evekhm/cms_iom_500 huggingface dataset:
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For discharges occurring on or after August 8, 2003, the Medicare contractor should use a Statewide average CCR if it is unable to determine an accurate CCR for a LTCH in one of the following circumstances:  1. New hospitals that have not yet submitted their first Medicare cost report.  (For this purpose, a new hospital is defined as an entity that has not accepted assignment of an existing hospitals provider agreement in accordance with 42 CFR 489.18.)  2. LTCHs whose overall CCR is in excess of 3 standard deviations above the corresponding national geometric mean.  Effective 10/1/2006, this mean is recalculated annually by CMS and published in the annual notice of prospective payment rates issued in acco rdance with 412.525(a)(4)(iv)(c)(2) and 412.529(c)(3)(iv)(c)(2) of the CFR.  3. Other LTCHs for whom accurate data with which to calculate an overall CCR are not available.   However, the policies of 150.24 part B and C can be applied as an alternative to the Statewide average CCR.   For those LTCHs assigned the Statewide average CCR, the CCR must be updated every October 1 based on the latest Statewide average CCRs published in each years IPPS annual notice of prospective payment rates (Table 8C for LTCHs) until the hospital is assig ned a CCR based on the latest tentative or final settled cost report or a CCR based on the policies of 150.24 part B and C of this manual.  A hospital is not assigned the Statewide average CCR if its CCR falls below 3 standard deviations from the national  mean CCR.  In such a case, the LTCH CCR is used.  150.26 - Reconciliation  (Rev. 4390, Issued: 09- 06-19, Effective: 10 -01-19, Implementation: 10- 07-19)  A. - General   For all LTCHs, reconciliation is effective beginning with discharges occurring in a hospitals first cost reporting period beginning on or after October 1, 2003.
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A. - General   For all LTCHs, reconciliation is effective beginning with discharges occurring in a hospitals first cost reporting period beginning on or after October 1, 2003.   Subject to the approval of the CMS Central Office, Medicare contractors shall reconcile a LTCHs outlier claims at the time of cost report final settlement if they meet the following criteria:   1. The actual CCR is found to be plus or minus 10 percentage points from the CCR used during that cost reporting period to make outlier payments, and
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2. Applicable outlier payments exceed $500,000 in that cost reporting period.  For the purposes of determining whether outlier payments meet the $500,000 threshold, MACs shall combine the following applicable payments depending on the cost reporting period:  a. For cost reporting periods beginning before October 1, 2015, high cost outlier payments made under 42 CFR 412.525 and short -stay outlier payments made under 42 CFR 412.529 (OUTLIER and SHORT STAY OUTLIER PAYMENTS on PS&R Report 11S);  b. For cost reporting periods beginning on or after October 1, 2015 and ending before October 1, 2017, high cost outlier payments made under 42 CFR 412.525 (that is, both high cost outlier payments made to site neutral payment rate discharges described under  42 CFR 412.522(a)(1) and to standard payment rate discharges described under 42 CFR  412.522(a)(2)), and short -stay outlier payments made under 42 CFR 412.529 (OUTLIER and SSO STANDARD PAYMENTS on PS&R Report 11S ); c. For cost reporting periods beginning on or after October 1, 2015 and ending after October  1, 2017  i. For discharges before October 1, 2017, high cost outlier payments made under 42 CFR 412.525 (that is, both high cost outlier payments made to site neutral payment rate discharges described under 42 CFR 412.522(a)(1) and to standard payment rate discharges described under 42 CFR 412.522(a)(2)), and short -stay outlier payments made under 42 CFR 412.529 ( OUTLIER and SSO STANDARD PAYMENTS on PS&R Report 11S ); ii. For discharges after October 1, 2017, high cost outlier payments made under 42 CFR 412.525 (that is, both high cost outlier payments made to site neutral payment rate discharges described under 42 CFR 412.522(a)(1) and to standard payment rate discharges  described under 42 CFR 412.522(a)(2)) ( OUTLIER on PS&R Report 11S ); or d. For cost reporting periods beginning on or after October
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and to standard payment rate discharges  described under 42 CFR 412.522(a)(2)) ( OUTLIER on PS&R Report 11S ); or d. For cost reporting periods beginning on or after October 1, 2017, high cost outlier payments made under 42 CFR 412.525 (that is, both high cost outlier payments made to site neutral payment rate discharges described under 42 CFR 412.522(a)(1) and to standard payment rate discharges described under 42 CFR 412.522(a)(2)) ( OUTLIER on PS&R Report 11S ).
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To determine if a LTCH meets the criteria above, the Medicare contractor shall incorporate all the adjustments from the cost report, run the cost report, calculate the revised CCR and compute the actual CCR prior to issuing a Notice of Program Reimbursemen t (NPR).  If the criteria for reconciliation are not met, the cost report shall be finalized.  If the criteria for reconciliation are met, Medicare contractors shall follow the instructions below in 150.28.  The NPR cannot be issued nor can the cost report be finalized until outlier reconciliation is complete. The criteria above replaces the criteria published in III of PM A-03-058.  As stated above, if a cost report is reopened after final settlement and as a result of this reopening there is a change to the CCR (which could trigger or affect outlier reconciliation and outlier payments), Medicare contractors shall notify the CMS Regional and Central Office for further instructions.  Notification to the CMS Central Office shall be sent via email to outliersIPPS@cms.hhs.gov.   Even if a LTCH does not meet the criteria for reconciliation, subject to approval of the CMS Regional and Central Office, the Medicare contractor has the discretion to request that a LTCHs outlier payments in a cost reporting period be reconciled if the L TCHs most recent cost and charge data indicate that the outlier payments to the hospital were significantly inaccurate.  The Medicare contractor sends notification to the CMS Central Office via email to outliersIPPS@cms.hhs.gov.  Upon approval of the CMS regional and Central Office that a LTCHs high cost and short stay outlier claims need to be reconciled, Medicare contractors shall follow the instructions in 150.27 and 150.28.  B. Reconciling Outlier Payments   Beginning with the first cost reporting period starting on or after October 1, 2003, all LTCHs are subject to the reconciliation policies set forth in this section.  If a LTCH meets the criteria in part A of this section, the Medicare contractor shall follow the instructions below in 150.28.  Further instructions for Medicare contractors on reconciliation and the time value of money are provided below in 150.27 and 150.28.  The following examples demonstrate how to apply the criteria for reconciliation:   Example A
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Cost Reporting Period: 01/01/2004-12/31/2004   CCR used to pay original claims submitted during cost reporting period:  0.40 (In this example, this CCR is from the tentatively settled 2002 cost report).  Final settled CCR from 01/01/2004-12/31/2004 cost report:  0.50.   Total outlier payments (short-stay and high cost outliers combined) in 01/01/2004-12/31/2004 cost reporting period: $600,000.   Because the CCR of 0.40 used at the time the claim was originally paid changed to 0.50 (by more than 10 percentage points) at the time of final settlement, and the provider received greater than $500,000 in (short-stay and high cost) outlier payments during that cost reporting period, the criteria has been met to trigger reconciliation, and therefore, the Medicare contractor notifies the CMS Regional Office and CMS Central Office.  The providers outlier payments for this cost reporting period will be reconciled using the actual CCR of 0.50.  In the event that multiple CCRs are used in a given cost reporting period, Medicare contractor shall calculate a weighted average of the CCRs in that cost reporting period.  (See Example B below for instructions on how to weight the CCRs).  The Medicare contractor shall then compare the weighted average CCR to the CCR determined at the time of final settlement of the cost reporting period to determine if reconciliation is required.  Again, total (combined short- stay and high cost) outlier payments for the entire  cost reporting period must exceed $500,000 in order to trigger reconciliation.  Example B   Cost Reporting Period: 01/01/2004-12/31/2004   CCR used to pay original claims submitted during cost reporting period:    - 0.40 from 01/01/2004-03/31/2004 (This CCR is from the tentatively settled 2001 cost report)  - 0.50 from 04/01/2004-12/31/2004 (This CCR is from the tentatively settled 2002 cost report)
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Final settled CCR from 01/01/2004-12/31/2004 cost report: 0.35   Total (short-stay and high cost) outlier payout in 01/01/2004-12/31/2004 cost reporting period: $600,000   Weighted Average CCR: 0.474, completed as follows:  CCR  Days  Weight  Weighted CCR  0.40  91  0.248 (91 Days / 366 Days)  (a) 0.099=   (0.40 * 0.248)  0.50  275  0.751 (275 Days / 366 Days )  (b) 0.375=   (0.50 * 0.751)  TOTAL  *366    (a)+(b) =0.4742   *NOTE : There are 366 days in the year because 2004 was a leap year.   The LTCH meets the criteria for reconciliation in this cost reporting period because the weighted average CCR at the time the claim was originally paid changed (by more than ten percentage points) from 0.474 to 0.35 at the time of final settlement, and the provider received (combined) outlier payments greater than $500,000 for the entire cost reporting period.   150.27 - Time Value of Money  (Rev. 2242, Issued: 06- 17-11, Effective: 07-01-11, Implementation: 07-01-11)  At the time of any reconciliation under 150.26, outlier payments may be adjusted to account for the time value of money of any adjustments to outlier payments as a result of reconciliation.  The time value of money is applied from the midpoint of the LTCH s cost reporting period being settled to the date on which the CMS Central Office receives notification from the Medicare contractor that reconciliation should be performed.  If a LTCHs outlier payments have met the criteria for reconciliation, the Medicare contractor shall follow the process in 150.28.  The index that will be used to calculate the time value of money is the monthly rate of return that the Medicare trust fund earns.  This index can be found at http://www.ssa.gov/OACT/ProgData/newIssueRates.html  The following formula will be used to calculate the rate of the time value of money.
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The following formula will be used to calculate the rate of the time value of money.   (Rate from Web site as of the midpoint of the cost report being settled / 365) * # of days from that midpoint until date of reconciliation.   NOTE:  The time value of money can be a positive or negative amount depending if the provider is owed money by CMS or if the provider owes money to CMS.  For purposes of calculating the time value of money, the date of reconciliation is the day on which the CMS Central Office receives notification.  This date is either the postmark from the written notification sent to the CMS Central Office via mail by the Medicare contractor, or the date an email was received from the Medicare contractor by the CMS Central Office, whichever is first.   The following is an example of the procedures for reconciliation and computation of the adjustment to account for the time value of money:  Example C   Cost Reporting Period: 01/01/2004-12/31/2004  Midpoint of Cost Reporting Period: 07/01/2004  Date of Reconciliation: 12/31/2005  Number of days from Midpoint until date of Reconciliation: 549  Rate from Social Security Web site: 4.625%  CCR used to pay actual original claims in cost reporting period: 0.40 (This CCR could be from the tentatively settled 2002 or 2003 cost report)  Final settled CCR from 01/01/2004-12/31/2004 cost report: 0.50  Total outlier payout in 01/01/2004-12/31/2004 cost reporting period: $600,000.  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 total outlier payments greater than $500,000, the criteria have been met to trigger reconciliation.  The Medicare contractor notifies the CMS Regional Office and CMS Central Office.
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The Medicare contractor reprices the claims in accordance with the process in 150.28 below.  The repricing indicates the revised outlier payments are $700,000.  Using the values above, determine the rate that will be used for the time value of money: (4.625 / 365) * 549 = 6.9565%  Based on the claims reconciled, the provider is owed $100,000 ($700,000-$600,000) for the reconciled amount and $6,956.50 ($100,000 * 6.9565 %) for the time value of money.  150.28 - Procedure for Medicare Contractors to Perform and Record Outlier Reconciliation Adjustments  (Rev. 4390, Issued: 09- 06-19, Effective: 10-01-19, Implementation: 10-07-19)  The following is a step- by-step explanation of the procedures that Medicare contractors are to follow if a LTCH is eligible for outlier reconciliation:   1) The Medicare contractor shall send notification to the CMS Central Office (not the hospital), via email to outliersIPPS@cms.hhs.gov and CMS Regional Office that a hospital has met the criteria for reconciliation. Medicare contractors shall include in their notification the provider number, provider name, cost reporting begin date, cost reporting end date, total short stay and high cost 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 that reconciliation is appropriate, the Medicare contractor shall follow steps 3-14 below. NOTE : Hospital cost reports will remain open until their claims have been processed for outlier reconciliation.  3) The Medicare contractor shall notify the hospital and copy the CMS Regional Office and Central Office via email at outliersIPPS@cms.hhs.gov that the hospitals outlier claims are to be reconciled.
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that the hospitals outlier claims are to be reconciled.   4) Prior to running claims in the *Lump Sum Utility, Medicare contractors shall update the applicable provider record in the Provider Specific File (PSF) by entering the final settled CCR from the cost report in the - 25 -Operating Cost to Charge Ratio field. No other elements in the PSF shall be updated for the applicable provider records in the PSF that span the cost reporting period being reconciled aside fr om the CCR.   *NOTE : The FISS Lump Sum Utility is a Medicare contractor tool that, 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 A ccess 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:   7) Type of Bill (TOB) equals 11X  8) Previous claim is in a paid status (P location) within FISS  9) Cancel date is blank   10) The Medicare contractor reconciles the claims through the applicable LTCH Pricer software and not through any editing or grouping software.   11) 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).   12) Medicare contractors shall upload the extract into Microsoft Access or a similar software program to generate a report that contains elements in Table 1. Medicare contractors shall ensure this report is retained with the cost report settlement work papers.
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13) For hospitals paid under the LTCH PPS, the difference between the Original PPS Payment Amount and Revised PPS Payment Amount from the Lump Sum Utility will reflect the difference between the total original short- stay and high cost outlier payment amount and the revised short -stay and high cost outlier payment amount. If the difference between the original and revised PPS Payment Amount is positive, then a credit amount (addition) shall be issued to the provider. If the difference between the original and revised PPS Payment is negative, then a debit amount (deduction) shall be issued to the provider.  14) Medicare contractors shall determine the applicable time value of money amount by using the calculation methodology in 150.27. If the difference between the Original PPS Payment Amount and Revised PPS Payment Amount from 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 PPS Payment Amount and Revised PPS Payment Amount from 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 negative, 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 PPS Payment Amount and Revised PPS Payment Amount.  15) For cost reporting periods beginning before May 1, 2010, under cost report 2552-96, the Medicare contractor shall record the original PPS  amount by summing lines 1.02 and 1.05 from Worksheet E -3, Part I, the outlier reconciliation adjustment amount (the difference between the Original PPS Payment Amount and Revised PPS Payment Amount from the Lump Sum Utility), the total time value of money and the rate used to calculate the time value of money on lines 50- 53, of Worksheet E -3, Part I of the cost report ( NOTE : the amounts recorded on lines 50, 51 and 53 can be positive or negative amounts per the instructions above). The total outlier reconciliation amount (the difference between the original PPS Payment Amount and Revised PPS Payment Amount (from the Lump Sum  Utility) plus the time value of money) shall be recorded on line 15.99 of Worksheet E -3, Part I. For
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(the difference between the original PPS Payment Amount and Revised PPS Payment Amount (from the Lump Sum  Utility) plus the time value of money) shall be recorded on line 15.99 of Worksheet E -3, Part I. For complete instructions on how to fill out these lines please see 3633.1 of the Provider Reimbursement Manual, Part II.
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16) For cost reporting periods beginning on or after May 1, 2010, under cost report 2552- 10, the Medicare contractor shall record the original PPS amount from Worksheet E -3, Part IV line 3, the outlier reconciliation adjustment amount (the difference between t he Original PPS Payment Amount and Revised PPS Payment Amount from the Lump Sum Utility), the total time value of money and the rate used to calculate the time value of money on lines 50- 53, of Worksheet E -3, Part IV of the cost report ( NOTE : the amounts r ecorded on lines 50, 51 and 53 can be positive or negative amounts per the instructions above). The total outlier reconciliation amount (the difference between the original PPS Payment Amount and Revised PPS Payment Amount (from the Lump Sum Utility) plus the time value of money) shall be recorded on line 20 of Worksheet E -3, Part IV.   17) The Medicare contractor shall finalize the cost report, issue a NPR and make the necessary adjustment from or to the provider.   18) After determining the total outlier reconciliation amount and issuing a NPR, Medicare contractors shall restore the CCR(s) 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 LTCH PPS, Medicare contractors shall enter the original CCR(s) in PSF field 25 -Operating Cost to Charge Ratio.  If the Medicare contractor has any questions regarding this process it should contact the Central Office, via email at outliersIPPS@cms.hhs.gov.   Table 1:  Data Elements for FISS Extract
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List of Data Elements for FISS Extract  Provider #  Health Insurance Claim (HIC) Number  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 (Value 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)  List of Data Elements for FISS Extract  Difference between these amounts  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
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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