Liberty Billing

News

Industry Trends – August 2017

September 7th, 2017

INDUSTRY TRENDS
Medicare
• The August 30, 2017 “Open Claims Issues” is attached with the dates for the scheduled fixes.
• The listing of the top “Part A Claim Submission Errors” is attached.
• Change Request 9911 has been revised. The revision identifies beneficiaries enrolled in the Qualified Medicare Beneficiary (QMB) program. The QMB is a Medicaid program. The system will trigger notifications to providers and to beneficiaries that the beneficiary is enrolled in the QMB program and not responsible to pay deductibles, coinsurance or copayments. (See Attachment)

New Jersey Hospital Association (NJHA) Update
State Issues
1. Budget: After a 3-day government shut down, the budget was signed into law in the early morning of July 4.
a. Charity Care – the $50 million cut was not restored so charity care will be funded at $252M in SFY 2018.
b. GME – GME received a $30 million increase, for total funding of $218M in SFY 2018.
2. Medicaid Waiver: The state has received approval from CMS to extend the 1115 demonstration waiver entitled “NJ FamilyCare Comprehensive Demonstration,” effective from Aug. 1, 2017 through June 30, 2022.
a. Included in that five-year extension was an extension of the New Jersey Delivery System Reform Incentive Payment Program (DSRIP) for the first three years of the renewal period at level funding ($166.6 million), meaning DSRIP will be funded at the $166.6M for SFY 2018 – 2020 (DYs 6 – 8).
b. Effective July 1, 2020, the state must have a successor program in place. The state must submit the outline of that successor program by next year.
c. The state must develop new funding and mechanics protocols by Aug. 31, 2017. CMS must approve the new funding and mechanics protocols by Oct. 1, 2017. Therefore, no DY6 payments can be made until October at the earliest.
d. In prior years, the hospitals provided monthly progress reports which dictated payments. Under this new structure the state anticipates that hospitals will provide progress reports every six months and payments will be made semi-annually.
3. Reorganization of Mental Health and Addiction Services:
a. In late June, Gov. Christie proposed a reorganization plan to move mental health and addiction services from the Department of Human Services to the Department of Health. This will automatically take effect 60 days after the proposal unless the Legislature passes concurrent resolutions opposing the move.
b. On July 31 the Assembly passed a resolution officially disapproving of the reorganization. If the Senate approves this resolution before the 60-day deadline, the plan will be rejected.

Federal Issues
1. ACA Repeal: three bills were voted on the Senate in late July:
a. Better Care Reconciliation Act (BCRA) – to replace the American Health Care Act (House Bill). This vote was a no, 43-57.
b. Obamacare Repeal and Reconciliation Act (ORRA) – a bill similar to 2015 bill passed in the Senate and subsequently vetoed by President Obama. This vote was a no, 45-55.
c. “Skinny” Repeal – to eliminate the individual and employer mandates. This vote was a no, 49-51.
d. Both the House and Senate are now on summer recess until after Labor Day. Likely after Labor Day discussions will shift to the debt ceiling and tax reform.
2. FY 2018 IPPS Final Rule Released:
a. Imputed Floor: CMS reversed its position in the FY 2018 IPPS proposed rule to discontinue the imputed (“rural”) wage index floor provision. The final rule confirms the policy will be extended for one year, through Sept. 30, 2018. The imputed floor wage index for New Jersey will be 1.1136 in FY 2018. NJHA estimates 17 N.J. hospitals will benefit by $36.5 million in inpatient and outpatient payments in FY 2018 due to the imputed floor.
b. Market Basket: The final rule includes an initial market basket update of 2.7 percent for hospitals that submit data on quality measures. The final rule also includes the following changes to the market basket:
i. A reduction of 0.6 percent to remove the one-time positive adjustment made in FY 2017 to restore cuts associated with the two-midnight policy.
ii. An increase of 0.4588 percentage points to partially restore cuts made as a result of a requirement in the American Taxpayer Relief Act (ATRA) of 2012.
iii. Two market basket reductions mandated by the Affordable Care Act (ACA): a 0.75 percent reduction and a 0.6 percent “productivity” cut.
iv. This results in a net market basket of 1.2 percent.
c. Medicare DSH:
i. The rule finalizes a three-year phase-in of using Worksheet S-10 data to determine the amounts and distribution of uncompensated care payments. As the FY 2014 data will be used in the FY 2018 calculation, CMS is allowing hospitals to submit revised FY 2014 S-10 worksheet data. NJHA encourages hospitals to review their data and submit any revisions to their Medicare Administrative Contractor (MAC) by the Sept. 30, 2017 deadline
ii. In FY 2018, CMS will begin using data from its National Health Expenditure Accounts (NEHA) instead of data from the Congressional Budget Office to estimate the percent change in the uninsured. Using NHEA data certified by the CMS Chief Actuary, the uninsured rate decreased from 14 percent in 2013 to 8.15 percent in FY 2018. This results in an increase in DSH payments of approximately $800 million versus FY 2017 levels. As compared to FY 2017, NJHA estimates an increase in Medicare DSH payments to N.J. hospitals totaling $84.5 million in FY 2018.
d. Hospital Readmissions Reduction Program (HRRP): NJHA estimates a reduction of $30.9 million for N.J. acute care hospitals in FY 2018 from the HRRP.
e. Value-based Purchasing (VBP): NJHA estimates a reduction of $8.7 million for N.J. acute care hospitals in FY 2018 from VBP.
3. HMS RAC Audits:
a. HMS has received CMS approval to initiate reviews in the JL MAC Region. The initial Additional Documentation Request (ADRs) letters were mailed on Tuesday, August 1st to approximately 49 providers in the entire JL region which includes NJ, DE, PA and MD.
b. Action needed: HMS encourages all providers to access the portal and customize their address and contact information to ensure all letters are reaching the correct contact in your facility. This is critical for hospitals, physicians, skilled nursing facilities, rehabilitation hospitals and long term care hospitals as there are audit issues already approved for many different provider types. To get to the portal, go to https://racinfo.hms.com/home.aspx.

Industry Trends – April 2017

May 5th, 2017

INDUSTRY TRENDS

No Fault Internal Appeals Procedure

Effective April 17, 2017, The Department of Banking and Insurance (DOBI) implements changes to the No Fault appeal process. The Requirements for Insurer Internal Appeals Procedures, published in the New Jersey Register at N.J.A.C. 11:3-4.78, creates Pre-Service and Post-Service Appeal Forms for Insurers Internal Appeal Procedures (attached).  The attached Appeal Forms were created to make the appeal process uniform for all No Fault payers.  Also attached are Frequently Asked Questions about the Internal Appeal Rule found on DOBI’s website.  Important facts:

  • An appeal letter, supporting the required “appeal rationale narrative,” is required with the completed Post-Service Appeal Forms.
  • Medical records are required with the Post-Service Appeal Forms, if the records were not previously submitted to the payer.
  • Pre-Service Appeal Forms are submitted when the No Fault payer denied or modified a pre-certification request for service.
  • Pre-Service appeals must be filed within 30 days of the written denial from the No Fault payer.
  • Arbitration must be filed within 45 days from Post-Service Appeal Form submission.
  • Check payer web sites for correct appeal fax numbers.

Medicare

  • The May 4, 2017 “Open Claims Issues” is attached with the dates for the scheduled fixes.
  • The listing of the top “Part A Claim Submission Errors” is attached.
  • Medicare Change Request 10005 dated March 3, 2017 is attached advising of the April 2017 Hospital Outpatient Prospective Payment System changes. (See Attached)
  • Medicare Change Request 9681 informs providers of the modifications to the national coordination of benefits agreement crossover process. (See Attached)

 

 

Industry Trends – March 2017

April 17th, 2017

INDUSTRY TRENDS

Medicare

  • April 3, 2017 “Open Claims Issues” attached with the dates for the scheduled fixes.
  • The listing of the top “Part A Claim Submission Errors” is attached.

 

NJ HFMA PFS Information

State Issues:

  • Budget Address: Governor Christie delivered his budget address on February 28. Healthcare items include:
    • Charity Care
      • $50 million reduction ($25 million state and $25 million federal match), reducing the pool from $302 million to $252 million.
      • 2015 charity care documentation will be used in the charity care distribution formula.
      • The total Charity Care pre-ACA was $1.3 billion. Covered lives are expected to materially decrease if ACA is repealed or replaced with the American Health Care Act (AHCA). The Horizon donation detailed below could be used to offset the loss covered lives as it is not designated only towards mental health services.
      • Graduate Medical Education increase of $30 million, raising the pool from $188 million to $218 million.
      • Delivery System Reform Incentive Payment (DSRIP) fund remains at last year’s level of $166.6 million.
      • Mental Health Subsidy Fund remains at $24.7 million, the same level as last year.

Horizon Blue Cross Blue Shield Capital Reserve

  • Horizon Blue Cross Blue Shield is required to maintain reserves of $500 million. They have over $600 million. The State is requesting they donate $300 million to the State, which would put their reserves below the required amount, but there has been no discussion as to how to resolve that inequity.
  • This donation is expected to occur annually.
  • Gov. Christie called for legislation requiring Horizon Blue Cross Blue Shield to make a voluntary, annual contribution out of its significant capital reserve to support addiction services for New Jersey’s vulnerable populations who access Charity Care and Medicaid.
  • The Governor further proposed that this fund be immediately used to increase access to inpatient and outpatient addiction services for these populations, but in future years could be used to support the broader mission of providing healthcare to the State’s most vulnerable.
      • Behavioral Health:
        • Recovery Efforts: $430 million in this year’s budget:
          • $5 million for the expansion of a statewide pediatric behavioral health pilot program;
          • $2.8 million to support the recovery coach program; and
          • $136 million of combined state and federal funds to further increase behavioral health reimbursement rates.
        • The Governor directed the Department of Health advertise the need of up to 900 newly licensed hospital beds for the treatment of residents suffering from co-occurring behavioral health and addiction issues.
        • The Governor anticipates budget savings from the enactment of “meaningful out-of-network reform.”
  • Property Taxes: S-2212 “Prohibits certain third-party property tax appeals,” also known as “the standing bill”, has been posted for a vote in the full Senate this coming Monday, March 13, 2017. This bill is one part of NJHA’s dual-prong legislative strategy to address the property tax issue.

 

  • Federal Issue: ACA Replacement Bill Introduced: (AHCA) Overview of key areas:
    • Medicaid:
      • Expansion States: As of Dec. 31, 2019, essential health benefits mandate of expansion repealed. Starting in 2020, states must stop enrolling childless adults at the enhanced match; beneficiaries can stay on Medicaid rolls and receive the enhanced federal funding. Disproportionate Share Hospital (DSH) cuts repealed in 2020.
      • Non-Expansion States: $10 billion in grant funding to increase federal rate to 100 percent for 2018-2021 and 95 percent in 2022. DSH cuts repealed in 2017.
      • Per-Capita Caps: Starting in 2019, Medicaid would be transformed to capita payments to states based on the number of Medicaid enrollees, using 2016 as the base year. Growth of funding caps indexed for medical care group of the consumer price index.
    • Repeal: Repeals the individual mandate penalty retroactive to January 2016, delays the Cadillac tax until 2025 and repeals most other ACA taxes after 2018.
    • Insurance Coverage Tax Credits: Provides advanced, refundable tax credits indexed for age from $2,000-$4,000 and further indexed for individuals with earnings of $75,000 per individual and $150,000 for joint filers (capped for income over $215,000, and $290,000 cap for joint filers).
    • Patient and State Stability Fund:
      • Creates a $100 billion fund for state grants aimed at stabilizing the individual market over 10 years.
      • States could use this money to create high-risk pools, help people with out-of-pocket costs, establish a reinsurance program or other ways to improve affordability.
      • States must submit a one-time application for the funding, which totals $100 billion over 10 years with $15 billion a year for the first two years and $10 billion a year for the remainder.
      • Establishes a default for any state that does not apply for funding that requires the establishment of a reinsurance program that would compensate plans at 75 percent of claims higher than $50,000 and up to $350,000.
    • Other:
      • Allows individuals to stay on parents’ health plans until age 26;
      • Prohibits denying coverage for preexisting conditions; and
      • Permits insurers to charge 30 percent higher premiums on new enrollees with a gap in coverage.
      • The process of the AHCA bill:
        • The House Energy and Commerce committee cleared the bill after more than 27 hours of debate along partisan lines with a 31-23 vote.
        • The markup in Ways and Means lasted more than 16 hours and the vote came after 4 am; the bill was approved 23-16.
        • Bill faces opposition from American Hospital Association, American Medical Association, AARP, and others. NJHA opposed due to potential drop in coverage.
        • CBO estimates may come as early as Monday. No estimates on coverage loss or cost yet. CBO score expected before bill goes through House budget committees.
        • To not pass House- 21 deflections needed from Republicans. To not pass Senate – 2 deflections needed from Republicans.

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   

 

Industry Trends – February 2017

March 6th, 2017

INDUSTRY TRENDS

Horizon NJ Health

Recently Horizon NJ Health presented a webinar stating that Hospitals can no longer bill newborns under the mother’s identification number. The mother has 48 hours from the birth to obtain a temporary identification number for the baby.  No other payers require this tight timeframe.  New Jersey Hospital Association has reached out to Horizon NJ Health to request a discussion on this topic.

 

Medicare

  • March 3, 2017 “Open Claims Issues” attached with the dates for the scheduled fixes.
  • Medicare Change Request MM9935 informs providers of the update to the Medicare Claims Processing Manual to include instructions on the Medicare Outpatient Observation Notice (MOON). Hospitals are required to provide the MOON to beneficiaries who receive observation services as an outpatient for more than 24 hours. (See Attached)
  • Medicare Change Request MM9818 has been revised. The revision clarifies how Medicare will process inpatient claims for services in a Non-VA facility that were not authorized by the VA. (See Attached)

 

  • Medicare Change Request MM9876 informs providers that influenza virus code 90682 will be payable by Medicare for dates of service on or after July 1, 2017. (See Attached)

 

 

No Fault Internal Appeals Procedure

Effective April 17, 2017, The Department of Banking and Insurance (DOBI) implements changes to the No Fault appeal process. The Requirements for Insurer Internal Appeals Procedures, published in the New Jersey Register at N.J.A.C. 11:3-4.78, creates Pre-Service and Post-Service Appeal Forms for Insurers Internal Appeal Procedures (attached).  The attached Appeal Forms were created to make the appeal process uniform for all No Fault payers.  Also attached are Frequently Asked Questions about the Internal Appeal Rule found on DOBI’s website.  Important facts:

  • An appeal letter, supporting the required “appeal rationale narrative,” is required with the completed Post-Service Appeal Forms.
  • Medical records are required with the Post-Service Appeal Forms, if the records were not previously submitted to the payer.
  • Pre-Service Appeal Forms are submitted when the No Fault payer denied or modified a pre-certification request for service.
  • Pre-Service appeals must be filed within 30 days of the written denial from the No Fault payer.
  • Arbitration must be filed within 45 days from Post-Service Appeal Form submission.
  • Check payer web sites for correct appeal fax numbers.

Industry Trends – January 2017

January 31st, 2017

INDUSTRY TRENDS

Medicare

  • The February 1, 2017 “Open Claims Issues” is attached with the dates for the scheduled fixes.
  • The “New Jersey Part A Top Claim Submission Errors” is attached with the resolution to correct the errors.
  • Medicare Change Request MM9956 informs providers of the latest tests approved by the FDA as waived tests under CLIA. (See Attached)

 

 

Medicaid

  • Medicaid released newsletter Volume 26 No. 18 providing an updated listing of surgical procedures that require a second opinion. (See Attached)
  • The Division of Medical Assistance and Health Services reported that drug testing CPT codes (G0477, G0479, G6038, G6039 and G6040) are valid codes. Unfortunately, the Medicaid system rejects claims billed with these codes that have 2016 dates of service. Claims with 2017 dates of service accept these CPT codes.       Medicaid plans to release a remittance advice message during the week of February 6, 2017 advising providers to resubmit claims with 2016 dates of service.

 

NJ HFMA PFS

NJ Economic Engine Report: New Jersey acute care hospitals provide the following in 2015:

  • $3.1 billion in purchased goods and services
  • 142,000 jobs, which included more than 119,000 full-time jobs
  • $8.7 billion in employee payroll spending
  • $483 million in estimated State income tax paid by employees.

 

NJ Issues

  • Property Tax
    • Active hospital/municipality property tax litigations are currently underway with 33 nonprofit hospitals.
    • This issue remains stalled due to a lack of agreement among key policy makers on how to proceed. The New Jersey Hospital Association (NJHA) will elevate the issue with a letter-writing campaign to key lawmakers and ongoing public outreach on the economic and community benefit contribution of the State’s hospitals.
  • Out of Network
    • NJHA supported the NJ state Senate version of the out-of-network legislation that would amend the bill to have the out-of-network payment be the highest of the Medicare rate, UCR or the average in-network rate paid by the insurer. The hospital could still arbitrate if they did not like that payment.
    • The version in the NJ Assembly that is not supported by NJHA would cap out-of-network payments to a range of between 100-250% of the Medicare rate.
    • The bill was supposed to come before the Senate Budget Committee December 5, 2016, however at the last minute Senator Vitale held the bills saying significant progress towards compromise was in process. It is still awaiting committee hearings and it is unknown when they will occur.
  • Disproportionate Share Hospital (DSH)
    • For the second consecutive year, Myers and Stauffer will distribute and collect the DSH surveys and supporting documentation using their dedicated Web portal. Providers are strongly encouraged to begin the process of pulling the internal exhibits that will be utilized for the 2014 DSH survey.
    • The webinar on the 2014 Medicaid DSH examinations has not yet been scheduled but Myers and Stauffer will communicate the details as soon as they are available and is expected in the coming weeks.
    • Providers with questions or concerns about the upcoming Medicaid DSH examinations for 2014 can submit them in advance of the annual training webinar.
    • NJHA will collect any comments and submit them to Myers and Stauffer directly. Providers should email Jennifer Thomas, coordinator of financial performance and reimbursement at jthomas@njha.com with their questions.

Federal Issues

      • Trump Transition:
        • U.S. Representative (R-GA) Tom Price is the designee to lead the Department Health and Human Services. His appointment cleared the Senate Finance Committee on February 1, 2017. They suspended their rules of operation to facilitate the approval.
          • A leading critic of the Affordable Care Act (ACA) or Obamacare, Price has introduced repeal-and-replace legislation in each Congress since 2010.
          • In addition, Price
            • proposed language that would eliminate the ACA’s exchanges and coverage mandate, and
            • advocated for policies including high-risk pools, allowing Medicare opt-outs along with tax credits to purchase a personal health plan and a repeal of Medicaid expansion.
        • Seema Verma, Centers for Medicare and Medicaid Services (CMS) Administrator Designee.
          • Verma is the CEO and founder of SVC Inc., a national health policy consulting company. She previously worked with Vice President-elect Mike Pence to design and implement Indiana’s Medicaid expansion plan for low-income individuals.
          • Verma also designed Medicaid reform and expansion programs, including waivers, in a number of other states.
            • She participated on the Republican Governor’s Public Policy Committee on Medicaid reform and contributed to the development of the report “A new Medicaid: A Flexible, Innovation and Accountable Future.”
        • ACA: The Republican party and incoming Trump administration has expressed their desire to repeal the ACA as soon as possible.
          • The Process: Congress plans to use the reconciliation process to achieve repeal quickly.
            • Reconciliation instructions will be included in an upcoming budget resolution (next two weeks).
              • The instructions will need to change spending by specified amounts as only those items that affect spending or revenue are eligible for reconciliation.
              • The budget resolution must pass both the House of Representatives and the Senate, but not the President. The Republicans have a majority in both.
              • Congress could pass two budget resolutions in 2017: one in January 2017 for the ACA and a second one later in the year for Medicaid restructuring and tax reform.
            • Reconciliation bills will follow and only need 51 votes to pass in the Senate. Some things that could be included:
              • Subsidies for purchasing insurance
              • Tax credits
              • Penalties for not having insurance
              • Medicaid expansion
            • Things that CANNOT be included:
              • Parental coverage for children up to age 26
              • Pre-existing coverage exclusion
              • Banning annual/lifetime limits
            • It is likely that repeal will pass quickly but the effective date will be delayed for a certain period of time to allow for replacement plans to be drafted. A transition period of 2-4 years has been floated however the “Freedom Caucus” has called for a much shorter time frame of 6 months or less.
            • Replace: it is unclear as to what this may look like. Speaker of the House, Paul Ryan has drafted a 37-page concept paper “A Better Way” which may offer ideas as to what they may pursue. Included in the paper:
              • Tax credits adjusted for age;        
              • Enhancement of the value of Health Savings Accounts (HSA’s)
              • Permission to purchase insurance across state lines
              • Per capita caps for Medicaid funding across four categories:
                • Aged
                • Blind and disabled
                • Children
                • Adults
                • States could opt out of the per capita cap and get a block grant.
      • Elimination of CMMI in 2020
      • American Hospital Association (AHA) statement: Any repeal effort must take place with a simultaneous installation of a replacement program. Otherwise, all funds secured from hospitals and post-acute providers should be restored or set aside.
      • The Impact:
        • Fiscal years 2010-2017:
          • NJ hospital contributions in support of the ACA: $1.437 billion
          • NJ post-acute contributions in support of the ACA: $430 million
        • FY 2018-2019 projected:
          • NJ hospital contributions in support of the ACA: $1.011 billion
          • NJ post-acute contributions in support of the ACA: $326 million
        • 10-year totals
          • Hospitals: $2.448 billion
          • Post-acute providers: $756 million
        • AHA has published a report detailing the potential impact of repeal. Their results:
          • The loss of coverage would have a net impact on hospitals of $165.8 billion with the restoration of Medicaid DSH reductions;
          • The ACA Medicare reductions are maintained and hospitals will suffer additional losses of $289.5 billion from reductions in their inflation updates;
          • Full restoration of Medicare and Medicaid DSH payment reductions embedded in ACA would amount to $102.9 billion back to hospitals.

Industry Trends – December 2016

January 3rd, 2017

INDUSTRY TRENDS

Medicare

The January 3, 2017 “Open Claims Issues” is attached with the dates for the scheduled fixes.

 

NJ HFMA PFS

NJ Out of Network Issue

  • There is a version of the bill in the assembly which would cap out of network payments to a range of between 100-250% of the Medicare rate.
  • Before being posted in the Senate the sponsors asked the hospital industry to consider a position of “Support” and they would amend the bill to instead have the out of network payment be the highest of the Medicare rate, UCR or the average in network rate paid by the insurer. The hospital could still arbitrate if they did not like that payment.
  • After lengthy discussions with the Executive Committee of the NJHA Board, they voted unanimously to support the Senate version of out-of-network legislation, with the compromise amendments to avoid the cap based on Medicare rates. The Medical Society of New Jersey still opposes the bill.
  • The bill was supposed to come before the Senate Budget Committee December 5, 2016, however at the last minute Senator Vitale held the bills saying significant progress towards compromise was in process. It is unknown if or when it will resurface.

Federal Issues

 21st Century Cures Act

  • The Senate voted 94-5 this week to approve the most expansive health related legislation since the creation of the Affordable Care Act in 2010, a set of bills commonly referred to as the 21st Century Cures Act. The House already approved the bill. It now heads to the President for his signature; he supports the bill.
    • The package authorizes funding for medical research, reforms the federal approval processes for devices and pharmaceuticals, restructures mental health agencies and programs and makes hospital Medicare payment changes. Some key items in the bill:
      • A socioeconomic adjustment to the Medicare readmissions penalty program
      • Funding for opioid programs
      • Relief from the Long-Term Care Hospital 25 percent rule
      • The ability to bill Medicaid separately for mental health and primary care services provided to an individual on the same day

 

    • MOON: CMS has released the final, OMB-approved Medicare Outpatient Observation Notice (MOON) / CMS-10611, and instructions. Hospitals must begin using the MOON no later than March 8, 2017.
  • Trump Transition:
    • President-elect Donald Trump selected U.S. Rep. Tom Price to lead the Department Health and Human Services and Seema Verma to head the Centers for Medicare and Medicaid Services.
      • Price is a leading critic of the ACA who introduced repeal-and-replace legislation in each Congress since 2010. He was the lead author of the 2015 ACA repeal bill that passed the House and Senate and was later vetoed by President Obama. He has advocated for policies including high-risk pools, allowing Medicare opt-outs along with tax credits to purchase a personal health plan and a repeal of Medicaid expansion.
      • Verma is the CEO and founder of SVC Inc., a national health policy consulting company. She previously worked with Vice President-elect Mike Pence to design and implement Indiana’s Medicaid expansion plan for low-income individuals. Verma also designed Medicaid reform and expansion programs, including waivers, in a number of other states.

 

    • Few details are known about Trump’s healthcare plans outside of repeal and replace the ACA. Little is known as to how he plans to complete that at this time. The AHA has published a report detailing the potential impact of repeal. The results are:
      • The loss of coverage would have a net impact on hospitals of $165.8 billion with the restoration of Medicaid DSH reductions;
      • The ACA Medicare reductions are maintained and hospitals will suffer additional losses of $289.5 billion from reductions in their inflation updates;
      • Full restoration of Medicare and Medicaid Disproportionate Share Hospital (DSH) payment reductions embedded in ACA would amount to $102.9 billion back to hospitals.

Industry Trends – November 2016

November 29th, 2016

INDUSTRY TRENDS

Medicare

  • The November 28, 2016 “Open Claims Issues” is attached with the dates for the scheduled fixes.
  • Medicare will begin removing the social security numbers from the identification cards. New identification cards will be issued with random numbers. New cards will begin to be mailed in April 2018.
  • Centers for Medicare & Medicaid released a Medicare guide explaining who pays first when the patient has other types of insurance coverage. (See Attached)
    • The following Medicare Change Requests and Special Editions were discussed at the November 17, 2016 AAHAM meeting:
    • Change request 9818 clarifies how claims should be billed and how Medicare contractors will process inpatient claims for services not covered by the Veterans Affairs and when the patients elect to receive services in Medicare Certified Facilities not authorized by the Veterans Affairs. (See Attached)
    • Change request 9782 provides updates to the therapy code list for physical therapy and occupational therapy for the calendar year 2017. Eight new codes have been added and four codes have been deleted. (See Attached)
    • Change request 9865 provides therapy caps for the calendar year 2017. (See Attached)
    • Change request 9735 provides a listing of services excluded from consolidated billing. The listing can be obtained at www.cms.gov/SNFConsolidatedBilling. (See Attached)
    • Change request 9603 advises providers of the use of modifier JW for claims with unused drugs from single use vials. The unused drug must be documented in the medical records. (See Attached)

Medicaid

The following issues were discussed at the November 17, 2016 AAHAM meeting:

    • Claims processing with edit code 480 (DRG change) were not mapping to the correct DRG. Claims with dates of service prior to October 1, 2015 should be submitted to the Hospital Reimbursement Unit at www.DHS.state.nj.us with a cover letter, including the name and telephone number of a contact person and the UB04. Claims with date of service after October 1, 2015 will be reprocessed.
    • Inpatient psychiatric claims denying with edit code 380 (HMO coverage) should be submitted to the Hospital Reimbursement Unit at www.DHS.state.nj.us with a cover letter, including the name and telephone number of the contact person, the UB04, EOB from the HMO and the Medicaid Remittance Advice.
    • Social hold claims should be sent to the Hospital Reimbursement at www.DHS.state.nj.us with a cover letter including the name and telephone number of the contact person, the UB04 and progress notes for each social hold day.

Industry Trends – October 2016

October 31st, 2016

INDUSTRY TRENDS

Medicare

  • The October 24, 2016 “Open Claims Issues” is attached with the dates for the scheduled fixes.
  • Attached is a listing of Medicare Part A most common claim errors and solutions.
  • Attached is Change Request 9793 providing the new influenza virus vaccine code. Implementation date is January 3, 2017.

HFMA

State Issues:

  • Property Tax Issue
    • A-3888 known as the “standing” bill, which would prohibit third party tax appeals, passed Assembly on September 19, 2016.
    • NJHA is pushing for its Senate counterpart (S-2212) to pass.
    • There are 37 property tax related litigations against not for profit hospitals in New Jersey in relation to the property tax issue.
  • Newborn Screening Fees
    • NJHA submitted comments on proposal to increase newborn screening fees from $90 to $150.
    • This would increase the cost statewide to $16M, a $6.5 increase over current levels.
    • Our letter asked for a breakdown of costs and which new tests they are covering, requirements to make insurance companies increase reimbursement for these tests and the option to use private labs for the testing, which may be more cost-efficient.Federal Issues:
  • Rules Expected in the Next Few Months:
    • OPPS Final Rule (including HOPD provision) – expected November 1.
    • MACRA Final Rule – originally was expected November 1, now believed it will come early, potentially in the next few days.
    • Home Health PPS/Value Based Purchasing proposed rule – expected shortly before November 1.
    • OIG/CMP Rules – expected before the end of the year.
    • 340B Omnibus Guidelines – rumors that this may come out next month.
    • Proposed CJR Changes – expected before the end of the Obama administration.
    • MOON – expected any day.
  • FAST Q2 2016: Latest FAST numbers for New Jersey acute care hospitals:
    • 5.7% operating margin (compared to 5.3% in Q2 2015).
    • 10% of hospitals operating in the red (compared to 17% in Q2 2015).
    • 185.3 days cash on hand (compared to 181.2 days in Q2 2015).
    • Inpatient admissions down 0.6%.
    • Outpatient visits up 2.1%.
    • Observation visits up 9.6%.

Industry Trends – September 2016

September 30th, 2016

INDUSTRY TRENDS

Medicaid

Medicaid released information that provides an update to the New Jersey Supplemental Prenatal Care Program (NJSPCP). This program provides prenatal medical care to pregnant women who would have qualified for the NJ FamilyCare Program, if they didn’t have immigration status.  (See Attachment).

 

Medicare

  • The September 19, 2016 “Open Claims Issues” is attached with the dates for the scheduled fixes.
  • PET scan claims are denying for missing/invalid diagnosis code. PET scan HCPCs 78816 and 78815 refer to cancer. These claims must have a cancer diagnosis code. Covered cancer diagnosis codes are found at:

https://www.cms.gov/medicare/coverage/determinationprocess/downloads/

 

New York Medicaid

New York Medicaid issued new 2017 ICD-10 codes for services provided from October 1, 2016 through September 30, 2017. The list is located at www.eMedNY.org.

 

Self Pay: Did you Know?

Certain insurance companies (NJ Cure) are known for sending payments which have the comment “if cashed, claim is considered “paid in full” and you will not bill the insured. Did you know that even if you DO cash the check, you have 90 days to RETURN the monies to the insurance company and pursue them for full payment?

 

HFMA Update

State Issue: Property Tax

  • NJHA sent out a blast e-mail to legislators in mid-August to call for swift passage of A-3635/S-2329, the moratorium and study commission bill, and A-3888/S-2212, known as the “standing” bill, which would prohibit third party tax appeals.
  • There are 35 property tax related litigations against not for profit hospitals in New Jersey outstanding in relation to the property tax issue.

 

Federal Issues

    • FY 2017 IPPS Final Rule
        • The final rule was released at the beginning of August, the below provisions will go into effect October 1, 2016.
    • Imputed Wage Index Floor – CMS finalized an extension of the imputed “rural” wage index floor policy for one year. The final imputed wage index floor for New Jersey in FY 2017 is 1.1358, an increase from the proposed FY 2017 value of 1.1257. According to the data currently published in CMS’s wage tables and NJHA’s modeling, the one-year extension of the imputed floor provision will benefit 18 New Jersey hospitals by $40.5 million in combined Medicare inpatient and outpatient payments in FY 2017.
    • Medicare Disproportionate Share Hospital (DSH) Reductions – CMS continues the Medicare Disproportionate Share Hospital (DSH) payment policy as mandated by the ACA.
      • For FY 2017, using Congressional Budget Office (CBO) estimates of the uninsured population from March 2015, CMS will retain 55.36% of the 75% uncompensated care pool, down from the 63.69% retained in FY 2016.
      • NJHA estimates a statewide reduction of $8.4 million in Medicare DSH payments in FY 2017 as compared to final FY 2016 Medicare DSH payments.
      • In addition, CMS did not finalize its proposal to begin the transition to Worksheet S-10 data for the Medicare DSH calculation in FY 2018.
        • Numerous commenters, including NJHA, expressed concerns regarding the quality of the data and urged the agency to delay the transition. The rule articulates that CMS expects to use Worksheet S-10 data in the calculation of Factor 3 in the future, no later than FY 2021.
        • In the interim, the agency will explore other ways of determining uncompensated care as used in Factor 3 of the DSH formula until the Worksheet S-10 data is ready for use.
    • Hospital Readmissions Reduction Program (HRRP)
      • CMS will add readmissions following coronary artery bypass graft (CABG) surgery to the HRRP for FY 2017. This is in addition to the four conditions that are already part of the program – pneumonia, heart failure and heart attack, chronic obstructive pulmonary disease (COPD) and total hip/total knee arthroplasties (THA/TKA).

 

 

Industry Trends – August 2016

August 28th, 2016

INDUSTRY TRENDS

Horizon NJ Health

  • Claims billed to Horizon NJ Health still have processing issues and hospitals are realizing increased receivables.   One hospital reported that they were told by TriZetto that their systems will not be fully updated until August 2016. To date, there does not seem to be material improvement. Issues include but are not limited to:
    • Claims are priced incorrectly.
    • Claims are returned if not completed on the red and white form. This includes some, but not all claims sent electronically.
    • Phone contacts take up to 45 minutes.
    • Claims deny for no authorization though the authorizations were obtained.
  • NJHA asked the Department of Business and Insurance to monitor. Providers who need assistance should contact Gregory Papazian via email at gregory_papazian@horizonblue.com. Mr. Papazian is responsible for all provider relations areas. You are encouraged to send this as a special request and NOT as a routine project list. If it is a routine “project” many hospitals noted it can take months to resolve.

 

Medicare

  • The August 30, 2016 “Open Claims Issues” is attached with the dates for the scheduled fixes.
  • Medicare Change Requests:
  • MM9603 will be implemented on January 3, 2017. Medicare is imposing the use of the JW modifier for any claims associated with discarded drug or biologicals not administered to any patient. This must also be documented in the patient’s medical record. (See Attachment)
    • SE1615 informs providers that Medicare will cover Zika Virus testing. (See Attachment)
    • MM9740 will be implemented on January 3, 2017. The Common Working File (CWF) is adding an auto-search capability that will eliminate the need to go through multiple hosts to obtain eligibility information.HFMA Update

Federal Issues: The Fiscal Year (FY) 2017 Proposed Hospital Outpatient Prospective Payment System (OPPS) Rule was released Wednesday, July 6, 2016.  Comments are due to CMS September 6, 2016.

  • Payment Update: CMS proposes to utilize the 2.8% hospital market basket increase for OPPS. Reductions will be taken as mandated by the Affordable Care Act (ACA):
    • 0.5% adjustment for multi-factor productivity and
    • an additional 0.75% adjustment.
    • this results in a net market basket of 1.55%.
  • ASC service payments are updated for inflation by the percentage increase in the Consumer Price Index for urban consumers (CPI-U), which is proposed at 1.7% for calendar year (CY) 2017.       In addition, there is a 0.5% multifactor productivity adjustment resulting in a net CPI-U update factor for CY 2017 of 1.2%.
  • Section 603 of the Bi-Partisan Budget Act:
    • CMS included information in the rule regarding implementation of Section 603 of the Bipartisan Budget Act of 2015.       Section 603 states that services furnished in off-campus provider based departments (PBD), (excluding dedicated emergency department services that began billing on or after November 2, 2015) will no longer be paid under the OPPS and will be paid under Part B payment systems beginning January 1, 2017.
    • Beginning in 2017, the rule proposes the payment be based on the physician fee schedule for site-neutral rates for most services furnished in a new off-campus PBD. The payment, which would be at the “non-facility” PFS rate, is for physicians only; CMS proposes no payment be made directly to the hospital by Medicare.
    • Existing off-campus PBD (before November 2, 2015) that expand their clinical services are subject to the site-neutral rate as would any facility that relocates after November 2, 2015.       An off-campus PBD that existed prior to November 2, 2015 and undergoes a change of ownership after that date will be exempt from the site-neutral rate only if the new owner accepts the existing Medicare provider agreement from the prior owner.
  • Electronic Health Record (EHR) Incentive Program:
    • In the rule, CMS recommends a 90-day reporting period for 2016, versus the full year.
    • They also propose to reduce the requirement for patients to view, download and transmit their information from the current 5% obligation down to a minimum of one patient.

 

State Issues The State Fiscal Year (SFY) 2017 Budget was finalized June 30, 2016:

  • Charity Care
    • The final SFY 2017 budget contains $200 million less for charity care, reducing in the pool from $502 million to $302 million. This is the result of a $150 million reduction in the Governor’s proposed budget and an additional $50 million cut that Governor Christie put forward as revenues lagged.
    • The Legislature stood with NJHA in rejecting this additional $50 million cut, but Governor Christie used the line-item veto to implement the reduction.
    • The charity care distribution formula uses the 2004 statute, pro-rating down to account for the reduced amount of charity care funding in the SFY 2017 budget. The distribution formula is the same as the one released in the Governor’s proposed budget in February.
    • The state is reimbursing hospitals with the highest relative charity care burden at 96% of what Medicaid would have paid for those patients (96 cents on the dollar) based on calendar year 2014 documented charity care. The formula removes any upward cap over the prior year that would have limited any charity care subsidy increase to hospitals.
  • Graduate Medical Education (GME) will see an increase of $60.7 million, raising that pool from $127.3 million to $188 million for the state’s 42 teaching hospitals.
    • The $188 million FY 2017 GME funding will be distributed using 2014 CMS Medicaid cost reports.
    • This year’s formula requires facilities receiving GME funding to report to the Commissioner of Health the number of physicians who plan to remain in New Jersey.
  • The Delivery System Reform Incentive Payment (DSRIP) fund will remain at last year’s level of $166.6 million.
  • The Mental Health Subsidy Fund will hold at the same level as last year at $24.7 million.