It is not uncommon for patients to retroactively become Medicaid eligible or ineligible a few months (or longer) after a hospital’s cost report filing. It is also not uncommon to get false positive or negative results due to the tools and methodology used to perform a Medicaid eligibility match. As most healthcare reimbursement professionals would surely agree, retroactive Medicaid eligibility verification is especially important for its impact on a qualifying hospital’s Medicare Disproportionate Share (DSH) calculation. When done so properly, retroactive verification of Medicaid eligible patients can confirm compliant results and yield significant increases to the Medicaid fraction of the Medicare DSH calculation.
Many consulting firms and healthcare data analytics companies offer to perform retroactive Medicaid verification services for qualifying Medicare DSH providers after the filing of the initial cost report. Some services offer automated tools that can submit Title XIX eligibility queries multiple times for providers in an attempt to identify additional reimbursement well after the initial cost report has been filed but they eliminate the “human factor” from the project entirely. And, other services merely chase after the “low-hanging fruit” of days that are identified as Medicaid eligible simply due to elapsed time, which can be months or even years after a cost report has been filed. But, few actually incorporate steps or research necessary to optimize providers’ Medicare DSH reimbursement, and even fewer seem to consistently account for the compliance aspect of cost report filings (we’ll address specific compliance issues in another post). However, we have proven that increases to a hospital’s Medicaid days for a given fiscal year are not purely a product of time passed.
CASE IN POINT - SOUTH CAROLINA
With all of the complexities involved, SCA has identified an average of almost 4% additional Medicaid eligible days, which are allowable for Medicare DSH, for our South Carolina provider clients over an 8-year span. The average yearly Medicare DRG payments for DSH qualifying hospitals in South Carolina from fiscal years 2008-2013 were just under $24.78 million, which translates into over $975,000 in potential Medicare DSH dollars a year. In some instances, our matching processes have increased providers’ Medicaid days by over 6% for a given fiscal year. In many cases, these findings are over and above the results of other third party consulting firms.
AND, did we mention that SCA’s Medicare DSH audit acceptance rate for provider clients nationwide since 2004 is 99.96%? This encompasses millions of Medicaid days audited by Medicare Administrative Contractors. Through the “human factor” component of our process, SCA’s service includes auditable support and support staff to assist provider clients through the audit and appeals process.
Nationwide, SCA provides Medicare DSH consulting engagements to provider clients in over 40 states. Our matching processes provide a much more comprehensive level of detail and a significantly higher level of accuracy when compared to automated-only eligibility research tools available. This has led to significant findings of additional allowable Medicaid days for our provider clients and it also results in the peace of mind our clients expect regarding compliance to the applicable Medicare DSH laws and regulations. Our Medicaid eligibility work in many states certainly stands out and a few examples are illustrated in the table below:
Over the last two decades, SCA has developed a multi-pronged approach to compiling the necessary data for the Medicare DSH calculation and this has allowed SCA to produce the most accurate, complete and compliant dataset possible for our provider clients to optimize their Medicare DSH reimbursement. Please contact us if you are interested in obtaining additional information about our retrospective Medicaid eligibility matching services and/or results.
