Following is a summary of the issues on which the DHLF has been focusing recently. This newsletter, as well as additional information and resources related to Forum activities, is available on our website – www. cadhlf.org.
As part of the state and federal advocacy agenda approved by the DHLF Board, we encourage you to invite Congressional, state Senate and Assembly representatives to visit your hospital during one of their district work periods (for state legislators, that is most Fridays). If you would like assistance in scheduling or planning a hospital visit by an elected representative, please contact Forum staff. Staff is very willing to make the contact with the offices and attend the tour if that might be helpful. If you do host a legislator/Congressional representative, drop staff a quick email to let us know as it is helpful to the advocates.
AB 113, District Hospital Inpatient Medi-Cal Intergovernmental Transfer (IGT) Program
The Department of Health Care Services (DHCS) is completing the calculations required to implement the 2013-14 AB 113 program. The AB 113 program provides supplemental payments to district/municipal hospitals for fee-for-service Medi-Cal inpatient services. The Centers for Medicare and Medicaid Services (CMS) must approve the calculation on the aggregate upper payment limit (the total amount available) prior to implementation of the 2013-14 program. Forum staff is in contact with DHCS and will keep members apprised of the progress of the approval. DHCS does plan to distribute payments prior to June 30 (contingent upon CMS approval) and as soon as an aggregate available amount is determined, we will let hospitals know so that we can assist with hospital-specific projections.
Hospital Presumptive Eligibility
Beginning January 1, 2014, as part of the Affordable Care Act, the Hospital Presumptive Eligibility (HPE) program provides individuals with temporary, no cost, Medi-Cal benefits for up to two months. The hospital application (required for hospital participation) and other information is available at:
District/municipal hospitals are encouraged to complete the application and subsequent on-line training to ensure immediate coverage is provided for the above eligible individuals.
2014-2016 Hospital Provider Fee
A key focus of the DHLF in 2014, along with other hospital constituency groups, will be the implementation of the 2014-16 hospital quality assurance fee (QAF). The funding for most district/municipal hospitals will differ from the prior 30-month fee (which ended December 31, 2013) as the current QAF will again require IGTs for most district hospitals to draw down funding via Medi-Cal managed care plans. While the 2014-15 QAF is more complex than the prior program, it will result in significantly more funding (in aggregate $18.6 million annually in the 2011-13 QAF compared to a minimum of $55 million annually in the 2014-16 QAF).
Due to the various new complexities in the current QAF, the CMS approval likely will take longer than for prior programs. CHA is working diligently on approval of the fee-for-service component, but the managed care component (which is how district/municipal hospitals will receive the majority of funding) always takes longer. Therefore, while QAF funding will be retroactive to January 1, 2014, distribution won’t be done until well into the 2014-15 fiscal year.
State Budget – AB 97 Medi-Cal Reductions
In concert with CHA, the DHLF advocacy priority in the 2014-15 state budget is to eliminate the AB 97 Medi-Cal reductions, which retroactively reduce distinct-part nursing facility rates (from June 2011 to September for rural facilities or October 2013 for non-rurals). Hearings on the budget have begun and grassroots advocacy will be requested at an appropriate time. (See also AB 1805 below.)
Other DHLF-Tracked Legislation
Efforts continue in the Legislature related to mandated charity care and community benefit for hospitals. DHLF advocates have been successful in exempting district/municipal hospitals from these efforts, however we are monitoring the efforts closely as any success could be expanded to other hospitals in the future.
AB 1805: Reversal of Medi-Cal rate reductions. DHLF Supported. Eliminates all the AB 97 Medi-Cal provider rate reductions, including the retroactive rate reduction on hospital-based distinct-part
nursing facilities. The DHLF supports this bill as the retroactive recoupment could result in compromised access to care for patients seeking care in a district hospital DP/NF.
Forum staff has been working with private hospitals and CHA regarding the implementation of APR-DRGs. As you recall, this reimbursement methodology was implemented in January for districts and last July for private hospitals.
In addition to the few billing items outlined below (on which the hospital industry is working with DHCS to resolve), another focus is DHCS’ plans regarding any reconciliation of the transitional rates (for districts in 2013-14, the impact is not to be more than plus/minus 2.5 percent). DHCS currently is not amenable to making any retroactive changes if the transition is inappropriate, but is considering options on a prospective basis. The DHLF will monitor this issue and determine next steps if the impact (either retroactive or prospective) is significant.
As part of this transition, ultimately TARs will be eliminated. DHCS has put together a survey on this subject to ensure the utilization management component is as seamless as possible. The survey was emailed to district/municipal hospitals earlier today and your attention to completing it is appreciated.
Please let staff know if you are experiencing any of the below billing issues or if you have identified additional issues.
- Crossover Claims
- Medicare/Medi-Cal crossover claims with bill type 121 are currently being rejected with remittance advice detail (RAD) code 9952, “Type of bill code APR-DRG claim invalid or missing”.
- Other Health Coverage:
- This issue is affecting claims with any other health coverage including LIHP and CCS claims.
- Example – baby is admitted at birth to NICU with commercial HMO coverage. Baby is covered for first 30 days under mom’s plan. Financial coverage and issued TAR/SAR under Medi-Cal starts on day 31. SAR for CCS has to begin with day of admission but financial eligibility does not start until 31.
- Claims line maximum: 22 lines
- The claim form can only accept 22 lines of information.
- Share of Cost – system isn’t recognizing a multiple month share of cost and overpaying hospitals
- Mom/Baby claims
- Hospitals receiving denials when the baby is using mom’s ID as system is seeing them as duplicate claims.
- CCS Newborn Accounts
- CCS newborn accounts are being held in suspense status 603, “Fiscal Intermediary Review Status”
- Patient relationship code on newborn claims
- Hospitals formerly used code 19 but that stopped paying, were told to us code 18, but this still generates denials for duplicate claim. Also provider manual says to use code 03 however hospitals told 03 is still valid. When hospitals use 03 claims deny.
- DRG E-Mail Address
- Hospitals report that the DRG e-mail address was terminated in early March and all questions need to go through the help desk.
Currently CHA is focused on negotiating a non-initiative compromise between the hospital industry and SEIU on the planned initiatives (capping CEO compensation and limiting hospital charges). While district/municipal hospitals are exempt from both initiatives, negative impacts could affect all hospitals via the hospital provider fee (as one example). Both CHA and the DHLF will continue to keep you apprised regarding these efforts.
DHLF April Board Meeting
Next week the DHLF will hold its first 2014 Board/member meeting. This will be a 2-day meeting beginning at noon on Wednesday, April 16. The first day will conclude with a reception. The 2nd day will start with breakfast on April 17 and the meeting will conclude by 1:30. Agenda items include discussions related to the current and upcoming 1115 waivers (including discussion related to district hospital behavioral health/substance abuse demonstrations in the 2015 waiver) , physician issues, capital financing options and discussions related to affiliations and other arrangements. If you have not yet RSVP’d, please do so to ensure logistics are appropriate. The meeting will be held at 1215 K Street, 14th Floor, Sacramento, CA.
Upcoming DHLF Board Events:
- April 16-17, 2014 – DHLF 2-day Board/Member Meeting. Sacramento.
- July 29, 2014 – DHLF Board Meeting, Rural DHLF Member (TBD)