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FFY2021 Medicare IPPS Proposed Rule & Other Recently Published Rules

IPPS Proposed Rule – FFY2021

CMS-1735-P drafted on 5/11/2020; Published in the Federal Register on 5/29/2020

On May 11, 2020, the Centers for Medicare & Medicaid Services (CMS) proposed a rule that focuses the agency’s efforts on a singular objective:  transforming the healthcare delivery system through competition and innovation to provide patients with better value and results.  The proposed rule updates Medicare payment policies and rates for hospitals under the Inpatient Prospective Payment System (IPPS) and the Long-Term Care Hospital (LTCH) Prospective Payment System (PPS), effective for discharges on or after October 1, 2020.

The policies in the IPPS and LTCH PPS proposed rule would bring significant changes to MS-DRG weights, along with associated cost report changes, as well as tightening of Medicare bad debt policies, standardization of data collection periods for quality programs, and easing of GME program closure policies.

Overall, the proposed rule is projected to result in an estimated increase of $2.0B (or 1.6%) in payments to providers, with smaller increases for urban, Medicare-dependent hospitals and larger increases for Mid-Atlantic and Pacific region hospitals.

Comments must be sent to CMS no later than 5pm EDT on July 10, 2010 at the applicable address provided in each section of the Proposed Rule or submitted electronically at http://www.regulations.gov.  When commenting, please refer to file code CMS-1735-P.


Medicare IPPS Base Rates

CMS is proposing a base rate increase of 3.2% for hospitals, mostly driven by a market basket increase of 3.0% and the reversal of the MACRA coding adjustment of 0.5%.  A new budget-neutrality factor adjustment was introduced this year to account for the change in Allogeneic Stem Cell Acquisition reimbursement to cost-based.

Click here for the full base rate calculation table and comparison to prior year.


MS-DRG v38 Changes

CMS has proposed their annual recalibration of the MS-DRG weights for FFY2021.  Transplants and one extensive burn DRG (927) have once again received the largest increases, while other heart assist devices and intracranial vascular procedures with hemorrhages have experienced significant reductions in weighting.  A listing of the largest changes in weighting between MS-DRGs v37 and v38 are noted below:

Click here for a table of the MS-DRG v37 to v38 comparison.

In addition, CMS has proposed the following new DRGs for FFY2021, some of which were further subdivisions of previous DRGs:

Note:  New MS-DRGs 521 and 522 will both be subject to the special transfer payment adjustment.

The proposed fixed-loss outlier threshold for FFY2021 is $30,006.


Proposed Market-Based MS-DRG Weights Beginning in FFY2024

In an effort to reduce the cost of healthcare, CMS has proposed a radical shift in how it hopes to compute the weighting for MS-DRGs in FFY2024 and beyond.  CMS believes that by moving from the cost-based DRG weight methodology that was introduced in FFY2007 to the proposed weighting methodology that would reflect the relative market value for inpatient services, it can reduce its reliance on hospital chargemasters for determining DRG reimbursement.

Building on the Hospital Price Transparency Rule (84 FR 65538, 11/27/2019), CMS believes that hospitals will be able to calculate median payer-specific negotiated charges for each MS-DRG, as they will already be required to gather and publish much of this data.  CMS recognizes that this cost report data would become publicly accessible, but because only the de-identified median values would be reported, any proprietary information would not be exposed.

CMS has proposed to begin gathering this data from hospitals by making changes to the Medicare cost report forms for cost reporting periods ending on or after January 1, 2021.  Hospitals will be required to tabulate and report for each MS-DRG the median payer-specific negotiated charges for all Medicare Advantage payers and for all combined third-party payers.  The required cost reporting changes will be proposed in more detail in the Information Collection Request approved under OMB No. 0938-0050.

CMS is seeking comment on this proposed weighting change and its relative burden of calculating, as well as other issues that may address payers that don’t pay under MS-DRGs and whether or not a transition period to these new market-based MS-DRGs should be provided.  Hospitals that do not negotiate payment rates, such as federally-owned facilities, Indian Health Service facilities, Critical Access Hospitals (CAHs), and hospitals located in Maryland, would be exempted from this proposed data collection.


Cost-based Reimbursement for Allogeneic Hematopoietic Stem Cell Acquisition Costs

CMS is proposing to begin reimbursing on a reasonable cost basis the acquisition costs associated with allogeneic hematopoietic stem cell transplants (i.e., when stem cells are obtained from a donor rather than the recipient).  Currently, these costs are included within the MD-DRG payment.  The proposed cost reimbursement will be similar to the methodology in which the acquisition costs for solid organs are reimbursed.  Providers will be billed and paid for these costs on an interim payment basis as a “pass-through” item.

Effective for cost reporting periods beginning on or after October 1, 2020, hospitals that provide these services will need to begin following these procedures:

  1. Gather and report acquisition costs on Line 77 of the Medicare cost report
    • (Note: This has been a requirement for services rendered on or after January 1, 2017.)
    • Acquisition costs include registry fees, tissue typing, donor evaluation, costs associated with the collection procedure, post-procedure evaluation of the donor, and the preparation and processing of stem cells
    • Overhead allocations associated with these costs will also be allowed. CMS is developing a worksheet similar to Worksheet D-4 to allow providers to capture these costs, as well as to report charges by routine and ancillary cost centers.
  2. Formulate a standard acquisition charge, and include this charge on the inpatient hospital bill for the MS-DRG using Revenue Code 815
  3. Tabulate the hospital’s Medicare share of costs by developing a ratio of the number of allogeneic hematopoietic stem cell transplants furnished to Medicare beneficiaries to the total number of those same procedures furnished to all patients

Toyon’s Take:  Because these amounts will now be reimbursed on a reasonable cost basis, it is important that hospitals verify that they are properly capturing all of these costs and statistics in order to ensure adequate reimbursement. 

For additional information or assistance with calculating these amounts, please contact Robert Howey at robert.howey@toyonassociates.com.


Clarification of Long-Standing Medicare Bad Debt Policies

In an effort to clarify the rules related to the demonstration of a reasonable collection effort, CMS is clarifying the policies related to claiming Medicare Bad Debts:

  • Similar Collection Efforts: CMS is stressing that the reasonable collection effort required for a non-indigent Medicare beneficiary must be similar to the effort made by the provider and/or collection agency acting on the provider’s behalf, puts forth to collect comparable amounts from non-Medicare patients.  The hospital needs to have a consistent collection policy for all payers.  Hospitals should be prepared for the MAC to sample and review both Medicare and non-Medicare patients during audits.
  • Timely Beneficiary Bills: A provider must issue a bill to the beneficiary or party responsible for the beneficiary’s personal financial obligations on or before 120 days after
    1. The date of the Medicare remittance advice; OR
    2. The date of the remittance advice from the beneficiary’s secondary payer, if any, whichever is latest

(Note:  Reasonable collection efforts include subsequent billings, collection letters and telephone calls, or personal contacts constituting a genuine collection effort.)

  • Determining Uncollectibility: A provider must make reasonable and customary attempts to collect a bill for at least 120 days from (and including) the date the first bill is mailed to the beneficiary.  If the debt remains unpaid on the 121st day from the date the first bill is mailed, the provider can cease collection efforts and write off the unpaid balance.  If a partial payment is received within the 120-day collection effort period, the 120-day time period resets on the date the partial payment is received.  The hospital must continue to bill the beneficiary for 120 days.
  • QMB Liability: For Qualified Medicare Beneficiaries (QMB), the State Medicaid program must be billed.  If the State does not provide a Medicaid RA, CMS is considering adopting a policy that the provider could obtain and submit to its MAC some form of alternative documentation to evidence a State’s Medicare cost-sharing liability (or absence thereof).  CMS welcomes suggestions from stakeholders regarding the best alternative documentation to the Medicaid RA that a provider could obtain and submit.
  • Write-Off Procedures: All Medicare bad debt, including Medicare/Medicaid crossover claims, must not be written off to a contractual allowance account but must be charged to an expense account for uncollectible accounts (e.g., bad debt or implicit price concession).  This would be effective for cost reports beginning on or after October 1, 2020.  CMS had previously stated that this would be effective for cost reports beginning on or after October 1, 2019, so it appears that providers will be granted additional time to implement these internal procedures.
  • Presumptive Charity: CMS is also proposing clarification to the definition of presumptive charity.  For a hospital to define an indigent non-dual eligible beneficiary, the provider must apply its customary methods under the following requirements:
    1. The beneficiary’s indigence must be determined by the provider;
    2. The provider must take into account a beneficiary’s total resources, which include but are not limited to, an analysis of assets (i.e., only those convertible to cash and unnecessary for daily living), liabilities, and income and expenses (Note: Extenuating circumstances affecting the determination of the beneficiary’s indigence must also be considered.); AND
    3. The provider must determine that no source other than the beneficiary would be legally responsible for the beneficiary’s medical bill (e.g., legal guardian).

Toyon’s Take: The provider must maintain and be ready to provide documentation describing the method by which indigence was determined.  Once indigence is determined and there has been no improvement in the beneficiary’s status, the bad debt may be deemed uncollectible without applying a collection effort.  Providers should review their Financial Assistance Policy, and if presumptive charity is being used as a method to determine indigence, we recommend sending a comment to ensure that CMS will allow this as a reasonable method in determining indigence.

For additional information, please contact Dylan Chinea at dylan.chinea@toyonassociates.com


Changes to Wage Index

Based on the CMS proposed changes for FFY2021, the occupational-mix adjusted national average hourly wage is estimated to be $45.07, representing an increase of 2.10% from the prior year.

CMS proposed and finalized a policy in FFY2020 to reduce wage index high-to-low disparities by increasing the values for low wage index hospitals below the 25th percentile (or a WIF of 0.8420 in FFY2021). In FFY2020, CMS anticipated that it would continue this policy for at least four years, acknowledging that providers in these lower-quartile states would improve employee compensation within four years as a result of the higher wage index. Accordingly, CMS is proposing to continue this policy in FFY2021. Consistent with the finalized policy in FFY2020, in FFY2021 CMS will “fund” this policy by applying a uniform budget neutrality adjustment. The proposed low wage index hospital policy budget neutrality factor is 0.998241 (compared to 0.997987 in FFY2020).

In FFY2020, CMS also proposed and finalized a change to the rural floor calculation by removing urban-to-rural reclassifications from the statewide rural floor. CMS is proposing to continue this policy in FFY2021 so that state rural floors would be calculated without including the wage data of urban hospitals that have reclassified as rural.

As a result of the policy changes noted above, CMS finalized a cap of 5% on the decrease of any hospital’s wage index from FFY2019 to FFY2020. While this cap was set to expire in FFY2020, CMS is proposing to continue to apply this cap in FFY2021 and apply a budget neutrality adjustment for this proposed transition policy in the same manner as FFY2020. The reason for the cap in FFY2021 is a result of the Office of Budget & Management (OMB) updates noted below.

CMS Proposed Changes to Core-Based Statistical Areas (CBSAs)

The wage index is calculated and assigned to hospitals on the basis of the labor market in which the hospital is located, based on OMB-established CBSAs. The current OMB delineations are based on OMB Bulletin No. 13-01 issued on February 28, 2013, which revised a number of CBSAs starting with FFY2015 due to changes in 2010 Census data. Normally, Census data only impacts CBSA delineations every 10 years; however, OMB Bulletin No. 18-04 issued on September 14, 2018, contained material changes to the OMB statistical area delineations. Specifically, under these revised OMB delineations, new CBSAs would be created, urban counties would become rural counties, rural continues would become urban counties, and some existing CBSAs would be split apart. In addition, the revised OMB delineations affect various hospital reclassifications, the out-migration adjustment (accounting for employee commuting patterns), and the treatment of hospitals located in certain rural counties known as “Lugar” hospitals.

CMS is proposing to incorporate the revised OMB delineations from OMB Bulletin No. 18-04 in FFY2021 to “increase the integrity of the IPPS wage index system by creating a more accurate representation of geographic variations in wage levels.”

The proposed changes to current CBSA designations due the revised OMB delineations include the following:

  1. Urban counties that would become rural
  2. Rural counties that would become urban
  3. Urban counties that would move to a different urban CBSA

Click here for tables listing the proposed changes to the counties noted in #1 – 3 above.

As mentioned above, and to mitigate any potential impact to a CBSA’s wage index due to the revised OMB delineations, CMS is proposing a transition policy to apply a 5% cap on any decrease to a hospital’s proposed FFY2021 wage index from the hospital’s final wage index from FFY2020. This policy would be made budget neutral consistent with the last fiscal period in which revised OMB delineations were applied (FFY2015). The proposed budget neutrality as a result of this transition policy is 0.998580.

Click here for a comparison of current and prior WIFs for each hospital, which includes the proposed transition policy cap of 5%.

Toyon’s Take:  The transition policy as proposed by CMS to apply the revised OMB delineations is appropriate and consistent with past year’s where CMS had to apply similar revisions to the CBSA designations. The impact to urban hospitals as a result of the revised OMB delineations is minimal with the exception of hospitals in the Northeast, primarily New York-New Jersey, as a number of counties were redefined to new CBSA designations and “moved out” of New York City which historically has produced a higher wage index for such hospitals. The impact to these hospitals specifically will be mitigated in FFY2021 as proposed due to the transition policy; however, beyond FFY2021 the impact could be significant. Hospitals in these areas need to pay close attention to their wage index filings and consider any reclassification opportunities, and also, if a hospital in these areas has an existing MGCRB reclassification, it should review the reassignment policy as proposed by CMS to ensure the hospital is reclassified to the expected geographic area.

Other Proposed Changes Impacting Wage Index

  • CMS acknowledges an increase in the number of wage index appeals relating to MACs’ disallowance of wages and hours that hospitals believe are associated with Part A administrative physician time but which the MACs believe are not properly documented as such, or are associated with Part B billable activities, which would not be allowable for wage index reporting.
    • While CMS does not propose any changes to how hospitals are to document Part A administrative physician time, it provides clarification and specific instructions as stated in the PRM.
  • CMS is proposing changes to existing regulations to allow MGCRB appeals to be submitted electronically, by fax, or by other electronic means.
  • Applications to the MGCRB for FFY2022 reclassifications, as well as cancellations and terminations, are due by September 3, 2020. All applications and supporting documents must be submitted via the Office of Hearings Case and Document Management System (OH CDMS) consistent with FFY2021 applications.
  • A new measurement of occupational mix is required for FFY2022. The Calendar Year (CY) 2019 Occupational Mix Survey was originally due July 1, 2020 via email attachment or overnight delivery to hospitals’ MACs; however, CMS is granting an extension until August 3, 2020 for hospitals nationwide. Refer to the final CY 2019 Occupational Mix Survey Hospital Reporting Form available on the CMS website at: https://www.cms.gov/medicaremedicare-fee-service-paymentacuteinpatientppswage-index-files/2019-occupational-mix-survey-hospital-reporting-form-cms-10079-wage-index-beginning-fy-2022

For additional information regarding wage index changes or updates, please contact Ryan Sader at ryan.sader@toyonassociates.com.


UC DSH Payments

CMS is proposing a decrease to Medicare UC DSH payments by $534M (or 6.4%), to $7.8B in FFY2021.  This decrease is driven by a $1.2B decrease in CMS’s estimation of national DSH payments for FFY2021, as compared to FFY2020.  National DSH payments are calculated under the former “empirical” method without accounting for changes from the ACA (i.e., Medicare UC DSH) in the determination of Factor 1 for UC DSH payments.

CMS has four significant proposals for UC DSH in FFY2021:

  • The most recent available single year of audited W/S S-10 will be used for Medicare DSH UC payments for all subsequent fiscal years. CMS proposed to add a new paragraph regarding this change under 42 CFR 412.106, “Special Treatment: Hospitals that serve a disproportionate share of low-income patients.”
  • Hospital UC DSH payments (Factor 3) are determined from one base-year of W/S S-10 UC costs from FFY2017 cost reports
  • To avoid the duplication of UC costs, hospitals acquired under a merger partway through the surviving hospital’s cost reporting period will not have their respective W/S S-10 UC cost data annualized
  • The trim methodology for all-inclusive rate providers (AIRP) will be modified. CMS proposes to recalculate UC costs for AIRPs, with UC costs greater than 50% of total operating costs, by applying a cost-to-charge ratio from the most recent available prior year cost report whereby UC costs are not greater than 50% of total operating costs.

Toyon is in the process of updating our national analysis to assist our clients with the evaluation of FFY2017 data used for FFY2021 UC DSH payments.  We will be providing this analysis over the coming weeks.

Toyon’s Take:  CMS’s projection of the uninsured population for Factor 2 includes insurance enrollment estimates through 2018.  Given the extraordinary events of COVID-19, projecting national uninsured rates may necessitate a more recent consideration of the timeliness of these estimates.

CMS’s proposal to use a single year of UC cost as the basis of UC DSH payments (Factor 3) is a significant change to the UC DSH reimbursement system.  Including this year’s audit of FFY2018 data (likely to be used for FFY2022 UC DSH payments), CMS and its MACs audited UC cost from W/S S-10 the last three years.

It is anticipated these audits will be an annual cycle of reported UC cost on the Medicare cost report.  The UC cost audits are also aligned when hospitals are preparing UC DSH listings on current year cost reports.  While annual audits are in place, Toyon recommends hospitals report current year UC DSH listings with the intent of amending these listings before or during the W/S S-10 audit. Moreover, from our work with MACs, it is Toyon’s understanding amended cost reports are NOT required to revise UC costs (rather this data is being documented independently resulting from the MAC audit schedules into the CMS HCRIS database).  

CMS’s use of FFY2017 data for FFY2021 payments also indicates the Agency’s decision to bypass the use of UC cost data from FFY2016.  As providers submit UC DSH listings for FFY2018 and subsequent years, Toyon recommends hospitals consider the appropriateness of reporting reversals related to FFY2016 UC cost write-offs.  In other words, it may not be appropriate to remove cost that CMS did not use in the development of UC DSH payments.

Click here for the DSH Supplemental PUF data.

Click here for the Analysis of UCC DSH Factor 1.

For additional information, please contact Fred Fisher at fred.fisher@toyonassociates.com.


High Percentage ESRD Discharge Hospitals

As noted previously, CMS proposed three new MS-DRGs for kidney transplant services with hemodialysis (MS-DRG 019, 650, and 651).  Accordingly, CMS has proposed to add these three MS-DRGs to the list of excluded MS-DRGs set forth in 42 CFR 412.104(a) when tabulating the additional payment for hospitals that have a higher percentage of Medicare ESRD beneficiaries.  In addition, CMS will be removing from the list of excluded MS-DRGs two DRGs that are no longer applicable.

An updated table of the excluded MS-DRGs is shown below:


Graduate Medical Education Changes for Residents in Closed Programs

To address concerns from stakeholders that their policy for allowing hospitals to seamlessly absorb displaced medical residents from closed programs is too restrictive, CMS is proposing to ease the current policy to match actual industry practice more closely.  The current CMS policy is that the definition of a displaced resident is one that is physically present at the hospital training on the day prior to or the day of the hospital or program closure.

In reality, residents begin their searches and programs begin accepting those residents soon after announcements are made that the hospital or program will be closing.  This allows residents to transfer to their new programs at a mutually convenient time with minimal disruption to their training.

CMS is proposing that the key day would now be the day that the closure was publicly announced (e.g., via a press release or formal notice to the ACGME), rather than the actual day of closure.  CMS is also proposing that the definition of a displaced resident be expanded to include individuals who have matched with the closed program but have not yet started training.  The revised definition of displaced residents is summarized in the table below:

These proposed changes would apply to the FTE cap transfer for displaced residents as well.  It is unclear when CMS intends this new policy to be effective, but presumably it would be effective immediately.

As an additional effort to reduce the amount of personally identifiable information (PII) in resident cap transfer agreements, CMS is also proposing to no longer require the full social security number of each resident but rather only the reporting of the last four digits.

For additional information, please contact Tom Hubner at tom.hubner@toyonassociates.com.


Rate Updates for Sole Community Hospitals (SCH) and Medicare-Dependent Hospitals (MDH)

CMS is proposing that the hospital-specific rates for SCHs and MDHs be updated by the following percentages, depending on the hospital’s ability to meet the different qualifying criteria:


Rural Referral Center (RRC) Annual Qualifying Data

Hospitals have different options to meet the RRC criteria set forth at 42 CFR 412.96.  For those that do not qualify under the 275-bed rule, other optional factors must be met.  Some of those factors are updated annually by CMS and include the following proposed amounts:


PRRB Procedural Flexibility

Since mid-2018, providers have been able to file appeal documents electronically with the Office of Hearings Case and Document Management System (OH CDMS).  Over 65 percent of all new appeals are now filed electronically, and CMS is proposing the following changes to enhance these numbers and reduce the administrative burden on the PRRB.

Proposed Changes:

  • “Date of Receipt” to be changed to mean date of electronic delivery for applicable documents
    • PRRB will continue to apply to receipts the presumed 5 days after the date of issuance
  • “In writing or written” defined to mean either hard copy or electronic submission
  • No earlier than FFY2021, the PRRB may update the Board instructions to require that all new submissions for new and pending appeals be filed electronically using OH CDMS
  • Subpoenas must now be sent via certified mail to ensure accordance with existing laws

For additional information, please contact Karen Kim at karen.kim@toyonassociates.com.


Changes to Quality Programs

While CMS is proposing several changes to the hospital quality reporting and payment programs, none of these changes represent significant structural or procedural changes to the programs.

Hospital Inpatient Quality Reporting (IQR)

CMS is proposing to progressively increase, over a 3-year period, the number of quarters for which hospitals are required to report eCQM data, from the current requirement of one self-selected quarter of data to four quarters of data.

In addition, CMS has proposed reducing the number of hospitals selected for validation from up to 800 to up to 400 hospitals.

Furthermore, CMS is proposing to require the use of electronic file submissions via a CMS-approved secure file transmission process for chart abstracted measure validation.  This proposal would nullify the existing submission of paper copies of medical records or copies on digital portable media, such as CDs, DVDs, or flash drives.

Hospital Value Based Purchasing (HVBP)

CMS is not proposing to add or remove any measures for the FY2023 and FY2024 program years. 

Hospital Readmission Reduction (HRR)

CMS is not proposing to remove or adopt any additional measures at this time.  However, in an effort to simplify rulemaking, CMS is proposing the automatic adoption of applicable periods beginning with the FFY2023 program year.  The period of data collection will become a rolling three-year period applicable to the FFY payments two years after the applicable period ends, as noted below:

Hospital Acquired Conditions (HAC)

Similar to the HRR program, CMS is proposing the automatic adoption of applicable periods beginning with the FFY2023 program year, as noted below:


Other Rules, Transmittals, and Articles Recently Published

Inpatient Psych Facility PPS FFY2021 Proposed Rule [CMS-1731-P]

(Display Copy available 4/10/2020; FR Publish Date 4/14/2020)

Fact Sheet Link

Federal Register Link

  • Per diem base rate increase from $798.55 to $817.59.
  • Will apply the most recent CBSA delineations and will have a 2-year transition for all providers negatively impacted by WIF changes.

 

Inpatient Rehab Facility PPS FFY2021 Proposed Rule [CMS-1729-P]

(Display Copy available 4/19/2020; FR Publish Date 4/21/2020)

Fact Sheet Link

Federal Register Link

  • Standard payment conversion factor increase from $16,489 to $16,847.
  • Will apply the most recent CBSA delineations and will have a 2-year transition for all providers negatively impacted by WIF changes.

Long-Term Care Hospital PPS Proposed Rule [CMS-1735-P]

(Display Copy available here 5/11/2020; FR Publish Date 5/29/2020) – Published as part of the IPPS Acute Care Hospital Proposed Rule

Fact Sheet Link

Federal Register Link

  • LTCH-PPS payments expected to increase by 0.9% or $36M.
  • Payments for cases that will complete the statutory transition to the lower payment rates under the dual rate system are expected to decrease by approximately 20%. This accounts for the LTCH site neutral payment rate cases that will no longer be paid a blended payment rate with the end of the statutory transition period, which represent 25% of all LTCH cases.

 

Skilled Nursing Facility FFY2021 PPS Proposed Rule [CMS-1737-P]

(Display Copy available 4/10/2020; FR Publish Date 4/15/2020)

Fact Sheet Link

Federal Register Link

  • Increase in unadjusted Federal per diem rates of 2.3%
  • Proposal to update the SNF VBP program and to change code mappings for case-mix groups

 

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FFY 2020 Medicare IPPS Final Rule – Correction Notice

CMS-1716-CN2 Published in the Federal Register on 10/8/2019
On October 8, 2019, the Centers for Medicare & Medicaid Services (CMS) issued a correction to the recent FFY2020 IPPS Final Rule in order to address errors in the V. 37 MS-DRG assignments and relative
weights. In addition, CMS is correcting technical errors in the calculation of Factor 3 of the Uncompensated Care DSH. These changes required a recalibration of the IPPS and LTCH PPS base rates, budget neutrality factors, final wage indices, and final outlier threshold, as well. As a result, CMS issued revisions to Tables 1-5, 7, and 18, as well as the DSH Supplemental File and the Impact File.

Because all the changes are effective for discharges on or after October 1, 2019, CMS will be holding IPPS and LTCH PPS claims with discharges on or after October 1 through October 21, 2019.

Overall, the corrected Final Rule is projected to result in an immaterial change in payments to providers from the original Final Rule. The Federal base rate is expected to decrease by 0.1% and the median change in UC DSH payments to most hospitals is favorable by 0.0819%. However, some
specific hospitals will see significant increases or decreases based on the adjustments made to the UCC costs by CMS and its contractors.

Medicare IPPS Base Rates 
CMS is increasing the base rate 2.7% for hospitals, mostly driven by a market basket increase of 3.0%.
 
FFY2020 Medicare IPPS Final Rule
MS-DRG v 37 Changes
As noted, CMS has revised the MS-DRG weights for FFY2020.
 
Click here for a table of the MS-DRG v36 to v37 comparison.

UC DSH Payments

CMS also revised the UC DSH Supplemental file and related Table 18 for Factor 3 values, in order to correct for hospitals where a MAC had accepted an amended report and/or adjusted cost report data but for which revisions had been inadvertently omitted from the HCRIS data used. UC DSH payments were materially corrected for nine California hospitals as a result of CMS agreeing to remove “expected payments” from the cost of charity care in FFY2015.
 
Toyon’s Take: Hospitals should continue to work with their MACs to ensure that the latest revised data has been incorporated into the HCRIS data used by CMS for the publication of any rules. We anticipate that FFY2017 data will be used next to establish the FFY2021 UC DSH payments. This data will be gathered from FYE 9/30/2017, 12/31/2017, 3/31/2018, or 6/30/2018 cost report Worksheet S-10.
 
For FFY2017 uncompensated care amounts, there is a new set of reporting instructions. There is considerable industry agreement that these instructions are less challenging than instructions in place for FFY2015.
 
Recommended Action: If your hospital has revisions to its FFY 2017 WS S-10 data, Toyon strongly urges that these revisions be submitted to your MAC before December 31, 2019. This is the deadline for MACs to submit FFY 2017 S-10 revisions for hospitals under audit.
 
Click here for the DSH Supplemental PUF data.
 
Toyon has a new national analysis tool to assist hospitals with the evaluation of uncompensated care and the relationship to current and projected DSH UC payments. For additional information, please contact Fred Fisher at fred.fisher@toyonassociates.com.
 
Rate Updates for Sole Community (SCH) and Medicare-Dependent Hospitals (MDH)
 
CMS did not revise the update factors for the hospital-specific rates of SCHs and MDHs noted below:  
 
FFY2020 Medicare IPPS Final Rule
 
However, you will need to be sure to apply the updated recalibrated budget neutrality adjustment factor of 0.996859 to your factor updates.
 
Other Updates
 
New Billing Requirements for Periodic Interim Payment (PIP) Providers
For those few hospitals that receive bi-weekly PIP payments, in lieu of operating IPPS DRG payments, CMS issued an update to Pub. 100-04, Chapter 1, Section 80.4. This revision, effective February 19, 2019, requires that providers bill timely and accurately.
 
In order to remain on PIP, providers must submit 85% of their bills timely and accurately. To meet this standard, bills must be submitted within 30 days of discharge and pass front-end edits for consistency and completeness. Evaluation by the MAC will occur in 4-month intervals for hospitals.
 
Note: If the provider does not meet these criteria, the MACs are instructed to discontinue PIP immediately.
 
Evaluation of the 30-day timeline will be based on the difference between the date on Form CMS-1450 FL6 (“Through Date”) and the date received by the MAC. A bill is not considered received unless it can pass MAC edits.
 
The evaluation of accurate bills excludes the following:
  • MSP cases
  • Special situations beyond the provider’s control that are documented by the MAC and approved by the RO
  • Bills that have not passed MAC front-end edits for acceptance. (Such bills are counted only when acceptable to the shared system edit processes.)
 
The tabulation of the error percentage is calculated in the following manner:
 
              Timely and Accurate %  =  Number of non-excluded bills received in 30 days or less
                                                                Total number of bills received
 
Toyon’s Take: MACs have started to send monthly “PIP Compliance Review Result” letters to providers as warnings when they’re not in compliance for any given month. You should review this manual section and work with your revenue cycle team to ensure that they are aware of these rules, understand the implications for failure to meet these criteria, and are continually monitoring for compliance.
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IPPS Final Rule – FFY 2019

CMS-1694-F drafted on 8/2/2018; Published in the Federal Register on 8/17/2018

On August 2, 2018, the Centers for Medicare & Medicaid Services (CMS) issued a final rule to help empower patients through better access to hospital price information, improve the use of electronic health records, and make it easier for providers to spend time with their patients. The final rule updates Medicare payment policies and rates under the Inpatient Prospective Payment System (IPPS) and the Long-Term Care Hospital (LTCH) Prospective Payment System (PPS), effective for discharges on or after October 1, 2018.

The policies in the IPPS/LTCH PPS final rule further advance the agency’s priority of creating a patient-centered healthcare system by achieving greater price transparency, interoperability, and significant burden reduction so that hospitals can operate with better flexibility and patients have what they need to be active healthcare consumers.

These changes result in the elimination of 39 total measures across 5 programs with well over 2 million burden-hours reduced for hospital providers impacted by the IPPS rule, saving them $75 million.

Overall, the final rule is projected to result in an estimated increase of $4.8B (or 4.0%) in payments to providers, ranging from 0.7% increases for rural, sole community hospitals up to 4.7% increases for larger urban hospitals in the New England region.

Medicare IPPS Base Rates

CMS is increasing the base rate for hospitals by 1.4%, mostly driven by a market basket increase of 2.9%.

Click here for the full base rate calculation table and comparison to prior year

MS-DRG v 36 Changes

As expected, CMS is recalibrating the MS-DRG weights for FFY2019. One noteworthy change is the inclusion of maternity-related DRGs in MDC 14, as discussed by CMS in the FFY2018 Proposed and Final Rules. Below is a listing of the largest changes in weighting between v35 and v36 of the MS-DRGs:

Click here for a table of the MS-DRG v35 to v36 comparison.

Post-Acute Care Transfer Policy Changes

Effective for discharges on or after 10/1/2018, patients discharged to hospice are to be included as transfer cases, as required by the Bipartisan Budget Act of 2018, saving the program an estimated $240M in FFY2019. The discharge status codes 50 or 51 will now be subject to the transfer policy.

Changes to Wage Index

CMS has calculated an occupational-mix adjusted national average hourly wage of $42.955567020. Of note, 263 hospitals will receive the rural floor.  Twenty-nine Massachusetts hospitals will receive an additional $121M (3.3%) due to the application of the rural floor.  In addition, Arizona hospitals will also experience a significant benefit of $58M from the application of the rural floor.

Click here for a comparison of current and prior WIFs in Table 3.

Three notable changes to wage index for FFY2019:

>1) Removal of “other” wage-related costs beginning with FFY2020

“Other” wage-related costs are traditionally reported on W/S S-3, Pt. IV line 25 and W/S S-3, Pt. II line 18 to recognize unusually large wage-related costs that are not reflected on the “core” list but may represent a significant wage-related cost. Such costs are subject to a specified 1-percent test to be considered allowable; this calculation was clarified in the Final Rule. Despite the clarification of the calculation of the 1-percent test, CMS is moving forward with excluding “other” wage-related costs from the wage index calculation starting with FFY 2020.

This is a result of the negligible impact these costs have on the overall wage index considering that only 8 hospitals out of 3,000+ IPPS hospitals in the wage index reported “other” wage related costs correctly. Many commenters were concerned about physician malpractice costs being excluded, as such costs are not specifically reported on W/S S-3, Pt. II line 18, though the costs are subject to the 1-percent test as an “other” wage-related cost. CMS clarified that the exclusion does include physician malpractice costs as well and provided statistics to denote the negligible impact that this would have on the overall wage index.

Toyon’s Take:  In an effort to begin to simplify wage index reporting, we agree with CMS’ decision to move forward with the exclusion of “other” wage related costs from the wage index calculation.

>2) Changing the “Lock-in” date for rural-designated hospitals

Based on current regulations, for a hospital’s wage data to be recognized in the rural wage index for the upcoming FFY, a hospital’s rural filing date (“lock-in” date) must be no later than 70 days prior to the second Monday in June of the current FFY, and the application must be approved by CMS in accordance with the regulations specified at 42 CFR 412.103.  In the current year, this “lock-in” date was April 2, 2018.

CMS confirmed that it will change the regulation at 42 CFR 412.103(b)(6) to reference the “lock-in” date as no later than 60 days after the public display date. This means that a provider’s urban to rural request must be approved by the CMS Regional Office no later than 60 days after the public display of the IPPS notice of proposed rulemaking in the Federal Register. CMS believes that allowing for such additional time (at least one month from current regulations) in the rate-setting process will eliminate errors and assist in ensuring a more accurate wage index, and also aligns the “lock-in” date with the 60 day-window for accepting public comments to the proposed rulemaking.

>3) Request for public comments on wage index disparities

CMS recognizes that there are disparities in wage reporting and regulations and sees an overall need for improving the wage index system.  While CMS did not publically address any comments in the Final Rule, CMS acknowledged that it looks forward to continuing to work on wage index disparities and that it has begun the process of “making wage index more equitable” with a policy allowing for the expiration of the imputed rural floor in all-urban states, notably New Jersey, Rhode Island and Delaware.

For additional information, please contact Ryan Sader at ryan.sader@toyonassociates.com.

UCC DSH Payments

CMS is increasing Medicare DSH UC payments by $1.5B, to $8.3B in FFY 2019.

CMS finalized its proposal to increase Medicare DSH UC payments by $1.5B, to $8.3B in FFY 2019. This increase is driven by the annual change in the estimated uninsured population, from 58.01% in FFY 2018 to 67.51% in FFY 2019. As anticipated, CMS is using uncompensated care cost from federal year 2014 and 2015 cost reports, as well as one final year of Medicaid and SSI proxy data, in the determination of each hospital’s allocation (i.e., “Factor 3”) of the $8.3B UC funding.

Hospitals Can Validate Their Data (Until August 31, 2018)

To arrive at estimated hospital UC payments in FFY 2019, CMS used uncompensated care cost, per publicly available cost report data, as of June 30, 2018. Hospitals have until August 31 to notify CMS at Section3133DSH@cms.hhs.gov with issues affecting the accuracy of their uncompensated care data. Hospital DSH UC data corresponding to the FFY 2019 Final Rule is here on the CMS website.

Toyon’s Take: Toyon will be using our S-10 HCRIS database to assist our clients with confirming their data. Sole community hospitals (SCH) should take note that CMS published uncompensated care amounts in the DSH Supplemental File for SCHs that may not receive DSH payments.

CMS continues to acknowledge that S-10 data “are not perfect”, and expects audits to begin in the fall of 2018. CMS does not disclose cost report years subject to audit, however Toyon expects these audits will relate to FY 2016 cost reports, as these are likely the next set of cost reports to be used for hospital UC DSH funding. CMS is also considering shifting to only one year of data (2016 cost reports) as the basis of hospital UC DSH payments for FFY 2020. Therefore, the accuracy of uncompensated care reporting on the FY 2016 cost report is critical for all DSH hospitals. Currently, CMS does not discuss a time-line for amending FY 2016 UC cost on the cost report, stating:

“To the extent these commenters were requesting a further opportunity to revise their Worksheet S-10 data for use in future rulemaking for FY 2020 or later years, we are not addressing the issue of future resubmissions in this final rule. Therefore, the normal timelines and procedures apply for a hospital to request to amend a cost report.”

Toyon anticipates a deadline for submitting UC revisions to the FY 2016 cost reports is forthcoming. We will send out a prompt update once this deadline is made publicly available. In the meantime, it continues to be extremely important to validate your hospital is compliantly reporting UC cost on the cost report.

Click here for the DSH Supplemental PUF data.

Click here for the Analysis of UCC DSH Factor 1.

For additional information, please contact Fred Fisher at fred.fisher@toyonassociates.com.

Graduate Medical Education Changes

CMS finalized its rule to allow “new” urban teaching hospitals (i.e., hospitals that established permanent FTE caps after 1996) to participate in Medicare affiliated group agreements (AGA) under certain limited circumstances, but with some modifications to the proposed rule. In the past, new teaching hospitals could only participate in an AGA if it resulted in an increase to the cap of the new teaching hospital. CMS confirmed that new urban teaching hospitals can continue to participate in an AGA wherein the new teaching hospitals receive increases to their FTE caps.

However, effective for new AGA’s beginning 7/1/2019 and after, this new rule would also allow two or more new urban teaching hospitals to participate in an AGA, including a reduction to one or more of the hospital’s caps. In addition, a new urban teaching hospital may participate in an AGA with an existing teaching hospital (i.e., a hospital with 1996 FTE caps) and receive a decrease to its FTE caps, as long as the new urban teaching hospital’s caps have been in effect for 5 or more years. To be specific, a new urban teaching hospital can lend FTE cap slots to an existing teaching hospital under an AGA effective with the July 1 date that is at least 5 years after the start of the hospital’s cost reporting period that coincides with or follows the start of the sixth program year of the first new program for which the hospital’s FTE cap was adjusted.

In addition, CMS announced an additional round of Section 5506 FTE cap redistributions (Round 13):

Applications for these additional FTE slots are due to CMS by October 31, 2018.

For additional information, please contact Tom Hubner at tom.hubner@toyonassociates.com.

 

Low Volume Hospitals 

As required by the Bipartisan Budget Act of 2018, CMS is implementing changes to the payment adjustments for low volume hospitals. Effective for FFY2019 through FFY2022, a hospital must be more than 15 road miles (i.e., by use of a web-based mapping tool) from another subsection (d) hospital and have less than 3,800 total discharges. It’s worthy of noting that the requirements have changed from a measure of Medicare discharges to a measure of Total discharges. The payment adjustment is an additional 25% for hospitals with less than 500 discharges, and a sliding scale is then applied for hospitals over that level down to 0% for 3,800+ total discharges.

LVA Adj = 0.25 – ((0.25/3300) x (Number of Total Discharges – 500))

Applications to receive the low volume adjustment must be received by September 1, 2018.

Toyon’s Take: Using the new 3,800-discharge criteria, an additional 38 hospitals may qualify for this Low Volume adjustment, if they meet the mileage criteria. Hospitals should review the data and mileage for this potential opportunity.

Click here  for a table of hospitals that may be eligible for the Low Volume adjustment.

For additional information, please contact Ron Knapp at ron.knapp@toyonassociates.com.

 

Changes to Quality Reporting 

Many measures between the various quality reporting systems have been determined by CMS to be duplicative, excessively burdensome, or “topped out,” meaning that most providers consistently perform well in a measure. As a result, CMS is making the following changes to these programs.

Hospital Inpatient Quality Reporting (IQR)

CMS is stratifying measure rates by dual-eligible Medicare/Medicaid patients. CMS is removing 19 measures and de-duplicating another 20 measures, for a reduction of 39 measures to be reported under the IQR program. CMS will also be adopting 1 claims-based readmission measure.

Click here  for a table of the 39 IQR measures to be removed.

Hospital Value Based Purchasing (HVBP)

CMS has decided to remove only 3 measures from the FFY2019 program year and another one beginning with the FFY2021 program year. Because 6 of the measures previously proposed by CMS to be removed from future program years will now remain, CMS is not planning to change the weighting of the domains for the time being. However, CMS is moving forward with changing the name of the Clinical Process domain to Clinical Outcomes.

HVPB Outcomes 75

 

 

 

 

 

 

 

 

Click here for a table of the 4 HVBP measures to be removed.

Hospital Readmission Reduction (HRR)

The only notable change made by CMS was to clarify the definitions of “dual-eligible” and “applicable period.” No new measures have been proposed.

Hospital Acquired Conditions (HAC)

CMS will start measuring hospital performance against peers with similar proportions of dual-eligible patients. In addition, CMS is adopting a new scoring methodology that updates measure weighting to address concerns raised about disproportionate weighting at the measure level for the subset of hospitals with relatively few NHSN HAI measures.

Click here for a table of the 6 HAC Reduction measures for FFY2019.

 

EHR Incentive Program Changes  

CMS is renaming the “EHR Incentive Program” to “Promoting Interoperability Program” to align with their plan to overhaul the incentive program by moving away from meaningful use measures to more of a focus on the patients and healthcare data exchange through interoperability.

CMS is seeking feedback on positive solutions to better achieve interoperability or sharing of data between providers with patients:

  • Reducing overall number of required measures from 16 to 6
  • New performance-based scoring methodology

Click here  for a table of the new scoring methodology.

 

Eligible hospitals would need to earn a score of 50 points or more out of a possible 100.

Additional Cost Reporting Requirements  

CMS is updating existing requirements related to supporting documentation that must be submitted with cost reports. Some of the changes are simply verbiage changes in the instructions to remove the reference to the Form CMS-339, which is no longer applicable as it has been incorporated into most cost reporting forms, and to change the reference to IRIS data from a separate IRIS diskette, which is no longer used by most providers.

However, effective with cost reporting periods beginning on or after October 1, 2018, the following documentation must be submitted with the Medicare cost report and agree to the amounts reported in the cost report:

  • Medicare bad debt listings
  • For DSH-eligible hospitals, Medicaid-eligible days listings and detailed listings of charity care and uninsured discounts provided
  • For hospitals that are part of a healthcare system, a completed Home Office cost statement
    • A copy of the Home Office cost statement should be submitted directly to the servicing MAC and to each MAC servicing its chain providers, rather than simply submitting a copy of the Home Office cost statement with every cost report submission
    • For hospitals that have a different fiscal year end from their Home Office, the amounts allocated from the Home Office to the hospital’s cost report must correspond to the appropriate portion of the cost reporting period as reflected in the Home Office cost statements

CMS has decided to postpone until a later time, the requirement that IRIS total counts for DGME FTEs (weighted and unweighted) and IME FTEs agree to the cost report. The reason for this postponement is because CMS’ XML-based IRIS software will not be updated to include FTE totals by 10/1/2018.

CMS has also indicated that they will be developing a standard format of required fields for the submission of charity care and uninsured discounts at a later time. For now, hospitals should include typical information for such listings, including patient name, dates of service, insurer (if applicable), and the amount of charity or uninsured discount given to the patient.

Toyon’s Take: This means that hospitals will no longer be able to submit cost reports using high-level data as placeholders for pending logs to be prepared at a later date. Detailed listings that support these key figures on the cost report must be submitted at the time of filing.

For additional information, please contact Daniel Pelayo at daniel.pelayo@toyonassociates

IPPS-Excluded Hospital Changes

CMS finalized a rule that will allow IPPS-excluded hospitals to operate IPPS-excluded units, as long as the unit is not the same type (e.g., psychiatric or rehabilitation) as the hospital. As further clarification, CMS specified that discharges from IPPS-excluded units will not be included in the calculation of a Long-Term Care Hospital’s average length of stay.

CMS also finalized its changes to the regulations at 42 CFR 412.22(h)(2)(iii)(A), effective on or after October 1, 2018. This change stipulates that an IPPS-excluded satellite facility that is part of an IPPS-excluded hospital that provides inpatient services in a building also used by an IPPS-excluded hospital, or in one or more entire buildings located on the same campus as buildings used by an IPPS-excluded hospital, is not required to meet the criteria in paragraphs (1) through (3) of this regulation, in order to be excluded from the IPPS.

Pricing Transparency 

CMS has expressed concerns from patients about hospital pricing, including surprise out-of-network billing from healthcare professionals (e.g., radiologists) and unexpected facility and physician fees after ER visits. In addition, CMS intends to enforce existing requirements of Section 2718(e) of the Public Health Services Act by drafting specific guidelines to address pricing transparency and by implementing a process to make non-compliant hospitals publically known.

CMS is requiring the following actions:

  • Posting of hospital and physician charge data on the CMS website
  • Effective January 1, 2019, hospitals make available a list of their standard charges via the internet in a machine-readable format and require that these lists be updated at least annually
  • As an alternative, hospitals may publish policies on the internet to allow the public to view a list of charges in response to an inquiry

CMS is also seeking feedback on barriers to publishing these charges and how to better inform patients of their obligations:

  • How should “standard charges” be defined? Average discount off charges or gross charges from the chargemaster?
  • What type of information would be most beneficial to patients?
  • Should healthcare providers be required to inform patients how much their out-of-pocket costs for a service will be before those patients are furnished that service?
  • Should CMS require healthcare providers to provide patients with information on what Medicare pays for a particular service?
  • What is the appropriate mechanism for CMS to enforce pricing transparency?

How does Medigap coverage affect patients’ understanding of their out-of-pocket costs?

Changes to Inpatient Admission Order Documentation 

CMS is removing the requirement that inpatient admission orders be written. If other available documentation, such as a physician certification statement when required, progress notes, or the medical record as a whole, supports that all the coverage criteria are met, and the hospital is operating in accordance with the hospital conditions of participation (CoPs), then written orders to admit are not required to be present in the medical record.

 

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