Alerts Posts

DHCS Invites DPNFs to File Supplemental Medi-Cal Claims

Wednesday, September 25th, 2013

A few weeks ago, DHCS emailed* public DPNFs a package enabling them to file DPNF supplemental Medi-Cal claims for the period from 6/1/11 to present. This email shows the state’s recognition that all public DPNFs qualify for this program due to the AB97 rate freeze/cut, even those with rates below the statewide maximum. This program enables public DPNFs to recoup 50% or more of the AB97 rate freeze/cut, including any eventual retroactive “clawback” if and when it occurs.

HFS Can Assist with DPNF Claim Submittal

HFS has been assisting several public DPNFs by preparing the claims for supplemental payment. Our professionals can provide a range of assistance depending on your organization’s specific needs, from simply providing education, to reviewing facility-prepared claims submissions, all the way to preparing the actual claims and following through to final payment.

For more information please contact John Pfeiffer, 510-867-1314, or

* If you did not receive the email package, contact John Pfeiffer:

ACA Mandatory Employee Notification – Deadline Approaching

Tuesday, September 24th, 2013

A little noticed provision in the Patient Protection and Affordable Care Act (ACA) requires ALL employers to notify their employees of the health insurance options they have available to them as a result of enactment of the ACA. According to the Department of Labor, all employers covered by the Fair Labor Standards Act (FSLA) are obligated to make the health insurance notification by OCTOBER 1, 2013. An FSLA covered employer is one with at least one employee and $500,000 in revenue.

This notification MUST occur whether the employer provides health insurance to the company’s employees or not. The Department of Labor has provided information about this mandatory notification and made model forms available for employers to use. (more…)

Implement EHR Now To Get Incentive Payments

Wednesday, June 26th, 2013

According to data released by HHS and the Wall Street Journal, more than half the physicians in the United States have received an incentive payment from the Federal Government for the implementation of certified Electronic Health Record (EHR) technology and the demonstration of Meaningful Use. Are your physicians part of this statistic?

Who is an Eligible Professional?
Medicare incentive payments for Eligible Professionals (EPs) started in 2011 and will be paid through 2016. EPs are defined as physicians, nurse practitioners, certified nurse-midwives, dentists, optometrists and physician assistants working in an FQHC or RHC that is led by a physician assistant. (more…)

DPNF Supplemental Payment Claims for AB97 Cuts Must be Filed Soon

Monday, June 17th, 2013

Two-Year Window is Closing
In recent months, DPNFs have been extremely active on the legal, political and legislative fronts to try to eliminate the onerous AB97 rate cuts and the potential “clawback” of payments the state made since June 1, 2011.

The legal effort got another setback when the U.S. Ninth Circuit Court recently decided to support the AB97 cuts. While there are still potential legal strategies which the industry might pursue, the outlook does not look good. On the legislative side, the industry is strongly backing AB900, but that law would only eliminate the rate cuts starting 7/1/13, leaving 25 months of AB97 rate cuts still in effect. (more…)

Relief from DPNF Rate Cuts

Thursday, January 31st, 2013

Supplemental Payments for Public DPNFs Are Available

Last month, a federal appeals court cleared the way for the AB97 Medi-Cal rate cuts to take effect. This makes it nearly certain that severe DPNF rate cuts (the 08-09 rates less 10%) will be implemented retroactive to June 1, 2011. For many facilities, the resulting rates are 10-20% below what the normal rates would be. This means that DPNFs, many of whom are almost wholly reliant on Medi-Cal payments, will soon be assessed a large payback by the state. However, a long-standing but little known state program is available to provide CPE-generated supplemental payments for publicly-owned or operated DPNFs. While this program will not replace the entire shortfall, it will still provide significant relief of at least 50% of the rate cuts.

DPNF Public Hospital Supplemental Payment Program

The Medi-Cal DPNF supplemental payment program has been in existence since 2001. It is similar to the hospital outpatient program (AB915) in that public DPNFs can claim a supplemental payment equal to the federal share of the amount by which costs exceed the payments received. In past years, prior to the rate cuts, only DPNFs with rates above the statewide median (currently $416.95) qualified for this program, because they were the only ones whose rates fell below projected costs. However, with the rate cuts of recent years, DPNFs with rates below the median now qualify for the program.

Timely Claim Forms Submittal!

The state has only a two-year window in which to claim the federal portion of the CPE from CMS. This means that DPNFs must be timely about submitting the claim forms. The state uses quarterly claim forms, and most DPNFs that already participate in the program submit a claim every quarter. DPNFs newly affected by the rate cuts should submit claim forms for quarters as far back as allowed.

HFS Can Help

HFS is assisting district and county DPNFs in preparing the claims for supplemental payment. Our professionals can provide a range of assistance depending on your organization’s specific needs, from simply providing education, to reviewing facility-prepared claims submissions, all the way to preparing the actual claims and following through to final payment.

We would be happy to answer any questions or assist with your DPNF supplemental payments. Please contact John Pfeiffer at 510-867-1314 or

Long Term Care Hospital Technical Trainings related to the LTCH CARE Data

Tuesday, August 28th, 2012

Submission and LASER Available for Download

CMS wants to ensure that Long-Term Care Hospitals (LTCHs) are aware of the following technical trainings related to the LTCH Continuity Assessment Record and Evaluation (CARE) Data Submission and LTCH Assessment Submission Entry & Reporting (LASER) that are available for downloading on the Quality Improvement and Evaluation System (QIES) Technical Support Office website.

Data Submission Recorded WebEx Trainings:

  • CMSNet and QIES User ID Registration Training –Now posted
  • LTCH Assessment Submission Process – Being posted this week
  • LTCH Assessment and Validation Reports – Being posted this week

LASER Trainings Available Now on 

  • LASER Login Process
  • LASER Patient and Assessment Entry
  • LASER Import and Export Process
  •  LASER Reports
  • LASER Demonstration Version of the tool

Please note the following required information pertaining to the CMSNet and QIES User ID Registration Training Recorded WebEx LTCH User ID Registration Process:

  • Effective August 20, LTCH providers required to submit LTCH CARE assessments for the LTCH Quality Reporting Program, may begin registering for their CMSNet and QIES User IDs. The CMSNet User ID allows users to access the CMS private Wide Area Network or WAN, where the LTCH CARE Submissions and CASPER Reporting systems reside.
  • Each provider will be allowed two CMSNet User IDs and two QIES User IDs. LTCH providers will be required to request the CMSNet user IDs first, followed by an online registration process for the QIES User ID.
  • It is important that the User ID registration processes be completed by September 14, 2012 to ensure that the necessary User IDs are available and activated prior to the October 1, 2012 LTCH CARE assessment submission requirement.

Please contact the QTSO Help Desk by phone, at 877-201-4721, or by email at if you have questions regarding this training session.

Help with the CARE Tool

HFS Consultants can assist with data gathering with the CARE tool and monitoring accuracy.

For more information, please contact Pat Bishop, at 800-888-4966, or

This information was included in the August 22, 2012 edition of the CMS Medicare FFS Provider e-News.

New CMS Demonstration Program

Tuesday, August 21st, 2012

Recovery Audit Pre-payment Review

CMS is now expanding its Medicare Recovery Audit program (RAC) to allow auditors to review claims before being paid to ensure compliance with Medicare payment rules. 

This demonstration program is in addition to the RAC program of the past several years where auditors review claims after payment. That program is remaining unchanged. In this demonstration program, CMS is focusing on seven states, including California, where past retrospective audits have resulted in high rates of payment recoveries. Four other states, excluding California, are set for audits of short impatient stay claims.

Demonstration Program Begins Aug. 27

CMS claims that this demonstration project will also lower what it calls error rates by focusing on claims prior to payment instead of what is called the traditional “pay and chase” method. This program will include Medicare inpatient claims for all general acute care hospitals. This demonstration begins on August 27, 2012 and lasts until August 26, 2015.

Which MS-DRGs Are Being Reviewed?

The California RAC auditor, Health Data Insights (HDI), will review the following MS-DRGs claims for the next six months beginning on August 27, 2012:

  • 312 Syncope & Collapse
  • 069 Transient Ischemia
  • 377 GI Hemorrhage w/MCC
  • 378 GI Hemorrhage w/CC
  • 379 GI Hemorrhage w/o CC/MCC
  • 637 Diabetes w/MCC
  • 638 Diabetes w/CC
  • 639 Diabetes w/o CC/MCC

After the six months, CMS has the option to increase the number of MS-DRG’s to be reviewed.  This review will be in addition to any other RAC reviews the hospital is currently experiencing as well as any other pre-payment MAC reviews. Additionally, all short stays will have the possibility of being reviewed for medical necessity. Hospitals receiving an Additional Document Request will have 30 days to submit documents. The RAC ( HDI.) will have 45 days in which to make a determination from the submitted data.

Help with Medical Documentation From HFS Experts

HFS believes that this new RAC effort will place a further burden on hospitals. In addition to potential payment denial, the pre-payment audit will impact cash flow by delaying payment for valid claims during the RAC audit process for up to 75 days. We believe that a proactive internal review of specific claims can benefit a hospital by helping to assure that Medicare rules are being followed and provide a basis for potential appeals of RAC denials. The Health Information Management group at HFS has extensive experience in assisting clients with medical documentation issues.


Call Gwynn Smith, HFS’s Director of Revenue Cycle Management, for an in-depth briefing and find out ways to minimize the impact of this new RAC effort on your hospital. Gwynn can be reached at 510-867-1309 or by email at

Are You Prepared for CMS Validation Surveys?

Wednesday, August 15th, 2012

The Centers for Medicare and Medicaid Services (CMS) is empowered to survey an accredited provider to validate the accreditation process of the Accrediting Organization, e.g. The Joint Commission or DNV. While all hospitals are subject to periodic accreditation surveys, the CMS surveys can be extremely rigorous and stressful. In many cases, hospital senior management may be singularly focused on the survey for a period of months.

HFS has found that while hospitals are usually well equipped to deal with periodic surveys from organizations such as The Joint Commission, they may not be as prepared for a CMS survey. There are two types of validation surveys:

  • Surveys conducted on a representative sample basis. These may be comprehensive surveys of all Medicare conditions or focused surveys on a specific condition or conditions.
  • Surveys in response to a “substantial allegation” are generally the result of a complaint. These surveys focus on those Medicare conditions related to the allegations.

Sanctions Resulting From CMS Surveys

CMS surveys are performed within the context of Medicare “Conditions of Participation” and can result in sanctions, including monetary penalties or the threat of decertification from the Medicare program. Compounding this is the fact that these sanctions are in addition to any imposed by the California Department of Public Health in its citation process.

Is Your Facility A Candidate for a CMS Visit?

CMS surveys, like accreditation surveys, are unannounced, but there are some indicators that a facility may be a candidate for a CMS visit. Here are some questions to ask:

  • Have we had frequent visits by CDPH following up on complaints?
  • Did the last CDHP visit result in substantial allegations of noncompliance?
  • Have we had a recent accreditation survey?
  • Did our last accreditation survey result in a number of deficiencies?

Other things that can result in a CDPH or CMS focused or comprehensive survey:

  • A death as a result of restraint or seclusion reported to CDPH and CMS.
  • Alleged discrimination against anyone with HIV positive status.
  • ESRD service complaints.

HFS Can Help

HFS has extensive experience in helping hospitals in quality management initiatives and preparing for accreditation surveys, including “mock” surveys. We have made assistance in the area of CMS surveys a priority, particularly in the area of survey preparedness. There have been about 20 CMS surveys in California in the past year. This is an area that deserves careful attention given the potential for a negative impact on a hospital’s reputation.


For more information, please contact Pat Bishop, at 800-888-4966, or Watch for further HFS alerts related to CMS surveys.

Sweeping Changes to District and Municipal Hospital Payments

Tuesday, August 7th, 2012

Effective July 1, 2012, the state of California made the biggest changes in decades to Medi-Cal reimbursement for district and municipal hospitals (known as Non-Designated Public Hospitals, or NDPHs). The payment methodology has changed from the choice of either a contracting or cost-based model to one based on Certified Public Expenditures (CPEs), plus an Uncompensated Care Pool and a Delivery
System Reform Incentive Program (DSRIP). This CPE-based methodology is in effect for at least three years.

Submit DSRIP Plan to Avoid Funding Loss

While this payment change engenders many implications affecting NDPHs, the most pressing issue is submitting an adequate DSRIP plan. DSRIP will account for approximately 20% of total Medi-Cal funding, so failure to submit a plan and claim those payments is not a viable option for most hospitals. The DSRIP plan must meet DHCS and CMS requirements, be monitored over a three-year period, and improve population health and clinical quality (including the patient care experience) in four categories: Infrastructure Development, Innovation and Redesign, Population Focused Improvements, and Urgent Improvement in Patient Care.

DSRIP Payment Toolkit

In association with Steve Clark and Associates (SCA), we have developed a toolkit of services to assist district and municipal hospitals in securing DSRIP payments. Our team of professionals can provide a range of assistance depending on a hospital’s specific needs, from simply reviewing a hospital-prepared DSRIP plan to full development and monitoring of the plan over three years.

October DSRIP Due Date

We believe DSRIP plans will have to be submitted by October 2012. The District Hospital Leadership Forum recently emailed its membership a DSRIP template for their reference and use.


Thursday, December 9th, 2010

CMS announced today December 9, 2010, that the amendment requiring the development of the HRIII RUG has been repealed.  Therefore, as of October 1, 2010 the RUG IV will remain in effect through out the 2010-2011 fiscal year.  Facilities will not need to monitor for possible payback of revenue received since October 1, 2010 under RUG IV. (more…)

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