HCRA HOSPITAL CONFERENCE
November 15, 2011 – updated April 24, 2013
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INTRODUCTIONS
• Phyllis Stanton,
Principal Health Care Fiscal Analyst, DOH
• John Kazukenus,
Manager, KPMG
•
Patrick Bryant,
Manager, KPMG
HCRA Refresher
SEMINAR OVERVIEW
1
2
Public Health Law on Patient Services Revenue
Third Party Payors Requiring an Election
Decision
3
Revenue Hospitals are Responsible For
4
HCRA Topics
5
Delinquency Process
6
Compliance Audits
7
Contact Information
HEALTH CARE REFORM ACT
PUBLIC HEALTH LAW §2807-j
The HCRA law requires Article 28 general hospitals,
D&TCs providing ambulatory surgical services, and
comprehensive D&TCs to pay a surcharge to the Public
Goods Pool on certain net patient services revenue.
Patient Services Revenue :
Defined as all moneys received for, or on account of, all patient
services related to a preadmission, inpatient, outpatient, or postdischarge visit, including all items or services as are necessary for
such care, except where excluded in §2807-j
.
Examples of Types of Third Party Payors* That Would Be
Considered
Non-Electing if No Election Submitted
•
•
•
•
•
•
Any not-for-profit insurer, licensed in NYS or elsewhere,
(if licensed in NYS they would be termed Article 43 Corporations);
Commercial insurers, licensed in NYS, or elsewhere;
This can include HMOs
HMOs organized under Article 44 of the NYS Public Health Law
Self funded plans domiciled in NYS or elsewhere;
This includes welfare plans, certain trusts
Other Insurer types, including HMOs, licensed out of state;
This includes foreign insurers
State and local Government payors other than NYS;
Example: Other state’s Medicaid programs
*This is a list of the most common types of payors that providers receive patient revenue from and is not
meant to be an all inclusive list.
PATIENT SERVICES REVENUE FOR WHICH THE HOSPITAL IS
RESPONSIBLE TO PAY A SURCHARGE ON
•
Revenue received from the patient for:
1.
2.
3.
•
•
•
Coinsurance
Self pay or uninsured
Copays and deductibles for which the provider has not received written release from
the payor stating they are paying the associated surcharge
Revenue received from non-electing payors –third party payors who have an election decision to make and
have not made an election. A list of all electing payors (current or past) can be found on
www.nyhealth.gov/nysdoh/hcra/hcrahome.htm or www.hcrapools.org entitled “Elector List.”
Revenue received from “unspecified” payors – payors who are not obligated to make an election decision
because they are not a third party “every day payor” or have been deemed by the Department to be
unspecified. Example 1: Foreign countries that have nationalized healthcare making payment directly for
claims. Example 2: employer paying a workers compensation claim, rather than submitting the claim to their
workers compensation carrier.
Revenue received from NYS agencies/programs authorized to pay NYS Medicaid inpatient rates, NYS
counties for county inmates, or NYC Corrections, that are not on the Elector List (at the current NYS
Medicaid rate of 7.04%). Details discussed on the next screen.
PHL § § 2807-j(2)(b), (d) and 2807-c (1) (a-1) refers
to those NY governmental agencies whose payments
are subject to the 7.04%
The only NY governmental entities that have a surcharge obligation, at 7.04%, are as follows:
•
•
Those making payments for inpatient claims and authorized to pay NYS Medicaid inpatient rates
Local correctional facilities (county inmates and NYC Corrections inmates)
•
All other NY governmental entities are exempt. Examples can be found on our May 27, 1997 letter:
http://www.health.ny.gov/nysdoh/hcra/legis.htm
•
Hospitals should ensure that they assess the 7.04% on their claims if they will be billing the agency or
facility and they are not listed on the Elector List. If they are billing the Medicaid Program directly, then
do not assess the 7.04% since the Medicaid Program pays the surcharge directly to the PGP. A list of the
known ones are found on the next screen. A list of the individual facilities are found on subsequent
screens.
•
If the agency is authorized to pay the Medicaid inpatient rates for services provided to eligible individuals,
then all revenue received from them for both inpatient and outpatient Medicaid payments is subject to the
7.04%. Again, if the hospital is billing the Medicaid Program directly, do not assess the surcharge since
the program pays the surcharge directly to the PGP.
•
If the agency’s program is not authorized to pay the Medicaid inpatient rates, then they are exempt from
the surcharge on any inpatient or outpatient claim.
REVENUE FROM NYS AGENCIES/FACILITIES
SUBJECT TO
THE NYS MEDICAID SURCHARGE RATE OF 7.04%
•
•
•
•
•
NYS Dept of Corrections (DOC)- payments for prison inmates
NYS Office of Mental Health (OMH)- payments for patients residing in their facilities
NYS Counties making payment for county Inmates
NYC Corrections making payment for city Inmates
NYS Liquidation Bureau’s Security Fund – making payments for insolvent NYS licensed
insurers from the Security Fund
The above list is not necessarily a comprehensive listing of state governmental agencies
that have programs that are only subject to the 7.04% NYS Medicaid surcharge rate. These
are the known ones. The Department will research any other programs brought to our
attention.
List of NYS Department of Corrections Prisons
Adirondack Correctional Facility
Albion Correctional Facility
Altona Correctional Facility
Arthur Kill Correctional Facility
Attica Correctional Facility
Auburn Correctional Facility
Bare Hill Correctional Facility
Bayview Correctional Facility
Beacon Correctional Facility
Bedford Hills Correctional Facility
Buffalo Correctional Facility
Butler Correctional Facility
Camp Georgetown
Cape Vincent Correctional Facility
Cayuga Correctional Facility
Chateaugay Correctional Facility
Clinton Correctional Facility
Collins Correctional Facility
Coxsackie Correctional Facility
Downstate Correctional Facility
Eastern NY Correctional Facility
Edgecomb Correctional Facility
Elmira Correctional Facility
Fishkill Correctional Facility
Five Points Correctional Facility
Franklin Correctional Facility
Fulton Correctional Facility
Gouverneur Correctional Facility
Gowanda Correctional Facility
Great Meadow Correctional Facility
Green Haven Correctional Facility
Greene Correctional Facility
Groveland Correctional Facility
Hale Creek ASACTC
Hudson Correctional Facility
Lakeview Shock Correctional
Lincoln Correctional Facility
Livingston Correctional Facility
Marcy Correctional Facility
Mid-Orange Correctional Facility
Mid-State Correctional Facility
Mohawk Correctional Facility
Monterey Shock Correctional
Moriah Shock Incarceration Cor Fac
Mt. McGregor Correctional
Ogdensburg Correctional Facility
Oneida Correctional Facility
Orleans Correctional Facility
Otisville Correctional Facility
Queensboro Correctional Facility
Riverview Correctional Facility
Rochester Correctional Facility
Shawangunk Correctional Facility
Sing Sing Correctional Facility
Southport Correctional Facility
Sullivan Correctional Facility
Summit Shock Incarceration
Taconic Correctional Facility
Ulster Correctional Facility
Upstate Correctional Facility
Wallkill Correctional Facility
Washington Correctional Facility
Watertown Correctional Facility
Wende Correctional Facility
Willard Drug Treatment Campus
Woodbourne Correctional Facility
Wyoming Correctional Facility
List of NYS Operated Psychiatric Facilities
Binghamton Psychiatric Center
Bronx Children's Psychiatric Center
Bronx Psychiatric Center
Brooklyn Children's Psychiatric Center
Buffalo Psychiatric Center
Capital District Psychiatric Center
Central New York Psychiatric Center
Creedmore Psychiatric Center
Elmira Psychiatric Center Greater
Greater Binghamton Health Center
Hudson River Psychiatric Center
Hutchings Psychiatric Center
Kingsboro Psychiatric Center
Kirby Forensic Psychiatric Center
Manhattan Psychiatric Center
Mid-Hudson Forensic Psychiatric Center
Mohawk Valley Psychiatric Center
Nathan S. Kline Institute
New York Psychiatric Institute
Pilgrim Psychiatric Center Queens
Rochester Psychiatric Center
Rockland Children's Psychiatric Center
Rockland Psychiatric Center
Sagamore Children's Psychiatric Center
St. Lawrence Psychiatric Center
South Beach Psychiatric Center
Western NY Children's Psychiatric Center
Non-electors Subject to the GME:
1
Corporations Organized and Operating in Accordance with Article 43 of the
NYS Insurance Law
• Not for Profit Insurers and HMOs
2
Corporations Operating in Accordance with Article 44 of the NYS PHL
• HMOs in NYS
3
Self Funded Plans Providing Inpatient Coverage – regardless of insurance
type except when providing coverage described in the next screen
• Regardless of Domicile
4
Insurers and HMOS Authorized to Write Accident and Health Policies
(regardless of which state/country they are licensed)
Non-electors NOT Subject to the GME:
•
•
•
•
•
•
NYS governmental agencies
Workers Compensation carriers providing coverage under NYS Law
Auto no-fault carriers providing coverage under NYS Law
Volunteer Firefighters providers of coverage under NYS Law
Volunteer Ambulance Workers providers of coverage under NYS Law
Indemnity Policies that do not provide inpatient coverage on an expense
incurred basis, but rather pay a fixed dollar per day for each as an inpatient.
(Most of these policies pay the member rather than the hospital, and if
patient has no other insurance, patient is to be treated as a self-pay with no
GME.
Fixed Dollar Patient Portions
1
Hospital’s Responsibility to Determine if Obligated to Surcharge on
Fixed Dollar Patient Portion
• In fixed dollar patient portions such as fixed dollar co-pays or deductibles, electing payors
have a choice between two options on how to pay the associated surcharge
• Hospitals are obligated to determine which option they’ve chosen, otherwise are obligated
themselves
2
3
The Electing Payor’s Choices of Surcharge Payment Options:
1. Payor pays claim by utilizing the second billing example found
on the DOH website. Hospital pays the surcharge out of fixed
dollar amount and gets reimbursed by payor
2. Payor pays the associated surcharge on the fixed dollar
amount directly to the Public Goods Pool via payor report
Fixed Dollar Patient Portions (continued)
3
Proper Reporting of Copays:
1. If payor chooses #1 above, hospitals will report the fixed dollar payment received from the
insured patient on Line #10 of their PGP report, entitled: “Self-Pay Uninsured…”
Hospital pays the surcharge out of the fixed dollar amount and gets reimbursed by payor
2. If payor chooses #2 above, and notifies hospital of such choice, the hospital will report the
fixed dollar payment received from the patient on the following lines:
• On Hospital Inpatient portion of the PGP report: Line 17
• On Hospital Outpatient portion of the PGP report: Line 19
3. In the absence of the electing payor notifying the hospital that they have chosen option #2
above, the hospital’s “default” is to report the fixed dollar payment on line 10 of the PGP
4. A non-electing payor, paying for covered services, must utilize Choice #1 (under Box 2) above,
and the hospital must report revenue on line 12, 12a or 12b
Revenue Received for Physician Billings
Effective with dates of service 4/1/11, Public Health Law §2807j (3)(a)(v) now exempts surcharges on revenue received for all
discrete physician billings (M.D.s or D.Os)
Physician services MUST be billed on a separate claim form,
separate from services provided (HCFA 1500 or 837P)
This change in law includes discretely billed employed
physician services
Foreign Payors and Patients
1
Foreign Insurance Companies and Medical Assistance Companies
• Foreign insurance companies are insurers licensed in other countries
• Medical assistance companies act as the conduit for claim payments between the foreign
insurance company and providers in U.S.; administer travel policies for expatriates
• Must make an election like any payor in order to pay current elector rate to the PGP
• If no election is made, hospital must pay the nonelector rate to the PGP currently at
37.90% and if an inpatient claim and an accident and health policy, or a self funded plan
(as known in U.S.), the regional GME percentage
2
Foreign Countries with Nationalized Health Plans or Paid Directly by
Foreign Governments
• Deemed Unspecified payor; pay directly to hospital when billed, at self pay rate currently
at 9.63%
• A List of those countries with known nationalized health plans can be found on our DOH
Web site under “Elector List”
Foreign Payors and Patients (continued)
3
Foreign Diplomatic Agents
• Exempt from all surcharges if protected under their diplomatic mission
Those protected by the diplomatic mission carry exemption paperwork
Surchargeability of Personal Items
Exemption of Personal Items
• Revenue from billed patient personal items, not
related to the medical service such as TVs,
telephones, and private rooms are not subject to the
HCRA surcharge since such items are not related to
the medical service provided
Medicare
1
Traditional Medicare Exemptions:
• Revenue received for Medicare covered services is exempt from surcharge; includes revenue
received from:
•
•
•
•
2
the Medicare program
an insurer contracted to administer on behalf of the Medicare program
a supplemental plan such as a Medigap policy, or,
the beneficiary themselves
Medigap/Supplemental Policies
• Pay for certain out-of-pocket expenses that Medicare covers but does not pay in full
• Also can cover certain services that are not payable by Medicare due to:
• Non-covered services
• Exhaustion of benefits
• Surcharges apply to services not covered, at rates based on election status of payor, but no
GME Per Unit of Payment Surcharge (if a non-elector)
Medicare (continued)
3
Medicare Advantage Part C
• Medicare Advantage Part C plans supply a person with all of their Part A and Part B benefits,
plus, depending on the plan chosen, may cover services that traditional Medicare will not, like
dental, vision, and unlimited inpatient days
• ANY service for which Medicare Advantage pays for, is exempt from the surcharge
DISTRIBUTION CHART
Is Revenue From the
Sources Below Exempt From:
Health Care Initiatives Pool –
includes the following 13:
1. Emergency Medical Services
2. Commissioner’s Priority Pool
3. Commissioner’s Emergency Assist. Dist.
4. Senate and Assembly Priority Pools
5. Payments to Poison Control Centers
6. Maternal and Child HIV Services
7. Health Facility Restructuring
8. Health Workforce Retraining
9. Primary Health Care Services
10. Rural Health Care Delivery –
Development and Access
11. Health Information and Health Care
Quality Improvement
12. AIDS Drug Assistance Program –
HIV Uninsured Care Program
13. Specialty Children’s and Cancer Hospitals
General Hospital Indigent Care Pool
BDCC Regional Pool Distributions
BDCC & Capital Statewide Pool Dist
Pt Services S/C
PHL 2807-j
Y/N
1% Statewide
PHL 2807-c(18)
Y/N
Cash Asmt Program
PHL 2807-d
Y/N
Distributions
Currently Active?
Y/N
Y - Report on line 2(g)
Y - Report on line 2(g)
Y - Report on line 2(g)
Y - Report on line 2(g)
Y - Report on line 2(g)
Y - Report on line 2(g)
Y - Report on line 2(g)
Y - Report on line 2(g)
Y - Report on line 2(g)
Y - Report on line 2(d)
Y - Report on line 2(d)
Y - Report on line 2(d)
Y - Report on line 2(d)
Y - Report on line 2(d)
Y - Report on line 2(d)
Y - Report on line 2(d)
Y - Report on line 2(d)
Y - Report on line 2(d)
Y - Report on line (3a)
Y - Report on line (3a)
Y - Report on line (3a)
Y - Report on line (3a)
Y - Report on line (3a)
Y - Report on line (3a)
Y - Report on line (3a)
Y - Report on line (3a)
Y - Report on line (3a)
Y
N (see Note 1)
Y
N
Y
N
Y
Y
N
Y - Report on line 2(g)
Y - Report on line 2(d)
Y - Report on line (3a)
Y
Y - Report on line 2(g)
Y - Report on line 2(d)
Y - Report on line (3a)
N
Y - Report on line 2(g)
Y - Report on line 2(g)
Y - Report on line 2(d)
Y - Report on line 2(d)
Y - Report on line (3a)
Y - Report on line (3a)
Y
N
Y - Report on line 2(i)
Y - Report on line 2(i)
Y - Report on line 2(i)
Y - Report on line 2(f)
Y - Report on line 2(f)
Y - Report on line 2(f)
Y - Report on line (3c)
Y - Report on line (3c)
Y - Report on line (3c)
Y
N
N
DISTRIBUTION CHART cont 2
Is Revenue From the
Sources Below Exempt From:
Health Care Efficiency and Affordability Law
of New Yorkers (HEAL NY) Capital Grant
Program
Electronic Health Records (EHR) Grants
(meaningful use)
Hospital-Medical Home (H-MH) Demonstration
Program
Healthy Women Partnership Program
Pt Services S/C
PHL 2807-j
Y/N
1% Statewide
PHL 2807-c(18)
Y/N
Cash Asmt Program
PHL 2807-d
Y/N
Distributions
Currently Active?
Y/N
Y - Report on line 2(h)
Y - Report on line 2(e)
Y - Report on line 4(d)
Y
Y - Report on line 2(h)
Y - Report on line 2(e)
Y - Report on line 4(d)
Y
Y - Report on line 2(h)
Y - Report on line 2(h)
Y - Report on line 2(e)
Y - Report on line 2(e)
Y - Report on line 4(d)
Y - Report on line 4(d)
Y
Y
General Hospital Recruitment and Retention
of Health Care Workers - includes the
following 2:
1. Non-Public General Hospitals (Rate
Adjustments and off-line Medicaid
Payments - See Note 2)
N - Report on line 5(a)
2. Public General Hospitals (Grants)
Y - Report on line 2(h)
N
Y - Report on line 2(e)
N
Y - Report on line 4(d)
N
N
Tobacco Control and Insurance
Initiatives Pool - includes the following 4:
1. Tobacco Use Prevention and Control Program Y - Report on line 2(g)
2. School Based Health Center Grants
Y - Report on line 2(g)
Y - Report on line 2(d)
Y - Report on line 2(d)
Y - Report on line (3b)
Y - Report on line (3b)
Y
Y
DISTRIBUTION CHART cont 3
Is Revenue From the
Sources Below Exempt From
Pt Services S/C
PHL 2807-j
Y/N
1% Statewide
PHL 2807-c(18)
Y/N
Cash Asmt Program
PHL 2807-d
Y/N
Distributions
Currently Active?
Y/N
3. Workforce Retention – Public General
Hospital Grants
4. Infertility Services Program
Y - Report on line 2(g)
Y - Report on line 2(g)
Y - Report on line 2(d)
Y - Report on line 2(d)
Y - Report on line (3b)
Y - Report on line (3b)
N
Y
NYS Community Health Care Conversion
Demonstration Project Grant Funds
Y - Report on line 2(g)
Y - Report on line 2(d)
Y - Report on line (3b)
N
High Need Indigent Care Adjustment Pool includes the following 4:
1. High Need Indigent Care Adjustment
2. DSH Share Rural Hospital Adjustment
3. Non-DSH Indigent Care
4. Non-DSH Share Rural Hospital Adjustment
Y - Report on line 2(i)
Y - Report on line 2(i)
Y - Report on line 2(i)
Y - Report on line 2(i)
Y - Report on line 2(f)
Y - Report on line 2(f)
Y - Report on line 2(f)
Y - Report on line 2(f)
Y - Report on line (3c)
Y - Report on line (3c)
Y - Report on line (3c)
Y - Report on line (3c)
Y
Y
Y
Y
Professional Education Pool –
includes the following 4:
1.Graduate Medical Education Distributions
2. Incentive Pool Distributions - Minority
3. Incentive Pool Distributions - Non-Minority
4. Empire Clinical Research Investigator
Program – (ECRIP) Distributions
Y - Report on line 2(i)
Y - Report on line 2(i)
Y - Report on line 2(i)
N
N
N
N
N
N
N
N
N
Y - Report on line 2(i)
N
N
Y
DISTRIBUTION CHART cont 4
Is Revenue From the
Sources Below Exempt From
Pt Services S/C
PHL 2807-j
Y/N
1% Statewide
PHL 2807-c(18)
Y/N
Cash Asmt Program
PHL 2807-d
Y/N
Distributions
Currently Active?
Y/N
Other DSH and Medicaid Payments – includes the
following:
Public General Hospital Indigent Care Adjustment
Y - Report on line 2(i)
Y - Report on line 2(f)
Y - Report on line (3c)
Y
IGT DSH (County and State Public Hospitals) –
includes the following 2:
1. Health and Hospitals Corporation (HHC)
2. All Other Qualifying Hospitals
Y - Report on line 2(i)
Y - Report on line 2(i)
Y - Report on line 2(f)
Y - Report on line 2(f)
Y - Report on line (3c)
Y - Report on line (3c)
Y
Y
Upper Payment Limit Payments
(Public Hospitals) See Note 2
N - Report on line 2(i)
Y- Report on 2(f)
Y - Report on line (3c)
Y
Supplemental Medicaid UPL Payments to
Voluntary Hospitals See Note 2
N - Report on line 2(i)
Y - Report on 2(f)
Y - Report on line (3c)
Y
Note 1 – Replaced by Commissioner’s Emergency
Assistance Distributions beginning in SFY 07/08.
DISTRIBUTION CHART cont 5
Note 2 – Upper Payment Limit Payments to Public and Voluntary Hospitals, Supplemental Medicaid UPL Payments to Voluntary Hospitals,
Non-Public General Hospitals rate adjustments and off-line Medicaid payments for Hospital Recruitment and Retention of Health Care
Workers are paid directly to hospitals by DOH’s MMIS. MMIS pays the related surcharge on these hospital adjustments directly to the
HCRA pool. Consequently, these revenues are not exempt from the surcharge. However, since this revenue is exempt from the 1%
Statewide (SW) Assessment, in order for hospitals to take this deduction on line 2(f) of the 1% SW report, hospitals should report this
revenue on line 2(i) of the Public Goods Pool (PGP) report (not line 5(a) where other NYS Medicaid Program dollars are reported. This
avoids double payment of the surcharge and also assumes the revenue is included on line 1 of the PGP report.
Special Note: Each of the payments listed in this chart must be reported on line 1 of the Public Goods Pool report.
Amnesty Provision
An amendment to the Health Care Reform Act was enacted April 15, 2011, that waives statutorily
required interest and penalty if delinquent obligations due, (based on estimated or actual amounts),
under Public Health Law (PHL) 2807-j, 2807-s and 2807-t, for reporting periods prior to January 1,
2011, are filed and paid in full between the dates of April 1, 2011, and December 31, 2011.
Who Should Take Advantage of this Opportunity:
• Providers who have not filed a monthly report to the Public Goods Pool for report periods prior to January 1,
2011. (Prior to collection action initiated by DOH).
• Providers who have not fully paid owed surcharge obligations on patient services revenue received prior to
January 1, 2011.
• Providers who discover an additional amount due to the PGP on patient services revenue received prior to
January 1, 2011.
Obligations not covered by the Amnesty Provision:
•
•
•
•
Any interest or penalty amount that has been paid to, or collected previously by, DOH.
Any surcharge or assessment payments made in response to a final audit finding issued by DOH or its designee.
Any delinquent amount (whether estimated or actual) that has been referred to NYS Medicaid for recoupment.
Any delinquent amount (whether estimated or actual) that has been referred to the NYS Attorney General’s Office
for collection.
DELINQUENCY PROCESS
Delinquency Notice
Estimated Billing Process
Action Taken for Non-Compliance
Delinquency Process
1
Delinquency Notice
• Delinquency notifications are sent via email and hardcopy mailing
around the 10th of each month (adjusted for weekends and holidays)
2
Estimated Billing Process
1. Delinquency letters and bills are mailed on a quarterly basis. The
hospital has sixty days from the date of the letter to file delinquent
report(s) and submit payment
2. A final notice is mailed with updated bill giving hospitals thirty additional days
• If delinquencies are not resolved within that time period, amount is deemed final and is not
subject to revision
3. Action is taken on the outstanding liability
Delinquency Process (continued)
3
Action Taken for Non-Compliance:
• Recoup from future Medicaid claim cycle checks paid by the state
• Offset against Medically Indigent/High Need distributions
• Submit referral to the state’s Attorney General’s Office to pursue legal collection
COMPLIANCE AUDITS
Key Phases/Milestones
Common Challenges and Better Practices
Key Phases/Milestones
Day 1
• Reviewee Notification
• Planning/Pre-Fieldwork
Day 45
Day 85
Day 125
• Entrance Conference
• Identify appropriate professionals to be
involved in review
• Testing Methodologies
• Begin work on Questionnaire
• Payor Determinations
• Hold initial discussions regarding data
extraction
• Preliminary Results
• Draft Report
• Exit Conference
• Provider Response
Day 235
• Receive Review Notification Package with
Milestones, Questionnaire and Data Blue
Print
• Data Extraction
• Data Exceptions
Conference
Day 195
Kick-Off
• Final Report
• Submit completed Questionnaire one
week prior to entrance conference
• Attend entrance conference
• Transfer complete set of data for one year
period
• Provide Data Representation Letter
• Provide reconciliation to tie financial
statements to data
Key Phases/Milestones (continued)
Day 1
Day 45
• Reviewee Notification
• Planning/Pre-Fieldwork
• Help resolve any data issues
• Entrance Conference
• Continue data extraction for remaining
years
• Data Extraction
• Testing Methodologies
Day 85
Day 125
• Payor Determinations
• Preliminary Results
• Data Exceptions
Conference
Day 195
• Draft Report
• Exit Conference
• Provider Response
Day 235
Fieldwork
• Final Report
• Review and provide feedback on testing
methodologies
• Approve of updated methodologies as
appropriate
• Review initial payor determinations
(direct vs. non-direct)
• Provide supporting documentation for
any disagreements
• Review and provide feedback on
preliminary results
• Provide supporting documentation for
any disagreements
• Participate in a conference call to discuss
the preliminary results
Key Phases/Milestones (continued)
Day 1
• Reviewee Notification
• Planning/Pre-Fieldwork
Day 45
• Entrance Conference
• Data Extraction
• Testing Methodologies
Day 85
Day 125
• Participate in a final meeting with KPMG
and DOH to discuss results included in
the draft report
• Payor Determinations
• Preliminary Results
• Receive final report from DOH
• Draft Report
• Exit Conference
• Provider Response
Day 235
• Review and provide feedback on the Draft
Report
• Submit formal response to be included in
the
final report
• Data Exceptions
Conference
Day 195
Closeout
• Final Report
Common Challenges and Better Practices
Potential Issue
Proactive
Planning
Contact person needs to
share audit notification
package timely to avoid
delays in notification and
receipt of questionnaire
Better Practice
• Contact information should be accurate and properly maintained;
contact person promptly shares the audit notification package with
appropriate stakeholders
• Reviewee understands that the review begins once the Audit Notification
Package is received
Reviewee does not
proactively plan or prepare • Appropriate planning for the review requires effort prior to the entrance
conference, including identifying appropriate professionals to participate,
for the review which impacts
discussing initial data extraction questions, etc.
the ability to move forward
as scheduled
Continuous
Communication
and Commitment
to Review
Professionals involved are
not responsive and/or not
being forthright with
information
• Status documents (e.g. status trackers, dashboards, milestone
documents, etc.) and emails should be reviewed and responded to in a
timely manner to help ensure all stakeholders are on the same page
• Any delays anticipated in advance should be communicated as soon as
possible to KPMG and DOH
• Cooperation and professionalism are displayed by all parties involved in
an effort to move the review forward
Common Challenges and Better Practices (continued)
Potential Issue
Complete
Questionnaire
Responses
Timely and
Complete Data
Transfer
Better Practice
Reviewee does not provide
sufficient or complete
responses to questionnaire
which may result in delays
and/or inappropriate testing
methodologies
• Work on the Questionnaire should begin upon receipt which enables
sufficient time to ask any questions about the document, loop in
appropriate professionals to assist with completion, and provide
complete and detailed responses as necessary.
Data and accompanying
Data Representation Letter
is not provided in a timely
manner or is not complete
which causes significant
delays
• Any questions related to the data extraction should be asked early on in
the process
• Completed Questionnaire should be able to stand on its own without
further explanation.
• Reviewee understands the data blueprint provided is ONLY a guide; all
data fields utilized for HCRA calculations and those necessary to pull
supporting documentation (if it should be needed) should be provided
• Reviewee and KPMG will work together to review sample data prior to
deadlines in order to help ensure data is transferred in a workable
format
• Complete and clear data dictionary should be provided with the data
• Unaltered Data Representation Letter is printed on Provider letterhead
and provided with appropriate authorization at the time the data is
delivered
Common Challenges and Better Practices (continued)
Potential Issue
Clear
Reconciliation
Better Practice
Reviewee cannot provide a • Providers need to be able to coordinate the appropriate financial and
clear reconciliation from its
operational professionals in order to provide a crosswalk to the control
audited financial statements
totals in the data provided to the dollars recorded on the entity’s audited
to the data provided
financial statements for net patient service revenue
• Clear explanations for any reconciling items are provided and sufficient
evidence supports each material amount
Other Billing
Systems
Discretely billed physicians, • With accurate and detailed answers to the Questionnaire, any of the
ambulatory services or other
additional billing systems utilized by the Provider will be identified and
services billed outside of the
properly vetted
Provider’s main system
need to be identified and
• Provider will provide details of what types of services are billed for under
vetted in an effort to ensure
the ‘other’ systems and if necessary provide supporting documentation
no applicable HCRA
to enable KPMG to gain comfort that it is not applicable to the review
surcharges apply
Approved
Testing
Methodologies
Testing methodologies are
• Reviewee takes the time required to review the testing methodologies
not adequately reviewed
provided and provide necessary feedback
prior to commencement and
completion of testwork
• Once approved, testing methodologies utilized to complete testwork will
not need to be revised
Common Challenges and Better Practices (continued)
Potential Issue
Better Practice
Sufficient
Supporting
Documentation
Supporting documentation is • Any statements made by the provider, especially as it relates to payor
not made available to
determinations, should be appropriately supported with documentation
corroborate statements
that demonstrates the statement
made by the Provider
Generic Payor
Names
Systems utilized categorize • Any generic payor names are broken down to provide actual payor
a significant number of
information so that a determination can be made on each as to their
payor names under a
election status
generic payor name (e.g.
commercial miscellaneous) • Supporting documentation will need to be provided to tie any
and the actual unique payor
supplementary data to the original data provided
names are not provided with
the initial data extraction
Common Challenges and Better Practices (continued)
Potential Issue
Foreign Patient
Payments
Reviewee does not remit
surcharge on foreign
national or foreign
government employee
payments received
Better Practice
• Not all foreign national or foreign governmental employees are exempt
from paying surcharges; ONLY foreign diplomatic missions covered by
Vienna convention which are self-insured for purposes of providing
health insurance coverage to their employees are considered exempt
from HCRA surcharge
Reviewee does not remit
• If a foreign patient without insurance coverage receives services from a
surcharges on revenue
HCRA designated provider, the patient is assessable at the self-pay
received for services
rate. Payments received directly from foreign governments are
provided to a foreign patient
considered "unspecified payors" under HCRA and are not obligated to
elect. Providers should assess the unspecified payor surcharge rate on
their claims to foreign governments. Regardless, providers are obligated
to remit the surcharge to the Pool. Payments received from foreign
insurance companies are subject to the surcharge percentage based on
their election status
Out of State
Workers
Compensation
and No Fault
Reviewee considers all
workers compensation and
no fault revenue as direct
• It should not be assumed that all workers compensation and no fault
related revenue should be treated as direct
• Workers Compensation and No Fault that are provided by a third party
insurer should be broken down by insurer name in order to identify
whether the applicable payor is direct or non-direct. In the case where
the state itself is the risk bearer, then the surcharge percentage would
be based upon the election status of that State
CONTACT INFORMATION
1
Contact the Office of Pool Administration:
Telephone: (315) 671-3800
Email: [email protected]
For Questions
Relating
To:
For
Questions
Relating
To:
• Electronic website for report submission questions
•Obtaining a user ID and password, or trouble with logging on
•Setting up file transfer Pool payments
•Questions relating to receipt of Pool payments
Contact Information (continued)
2
Contact the Department of Health:
Telephone: (518) 474-1673
[email protected]
For Questions Relating To:
• The surchargeability of revenue and distributions
• Interpretation of the Public Health Law on HCRA
• Specific report line questions about reportable revenue and deductions
• Any questions regarding the 1% Statewide Report
• Any delinquencies, Medicaid recoupments or referrals to the state’s Attorney General’s
Office based on HCRA delinquencies
• Electing Payors or Third Party Administrators
QUESTIONS