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By the Numbers

A monthly compendium of OHA finance and patient financial services policy and payment alerts


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HCAP Model Updated

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 Read More . . .

OIG Identifies Vulnerabilities in Hospital Wage Index

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 Read More . . .

ODM Changes Utilization Review Vendor

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 Read More . . .

Ohio Medicaid Proposes Restricted Medicaid Coverage Rule

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 Read More . . .

OHA Provides Toolkit for Complying with New Federal Rule on Posting Standard Charges

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 Read More . . .

OHA Releases Brief on CMS Final CY 2019 OPPS Rule

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.   Read More . . .

New Online Tool Shows Costs for Common Surgical Procedures

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 Read More . . .

OHA Reminds Members Location Addresses on Claims Must Match Medicare Records

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 Read More . . .

New Medicare Card Mailing Update – Wave 6 Ends

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 Read More . . .

UHC Announces Prior Authorization for Site of Care Outpatient MR/CT Services

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 Read More . . .

VA Choice Program Expands Claims Contractor Role

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 Read More . . .

CMS Publishes Final CY 2019 Physician Fee Schedule Rule

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 Read More . . .

Ohio BWC Proposes 2019 OPPS, ASC Rules

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 Read More . . .

OHA Publishes Most Commonly Denied Medicaid Non-Covered Codes

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 Read More . . .

Update: ODM Addressing Inappropriate Denials for Invalid NDC/HCPCS

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 Read More . . .

Member Hospitals Encouraged to Join County Stepping Up Initiative

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 Read More . . .

ODM Updates Quality Metrics

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 Read More . . .

OHA President Expresses Concerns About Site-Neutral Policies, AHA Launches Ad Campaign

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 Read More . . .

CMS Releases FAQ on New Transparency Requirement

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 Read More . . .

ODM Announces SFY 2019 Hospital Franchise Fee, UPL Payment Schedules

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 Read More . . .

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