colorado hospital quality incentive payment (hqip) program · new cmis were created for each...

1

HOSPITAL MEETINGFriday, July 7, 2017

8:00 AM – 12:00 PM

Location: The Department of Health Care Policy & Financing, 303 East 17th Avenue, Denver, CO 80203. 11th Floor Rooms A&B.

For more information contact: Diana Lambe at 303.866.5526 or [email protected]. & Elizabeth Quaife at 303.866.2083 or [email protected]

mailto:[email protected]:[email protected]

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Overview of Meeting

• General Hospital Meeting 8:00-10:00• Break 10 min.

• General Hospital Meeting cont’d 10:10-noon

Colorado Department of Health Care Policy and Financing

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HOSPITAL ENGAGEMENT MEETING TOPICS 7/7/2017 8am-12pm • General Hospital Meeting

- Hospital Transformation (Added Topic)- New Specialty Hospital Rates Methodology Update- IPP-LARCs implementation timeline- Update on GME Q2-2015 Payments- Cost Settlement Updates- EAPG Rate Update- Innovative Medications (Added Topic)

• Rate Related System Issues Update - ICD-10 10/1/2016 update on new Diagnosis Codes- Transfer Claims Update (affects only Rehabs & LTACs)- Baby Diagnosis on Mom's Claims- Mass Adjustment Update for 3 Low Volume Payment Hospitals

- Ongoing Issues Impacting EAPGs - EAPG Mass Adjustment Scheduling

Sheet1

HOSPITAL ENGAGEMENT MEETING TOPICS5/5/17TIMEOwner / Specific Materials needed to facilitate discussionMarch-17May-17July-17September-17November-17

General Hospital MeetingX8:00-12:00 noon

-Fiscal Year 2017-18 Inpatient Base RatesXDiana /

-Overview on how Inpatient Base Rates are builtXDiana /

-APR-DRG prospective weight changes due to removal of IPP-LARCs

-Update rates every other year methodology discussionXDiana /

-DRG base rate communicationXDiana /

-New Specialty Hospital Rates Methodology UpdateElizabeth

-Rate Related System Issues Update

-ICD-10 10/1/2016 update on new Diagnosis Codes - UPDATEX

-Transfer Claims Update (affects only Rehabs & LTACs)

-Baby Diagnosis on Mom's Claims Diana /

-Radiology Procedure Codes

-Outpatient Hospital PaymentsXAndrew /

-Cost Settlement UpdatesAndrew /

-Rate UpdateAndrew /

-Ongoing Issues Impacting EAPGsAndrew /

-Mass Adjustment SchedulingAndrew /

-Hospital Organizational Structureif time allows

-Hospital owned primary care practicesif time allowsAna/

-Stand alone emergency departmentsif time allowsAna/

-Salaried vs. non-salaried physicians within hospitalsif time allowsAna/

-Payment Reform Projects

-Community based projects

-Hospital Report Card

-Hospital site visits

-Yearly Hospital Meeting (Inpatient Base Rates)X

-Cost Shift Avoidance Discussion Shane / Kevin

HOSPITAL ENGAGEMENT MEETING TOPICS 7/7/2017 8am-12pm

· General Hospital Meeting

- Hospital Transformation (Added Topic)

- New Specialty Hospital Rates Methodology Update

- IPP-LARCs implementation timeline

- Update on GME Q2-2015 Payments

- Cost Settlement Updates

- EAPG Rate Update

- Innovative Medications (Added Topic)

· Rate Related System Issues Update

- ICD-10 10/1/2016 update on new Diagnosis Codes

- Transfer Claims Update (affects only Rehabs & LTACs)

- Baby Diagnosis on Mom's Claims

- Mass Adjustment Update for 3 Low Volume Payment Hospitals

- Ongoing Issues Impacting EAPGs

- EAPG Mass Adjustment Scheduling

links to registration

MAY 5, 2017 MEETING TIMES AND LINK TO REGISTER

General Hospital Meeting 8:00 - 12:00 noonhttps://cohcpf.adobeconnect.com/e237cw187s6/event/event_info.html

https://cohcpf.adobeconnect.com/e237cw187s6/event/event_info.html

Sheet3

Budget N Year:

Administrator: Administrator:Budget Neutrality baseline year. Should always be FY 02-03 until "Budget Neutrality" goes away.FY 02-03Formula pulls value inFormula pulls value inFormula pulls value inFormula pulls value inFormula pulls value inAdj Dischrgs for prior yr * Volume Inflator (R138)Formula pulls value indon't delete=$H66*$I66*J66*'Budget Actions'!$D$4Formula pulls value in=H66*I66*L66Formula pulls value in where appropriate from PPS & Non-PPS tables=N66*$R$128all currently 100% COL Rpulls in peer grp avg for CAH or low discharge hospitalsMedicaid Rate + Add OnsMedicaid Rate + Add-Ons * Est dischgs * CMIDifference between prior yr and current yr est paymentspercent change in payments current yr/prior yrformulaformulaformulaformulaformulaformulaformulaformula

PCG Report:

Administrator: Administrator:The year FY of the CFMC report that is used for discharges, CMI, and ALOS.FY 14-15 EstimatedQ2+AB2+AC2+AD2EstimatedBUDGET: $0.00

Prior Year:

Administrator: Administrator:Year that is prior to the year that rates are being calculated for.FY 15-16TBD: 3A=New TEFRA1=PediatricsCheck this formulaFY 16-17Estimated

OITDSS: estimated amt using last year's rate

this is NOT budget neutral # - budget neutral is in col Kcmi adjusted rate

OITDSS: dl - don't know what this means. This column should be Medicare Final Rate LESS DSH + LVA (if applicable)we pay % of medicare rate to match budget neutralityadj by specialty %FY 16-17FY 16-17FY 16-17FINAL% OF MEDICARE:0.00%

Current Year:

Administrator: Administrator:FY that rates are being set for.


this is NOT budget neutral # - budget neutral is in col K

OITDSS: dl - don't know what this means. This column should be Medicare Final Rate LESS DSH + LVA (if applicable)FY 16-172=Not SpecialNon-CMI Adjusted DischargesPayments withFY 16-171-Oct-15FY 16-17MedicaidMedicaidPaymentsFY 16-17EstimatedMedicaid Cost Add-Ons / Cost per DischargeAmt over budget neutrality$0.00

1 = CAH3=RehabPeer GroupEstimatedFY 02-03Payments withMedicare Initial Rate = Final Medicare DRG Rate - DSH + LVA (where appropriate)

Chris: Jessica:1 = CAH2 = not3 = TEFRAMedicaidRates withRate with Rate withWithout Difference inMedicaid RateFY 16-17FinalFinal10% add on10% add on10% add on

Provider2 = Not4=Spinal RehabRural = 1CAH = 1FY 14-15FY 16-17FY 14-15FY 02-03Rates Incl PriorFY 15-16FY 15-16RateSpecialty CAH and lowMedicaidUpcoming YearEstimatedPercentw/Budget PaymentsFY 15-16FY 16-17Year over Year0.10.10.1FINAL RATES for RATE LETTERS

NumberProviders3 = TEFRA5=LTACUrban = 2Non-CAH = 2DischargesDischargesCase MixRates

: This will always be 02-03 Rates because that is our baseline year. Changing this would require State Plan Amendment.

Chris: Jessica:1 = CAH2 = not3 = TEFRABudget Actions

jlwagn: Check the cell reference for this formula in the Budget Actions tab. Rates

Administrator: Administrator:Final MK Rates from previous FYRates(% of Medicare)Percentages

Jessica Wagner: Jessica Wagner:1= pediatric2 = no special3 = rehab4 = spinal cord5 = urban safety net

Dischage avg.

Domenica Blum: Formulas are different for the rehabsAdd-OnsBudget ActionsPaymentsChangeActionsw/Budget ActionsInpatient Base RateInpatient Base Rate% ChangeNurseryNICUGMERATE w/out GME (purple) - goes in rate letterREASONS FOR RATE INCREASE/DECREASE% Diff in Rate from Prior Year

RURAL HOSPITALS

w/LVP GAF Fix

XXXXXSample HospitalERROR:#N/AERROR:#N/AERROR:#N/AERROR:#N/AERROR:#N/AERROR:#N/A

OITDSS: this estimates how many discharges will occur in next fiscal year for each hospital

Administrator: Administrator:Final MK Rates from previous FYERROR:#N/AERROR:#N/AERROR:#N/A

OITDSS: calculating the estimated dollar amount that should be spent this year by hospital to come up with a budget neutral amount


Domenica Blum: Formulas are different for the rehabsERROR:#N/AERROR:#N/AERROR:#N/AERROR:#N/AERROR:#N/AERROR:#N/AERROR:#N/AERROR:#N/AERROR:#N/AERROR:#N/AERROR:#N/AERROR:#N/AERROR:#N/AERROR:#N/AERROR:#N/AERROR:#N/AERROR:#N/AERROR:#N/AERROR:#N/AERROR:#N/AERROR:#N/A

XXXXXSample HospitalERROR:#N/AERROR:#N/AERROR:#N/AERROR:#N/AERROR:#N/AERROR:#N/AERROR:#N/AERROR:#N/AERROR:#N/AERROR:#N/AERROR:#N/AERROR:#N/AERROR:#N/AERROR:#N/AERROR:#N/AERROR:#N/AERROR:#N/AERROR:#N/AERROR:#N/AERROR:#N/AERROR:#N/AERROR:#N/AERROR:#N/AERROR:#N/AERROR:#N/AERROR:#N/AERROR:#N/AERROR:#N/AERROR:#N/AERROR:#N/A
























































































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GROUND RULES FOR WEBINAR

• WE WILL BE RECORDING THIS WEBINAR

• We are going to try to avoid muting the phone lines to encourage conversation, so please don’t:

• Put us on hold• Drive in your car w/window open while listening• Sit in a noisy location

• Please speak clearly when asking a question and give your name and hospital

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Welcome & Introductions

• Thank you for participating today!

• We are counting on your participation to make these meetings successful

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• 3/3/2017

• 5/5/2017

• 7/7/2017

• 9/1/2017

• 11/3/2017

Dates for Future Hospital Engagement Meetings in 2017

The agenda for upcoming meetings will be available on our external website in

advance of each meeting. https://www.colorado.gov/hcpf/inpatient-

hospital-payment

Registration links for each session during the day will also be available prior to the

meeting.

Just click on the links to register for each session and you will receive the link to

connect to the webinar.

https://www.colorado.gov/hcpf/inpatient-hospital-payment

Colorado Hospital Transformation Program

Colorado’s Delivery System Reform Incentive Payment (DSRIP) Program Incentive Payment (DSRIP) program

Matt HaynesSpecial Finance Projects Manager

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2017

On the Road to Better HealthHow the Department of Health Care Policy and Financing is Driving Improved Health Care Delivery and Payment Systems in Colorado

Payment Reform Models

Taxpayers Clients

H

FQHCs

PCPs

1

2WHY? Because almost one of four

Coloradans is covered by Health First Colorado, HCPF has the ability to

move the market.

3WHO? HCPF

partners with key stakeholders.

4

HOW? HCPF works with stakeholders to build a value-based system.

5DESTINATION?

System Transformation.

Quadruple Aim• Lowered Costs• Improved Quality• Improved Health• Provider Satisfaction

LTSS

Specialists

RAEs

Desired Outcome1 2 3 4

Who Gets Payments for Services

9FY15-16 data 6

SB 17-267 - Enterprise• Establishes the Provider Fee program as a state

enterprise• Directive to pursue Delivery System Reform

Incentive Payments Planning Phase Goals Focus Areas

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Next Steps• Stakeholder Re-engagement Program and Community Engagement Process

Development Measures and Metrics Application Process and Documents Project Scoring and Valuation Program Evaluation

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The Sweet Spot

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Hospital Priorities and Initiatives

HCPF Major Initiatives and Priorities

Community Identified Needs and

Sweet Spot

Questions and Discussion

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Contact Information

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[email protected]

mailto:[email protected]

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• Specialty Hospital Analyst: Elizabeth Quaife

• Reviewing Budget Neutral Options to be effective in 2018

• Comparing different options for long-term solution

• Any feedback or questions please contact Elizabeth Quaifeat 303.866.2083 or [email protected]

New Specialty Hospital RatesMethodology Update

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APR-DRG Weight Changes due to Removal of IPP-LARC

• Utilization of Immediate Post-Partum Long-Acting ReversibleContraceptives (IPP-LARCs / IUDs and Implants) prior to hospitaldischarge is efficacious in preventing unintentional follow-uppregnancies.

• IPP-LARCs are currently paid as part of the global OB payment,through the APR-DRG system.

• A method to “carve-out” IPP-LARCs from the APR-DRG system hasbeen developed and will be submitted to CMS for approval.

• The Department is planning on instituting this change in payment onJuly 1, 2017 provided that approval is received from CMS.

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IPP-LARCs ImplementationEstimated Timeline

CMS approval for FY2017-18 rates is

received

7/1/2017

Mass Adjustment of all claims back to 7/1/2017 to reflect FY2017-18 CMS

approved rates and Adjusted Birth DRG weights as proposed.

~October 2017 ?

Mass Adjustment of Claims with correct coding will receive payment for IPP-LARCs at this time

CMS approval for IPP-LARCs State Plan change is

received

Please Note: The State has no control over when CMS approves State Plan changes.

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APR-DRG Weight Changes due to Removal of IPP-LARC (7/1/2017)

DRG-SOIAffected Birth

DRGsFY2015-16

Weight w/ LARCs

Weight w/LARCs removed

Difference in Weights

540-1 3,277 0.5893 0.5853 0.0040540-2 less than 30 0.9434 0.9394 0.0040540-3 less than 30 1.3456 1.3416 0.0040540-4 141 3.1956 3.1916 0.0040542-1 1,238 0.3787 0.3747 0.0040542-2 less than 30 0.5629 0.5589 0.0040542-3 less than 30 1.0438 1.0398 0.0040542-4 9,286 4.8252 4.8212 0.0040560-1 719 0.4795 0.4755 0.0040560-2 6,850 0.5601 0.5561 0.0040560-3 99 0.7559 0.7519 0.0040560-4 1,718 2.2333 2.2293 0.0040

23,393

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• Proposed method for extra “carve-out” payment of Immediate Post Partum LARCs (Long Acting Reversible Contraceptives)

Maternity Immediate Post-Partum Long-Acting Reversible Contraceptives

DIAGNOSIS CODES JCODE MODIFIER NDC

Z30.430 J7298 FP 5041942101Z30.49 J7307 FP 00052027401

DIAGNOSIS CODES JCODE MODIFIER NDC

Z30.430 J7298 5041942101

Please note, The Department is only recommending what needs to appear on a claim in order to receive credit for inserting an IPP-LARCs

LARCS SUPPLEMENT

PAID

REQUIREMENTS FOR INPATIENT HOSPITAL IPP-LARCS CLAIMS

LARCS SUPPLEMENT

NOT PAIDANY CLAIMS SUBMITTED WITHOUT THE FP MODIFIER OR ANY OTHER REQURIED CODES WILL NOT RECEIVE PAYMENT FOR THE LARCS SUPPLEMENT

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• After adjusting the APR-DRG weights for 540, 542 & 560, new CMIs were created for each hospital and entered into the base rate setting calculations.

• Hospitals base rates increased by an average of $0.23 ($0.18 - $0.46) which translates to a reduction in the overall budget for FY2017-18 of $574,865.

• In FY2015-16, DRGs 540, 542 & 560 accounted for 23,393 discharges out of a total of 95,262 total discharges or nearly 25% of all discharges.


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LARCs insertions will be paid between $656 - $893Average = $774


NEW

LARC DEVICE NAME HCPCS/CPT CODE NDCCurrent Nov-2016

FFS Rate

Skyla IUD- Levonorgestrel IUS 13.5mg - 3 years

J7301 50419042201 $715.85

Mirena IUD- Levonorgestrel IUS 52mg -

5 years

J7298 changed as of 1/1/16 / J7302 discontinued code

50419042101 $892.99

Nexplanon - etonogestrel 68mg Implant - 3 years

J730752027401/52027201 - for

Implanon (being phased out as July 2016)

$777.37

Paragard - (CuT38A)- 10 years

J7300 51285020401 $742.70

Liletta IUD- Levonorgestrel IUS 52mg -

3 years

J7297 new code as of 1/1/16

Two-handed inserter: 5254403554/52544003554 One-

handed inserter: 00023585801/0023585801

$656.25

Kyleena - NEW IUD - Levonorgestrel IUS

19.5mg - 5years

Q9984 - NEW code as of 7/1/17

50419-424-01 50419-424-08 50419-424-71

Per invoice/Suggested

Manuf Retail $858.33

Sheet1

HOSPITAL ENGAGEMENT MEETING TOPICS5/5/17TIMEOwner / Specific Materials needed to facilitate discussionMarch-17May-17July-17September-17November-17

General Hospital MeetingX8:00-12:00 noon

-Fiscal Year 2017-18 Inpatient Base RatesXDiana /

-Overview on how Inpatient Base Rates are builtXDiana /

-APR-DRG prospective weight changes due to removal of IPP-LARCs

-Update rates every other year methodology discussionXDiana /

-DRG base rate communicationXDiana /

-New Specialty Hospital Rates Methodology Update

-Rate Related System Issues Update

-ICD-10 10/1/2016 update on new Diagnosis Codes - UPDATEXDiana /

-Transfer Claims Update (affects only Rehabs & LTACs)

-Baby Diagnosis on Mom's Claims

-Radiology Procedure Codes

-EAPG UPDATEXAndrew /

-Hospital Organizational Structureif time allows

-Hospital owned primary care practicesif time allowsAna/

-Stand alone emergency departmentsif time allowsAna/

-Salaried vs. non-salaried physicians within hospitalsif time allowsAna/

-Payment Reform Projects

-Community based projects

-Hospital Report Card

-Hospital site visits

-Yearly Hospital Meeting (Inpatient Base Rates)X

-Cost Shift Avoidance Discussion Shane / Kevin

HOSPITAL ENGAGEMENT MEETING TOPICS 7/7/2017 8am-12pm Hospital Engagement Meeting Time Line:

· General Hospital Meeting TopicPerson(s) Responsible

- New Specialty Hospital Rates Methodology UpdateHospital TransformationMatt Haynes

- IPP-LARCs implementation timelineSpecialty HospitalElizabeth Quaife

- Update on GME Q2-2015 PaymentsIPP LarcsDiana Lambe/Melanie Reece

- Cost Settlement UpdatesUpdate GMEDiana Lambe

- EAPG Rate UpdateBaby Diagnosis on Mom'sRaine Henry

- Innovative MedicationsInnovative MedicationsKevin Martin

Mass AdjustmentDiana Lambe/Clint Eatman

· Rate Related System Issues Update Cost Settlement UpdatesAndrew Abalos

- ICD-10 10/1/2016 update on new Diagnosis CodesEAPGsAndrew Abalos/Clint Eatman

- Transfer Claims Update (affects only Rehabs & LTACs)

- Baby Diagnosis on Mom's Claims

- Mass Adjustment Update for 3 Low Volume Payment Hospitals

- Ongoing Issues Impacting EAPGs

- EAPG Mass Adjustment SchedulingLARC DEVICE NAMEHCPCS/CPT CODENDCCurrent Nov-2016 FFS Rate

Skyla IUD- Levonorgestrel IUS 13.5mg - 3 yearsJ730150419042201$715.85

Mirena IUD- Levonorgestrel IUS 52mg - 5 yearsJ7298 changed as of 1/1/16 / J7302 discontinued code50419042101$892.99

Nexplanon - etonogestrel 68mg Implant - 3 yearsJ730752027401/52027201 - for Implanon (being phased out as July 2016)$777.37

Paragard - (CuT38A)- 10 yearsJ730051285020401$742.70

Liletta IUD- Levonorgestrel IUS 52mg - 3 yearsJ7297 new code as of 1/1/16 Two-handed inserter: 5254403554/52544003554 One-handed inserter: 00023585801/0023585801$656.25

Kyleena - NEW IUD - Levonorgestrel IUS 19.5mg - 5yearsQ9984 - NEW code as of 7/1/1750419-424-01 50419-424-08 50419-424-71Per invoice/Suggested Manuf Retail $858.33

links to registration

MAY 5, 2017 MEETING TIMES AND LINK TO REGISTER

General Hospital Meeting 8:00 - 12:00 noonhttps://cohcpf.adobeconnect.com/e237cw187s6/event/event_info.html

https://cohcpf.adobeconnect.com/e237cw187s6/event/event_info.html

Sheet3

Budget N Year:

Administrator: Administrator:Budget Neutrality baseline year. Should always be FY 02-03 until "Budget Neutrality" goes away.FY 02-03Formula pulls value inFormula pulls value inFormula pulls value inFormula pulls value inFormula pulls value inAdj Dischrgs for prior yr * Volume Inflator (R138)Formula pulls value indon't delete=$H66*$I66*J66*'Budget Actions'!$D$4Formula pulls value in=H66*I66*L66Formula pulls value in where appropriate from PPS & Non-PPS tables=N66*$R$128all currently 100% COL Rpulls in peer grp avg for CAH or low discharge hospitalsMedicaid Rate + Add OnsMedicaid Rate + Add-Ons * Est dischgs * CMIDifference between prior yr and current yr est paymentspercent change in payments current yr/prior yrformulaformulaformulaformulaformulaformulaformulaformula

PCG Report:

Administrator: Administrator:The year FY of the CFMC report that is used for discharges, CMI, and ALOS.FY 14-15 EstimatedQ2+AB2+AC2+AD2EstimatedBUDGET: $0.00

Prior Year:

Administrator: Administrator:Year that is prior to the year that rates are being calculated for.FY 15-16TBD: 3A=New TEFRA1=PediatricsCheck this formulaFY 16-17Estimated


this is NOT budget neutral # - budget neutral is in col Kcmi adjusted rate

OITDSS: dl - don't know what this means. This column should be Medicare Final Rate LESS DSH + LVA (if applicable)we pay % of medicare rate to match budget neutralityadj by specialty %FY 16-17FY 16-17FY 16-17FINAL% OF MEDICARE:0.00%

Current Year:

Administrator: Administrator:FY that rates are being set for.


this is NOT budget neutral # - budget neutral is in col K

OITDSS: dl - don't know what this means. This column should be Medicare Final Rate LESS DSH + LVA (if applicable)FY 16-172=Not SpecialNon-CMI Adjusted DischargesPayments withFY 16-171-Oct-15FY 16-17MedicaidMedicaidPaymentsFY 16-17EstimatedMedicaid Cost Add-Ons / Cost per DischargeAmt over budget neutrality$0.00

1 = CAH3=RehabPeer GroupEstimatedFY 02-03Payments withMedicare Initial Rate = Final Medicare DRG Rate - DSH + LVA (where appropriate)

Chris: Jessica:1 = CAH2 = not3 = TEFRAMedicaidRates withRate with Rate withWithout Difference inMedicaid RateFY 16-17FinalFinal10% add on10% add on10% add on

Provider2 = Not4=Spinal RehabRural = 1CAH = 1FY 14-15FY 16-17FY 14-15FY 02-03Rates Incl PriorFY 15-16FY 15-16RateSpecialty CAH and lowMedicaidUpcoming YearEstimatedPercentw/Budget PaymentsFY 15-16FY 16-17Year over Year0.10.10.1FINAL RATES for RATE LETTERS

NumberProviders3 = TEFRA5=LTACUrban = 2Non-CAH = 2DischargesDischargesCase MixRates

: This will always be 02-03 Rates because that is our baseline year. Changing this would require State Plan Amendment.

Chris: Jessica:1 = CAH2 = not3 = TEFRABudget Actions

jlwagn: Check the cell reference for this formula in the Budget Actions tab. Rates

Administrator: Administrator:Final MK Rates from previous FYRates(% of Medicare)Percentages


Dischage avg.

Domenica Blum: Formulas are different for the rehabsAdd-OnsBudget ActionsPaymentsChangeActionsw/Budget ActionsInpatient Base RateInpatient Base Rate% ChangeNurseryNICUGMERATE w/out GME (purple) - goes in rate letterREASONS FOR RATE INCREASE/DECREASE% Diff in Rate from Prior Year

RURAL HOSPITALS

w/LVP GAF Fix

XXXXXSample HospitalERROR:#N/AERROR:#N/AERROR:#N/AERROR:#N/AERROR:#N/AERROR:#N/A

OITDSS: this estimates how many discharges will occur in next fiscal year for each hospital

Administrator: Administrator:Final MK Rates from previous FYERROR:#N/AERROR:#N/AERROR:#N/A

OITDSS: calculating the estimated dollar amount that should be spent this year by hospital to come up with a budget neutral amount


Domenica Blum: Formulas are different for the rehabsERROR:#N/AERROR:#N/AERROR:#N/AERROR:#N/AERROR:#N/AERROR:#N/AERROR:#N/AERROR:#N/AERROR:#N/AERROR:#N/AERROR:#N/AERROR:#N/AERROR:#N/AERROR:#N/AERROR:#N/AERROR:#N/AERROR:#N/AERROR:#N/AERROR:#N/AERROR:#N/AERROR:#N/A

























































































22

• IPP-LARCs insertions will be paid an average of $774

• Using the LARCs average above, and based on the 712 claims we were able to identify in 2015, the Department would pay $551,088 for IPP-LARCs insertions.


23

• Proper billing procedures for Newborn on Mother’s Claim can befound in the Inpatient/Outpatient Billing Manual.

• If the Mother is in the hospital, the mother and baby's charges(procedure and diagnosis codes) are billed on one claim as one stay.Services should be billed on the mother’s claim until the time themother is discharged.

• If procedures for the newborn were performed during the mother’sstay, they should only appear on the mother’s claim. They shouldnot appear on the newborn’s claim after the mother wasdischarged. If they do appear on the newborn’s claim, the claim willdeny.

• Mother’s claims with a newborn diagnosis or procedure that has anage or gender restriction are currently encountering errors. TheDepartment is working on a solution to this problem.

Newborn on Mother’s Claim

Innovative Medications• The prevalence of innovative drugs is increasing Spinraza Brineura

• These drugs often treat a small population at a high price

• Since current hospital payment methodologies are based on costs it takes several years to incorporate these costs into the payments

24

Innovative Medications

• We have been researching various options but this is a very resource intensive process

• Addressing individual drugs is not a sustainable option

• The larger issue that needs to be addressed is how to update payment methodologies with data that is more recent than ~3 years in the past

25

GME Q2-2015 Payments• Payments to Hospitals awaiting their GME Q2-2015

payments were made prior to the fiscal year end close on 6/30/2017.

• GME Hospitals should receive the payments very soon if they haven’t already received them.

• Letters sent to hospitals detailing the payments were sent in December 2016. If you need another copy of the letter please contact [email protected] or 303.866.5526. Thank you for your patience.

26

mailto:[email protected]

OVERVIEW OF MASS ADJUSTMENTS9,501 Claims

8,484 ICD10 New Diagnosis/New

Surgical Procedure Codes Claims

10/1/2016 - 2/28/2017

• 3,948 Paid Claims• 4,536 Denied Claims

722 claims CMS RuralDemonstration Hospitals –LVP restored, paid dates

>= 7/1/2016 &

28

• The old MMIS system was not able to recognize the new ICD10 Diagnosisand Surgical Procedure Codes that were instituted on 10/1/2016. The NewMMIS was able to correctly process these claims as of 3/1/2017.

ICD10 – NEW DIAGNOSIS/SURG PROC CODES

HOSPITAL SYSTEM HOSPITAL NAME COUNT(CLM_TCN)Denver Health Medical Center, Hospital 1070

UC HEALTH University of Colorado Hospital 895UC HEALTH Memorial Hospital 767SCL Health Exempla Saint Joseph Hospital, Inc. 456

Centura Health Centura Health-Penrose-St. Francis Health Services 368Parkview Medical Center 343

SCL Health Exempla Lutheran Medical Center 338HealthOne HealthOne The Medical Center of Aurora 276UC HEALTH Poudre Valley Hospital 250

Banner Banner Health-North Colorado Medical Center 237HealthOne HealthOne Swedish Medical Center 220

Centura Health Centura Health-St. Anthony North Hospital 196HealthOne HealthOne North Suburban Medical Center 192HealthOne HealthOne Presbyterian/St. Luke's Medical Center 164

Centura Health Centura Health-St. Anthony Central Hospital 163Centura Health Centura Health-Avista Adventist Hospital 158

The Children's Hospital 152HealthOne HealthOne Rose Medical Center 150SCL Health Exempla Good Samaritan 149UC HEALTH Medical Center of the Rockies 144SCL Health St. Mary's Hospital and Medical Center, Inc. 142

Centura Health Centura Health-St. Mary Corwin Medical Center 138Centura Health Centura Health-Longmont United Hospital 118Centura Health Centura Health-Parker Adventist Hospital 116

HealthOne HealthOne Sky Ridge Medical Center 112

8,484 ICD-10 NEW DIAGNOSIS CLAIMS FROM OLD MMIS 10/1/2016 - 2/28/2017 TO BE MASS ADJUSTED

8,484 ICD10 New Diagnosis/Surgical Procedure Codes

Claims 10/1/2016 -2/28/2017

FINAL CT BY PROV

8,484 ICD-10 NEW DIAGNOSIS CLAIMS FROM OLD MMIS 10/1/2016 - 2/28/2017 TO BE MASS ADJUSTED

NPIHOSPITAL SYSTEMHOSPITAL NAMEBILL_PROV_NPI_IDBILL_PROV_LOC_IDCOUNT(CLM_TCN)

1689624686Denver Health Medical Center, Hospital16896246861036401070

1477531580UC HEALTHUniversity of Colorado Hospital1477531580128069895

1144397134UC HEALTHMemorial Hospital1144397134115047767

1417946021SCL HealthExempla Saint Joseph Hospital, Inc.1417946021110781456

1932112125Centura HealthCentura Health-Penrose-St. Francis Health Services1932112125128946368

1104881507Parkview Medical Center1104881507126187343

1669461281SCL HealthExempla Lutheran Medical Center1669461281108667338

1659327013HealthOneHealthOne The Medical Center of Aurora1659327013127686276

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