(Medicare Claims Processing Manual)

Because the CCR fluctuated from 0.40 at the time the claims were originally paid to 0.50 at the time of final settlement and the provider has an OPPS outlier payout greater than $500,000, the criteria have been met to trigger reconciliation.  The Medicare contractor notifies the CMS Central and Regional Offices.   The Medicare contractor reprices the claims in accordance with the process in 10.7.2.4 below.  The repricing  indicates the revised outlier payments are $700,000.    Using the values above, the rate that is used for the time value of money is determined:    (4.625 / 365) * 548 = 6.9438%   Based on the claims reconciled, the provider is owed $100,000 ($700,000 -  $600,000) for the reconciled amount and $6,943.80 for the time value of money.   10.7.2.4 - Procedures for Medicare Contractors to Perform and Record Outlier Reconciliation Adjustments (Rev.  4233, Issued: 02- 08-19, Effective: 03- 12-19, Implementation: 03- 12-19)  The term Medicare beneficiary identifier (Mbi) is a general term describing a beneficiary's Medicare identification number. For purposes of this manual, Medicare beneficiary identifier references both the Health Insurance Claim Number (HICN) and the Medi care Beneficiary Identifier (MBI) during the new Medicare card transition period and after for certain business areas that will continue to use the HICN as part of their processes.   The following is a step- by-step explanation of the procedures that Medicar e contractors are to follow if a hospital (or CMHC) is eligible for outlier reconciliation:   1) The Medicare contractor sends notification to the CMS Central Office (not the hospital or CMHC), via the street address and email address provided in 10.11.3.1 a nd to the CMS Regional Office that a hospital or CMHC has met the criteria for OPPS outlier reconciliation.  Medicare contractors shall include in their notification the provider number, provider name, cost reporting begin date, cost reporting end date, total outlier payments in the cost reporting period, the CCR or weighted average CCR from the time the claims were paid during the cost reporting period eligible for reconciliation and the final settled CCR.   2) If the Medicare contractor receives approval from  the CMS Central Office and Regional Office that OPPS outlier reconciliation is appropriate, the Medicare contractor follows steps 3- 14 below.  NOTE : Hospital and CMHC cost reports will remain open until their claims have been processed for OPPS outlier re conciliation.   3) The Medicare contractor shall notify the hospital or CMHC and copy the CMS Regional Office and Central Office in writing and via email (through the address provided in 10.11.3.1) that the hospital or CMHCs OPPS outlier claims are to be rec onciled.   4) Prior  to running claims in the FISS Lump Sum Utility*, Medicare contractors shall update the applicable provider record in the Outpatient Provider Specific File (OPSF) by entering the final settled CCR from the cost report in Outpatient Cost to  Charge Ratio field.  No other elements in the OPSF shall be updated for the applicable provider records in the PSF that span the cost reporting period being reconciled aside from the CCR.  *NOTE : The FISS Lump Sum Utility is a Medicare contractor tool tha t, depending on the elements that are input, will produce an extract that will calculate the difference between the original PPS payment amounts and revised PPS payment amounts into a Microsoft Access generated report.  The Lump Sum Utility calculates the original and revised payments offline and will not affect the original claim payment amounts as displayed in various CMS systems (such as NCH).    5) Medicare contractors shall ensure that, prior to running claims through the FISS Lump Sum Utility, all pending claims (e.g., appeal adjustments) are finalized for the applicable provider.   6) Medicare contractors shall only run claims in the Lump Sum Utility that meet the following criteria:     TOB 12X, 13X, 34X, 75X, 76X or any TOB with a condition code 07   Claim has a line item date of service of January 1, 2009 or later that also contains a Pay Method Flag of 0   Previous claim is in a paid status (P location) within FISS   Cancel date is blank   7) The Medicare contractor reconciles the claims through the OPPS Pricer so ftware and not through any editing or grouping software.   8) Upon completing steps 3 through 7 above, the Medicare contractor shall run the claims through the Lump Sum Utility.  The Lump Sum Utility will produce an extract, according to the elements in Table 1 below.  NOTE :  The extract must be importable by Microsoft Access or a similar software program (Microsoft Excel).    9) Medicare contractors shall upload the extract into Microsoft Access or a similar software program to generate a report that contains el ements in Table 1.  Medicare contractors shall ensure this report is retained with the cost report settlement work papers.   10) For hospitals paid under the OPPS, the Lump Sum Utility will calculate the difference between the original outlier amount (value code 17) and the revised outlier amount (value code 17).  If the difference between the original and revised outlier amount  is positive, then a credit amount (addition) shall be issued to the provider. If the difference between the original and revised outlie r amount is negative , then a debit amount (deduction) shall be issued to the provider.   11) Medicare contractors shall determine the applicable time value of money amount by using the calculation methodology in 10.7.2.3.  If the difference between the original and revised outlier amount (calculated by the Lump Sum Utility) is a negative amount then the time value of money is also a negative amount. If the difference between the original and revised outlier amount (calculated by the Lump Sum Utility) is a positive amount then the time value of money is also a positive amount.   Similar to step 10, if the time value of money is positive, then a credit amount (addition) shall be issued to the provider.  If the time value of money is ne gative, then a debit amount (deduction) shall be issued to the provider.  NOTE : The time value of money is applied to the difference between the original outlier amount (value code 17) and the revised outlier amount (value code 17).   12) For cost reporting pe riods beginning before May 1, 2010, under cost report 2552- 96, the Medicare contractor shall record the original outlier amount from Worksheet E, Part B, line 1.02 (prior to the inclusion of line 54 of Worksheet E, Part B), the outlier reconciliation adjus tment amount (the difference between the original and revised outlier amount (calculated by the Lump Sum Utility),  the total time value of money, the rate used to calculate the time value of money and the sum of lines 51 and 53 on lines 50- 54, of Worksheet  E, Part B of the cost report ( NOTE :  the amounts recorded on lines 50, 51, 53 and 54 can be positive or negative amounts per the instructions above).  The total outlier reconciliation amount (Worksheet E, Part B, line 54) shall be included on Worksheet E, Part B, line 1.02.  For complete instructions on how to fill out these lines see 3630.2 of the Provider Reimbursement Manual, Part II.   For cost reporting periods beginning on or after May 1, 2010, under cost report 2552- 10, the Medicare contractor shall  record the original outlier amount from Worksheet E, Part B, line 4 (prior to the inclusion of line 94 of Worksheet E, Part B), the outlier reconciliation adjustment amount (the difference between the original and revised outlier amount (calculated by the  Lump Sum Utility),  the total time value of money, the rate used to calculate the time value of money and the sum of lines 91 and 93 on lines 90- 94, of Worksheet E, Part B of the cost report ( NOTE : the amounts recorded on lines 90, 91, 93 and 94 can be pos itive or negative amounts per the instructions above).  The total  outlier reconciliation amount (Worksheet E, Part B, line 94) shall be included on Worksheet E, Part B, line 1.02.   13) The Medicare contractor shall finalize the cost report, issue a NPR and make the necessary adjustment from or to the provider.  14) After determining the total outlier reconciliation amount and issuing a NPR, Medicare contractors shall restore the CCR(s) elements to their original values (that is, the CCRs used to pay the claims) in  the applicable provider records in the PSF to ensure an accurate history is maintained. Specifically, for hospitals paid under the OPPS, Medicare contractors shall enter the original CCR in PSF field 25 -Operating Cost to Charge Ratio.  Medicare contractors shall contact the CMS Central Office via the address and email address provided in 10.11.3.1 with any questions regarding this process.  Table 1:  Data Elements for FISS Extract   List of Data Elements for FISS Extract  Provider #  Medicare beneficiary identifier  Document Control Number (DCN)  Type of Bill  Original Paid Date  Statement From Date  Statement To Date  Original Reimbursement Amount (claims page 10)  Revised Reimbursement Amount (claim page 10)  Difference between these amounts  Original Deductible Amount, Payer A, B, C (Value Code A1, B1, C1)  Revised Deductible Amount, Payer A, B, C (Value Code A1, B1, C1)  Difference between these amounts  Original Coinsurance Amount, Payer A, B, C (Value Code A2, B2, C2)  Revised Coinsurance Amount, Payer A, B, C (Value Code A2, B2, C2)  Difference between these amounts  Original Outlier Amount (Value Code 17)  Revised Outlier Amount (Value Code 17)  Difference between these amounts  Original DSH Amount (Value Code 18)  Revised DSH Amount (Val ue Code 18)  Difference between these amounts  Original IME Amount (Value Code 19)  Revised IME Amount (Value Code 19)  Difference between these amounts  Original New Tech Add -on (Value Code 77)  Revised New Tech Add -on (Value Code 77)  Difference between these amounts  Original Device Reductions (Value Code D4)  Revised Device Reductions (Value Code D4)  Difference between these amounts  Original Hospital Portion (claim page 14)  Revised Hospital Portion (claim page 14)  Difference between these amounts  Original Federal Portion  (claim page 14)  Revised Federal Portion  (claim page 14)  Difference between these amounts   List of Data Elements for FISS Extract  Original C TOT PAY (claim page 14)  Revised C TOT PAY (claim page 14)  Difference between these amounts  Original C FSP (claim page 14)  Revised C FSP (claim page 14)  Difference between these amounts  Original C OUTLIER (claim page 14)  Revised C OUTLIER (claim page 14)  Difference between these amounts  Original C DSH ADJ (claim page 14)  Revised C DSH ADJ (claim page 14)  Difference between these amounts  Original C IME ADJ (claim page 14)  Revised C IME ADJ (claim page 14)  Difference between these amounts  Original Pricer Amount  Revised Pricer Amount  Difference between these amounts  Original PPS Payment (claim page 14)  Revised PPS Payment (claim page 14)  Difference between these amounts  Original PPS Return Code (claim page 14)  Revised PPS Return Code (claim page 14)  DRG  MSP Indicator (Value Codes 12 -16 & 41 -43 - indicator indicating the claim is MSP; Y = MSP, blank = no  MSP  Reason Code  HMO -IME Indicator  Filler    10.8 - Geographic Adjustments  (Rev. 1, 10-03-03) A-01-93  Adjustments for differences in wages across geographical areas are made using inpatient hospital PPS wage index (post- reclassification, post -floor).