Medicare DSH reimbursement is dependent on two variables intended to measure the volume of indigent care provided by acute care hospitals: the Medicaid fraction and the Medicare fraction. The Medicaid fraction is relatively well understood, and has received a tremendous amount of industry attention as a result of CMS 97-2 clarifications. The other variable, the Medicare fraction, is much less well understood, and is determined by summary data calculated by the federal government – the SSI ratio. There is strong conviction in the industry that the process by which the SSI ratio is generated may contain significant errors, and that populations of patients that were intended by law to be included in the Medicare fraction are not being accounted for at all.
Potential SSI Opportunity
A small variance in one of the DSH variables can have a significant impact on the bottom line. It is anticipated that a favorable decision regarding the SSI calculation could represent substantial additional revenue for providers.
Challenging the SSI Ratio
Many hospitals have established appeals on settled cost reports to challenge the accuracy of the SSI ratio, and several group appeals are currently being watched closely. To turn this issue into dollars, it will be necessary to produce accurate, detailed reports for large volumes of patient service data. The burden will be on the Provider to pursue corrected reimbursement retroactively, thereby requiring the maintenance of historical data.
Because the specific rules regarding how to accurately report the Medicare fraction will evolve over time, it will be necessary to revise reports iteratively as the Medicare community develops a plan for mandating requirements meeting new regulations. The audit requirements will evolve and will demand substantial analytic efforts, including reconciliation of data across provider and government systems.
CMS has established a mechanism whereby providers can pursue realignment of the SSI ratio percentage by adjusting the summary data from the federal fiscal year to the hospital’s own fiscal year.
RSG Inc. assumes responsibility for the production of Medicare Disproportionate Share claims. Our comprehensive approach provides:
- Full scale data acquisition and warehousing to ensure that all fiscal years with potential opportunity can be pursued.
- Full scale data integration and analysis including Medicaid eligible and SSI components.
- Thorough analysis of SSI detail obtained from CMS to accurately predict whether an SSI realignment would benefit the provider.
- All data analysis and reporting handled independently by RSG, outside of clients’ IT environment.
- 100% audit support – all auditor requests handled through our data storehouse of remittance and patient account information developed as a part of the project.
- Standard and ad hoc reports produced to give clients a thorough financial understanding of efforts, results, and expectations.