As discussed in a previous blog, a hospital’s Supplemental Security Income (SSI) percentage is a primary component of Medicare Disproportionate Share (DSH) reimbursement and plays a significant role in determining the reimbursement impact. Also referred to as the “Medicare” fraction of the Medicare DSH calculation, the SSI ratio represents the percent of patient days for beneficiaries who are eligible for both Medicare Part A and SSI. By default, SSI ratios are based on the Federal Fiscal year end (10/01 – 09/30) and are generally published annually by the Centers for Medicare and Medicaid Services (CMS). Current CMS regulations allow for a hospital to request to have its SSI ratio recalculated based on the hospital’s cost reporting period where different from the Federal fiscal year. But how do you determine if your hospital would benefit from a recalculation?
It is a common misconception (more on these later as this is not the only one) that stakeholders can attempt to estimate if they benefit from an SSI ratio recalculation by simply identifying provider fiscal years where their SSI percentage increased from one year to the next. HOWEVER, patient-level detail must be obtained and analyzed to accurately calculate and prepare a request for an SSI percentage recalculation from the Federal fiscal year to hospital fiscal year. Once requested, hospitals are “stuck” with the recalculated SSI percentage. So, if not analyzed properly, a recalculation could actually harm the hospital by decreasing reimbursement.
Data Required
CMS mines SSI patient detail data from a maintained record set entitled “Medicare Provider Analysis and Review” (MedPAR). The MedPAR file contains IPPS billing records for all Medicare beneficiaries who received inpatient hospital services. And, it is this patient detail that should be analyzed and used to properly determine the effects of a recalculation. When requesting the MedPAR data, it must be done through routine use procedures and the required data use agreement (DUA). Upon approval, CMS will provide the detail data for a hospital’s patients who are eligible for both SSI and Medicare benefits.
Let’s establish a quick example to work with. Hospital A’s fiscal year end is 12/31/2013. Traditionally, the 9/30/2013 SSI percentage would be used in the Medicare DSH calculation. However, since CMS regulations allow for an SSI recalculation, a recalculated SSI percentage would use a combination of data from the 9/30/2013 and 9/30/2014 routine use files that cover the months included in the hospital’s cost reporting year.
Data Analysis
While the concept of requesting an SSI percentage recalculation is fairly simple, hospitals should be aware that the process contains many steps including data reconciliation and will likely not happen overnight. Verification of the published SSI percentage is always a recommended first step which can be accomplished by reconciling the routine use patient-level data. When reviewing the routine use data, it is also recommended to be aware of the potential impact of Medicare Advantage days, as the Allina Health Services v. Sebelius decision at the US Circuit Court of Appeals for the DC District could have implications on what data should ultimately be included in your SSI percentage. These are just a couple of data “scrubbing” procedures that must be completed prior to requesting an SSI recalculation. After ALL data “scrubbing” measures are performed and your recalculated SSI percentage is found to be higher than the CMS published SSI percentage for your hospital and FY, then your provider would benefit from a recalculation and should prepare a recalculation request.
Hospitals should research annually whether their facility could benefit from an SSI realignment. In addition to Medicare DSH reimbursement reviews, SCA has vast experience in facilitating SSI recalculation data analyses and requests on behalf of its clients and has performed hundreds of SSI redetermination requests to date. Please contact us to learn more about this service and how SCA can help you determine if an SSI enhancement is in the best interest for your hospital. Don't forget to subscribe to our blog so you don't miss future posts in our SSI recalculation series!
