evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual)
20.1.2.5 - Reconciliation  (Rev. 4390, Issued: 09- 06-19, Effective: 10 -01-19, Implementation: 10- 07-19)  A. - General   Under 42 CFR 412.84(i )(4), for discharges occurring on or after August 8, 2003, high cost outlier payments may be reconciled upon cost report settlement to account for differences between the CCR used to pay the claim at its original submission by the provider, and the CCR det ermined at final settlement of the cost reporting period during which the discharge occurred.  This new regulation was implemented in two phases (further explanation on these two phases is provided below).  Hospitals that Medicare contractors identified using the criteria in I.A. of PM A -03-058 (under which Medicare contractors identified hospitals whose charges appeared to have been increasing at an excessive rate) are subject to the reconciliation policies described in this section for discharges occurri ng on or after August 8, 2003.  For all other hospitals, 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, a hospitals outlier claims will be reconciled at the time of cost report final settlement if they meet the following criteria:   1. The actual operating CCR is found to be plus or minus 10 percentage points from the CCR used during that time period to make outlier payments, and   2. Total outlier payments in that cost reporting period exceed $500,000.   To determine if a hospital 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 operating CCR prior to issuing a Notice of Progra m Reimbursement (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 20.1.2.7.  The NPR cannot be issued nor ca n the cost report be finalized until outlier reconciliation is complete.
(Medicare Claims Processing Manual)
The first criterion requires a 10 percentage point fluctuation in the operating CCR only (and not the capital CCR).  However, if a hospital meets both criteria, claims will be reconciled using the operating and capital CCRs from the final settled cost repo rt.  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 hospital does not meet the criteria for reconciliation, subject to approval of the Regional and Central Office, the Medicare contractor has the discretion to request that a hospitals outlier payments in a cost reporting period be reconciled if the hospitals most recent cost and charge data indicate that the outlier payments to the hospital were significantly inaccurate.  The Medicare contractor sends notification to the Central Office via email at outliersIPPS@cms.hhs.gov.  Upon approval of the CMS Regional and Central Office that a hospitals outlier claims need to be reconciled, Medicare contractors should follow the instructions in 20.1.2.7.  B. - Reconciling Outlier Payments for those Hospitals Identified in PM A -03-058   As stated above, for a hospital that met the criteria in I.A. of PM A-03-058, reconciliation begins for discharges occurring on or after August 8, 2003.  To establish whether a hospitals outlier payments are subject to reprocessing, Medicare contractors determine if the CCR and total outlier payments from the entire cost reporting period meet the two criteria in part A of this section.  However, if both criteria for reconciliation are met, only the discharges that occurred between August 8, 2003 and the end of the cost reporting period will be reconciled.  These hospitals will be subject to reconciliation in subsequent cost reporting periods if they meet the two criteria outlined in part A of this section.  See example A below.
(Medicare Claims Processing Manual)
The Medicare contractors shall notify the CMS Regional Office and CMS Central Office of any hospital that meets the criteria for reconciliation. Notification to the CMS Central Office shall be sent via email to outliersIPPS@cms.hhs.gov.  Further instructions for Medicare contractors on reconciliation and the time value of money are provided below in 20.1.2.6 and 20.1.2.7.  EXAMPLE A:   Cost Reporting Period: 09/01/2002-08/31/2003  Operating CCR used to pay original claims submitted during cost reporting period: 0.40 (In this example, this CCR is from the tentatively or final settled 2002 cost report)  Final settled operating CCR from 09/01/2002-08/31/2003 cost report: 0.50  Total outlier payout in 09/01/2002-08/31/2003 cost reporting period: $600,000  Because the CCR of 0.40 used at the time the claim was originally paid changed to 0.50 at the time of final settlement, and the provider received greater than $500,000 in outlier payments during that cost reporting period, the providers claims for discharges from August 8, 2003 through August 31, 2003 shall be reconciled using the correct CCR of 0.50.  The same criteria shall be applied to the cost report beginning on 09/01/2003 to determine whether reconciliation of outlier payments for that cost reportin g period is necessary. For details on how to apply multiple CCRs in a cost reporting period, see example C below.  C. - Reconciling Outlier Payments for those Hospitals Not Identified in PM A -03-058   Beginning with the first cost reporting period starting on or after October 1, 2003, all hospitals are subject to the reconciliation policies set forth in this section.  If a hospital meets the criteria in part A of this section, the Medicare contractor shall notify the CMS Regional Office and Central Office via email at outliersIPPS@cms.hhs.gov . Further instructions for Medicare contractors on reconciliation and the time value of money are provided below in 20.1.2.6 and 20.1.2.7.   The following examples demonstrate how to apply the criteria for reconciliation:  EXAMPLE B:
(Medicare Claims Processing Manual)
The following examples demonstrate how to apply the criteria for reconciliation:  EXAMPLE B:   Cost Reporting Period: 01/01/2004-12/31/2004  Operating 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 operating 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 of 0.40 used at the time the claim was originally paid changed to 0.50 at the time of final settlement, and the provider received greater than $500,000 in outlier payments during that cost reporting period, the criteria has been met to trig ger reconciliation, and therefore, the Medicare contractor shall notify the CMS Regional Office and Central Office.  The providers outlier payments for this cost reporting period will be reconciled using the correct CCR of 0.50.  In the event that multiple CCRs are used in a given cost reporting period, Medicare contractors should calculate a weighted average of the CCRs in that cost reporting period.  (See Example C below for instructions on how to weight the CCRs).  The Medicare contractor shall then compare the weighted CCR to the CCR determined at the time of final settlement of the cost reporting period to determine if reconciliation is required.  Again, total outlier payments for the entire  cost reporting period must exceed $500,000 in order to trigger reconciliation.   EXAMPLE C:
(Medicare Claims Processing Manual)
EXAMPLE C:   Cost Reporting Period: 01/01/2004-12/31/2004 Operating CCR used to pay original claims submitted during cost reporting period:  - 0.40 from 01/01/2004-03/31/2004 (This CCR could be from the tentatively settled 2001 cost report)  - 0.50 from 04/01/2004-12/31/2004 (This CCR could be from the tentatively settled 2002 cost report)  Final settled operating CCR from 01/01/2004-12/31/2004 cost report: 0.35 Total Outlier payout in 01/01/2004-12/31/2004 cost reporting period: $600,000 Weighted Average CCR: 0.474  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 hospital meets the criteria for reconciliation in this cost reporting period because the weighted average CCR at the time the claim was originally paid changed from 0.474 to 0.35 (which is greater than 10 percentage points) at the time of final settlement, and the provider received an outlier payment greater than $500,000 for the entire cost reporting period.  20.1.2.6 - Time Value of Money  (Rev. 4390, Issued: 09- 06-19, Effective: 10-01-19, Implementation: 10-07-19)
(Medicare Claims Processing Manual)
Effective for discharges occurring on or after August 8, 2003, at the time of any reconciliation under 20.1.2.5, outlier payment 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 hospitals 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 hospitals outlier payments have met the criteria for reconciliation, CMS will calculate the aggregate adjustment using the instructions below concerning reprocessing claims and determine the additional amount attributable to the time value of money of that adjustment.  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.   (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 via email from the Medicare contractor.   The following is an example of the computation of the adjustment to account for the time value of money:  EXAMPLE
(Medicare Claims Processing Manual)
The following is an example of the computation of the adjustment to account for the time value of money:  EXAMPLE   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%  Operating 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 operating 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 .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 c ontractor notifies the CMS Regional and Central Office.   The Medicare contractor reprocesses and reconciles the claims. The reprocessing 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.  20.1.2.7 - 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 hospital 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
(Medicare Claims Processing Manual)
and 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 operating and capital outli er payments in the cost reporting period, the operating CCR or weighted average operating CCR from the time the claims were paid during the cost reporting period eligible for reconciliation and the final settled operating and capital CCR.  2) If the Medicare contractor receives approval from the CMS Central Office that reconciliation is appropriate, the Medicare contractor follows 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.   4) Prior to running claims in the *Lump Sum Utility, Medicare contractors shall update the applicable provider records in the Inpatient Provider Specific File (IPSF) by entering the final settled operating and capital CCR from the cost report in the operating and capital CCR fields.  Specifically, for hospitals paid under the IPPS, Medicare contractors shall enter the revised  operating CCR in PSF field 25 -Operating Cost to Charge Ratio and the revised capital CCR in PSF field 47 - Capital Cost to Charge Ratio.  No other elements in the IPSF (such as elements related to the DSH and IME adjustments) shall be updated for the applicable provider records in the IPSF that span the cost reporting period being reconciled aside from the elements for the operating and ca pital CCRs.   *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 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:
(Medicare Claims Processing Manual)
6) Medicare contractors shall only run claims in the Lump Sum Utility that meet the following criteria:    Type of Bill (TOB) equals 11X   Previous claim is in a paid status (P location) within FISS   Cancel date is blank   7) The Medicare contractor reconciles the claims through the applicable IPPS Pricer software 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 elements in Table 1. Medicare contractors shall ensure this report is retained with the cost report settlement work papers.   10) For hospitals paid under the IPPS, the Lump Sum Utility will calculate the difference between the original and revised operating and capital outlier amounts.  If the difference between the original and revised operating and capital outlier amounts (calcula ted by the Lump Sum Utility) is positive, then a credit amount (addition) shall be issued to the provider.  If the difference between the original and revised operating and capital amounts (calculated by the Lump Sum Utility) is negative, then a debit amou nt (deduction) shall be issued to the provider.  NOTE:  The difference between the original and revised operating outlier amounts and the difference between the original and revised capital outlier amounts are two distinct amounts calculated by the lump sum utility and are recorded on two separate lines on t he cost report.
(Medicare Claims Processing Manual)
11) The operating and capital time value of money amounts are two distinct calculations that are recorded separately on the cost report.  Medicare contractors shall determine the applicable time value of money amount by using the calculation methodology in 20.1.2.6.  If the difference between the original and revised operating and capital outlier amounts is a negative amount then the time value of money is also a negative amount.  If the difference between the original and revised operating and capital outlier  amounts 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 and revised operating and capital outlier amounts.  12) For cost reporting periods beginning before May 1, 2010, under cost report 2552- 96, the Medicare contractor shall record the original operating and capital outlier amounts, the operating and capital outlier reconciliation adjustment amount (the difference between the original and revised operating and capital outlier amounts calculated by the Lump Sum Utility), the operating and capital time value of money and the rate used to calculate the time value of money on lines 50- 56, of Worksheet E, Part A of the cost report ( NOTE : the amounts recorded on lines 50 -53 and 55 thru 56 can be positive or negative amounts per the instructions above).  The total outlier reconciliation adjustment amount (the difference between the original  and revised operating and capital outlier amount (calculated by the Lump Sum Utility) plus the time value of money) shall be recorded on line 24.99 of Worksheet E, Part A.  For complete instructions on how to fill out these lines please see  3630.1 of the Provider Reimbursement Manual, Part II.  NOTE :  Both the operating and capital amounts are combined and recorded on line 24.99 of Worksheet E, Part A.
(Medicare Claims Processing Manual)
For cost reporting periods beginning on or after May 1, 2010, under cost report 2552-10, the Medicare contractor shall record the original operating and capital outlier amounts, the operating and capital outlier reconciliation adjustment amounts (the diffe rence between the original and revised operating and capital outlier amounts calculated by the Lump Sum Utility), the operating and capital time value of money and the rate used to calculate the time value of money on lines 90-96, of Worksheet E, Part A of the cost report ( NOTE : the amounts recorded on lines 90-93 and 95 thru 96 can be positive or negative amounts per the instructions above).  The total outlier reconciliation adjustment amount (the difference between the original and revised operating and capital outlier amount (calculated by the Lump Sum Utility) plus the time value of money) shall be recorded on line 69 of Worksheet E, Part A.  NOTE :  Both the operating and capital amounts are combined and recorded on line 69 of Worksheet E, Part A.  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 operating and capital CCR(s) elements to their original values (that is, the CCRs used to pay the claims) in the applicable provider records in the IPSF to ensure an accurate history is maintained.  Specifically, for hospitals paid under the IPPS, Medicare contractors shall enter the original operating CCR in PSF field 25 -Operating Cost to Charge Ratio and the original capital CCR in PSF fiel d 47 -Capital Cost to Charge Ratio.  If the Medicare contractor has any questions regarding this process it should contact the CMS Central Office via the address and email address provided in 20.1.2.1 (B).   Table 1:  Data Elements for FISS Extract
(Medicare Claims Processing Manual)
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 Medicare Lifetime Reserve Amount in the first calendar year period (Value Code 08)  List of Data Elements for FISS Extract  Revised Medicare Lifetime Reserve Amount in the first calendar year period (Value Code 08)  Difference between these amounts  Original Medicare Coinsurance Amount in the first calendar year period (Value Code 09)  Revised Medicare Coinsurance Amount in the first calendar year period (Value Code 09)  Difference between these amounts  Original Medicare Lifetime Reserve Amount in the second calendar year period (Value code 10)  Revised Medicare Lifetime Reserve Amount in the second calendar year period (Value code 10)  Difference between these amounts  Original Medicare Coinsurance Amount in the second calendar year period (Value code 11) Revised Medicare Coinsurance Amount in the second calendar year period (Value code 11) 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  TOT CHRG   total billed charges (claim page 3)  COV CHRG   total covered charges (claim page 3)  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  Original C TOT PAY (claim