By the Numbers
A monthly compendium of OHA finance and patient financial services policy and payment alerts
11/30/2018
There has been a small update to the 2018 HCAP model. Heather Hill Care Communities closed during the program year, and the model has been adjusted. Because this hospital was not going to receive a net gain, this will not substantially change the closed hospital or statewide residual pots. Data for the time when the hospital was clo
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11/30/2018
The U.S. Department of Health and Human Services’ Office of Inspector General on Nov. 27 released a report identifying vulnerabilities in the hospital wage index system that impact Medicare payments to providers.
The report goes on to state ways in which the current data used to calculate wage indexes is not always an accurat
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11/30/2018
The Ohio Department of Medicaid has announced a new hospital utilization review vendor. Effective Dec. 1, HMS Permedion will assume responsibility for processing:
Home health prior authorizationsBehavioral health prior authorizations for Medicaid fee-for service consumers not participating in a managed care planHospital medical-s
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11/30/2018
The Ohio Department of Medicaid on Nov. 1 proposed rule 5160:1-6-06.5 on how to calculate and apply a restricted Medicaid coverage period when an institutionalized individual improperly transferred an asset. Differences between this rule and the rule it is replacing are the addition of language regarding about how to calculate
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11/30/2018
On Jan. 1, 2019 a new federal rule goes into effect that requires hospitals to post their “standard charges” on the hospital’s website in a “machine readable” format. OHA has prepared a toolkit for hospital members to assist in understanding the rule’s requirements and communicating with pati
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11/30/2018
CMS on Nov. 2 published its final calendar year 2019 Medicare Outpatient Prospective Payment System Rule Update. The rule proposes to increase the OPPS Payment Rate +1.09 percent from the CY 2018 OPPS conversion factor.
OHA’s Payment Rule Brief can be found here.
Contact Shawn Stack with questions.
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11/30/2018
The Centers for Medicare & Medicaid Services on Nov. 27 launched a new online tool that allows consumers to compare Medicare payments and co-payments for certain procedures that are performed in both hospital outpatient departments and ambulatory surgical centers. The Procedure Price Lookup tool displays national averages for th
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11/30/2018
Ohio’s Medicare Administrative Contractor, CGS, wants to make certain hospitals are verifying off-campus, outpatient, provider-based department location addresses on claims match exactlythe address that has been provided and updated to CMS’ PECOs system.
CMS must begin to activate systematic validation edit
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11/30/2018
CMS finished mailing cards to people with Medicare who live in Waves 1-5 and is beginning distribution in wave 6 states (Arizona, Colorado, Idaho, Montana, Nevada, New Mexico, Texas, Utah, Washington and Wyoming). Card mailing in Wave 7 states and territories continues. Ohio is in Wave 7.
If someone with Medicare says they did
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11/30/2018
United Healthcare in October announced in its Provider Bulletin that the payer would be requiring specific criteria be met to support medical necessity when performing advanced radiological imaging procedures in hospital outpatient departments.
UHC stated said one of the following criteria must be met to perform advanced radiologic
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11/30/2018
The Veterans Administration announced Oct. 2 in a press release that the Triwest contract will extend and expand to cover the entire country for the Patient-Centered Community Care, PC3, and Veterans Choice Program, or VCP.
A press release from TriWest provided more details regarding the expansion plans. TriWest sta
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11/30/2018
The Centers for Medicare & Medicaid Services on Nov. 1 issued its final rule updating calendar year 2019 Physician Fee Schedule.
The CY 2019 Physician Fee Schedule has a conversion factor of $36.04, a small increase over the CY 2018 rate of $35.99 which also reflects a budget-neutrality adjustment required by law and an update
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11/30/2018
Ohio Bureau of Workers' Compensation released two proposed fee schedule rules on Outpatient Hospital Reimbursement Rule, Ohio Administrative Code 4123-6-37.2 to become effective May 1, 2019 and the current Ambulatory Surgical Center Services Rule, Ohio Administrative Code 4123-6-37.3 also set to be effective May 1, 2019.
Review
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10/31/2018
OHA has been working with the Ohio Department of Medicaid’s Hospital Policy Team to develop a list of commonly billed non-covered outpatient codes. As a part of OHA’s continued outreach and education, here is a list of the most commonly billed non-covered outpatient codes and corresponding comments OHA has created t
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10/31/2018
The Ohio Department of Medicaid’s Hospital Policy Team reported to OHA that, due to an oversight, edit 4891, Invalid NDC/HCPCS combination, was returned to a deny status effective Oct. 1. ODM is planning an emergency update to have the denials returned to pay/post status prior to that date.ODM confirmed on Oct. 15 that the eme
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10/31/2018
The OHA Behavioral Health Leadership Council in 2017 set a priority to work with law enforcement and the judicial system to understand the roles of these stakeholders in the bigger picture of behavioral health care in Ohio. In researching this topic, OHA joined Ohio’s Stepping Up initiative. Stepping Up is part of a natio
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10/31/2018
Reports have been delayed for an unspecified amount of time for latest round of episode-based payments, but the Ohio Department of Medicaid hosted a webinar on Oct. 23 and shared some design updates, largely in the quality metrics. At this point, there are nine episodes tied to payment:
EpisodePrincipal Accountable Pro
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10/31/2018
OHA President and CEO Mike Abrams, in a letter to the editor, on Oct. 12 detailed the hospital community’s concern about the Centers for Medicare & Medicaid Services' proposal to expand certain payment policies in 2019 that could harm access to care, particularly for the most vulnerable, by cutting $51 millio
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10/31/2018
The Centers for Medicare & Medicaid Services recently expanded on new health care price transparency requirements for hospitals in a series of frequently asked questions published on its website.
The FAQs cover which hospitals are subject to the new requirements, the definition of machine-readable, and what items and serv
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10/31/2018
The Ohio Department of Medicaid has set dates for hospital assessments and supplemental Medicaid upper payment limit, or UPL, payments for SFY 2019:
1st Assessment: Oct. 29
1st Payment: Nov. 12
2nd Assessment: Jan. 14, 2019
2nd Payment: Jan. 28, 2019
3rd Assessment: Feb. 25, 2019
3rd Payment: March 11, 2019
4th Assessment: Ap
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