicaid Services (CMS) seek legislative authority to modify how coinsurance is calculated for outpatient services received at CAHs. Some ways in which CMS could modify how coinsurance is calculated for such services include (1) computing coinsurance so that it is based on interim payment rates rather than charges and (2) processing claims for outpatient services at CAHs as if they were paid under OPPS for the purpose of calculating an OPPS equivalent coinsurance. CMS responded to the report, but neither concurred nor nonconcurred with our recommendation

Read more:

Medicare Beneficiaries Paid Nearly Half of the Costs for Outpatient Services at CAHs

From: MLN Matters Article MM8708 – 5/2/14

Provider Action Needed

This article is based on Change Request (CR) 8708, which clarifies the payment for reasonable and necessary medical or surgical services performed by an anesthesiologist or CRNA in a method II Critical Access Hospital (CAH). Make sure your billing staffs are aware of this clarification.

Anesthesiologist/CRNA Related Services in a Method II CAH