OHA update Ohio Hospital transparency February 20, 2019

Agenda OHIO HOSPITAL TRANSPARENCY MEDICARE’S ‘ER’ MODIFIER PRIVATE PAYER SCORECARD AAHAM Western Reserve Chapter February 20, 2019

OHA Price transparency tool-kit CMS Final 2019 IPPS Rule Transparency Provision Effective Jan. 1, 2019 published on pages 2135-2142. Requires hospitals to make available a list of current ‘standard charges’ via the internet in a machine-readable format, and to update it at least annually. Requirement can be met in form of chargemaster itself or another form of the hospital’s choice in machine readable format. AAHAM Western Reserve Chapter February 20, 2019

OHA Price transparency tool-kit CONT… In it’s final 2019 IPPS rule, CMS acknowledged chargemaster data is: “not helpful to patients for determining what they are likely to pay for a particular service or hospital stay” AAHAM Western Reserve Chapter February 20, 2019

OHA Price transparency tool-kit CONT… OHA’s Recommend Disclaimer: The information provided is a comprehensive list of charges for each inpatient and outpatient service or item provided by a hospital, also known as a chargemaster. It is not a helpful tool for patients to comparison shop between hospitals or to estimate what health care services are going to cost them out of their own pocket. For more information about the cost of your care, please contact our patient financial services staff. AAHAM Western Reserve Chapter February 20, 2019

OHA Price transparency tool-kit CONT… CMS Issued Two Sets of Transparency FAQs Following the 2019 IPPS Rule which include: Hospitals may choose the format to present their “standard charges” to the public, as long as the information represents the current “standard charges as reflected on its chargemaster.” “Machine readable format” is a format that can be imported/read into a computer system. Examples of “machine readable format” are XML and CSV. Word and PDF formats are not acceptable. AAHAM Western Reserve Chapter February 20, 2019

OHA Price transparency tool-kit CONT… The requirement applies to all hospitals and all items and services provided by the hospital. Compliance with a state-level price transparency initiative is not sufficient to satisfy the federal requirements. Hospitals must establish and update and make public a list of the hospital’s standard charges for all items and services, including all drugs, biologicals, and all other items and services provided by the hospital. AAHAM Western Reserve Chapter February 20, 2019

OHA Price transparency tool-kit CONT… Hospitals are required to establish and update and make public a list of the hospital’s standard charges for each diagnostic-related group (DRG). Please note, however, that per the FAQ, the following types of non-DRG reimbursed hospitals are exempt from the requirement to publish their standard charges for DRGs: Psychiatric hospitals; Rehabilitation hospitals; Children’s hospitals; Long term acute care hospitals; Certain cancer hospitals. AAHAM Western Reserve Chapter February 20, 2019

OHA Price transparency tool-kit CONT… The Affordable Care Act (ACA) included a requirement for all hospitals to establish, update and make public a list of hospital’s “standard charges” for items and services provided by the hospital, including diagnosis related groups, DRGs. The information is to be made available each year. The requirement was published in Section 2718(e) of the Public Health Services Act in 2015, which was part of the ACA (pages 2044-5). AAHAM Western Reserve Chapter February 20, 2019

OHA Price transparency tool-kit CONT… The ACA indicated hospitals could satisfy the rule by posting information on the internet, not specifying the method in which they must post the average DRGs. To View OHA’s Toolkit Go To: www.ohiohospitals.org > Under Advocacy Policy Drop Down > Finance News > Search Window: Toolkit AAHAM Western Reserve Chapter February 20, 2019

Medicare “er” modifier Items and services furnished by a provider-based off-campus emergency department Required to be reported on every claim line for outpatient hospital services furnished in an off-campus provider-based emergency department that meets the definition of a “dedicated emergency department” Not required for Critical Access Hospitals (CAHs) AAHAM Western Reserve Chapter February 20, 2019

Medicare “er” modifier A remote location of a Medicare-enrolled hospital provider (i.e. second campus of a provider that utilizes the same provider number as the main hospital location) is considered an off-campus provider-based location of the main campus under the definitions of the provider-based rule at 42 CFR 413.65. Therefore, even though the second campus has inpatient beds and may be treated, licensed, or registered by state regulators as a distinct hospital, the second campus is still part of the main provider for Medicare enrollment and provider-based purposes. AAHAM Western Reserve Chapter February 20, 2019

OHA Private payer scorecard Responding to members’ heightened anxiety about the behaviors of private payers – commercial, Medicaid managed care and Medicare Advantage – the OHA Board of Trustees directed OHA staff to convene a member-driven Private Payer Work Group composed of hospital CFOs, finance leaders, revenue cycle professionals, managed care contracting experts and legal counsel to explore how OHA could best assist members in their relations with the private payers. AAHAM Western Reserve Chapter February 20, 2019

OHA Private payer scorecard Cont… Scorecard data will be used in aggregated for to: Enhance OHA’s advocacy efforts by providing measurable data that will demonstrate the burden hospitals endure in their relations with payers Provide data back to participating members allowing you to benchmark your organization’s experience with a payer to facilitate any internal process improvements and to identify opportunities for outreach to payers to resolve issues. AAHAM Western Reserve Chapter February 20, 2019

Questions ??? AAHAM Western Reserve Chapter February 20, 2019

Shawn Stack Director, Health Economics and Policy Shawn.Stack@ohiohospitals.org