Hospital

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Monitoring provider coding and billing risks is a constantly evolving challenge.  One great tool to monitor high risk provider billing in your organization is the Comparative Billing Report (CBR).  CBRs are generated by Medicare Administrative Contractors and summarize Medicare claims data statistics for individual providers.  CBRs are released only to the individual providers they provide data for and present results of statistical analyses that compare an individual provider’s billing practices for a specific billing code or policy group with the practices of that provider’s peer groups and the national averages. Each CBR is unique to its recipient, and each provider sees only his/her own billing data. No data attributable to any specific provider is made publicly available.

While healthcare organizations do not have access to specific providers’ reports or data, CBR topics and national- and state-level data are available online.  Healthcare organizations can combine these datasets with their providers’ Medicare claims data to monitor for potentially high outlier providers within its network.  Dean Dorton has developed an interactive report which breaks down the topics and benchmarks for select CBR topics from recent years.

Dean Dorton Healthcare

Lance Mann, CPA, CFE, CGMA
Assurance Director
lmann@deandortonstg.wpenginepowered.com • 502.566.1005

Adam Shewmaker, FHFMA
Healthcare Consulting Director
ashewmaker@ddafhealthcare.com • 502.566.1054

Article Dean Dorton

The President signed the bipartisan CARES Act on March 27, 2020, providing $100 billion in relief funds to America’s healthcare providers and facilities in response to COVID-19.  On July 22, 2020, the Department of Health and Human Services (HHS) updated their Frequently Asked Questions (FAQ) page with important information regarding the applicability of Single Audit requirements for entities receiving Provider Relief Funds under the CARES Act.

Both non-for-profit and for-profit entities who have received and expended more than $750,000 in Provider Relief Funds (CFDA 93.498) within a fiscal year will be required to have a single audit completed on these funds.

See below for frequently asked questions:

Our team of experts hosted a webinar on August 13, 2020 to provide more information about the Single Audit process and walk through these new requirements. If your organization is new to Single Audits, we highly recommend that you watch the webinar recording.

In addition, we will inform you of a follow-up webinar later in the coming months after the 2020 Compliance Supplement that includes CARES Act procedures is released.

Watch the Webinar

For more information on Provider Relief Funds follow the link below:

More Information

Article Dean Dorton

Are you ready to comply with the new Hospital Pricing Transparency Requirements? Have you started on your calculations yet? Is this project a priority right now? If not, it’s time to take serious action.

The rule requires hospitals to publish their negotiated rates for certain services with insurers by January 1, 2021.

Two broad requirements of the rule are:

  • Producing annually a machine-readable file of “standard charges for all hospital items and services (including gross charges, discounted cash prices, payer-specific negotiated charges, and deidentified minimum and maximum negotiated charges).”
  • Displaying online “discounted cash prices, payer-specific negotiated charges, and deidentified minimum and maximum negotiated charges for at least 300 ‘shoppable’ services.”

Why should I be concerned?

The calculations themselves are more than simple copy and paste into a Microsoft Excel® document and post online.

Consider the following:

  1. Time crunch—this rule was contested in court by the American Hospital Association and it was upheld—now you only have 6 months to comply
  2. Complexity—the rule requires hospitals to perform complex calculations/analysis to generate the required files
  3. Stretched resources—you may not have the expertise or available manpower to comply by January 1, 2021

What happens if I don’t comply?

Various penalties are possible.

Hospitals that do not meet the rule’s requirements by January 1, 2021 face a range of possible actions, including:

  • Warning notices
  • Requests for corrective-action plans
  • Levies of civil monetary penalties of up to $300 per day
  • Publicizing of penalties (which could put your hospital at a competitive disadvantage if patients would rather choose a provider that is complying with the rule)

We need help, now what?

We are helping many hospitals (of all sizes) comply with these requirements by performing analysis and calculations for them. Dean Dorton’s healthcare consulting team has the right experience and expertise to help you with the calculations, analysis, and compilation of the list required to comply by January 1, 2021. We provide hospital price transparency services which include the following:

  1. Update your machine-readable Standard Charge files with payer-specific negotiated rates
  2. Analyze the hospital’s prior year volume to identify the facility’s top 300 shoppable services
  3. Create a list of the hospital’s top 300 shoppable services with payer-specific negotiated rates

Adam Shewmaker, FHFMA
Director of Healthcare Consulting Services
ashewmaker@ddafhealthcare.com • 502.566.1054

More information:

Calendar Year (CY) 2020 Outpatient Prospective Payment System (OPPS) & Ambulatory Surgical Center (ASC) Price Transparency Requirements for Hospitals to Make Standard Charges Public final rule (CMS-1717-F2):

Final Rule

Fact sheet on the Transparency in Coverage Proposed Rule (CMS-9915-P):

Fact Sheet

Article Dean Dorton

The House’s latest Medicare extenders bill, proposed by Rep. Kevin Brady, chairman of the Ways and Means Committee, would extend several Medicare payment provisions sought by rural hospitals. Medicare payment programs such as the Medicare Dependent Hospital Program, the Low-Volume Adjustment Programs, and payments for Ground Ambulance Add-Ons and the Home Health rural add-on services, which are key aspects of rural healthcare, would be extended. But the detrimental cut to at least partially pay for all the extensions will be the swing bed payments used by many critical access hospitals (CAH). The proposal aims to cut swing bed payments to the lower Skilled Nursing Facility Prospective Payment System rates. Swing bed services are currently paid at the 101% of reasonable costs at CAHs.

This proposal, however, is not new. It was an issue in 2010 when the Office of Inspector General (OIG) recommended the same cut to swing bed services at CAHs. The recommendation was met with great opposition from CMS due to concerns with the OIG’s findings on the availability of skilled nursing services at nearby facilities and OIG’s calculations of potential savings appeared inflated, especially with the additional costs of transportation of moving a patient to an alternative facility.

The current bill is also met with opposition by organizations such as the American Hospital Association (AHA) and the Critical Access Hospital Coalition. Thomas Nickels, executive vice president of the AHA, stated that the AHA strongly opposed the cuts to CAHs to pay for the Medicare extensions as “CAHs are often the only source of healthcare in their communities and swing bed services allow seniors to stay close to home to receive care, rather than being transferred to another facility. This is the time when Congress should be looking to stabilize access to care, rather than reducing payments for critical healthcare services in our most vulnerable rural communities.”

The Critical Access Hospital Coalition wants its member hospitals to call on state representatives to protect swing bed payments rates.

Questions?

Dan Schoenbaechler | dschoen@ddafhealthcare.com | 502.566.1097
Shawn Stevison | sstevison@ddafhealthcare.com | 502.566.1066

Article Dean Dorton

The use of prospective financial statements continues to grow as companies require their use to obtain financing and raise capital. Now more than ever, sophisticated investors and bankers want to know what “will” rather than what “did” happen.

Due to the need for more “forward-looking” information, the American Institute of Certified Public Accountants Codification of Statements on Standards for Attestation Engagements officially codified Financial Forecasts and Projections in January 1989, giving accountants standards to follow when preparing forecasts and projection reports.

Why does the matter to me? For any businesses, prospective financial statements may be needed for a number of reasons including:

  1. Obtain bank financing
  2. Private or public placement
  3. Internal management decisions

Dean Dorton performs forecasts and projections for many scenarios including closely-held businesses’ internal use only and third-party use examination engagements for boards and banks.

In recent years, Dean Dorton has provided forecasts and projections related to the United States Department of Agriculture’s (USDA) Rural Development programing. Most of the USDA related projects require an examination report from an independent accountant on the project’s feasibility. As per the USDA’s Fiscal Year 2015 Rural Development Progress Report, the USDA invested $29.75 billion in nearly 171,000 projects across the nation. Many of those projects have been in Kentucky and Southern Indiana.

Some of our other recent forecasts and projection projects:

  • A new hospital patient tower
  • New hospital construction to move to all single-occupancy rooms
  • New building construction or expansion for college and universities
  • Improved debt service requirements with debt restructurings and refinancing

To learn more, contact your Dean Dorton advisor or David Richard at drichard@deandortonstg.wpenginepowered.com.

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Are YOU Ready?

On October 1, the Centers for Medicare and Medicaid Services (CMS) lifted its partial code freeze and thousands of new codes went into effect. In addition, the Medicare grace period on code specificity for Part B post-payments audits also ended.

According to CMS, the ICD-10 flexibilities “were solely for the purpose of contractors performing medical review so that they would not deny claims solely for the specificity of the ICD-10 code as long as there is no evidence of fraud.” These flexibilities are not extended beyond October 1, and CMS plans no other guidance around the topic.

What does that mean for your coding efforts?

For most organizations, the biggest adjustment will be avoiding unspecified ICD-10 codes when documentation supports a more detailed code. CMS is not phasing in specificity requirements, as it believes providers should already be coding to that level. Historically, insurance companies do not outwardly specify which codes they will and will not reimburse. This is because insurers want providers to submit claims based on the accuracy of a patient’s condition, not based on which codes get paid.

The Centers for Disease Control and Prevention (CDC), which administers the diagnosis codes, released the 2017 ICD-10-CM codes on June 24, 2016. This information can be found at www.cms.gov. There are 1,974 additions, 311 deletions, and 425 revisions. The resulting total for diagnosis codes is 71,486.

The addenda for the Index, Table of Drugs and Chemicals, Neoplasm Table, External Cause Index, and Tabular are included in this release. The addenda provide information regarding the changes for the code set.

The Code Descriptor in Tabular Order provides the code descriptor at each level of the code set. Of special interest, the 2017 ICD-10-CM Official Coding and Reporting Guidelines contains a new coding convention #19 in regards to Code Assignment and Clinical Criteria. This guidance states “the assignment of a diagnosis code is based on the provider’s diagnostic statement that the condition exists. The provider’s statement that the patient has a particular condition is sufficient. Code assignment is not based on clinical criteria used by the physician to establish the diagnosis.”

A brief highlight of some of the additions and changes throughout the code set include:

  • There is only one addition to Chapter 1 (Infectious and Parasitic Diseases) which is A92.5. This code has been assigned by the World Health Organization (WHO) for the Zika Virus.
  • The changes in Chapter 5 (Mental, Behavioral, and Neurodevelopmental Disorders) include additions to capture hoarding, various obsessive-compulsive disorders, and social pragmatic communication disorder.
  • Chapter 9 (Diseases of the Circulatory System) updates include the addition of hypertensive urgency, emergency, or crisis; reducing specificity of nontraumatic subarachnoid hemorrhage and the communicating artery; expansion of the cerebral infarction and sequela of stroke codes; addition of aneurysm of precerebral and vertebral arteries; and addition of dissection of unspecified arteries.
  • Chapter 13 (Diseases of the Musculoskeletal System and Connective Tissue) added bunion, bunionette, pain in joints of the hand, more specificity to temporomandibular joints, cervical disc disorders at specific levels, atypical femoral fractures, and periprosthetic fractures.
  • Chapter 14 (Diseases of the Genitourinary System) have a few title changes as well as the code additions for specific urinary incontinence conditions, various prostatic dysplasia, testicular and scrotal pain, erectile dysfunction, ovarian cysts, conditions of the fallopian tubes, and complications of the urinary tract including fistulas, hemorrhage, infection, malfunction, et cetera.
  • Chapter 19 (Injuries, Poisoning, and Certain Other Consequences of External Causes) changes include significant number of additions regarding the specific fractures to bones of skull; various fracture types of the foot; title revisions to complications involving prosthetic devices; new stenosis of cardiac stent codes, and additions to complication types including breakdown, displacement, infection, erosion, exposure, pain, fibrosis, thrombosis, and leakage.

After review of the entire list of ICD-10 changes contained in the CDC link above, it becomes increasingly evident that the level of code detail creates an unprecedented opportunity to improve documentation accuracy and specificity, which will ultimately help drive better patient outcomes.

Dean Dorton can help by offering comprehensive coding chart audits and physician education training. For more information, contact Dawn Wilson at 502-566-1007 or dwilson@ddafhealthcare.com.