Miscellaneous Topics Mark Hudak JL Audit Manager September 23rd, 2016 Proprietary and Confidential

Miscellaneous Topics SSI Hold Update FY 2014 SSI Ratios Exceptions to NPR Reopening Issues Audit Schedule Medicare Bad Debts

SSI Hold Update PPS Hospitals receiving operating or capital DSH on hold for SSI ratio are now being NPR’d Round 6 FYE’s 12/31/2013 up through 8/31/2014 NPR’d by May 12, 2016 (unless other deadlines or holds apply)

Current NPR Timeline (cont.) DSH Hospitals Using the FY 2013 SSI Percentage - Cost Reports which begin between 10/01/12 – 09/30/13 - Mostly FYEs 12/31/2013 and 06/30/2014 90% Due 05/12/2016 100% Due 11/12/2016

SSI Hold Update CMS has granted a 6 month extension on all FYE’14 cost reports. All non-audits are due to be NPR’d 18 months from date of acceptance of cost report. Includes non-DSH, non LIP PPS hospitals, CAHs, Psych, LTAC’s, and all other non-hospital types

FY 2014 SSI Ratios FYE’s 12/31/2014 up through 8/31/2015 NPR’s will not be issued at this point because providers have been given the option of submitting amended FY 2014 cost reports in light of CMS’ proposal to begin using W/S S-10 data to determine uncompensated care payments starting in FY 2018. This instruction is in effect until further notice. This includes both the initial NPR and/or any revised NPRs.

FY 2014 SSI Ratios For revisions to be considered, hospitals must submit their amended cost report containing the revised Worksheet S-10 (or a completed Worksheet S-10 if no data had been included on the previously submitted cost report) no later than September 30, 2016. Submissions received on or after October 1, 2016 will not be accepted.

FY 2014 SSI Ratios This instruction applies only to Worksheet S-10 of FY 2014 cost reports for IPPS hospitals; Revisions to Worksheet S-10 from other fiscal years or revisions to other worksheets of the FY 2014 cost reports are not subject to this instruction. FY 2014 cost reports = 12/31/14 and 6/30/15 cost reports

FY 2014 SSI Ratios In addition, the A/B MACs shall: The A/B MACs may continue to work on cost report audit processes, but shall not issue the NPRs. In addition, the A/B MACs shall: Update the Provider Specific File in PRICER with the FY 2014 SSI ratios included on the CMS Website within 15 business days of the issuance date of the respective TDL. (September 8, 2016)

FY 2014 SSI Ratios A/B MACs shall use the FY 2014 SSI ratios when completing tentative settlements and interim rate reviews. For Periodic Interim Payment (PIP) hospitals, the A/B MACs shall use the FY 2014 SSI ratios when completing PIP rate reviews.

Exceptions to NPR Outlier reconciliation necessary by CMS PY cost report is an audit and not NPR’d yet Once NPR’d, subsequent open cost reports will be due to be NPR’d 6 months from PY NPR date.

Exceptions to NPR Specific issues that need CMS intervention Material negative charges on PS&R If negative ancillary charges exceed $250,000, the cost report settlement is held until this is resolved. There is no time-frame for resolution of this issue. We are still waiting on instructions from CMS.

Exceptions to NPR PIP/RAC Adjustments Specific issues that need CMS intervention PIP/RAC Adjustments When a “RAC” audit occurs, the claims adjustments are not accurately captured in the PS&R summary of claims, so if the cost report were settled, Novitas would underpay the provider. Decision matrix - Before settling any PIP hospital, we compare the “Outlier payments” to the “Actual Claim Payments PIP” field on the PS&R summary report. If these amounts agree, we proceed to settlement. If they do not agree, the settlement is put aside to be revisited later.

Reopening Issues Reopening Request Letter Provider must be specific and include in your request letter every issue that needs addressed For instance, if submitting additional MA days the provider should also request the DSH percentage to change Believe it or not, CMS had a finding with Novitas adjusting the DSH percentage when the reopening request was for additional MA days Based on CMS “guidance”, Novitas will only process the request for the items specifically requested.

Reopening Issues SSI Realignment Reopening Requests For whatever reason, these requests forwarded to CMS were never made a priority. As a result, quite a backlog built up over the years. CMS is now telling us that the resolution of these requests will be made a priority. Hopefully this will result in the providers’ requests being completed by CMS and the MAC (Novitas) issuing reopenings for those requests, if accepted.

Reopening Issues Reopening Information Requests Due to multiple cost report years being NPR’d relatively recently, we are experiencing an uptick in the volume of reopenings received. In order to complete this increased workload timely, we as a MAC need to adhere to strict document request requirements. When we send out our information request, we will give the provider 30 days to provide the support. Any missing information will be treated as errors.

Reopening Issues Reopening Information Requests When the auditor completes the testing, the audit adjustment report will be sent to provider giving them two weeks to respond prior to issuing NPR. Additional information sent will not restart the “180 day” clock The expectation is that when a reopening request is made, the information to support that request is already available. We are experiencing delays because the provider cannot locate requested documentation such as charity care application detail, collection history, EVS slips for MA days, etc. Bad debt accounts and DSH accounts that are missing information should not be included in the bad debt log or MA days log.

Audit Schedule Audit Schedule We are currently conducting audits and they will continue into the fall. We will be auditing cost reports with FYE 2013- 2015 Audits selected were based largely on dollars at risk CMS had to approve our audit plan Audits must have final exit conference held or waived by January 31, 2017

Medicare Bad Debts Typical causes of adjustments Medical Assistance not properly billed for dual eligibles Self – pay accounts being written off prior to coming back from collection agency Outpatient bad debts including coinsurance relating to fee based services such as physical therapy Charity care not properly documented by the provider Any 3rd party or patient payments not reducing the bad debt claimed

QUESTIONS?