Health Information Management

Update Medicare Advantage patient information needed to determine Medicare DSH payments for FYs 2007, 2008 by August

HIM-HIPAA Insider, June 15, 2010

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In the May 5 transmittal R696OTN, CMS reminded hospitals of the importance of submitting informational only claims for their Medicare Advantage patients to the respective MACs or FIs. This is particularly important for hospitals paid under the inpatient prospective payment system (IPPS), as well as the inpatient rehabilitation facility prospective payment system (IRF PPS) and the long term care hospital prospective payment system (LTCH PPS).

The inpatient days reported on the informational only claims are needed to calculate the number of inpatients eligible for Medicare who are receiving Supplemental Security Income (SSI), which, in turn, is used to accurately determine Medicare disproportionate share (DSH) payments for IPPS hospitals and low income patient (LIP) payments for IRF PPS hospitals. This information is also used to determine LTCH short stay outlier payments and to evaluate Medicare’s greater than 25 day average length-of-stay requirement for LTCH patients.
In calculating a hospital’s DSH percentage, which generally determines whether a hospital will qualify for a DSH adjustment to its operating and/or capital DRG payments, the hospital must determine the number of low income patients who received inpatient services during the year in question. Patients who qualify as low income patients include those who have Medicare Part A coverage by reason of disability (are receiving SSI), and patients who are not eligible for Medicare Part A, but who are eligible for Medicaid.
CMS has agreed to identify those patients with Medicare Part A by reason of disability (including Medicare Advantage beneficiaries), for both the government’s fiscal year (FY), as well as the hospital’s cost report year. The hospital may then select either year as the basis for determining their DSH percentage. The relevant patient information is available on the CMS Web site.
Hospitals are encouraged to carefully review their inpatient records for FYs 2007 and 2008 so that they can comply with these deadlines and, ultimately, receive all relevant consideration for the inpatient services provided to Medicare Advantage beneficiaries.
Editor’s note: This article, by Judith Kares, JD, CPC, regulatory specialist for HCPro, Inc., was excerpted from Medicare Weekly Update. To read the remainder of the article, please visit the MedicareFind MedicareMentor blog.

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