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Last week, CMS published Transmittal 1695 to the Claims Processing Manual, reaching back to FY 2006 to include Medicare Advantage (MA) Plan members in the Disproportionate Share Hospital (DSH) calculation. CMS calculates a DSH adjustment to DRG payments for hospitals serving a disproportionate share of low income patients.
By regulation, low-income patients include certain Medicaid patients (Medicaid portion) and certain Medicare patients (Medicare portion). The Medicare portion is a ratio of Medicare Part A patients receiving Social Security Income (SSI) (disabled) divided by the total Medicare Part A patients. The Medicare portion includes MA members because they are eligible for Medicare Part A, even though the payment is being made through a MA plan. The effect of including MA members may be positive or negative for hospitals, depending on how the addition of the MA members affects the overall Medicare portion ratio.
This issue may sound familiar because in July of 2007 CMS published Transmittal 1311 that gave instructions for hospital to include MA members in their Disproportionate Share calculation for FY 2007. Transmittal 1695 requires hospital who received DSH to go back as far as FY 2006 and submit MA plan member data. The affected providers have a limited time frame to submit the claims data for FY 2006: from the implementation date, July 6, 2009, through November 30, 2009.
The process for submitting MA member data entails submitting a separate claim to the MAC/FI with condition code 04 (Information Only) and the Medicare Beneficiary’s HICN. CMS has instructed contractors to override timely filing edits for these claims. They have also turned off the Medicare Summary Notice to the patient.
NOTE: Teaching hospitals are not affected by this requirement because they would have already submitted a claim for Indirect Medical Education payment with condition code 04 and 69, which would allow CMS to account for the MA plan members in their DSH calculations.
The stimulus plan passed by the Senate Tuesday includes millions of dollars for Medicaid, meaning hospitals may see a lift in reimbursements.
The Senate voted to approve an $838 billion economic stimulus plan after the House passed a $820 billion version earlier, The New York Times reported.
“Throughout our history, the federal government has catalyzed a good idea, invested in the ingenuity and entrepreneurship of the American people, and let the private sector flourish,” the majority leader, Senator Harry Reid of Nevada, said before the vote, The New York Times reported. “Faced with an economic crisis today, we have an opportunity to make similar investments that will help our country prosper in the years to come.”
Read the full story in The New York Times.
It does not pay enough money.
That is the contention of Wellcare, Florida’s largest Medicaid insurer, which announced it is leaving the state’s Medicaid Reform program, The Miami Herald reported this week. Government reimbursement rates are just too low, the insurer said.
”WellCare’s action is a result of recent state budget cuts that make it economically unfeasible to continue offering members sufficient access to quality health services in those programs,” the company said in a written statement.
”It’s fair to say that the rate cuts are substantial enough that some plans will soon have to decide whether to stay,” said Michael Garner, president of the Florida Association of Health Plans, in The Herald.
The governor of Minnesota faces a dilemma because of the growing number of Medicaid-eligible patients in his state, the Minneapolis Star Tribune reports.
Governor Tim Pawlenty’s budget includes a $3 billion share for Medicaid, which is one-fifth of his budget. But cutting isn’t easy. He has a Legislature that wants to expand access to healthcare for the poor.
Read the full story in the Tribune.
Medicaid enrollments are surging in some states because workers are losing their health insurance along with their jobs, The New York Times reported January 22.
Some states saw surges between 5% and 10% in the last 12 months. Growth rates doubled from the prior year in some states.
Read the full story in The New York Times.
Seven hospitals in New York have been accused of fraudulently billing the Medicaid program for detox services without the appropriate state certifications, according to an Associated Press (AP) article.
The article also stated that four of the seven hospitals paid kickbacks to get more patients into their drug treatment programs. Another hospital allegedly recruited homeless people to enter a three-day stay in detox in exchange for cigarettes, beer, food, and other items.
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