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©2015 MFMER | slide-1
Medicare Cost Report Basics: Information for the TFC
Robert Howey, CPA Revenue Cycle Manager
Transplant Financial Coordinators Association Workshop September 30, 2015
©2015 MFMER | slide-2
Tell me and I forget Teach me and I remember Involve me and I learn.
- Benjamin Franklin
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Objective
After the session, you will be able to:
• Understand the preparation of the cost report and types of
costs included/excluded
• Understand the Medicare cost report reimbursement
methodology
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Agenda
I. Medicare Cost Report Overview
II. Types of Organ Acquisition Costs
III. Medicare Reimbursement Methodology
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• What is a Medicare cost report? • Why is it important? • What are organ acquisition costs?
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Generally, represents the necessary and reasonable costs attributable to acquiring an organ and preparing the potential donor and transplant recipient for organ transplantation.
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I II III IV
Evaluation Maintenance Transplant Surgery
Post-Transplant
ORGAN ACQUISITION FOR RECIPIENTS
ORGAN ACQUISITION FOR LIVE DONORS1
PRE-TRANSPLANT
1Effective 11/28/11, excludes post-discharge complications
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Direct Organ Acquisition Costs Dedicated Support Personnel (examples): • Administrator/Manager
• RN Coordinator
• Social Worker
• Dietitian
• Financial Coordinator
• Appointment Schedulers
• Database Administrator
• Medical/Surgical Director
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Direct Organ Acquisition Costs
If not 100% organ acquisition activity,
complete a TIME SURVEY.
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Direct Organ Acquisition Costs Other Direct Costs (examples): • OPO organ fee • Transplant registry fees (UNOS only) • Tissue typing of donor and recipient • Physician preadmission transplant evaluation • Other external diagnostic testing • Transportation costs for organ retrieval • Surgeon procurement fee • Other departmental costs
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Direct Organ Acquisition Costs NOT considered OAC: • Burial expenses for deceased donor • Costs for organs sent outside the U.S. • Living donor travel • Services related to treatment for the underlying
disease
SOURCE: PROVIDER REIMBURSEMENT MANUAL (PUB. 15-1), SECTION 2773B
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TRANSPLANT RECIPIENT SERVICES
MEDICARE NON-MEDICARE HOSPITAL PHYSICIAN HOSPITAL PHYSICIAN
Pre-Transplant
Write-off charges and capture for cost report Reimbursed via C/R
Bill to transplant hospital
Bill to Payer Capture charges for cost report
Bill to transplant hospital
Transplant I/P Episode
Bill to MAC Reimbursed DRG
Bill to Carrier Reimbursed via Fee Schedule
Bill to payer
Bill to payer
Post-Transplant
Bill to MAC Reimbursed APC
Bill to Carrier Reimbursed via Fee Schedule
Bill to payer Bill to payer
©2015 MFMER | slide-20
TRANSPLANT LIVE DONOR SERVICES
MEDICARE NON-MEDICARE HOSPITAL PHYSICIAN HOSPITAL PHYSICIAN
Pre-Transplant
Write-off charges and capture for cost report Reimbursed via C/R
Bill to transplant hospital
Write-off charges and capture for cost report Reimbursed via SAC
Bill to transplant hospital Reimbursed via SAC
Transplant I/P Episode
Write-off charges and capture for cost report Reimbursed via C/R
Bill to Carrier w/ Q3 modifier Reimbursed via Fee Schedule
Write-off charges and capture for cost report Reimbursed via SAC
Bill to recipient’s payer
Post-Transplant Follow-Up
Write-off charges and capture for cost report Reimbursed via C/R
Bill to Carrier w/ Q3 modifier Reimbursed via Fee Schedule
Write-off charges and capture for cost report Reimbursed via SAC
Bill to recipient’s payer
Post-Discharge Complications (effective 11/28/11)
Bill to MAC Reimbursed via IPPS/OPPS Occ Code 36 Pat Rel Code 39
Bill to Carrier w/ Q3 modifier Reimbursed via Fee Schedule
Bill to recipient’s payer
Bill to recipient’s payer
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Common OAC Overhead Costs
• Space (Square Footage)
• Building
• Equipment
• Plant Operations
• Housekeeping
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Common OAC Overhead Costs
• Employee Benefits (Salaries)
• Cafeteria (FTEs)
• Administration (Accumulated Cost)
• Accounts Receivable (Gross Charges)
• Medical Records (Gross Charges)
• Nursing Administration (Nursing FTEs)
• Social Services (Time Spent)
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Medicare Reimbursement
X Medicare Usable Organs
Total Usable Organs
Medicare Organ Acquisition
Reimbursement
Medicare Ratio
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Medicare Ratio
Medicare Usable Organs Total Usable Organs
Medicare Primary Transplants Total Transplants
Medicare Secondary Transplants (if Medicare had some liability)
Deceased Donor Organs
Organs Sold to Other Hospitals (e.g, Paired Exchange)
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Takeaways • Accounting for TFC costs:
• Salary/Benefits • Space • Other overhead
• Review policies/procedures • Donor/recipient financial responsibility • Medicare transplants
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Citations for Organ Acquisition • Paper Based Manuals
• Provider Reimbursement Manual, Part I, Chapter 27
• Internet-Only Manuals (IOM) • Medicare Benefit Policy Manual (Pub. 100-02, Chapter
11, Section 140) • Medicare Claims Processing Manual (Pub. 100-04,
Chapter 3, Section 90)
https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/index.html
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