Medicare Posts

Information for Clinics and other Safety Net Providers

Tuesday, February 18th, 2014

There are several updates on regulatory and other changes that impact RHCs, FQHCs and other clinic based providers. The following is information on: Medi-Cal Code 18 rate setting, tracking your combined payments, when you should bill the secondary bill, and Medicare rate setting.

calculator-handsMedi-Cal Code 18 Rate Setting Results
DHCS implemented Medi-Cal managed care into the remaining California counties effective November 1st. Clinics have either Anthem Blue Cross (“ABC”), Centene (“CHW”) or Partnership (“PHP”) as their managed care plan. Clinics should have submitted their initial Form 3100 to DHCS to obtain an initial rate Code 18 (“wraparound”) rate. We’ve noticed that DHCS Audits group has been approving the initial rate at 100% of the requested amount. This leads us to advise the following: (more…)

Healthcare Organizations Can Expect Financial Pinch in 2014

Wednesday, January 15th, 2014

The Patient Protection and Affordable Care Act (PPACA) is a game changer for hospital and health system revenues, costs, and operations. In addition, legislative and regulatory actions, as well as industry trends, will produce a challenging economic landscape for providers in 2014. HFS executives provide insight on the significant changes and trends that healthcare organization executives can expect in 2014.

CEO Insight on the Affordable Care Act
Trahan WhittenThe largest issue facing healthcare organizations is the multi-faceted impact of the PPACA on both revenues and expenses. Revenues are decreasing dramatically from both Medicare and Medicaid (Medi-Cal), which do not even cover the cost of care to their beneficiaries. At the same time, insurance companies are demanding lower rates and eliminating providers from their networks, which cannot compete on costs. This will place a premium on healthcare organizations’ ability to manage cost reduction, both labor and non-labor and to achieve revenue recovery in 2014. HFS is perfectly positioned to help accomplish these difficult competing priorities.
-Trahan Whitten


Medicare Bad Debts-FY 2013 and Beyond

Monday, August 26th, 2013

money_stethoscopeThe Middle Class Tax Relief and Job Creation Act of 2012 (the “Act”) delayed the implementation of significant reductions to Medicare physician payments that would have occurred in federal fiscal year (FFY) 2013.  In the budget neutral environment that now defines the Medicare and Medicaid programs, “funding” for this delay has to come from somewhere else within the system.  Thus, the Act also included several revisions to Medicare bad debt policy, some of them significant.  These changes will have varying impacts on Medicare bad debt reimbursement for hospitals, critical access hospitals, FQHCs and RHCs, and skilled nursing facilities.  In total, Medicare bad debt reimbursement for these types of providers is projected to decrease by almost $7 billion through FFY 2022.


Meeting the Health Insurance Exchanges Challenge

Monday, June 24th, 2013

Understanding the Financial and Operational Impact

The next stage in what is being called the largest change in American healthcare since the adoption of Medicare/Medicaid in 1965 begins on October 1, 2013, when Health Insurance Exchanges (or Marketplaces) are scheduled to open to enroll participants for coverage, which will begin on January 1, 2014.

thescopecalculatorAs the October 1 date rapidly approaches, some see this as an important step toward universal healthcare, while others see it as a potential “train wreck.” Will the Exchanges be able to meet deadlines for enrollment and coverage implementation? To date, 16 states and the District of Columbia have established state exchanges, including Washington, Oregon, California, Idaho, Nevada and Hawaii. The remaining states will be in federally facilitated marketplaces or a state/federal partnership exchange model. (more…)

Healthcare Reform Impacts FQHCs and RHCs in California

Tuesday, May 14th, 2013

PatientSignInAmong the changes mandated in the Affordable Care Act is the expansion in the next few years of Medi-Cal eligible patients. As part of the implementation of California’s Medi-Cal program, Medi-Cal managed care will be arriving in the 25 counties not currently using the plan. This now goes into effect on September 1, 2013. For those already enrolled in managed care plans, there are significant changes in the annual reporting.


HIPAA Compliance FAQs

Monday, April 8th, 2013

QandACommon Questions we’ve received from clients about HIPAA Compliance changes.

Q: If you have a deceased patient, does HIPAA still apply?

A: Yes, the medical record remains confidential regardless of the

patient’s status.

Q: What are the rules for emailing or texting protected health information (PHI) to outside vendors?

A: It must be under a Business Associates Agreeement and it must have an encrypted secure line. Standard text messaging is not HIPAA compliant.


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

CMS to Award New J1 MAC for Medicare Claims

Monday, January 21st, 2013

As required by regulation, CMS must ask for new bids for Medicare claims adjudication and enrollment every five years as Medicare Administrative Contractor (“MAC”) for each region. The new contract term begins in 2013.

Palmetto GBA in Georgia has been the MAC for Region J1 (now named Jurisdiction E), which includes California, for the past five years. Apparently the new contract has been awarded to Noridian Administrative Services out of Fargo, North Dakota. They have been the Medicare Part A & B MAC for Jurisdiction F, which includes upper mid-West and Pacific Northwest states, for the past five years. The CMS award is currently under appeal and may take more time to finalize.

Hospitals Expecting NPR Overload

Friday, January 18th, 2013

Over the past six months, CMS has published five years of Supplemental Security Income (SSI) data. The SSI data is used to develop Medicare Disproportionate Share Hospital (DSH) payments. Because DSH impacts a majority of hospitals across the United States, CMS previously ordered Medicare Administrative Contractors (MACs) not to issue any Notices of Program Reimbursement (NPRs) until CMS published revised SSI information incorporating data from Medicare Advantage patients. Now, the recent publication of SSI data has prompted MACs to finalize NPRs for Medicare cost reports that have been on hold for the past several years.

This development is causing an avalanche of NPRs for hospitals across the United States. For many, this means reviewing adjustments made three years ago, while at the same time, filing the current year cost report and dealing with other current finance and reimbursement issues. Also, with multiple NPRs being issued at the same time, the 180-day appeal window is starting to tick down for many cost reports. Good news: (more…)

Hospitals – Are You Still Waiting For Your Medi-Cal Incentive Payment?

Friday, January 4th, 2013

As of September 2012, over 3,000 physicians and 184 hospitals have received over $339M in Medi-Cal incentive payments since the State Level Registry (SLR) began issuing checks last October. Contrary to Medicare’s requirement to implement the entire system and demonstrate meaningful use, the State Medi-Cal program simply requires some basic data and will issue a check even before the project goes live.

The American Recovery and Reinvestment Act of 2009 provides for Medicaid incentive payments to eligible acute care and children’s hospitals that are meaningful users of certified Electronic Health Record (EHR) technology. An eligible acute care inpatient hospital is defined as a health care facility with an average length of stay (ALOS) of 25 days or fewer, and a Claim Control Number (CCN) ending with 0001-0879 or 1300-1399. In addition, to be eligible to receive a Medicaid EHR incentive payment, acute care hospitals must also meet a 10 percent Medicaid patient volume threshold. (more…)