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Uncompensated Care Frequently Asked Questions The
answers to these frequently asked questions reflect the Ohio
Administrative Code (OAC) rules established by the Ohio Department of Job and
Family Services (ODJFS) on the allowance and documentation of
uncompensated care for hospital services related to the Hospital Care
Assurance Program (HCAP). They are
designed to provide guidance to OHA member hospitals, but do not reflect
any particular legal interpretation on the part of the ODJFS.
OHA recommends members review their “HCAP” policies and
procedures with legal counsel to ensure they are in compliance with state
laws and rules. OHA members are encouraged to check this site frequently for updates to existing FAQ's and additional information. All updates to this site will be dated for reference. All ODJFS rules and manuals are available at this site. Covered Topics
Public
Rules and Income Guidelines
1.1 Which rule explains how
hospitals must manage public notices and requests for free care, and where
can I get a copy of it? The rule number is OAC
5101:3-2-07.17, and it is available
here. (4/14/03) 1.2
Which
rule explains how a hospital’s auditor must conduct its annual review of
a hospital’s Medicaid Cost Report Schedule F uncompensated care data,
and where can I get a copy of it? The rule number is OAC
1.3 Where can I get the federal
poverty income level (FPL) guidelines? Federal poverty income
guidelines are
available from the Health
& Human Services Web site.
Remember, they go into effect each year on the date they were
published in the Federal Register. Eligibility
for any date of service on or after that date should be judged by the new
guidelines. Dates of service
prior to that date should be judged by the old guidelines. (4/14/03) Applications
for Free Care
2.1 Is there a standard
application for free care? There is no required application,
but OHA and the Ohio Department of Job and Family Services (ODJFS)
recommend this sample.
This recommended free-care application includes all the data
elements needed to substantiate a hospital’s decision to approve a
patient account for HCAP. (6/13/05) 2.2a Is there a limit to the
amount of time a hospital must take applications for free care? OAC
2.2b Does the answer to 2.2a mean a hospital must deny an application for free care for dates of service after Dec. 14, 2000, if the date of service is more than three years old? No. OAC
2.2c Can an HCAP application be taken over the telephone or the internet? In most cases no. Hospitals are permitted to take an HCAP application over the phone or the internet only as a last resort. The reason is that an application taken by phone cannot be signed by the patient or authorized applicant. If an application is taken over the telephone, the interviewer is expected to ask the questions exactly as they are listed on the recommended HCAP application and to mail a copy of the completed application to the patient or authorized applicant to sign and return, so the hospital has the attestation for its records. If there is some reason the patient/applicant cannot sign the application, the interviewer is expected to sign the form him/herself and document why the patient/applicant was not able to sign. (9/28/07)2.3 May a hospital require an uninsured patient to apply for Medicaid before it accepts an application for free care?
2.4a If an uninsured patient states his injuries were the result of an accident, must the hospital bill a liability insurer before writing the account off to HCAP? Hospitals should always pursue payment for medical care from every reasonable source, governmental and private, and it is important to keep in mind a liability insurer may pay a patient's charges in full. However, there is no requirement that hospitals prove a source of liability coverage does not exist prior to writing an eligible account off to HCAP. (4/14/03)UPDATED (7/1/05) 2.4b If a hospital becomes aware a patient received a payment from a liability insurer, must it pursue the patient for that payment prior to writing the account off to HCAP? A liability insurer is not a
health care third-party payer, so OAC
2.5 If an old patient account
has gone to collection, can the patient still apply for free care? Yes, the time limits outlined in question
2.2a apply, regardless of whether the hospital has placed an
account in collection. (4/14/03) 2.6a Is a
separate application required for a patient with multiple outpatient
encounters or inpatient admissions? Applications for
Disability Assistance Medical recipients need only be taken once each
month, as a DAM recipient is generally eligible for the entire month. 2.6b Can an application for an inpatient hospital admission also be used to cover any outpatient care that is required post-discharge? Yes, an inpatient application
can also be used to cover outpatient services for the patient in the
90-day period immediately following the first day of the inpatient
admission. (09/28/07) 2.7a Who can sign a free care
application and attest to the accuracy of the information it contains? The application should be signed
by the patient or by someone who has a legal right to represent the
patient, such as a parent or spouse. (4/14/03) 2.7b Can a hospital write
off charges to HCAP for a self-pay patient who does not respond to
repeated requests for information? No. As outlined in this section, there are numerous ways a hospital can document and verify a patient’s eligibility for free care. However, if a patient is non-cooperative or non-responsive for whatever reason, income and/or family size on the date of service cannot be verified, so the hospital may not apply those charges to HCAP. (3/22/04) 2.7c If another payer
declares a non-cooperative patient to be self-pay, can the patient apply
for HCAP? 2.8 Must a signed application
for free care also be notarized? No. (4/14/03) 2.9 Occasionally we have a
Medicaid managed care patient who goes to an out-of-panel hospital for
elective care. If the hospital puts the patient on notice that (s)he
will be responsible for the charges, as required by OAC
5101:3-26-11, can
the patient later apply for HCAP? No. If the patient is on Medicaid,
including Medicaid managed care, the patient cannot apply for HCAP and the
hospital cannot include that patient on Schedule F. (6/18/03) 2.10 Can a non-Medicaid managed care patient who has self-pay charges arising from an out-of-panel encounter apply for HCAP? Yes, assuming the non-covered services would be considered eligible according to OAC2.11 OAC 5101:3-2-0717(B)(4) requires a signed application. Is an electronically stored facsimile copy of the signed original application acceptable for audit, or must the hospital maintain the original? A facsimile copy of an electronically stored original application is acceptable, providing: Hospital will lose credit for
the HCAP write-off if, upon review, the hospital is unable to retrieve
an electronically stored application. (9/28/07) 3.1 What documentation is
required to support an application for free care? Each hospital must have an
internal policy outlining its free-care documentation requirements.
At the very least a hospital should require an application that
contains all data elements contained in the sample Ohio Department of Job
and Family Services (ODJFS) application (see FAQ 2.1), which has been signed by the
patient or by someone who has a legal right to represent the patient, such as a parent or
spouse.
No additional documentation of family size or income is required
unless a hospital’s internal policy requires it. If a patient or applicant is
physically unable to complete an application, or does not live in the
vicinity of the hospital and is unable to return a signed application by mail,
the hospital may complete the application via the telephone. This should be considered a last resort.
The person interviewing the patient should complete all the
questions on the application, sign and date it, and document why the
patient or applicant was not able to complete and sign the application
himself/herself. If a signed application is all a
hospital requires, and the patient/applicant reports zero income for the
period in question, ODJFS recommends the hospital clarify how the
applicant and his family are surviving.
This information should be documented at the bottom of the
application. Hospitals should also note that
they have the right to deny a signed application if they can document a
reasonable doubt that the applicant is telling the truth. (4/14/03)UPDATED
(7/1/05) 3.2a.
Must a hospital have a written HCAP / free care policy? 3.2b
If
a hospital decides to change its internal policy, when should the policy change be implemented? The policy change cannot be implemented retroactively. The hospital must choose a specific date on which to change its policy and all actions for dates of service on or after that date must be judged under the revised documentation standards. (updated 9/30/04) 3.3 Is an income tax return
acceptable income documentation? No. By its nature, an income tax
return does not generally cover the date of service, which
3.4. How are
“reasonable” business expenses defined for a self-employed applicant? 4.1 How long must a patient have
lived in Ohio to qualify for free care? OAC
4.2 Can an illegal alien qualify
for free care? Yes,
assuming s(he) meets the residency requirement defined in question 4.1. (5/7/03)
4.3
Do
the residency requirements apply to accounts with family incomes above the
federal poverty income limits? No. (5/7/03)
4.4 Can a prisoner or detainee
in a county or city jail apply for free care? The Department of Health and Human
Services has taken the position that detainees can not apply for
free care, since, by Ohio law, the city or county is supposed to arrange
for medical care for persons they have under arrest or are detaining.
OHA is aware that some counties and municipalities delay arresting
a suspect until after medical care has been delivered.
In these cases the patient can apply for free care since (s)he was
not under detention at the time of service. (4/14/03)
Calculation
of Income
5.1 Is there any limit to what
can be considered income? OAC
“Reasonable business expenses” may be deducted for
self-employed patients or their families.
However, the rule does not exempt other sources of non-wage income.
So, all sources of income, including but not limited to, alimony,
child support, veterans’ benefits and social security should all be
counted. Note that child support and
SSI payments for children must be handled differently than other
forms of non-wage income. ODJFS has advised OHA that child support and
SSI payments for children may be counted as income for a family only
when the patient is a child who is the intended recipient of that
support payment. That is, if child support is involved and the mother
or father is the patient, the family size would remain the same but you
would not count the child support as income for the family. If a child
is the patient, you would count the child support as income. (4/14/03) 5.2a Are a patient's assets taken into consideration as income? No, a patient's assets should
not be counted as income. (10/25/07) 5.2b A patient has a savings account, which is an asset; are withdrawals from a savings account then counted as income? What about interest and dividends? Withdrawals from an asset such
as a savings account or brokerage account would not be considered
income. However, interest and dividends on a non-retirement savings or
brokerage account would be considered income. See 5.2c for treatment of
retirement accounts. 5.2c The patient has a retirement account (IRA, 401(k), 403(b)), how should these be treated? Funds in a retirement account
would be considered an asset. Any distributions from a retirement
account, monthly or lump-sum, should be treated as income as these funds
were not previously taxed. Interest and dividends paid directly to a
retirement account would not be considered income until withdrawn.
5.3 Should a hospital take into
account a patient’s or his/her family’s tax returns to determine
income? See FAQ 3.3. (9/30/04) 5.4 Are tuition grants and
scholarships considered income? Would the entire scholarship and
grant amount be considered, or only the balance after tuition, room, and
board? No scholarship or grant that is specifically earmarked for tuition should be counted as income. In general, a scholarship or grant is paid directly to the college or school. If one is payable to the student, the portion of it that goes toward tuition would not be counted as income and the portion that goes to living expenses would be counted as income. If documentation is required, a hospital may ask the patient/student for tuition receipts from the college or school. It should be noted that most colleges offer health insurance to students at reduced premium rates. A hospital should be sure the patient/student is not insured and encourage him/her to seek health insurance, if possible. (6/18/03) 5.5 OAC
A hospital must calculate income using both methodologies and use the result that is most beneficial for the patient to support eligibility for free care. As such, if using both methodologies results in conflicting eligibility determinations, use the one that allows the patient to qualify. If a hospital's policy demands documentation and the patient can only document one of the methodologies, qualify the patient if the documentation demonstrates (s)he is eligible. If it does not, consider using a signed application (See FAQ 2.1) with which the patient can attest to his/her family income using the other methodology. (9/30/04) 5.6a Should a hospital count the income of a spouse who does not live in the same home as his/her spouse and/or children? Yes. OAC
5.6b Regarding the answer to 5.6a: What if a patient or the patient’s parent is still married, but the patient or patient's parent can not locate his/her spouse? Similarly, what if the patient or patient’s parent can locate his or her spouse, but the spouse does not, or will not, contribute to the “family’s” income? In both instances, OAC
5.6c. Do the answers to 5.6a & 5.6b change if a spouse is married, but legally separated? No. (7/1/05) 6.1 OAC 5101:3-2-07.17 allows a
hospital to include only medically necessary, “hospital-level”
services in HCAP write-offs. How
does a hospital determine which services are considered “hospital
level?” ODJFS
maintains a list of Medicaid-covered UB-92 Revenue
Codes.
It is Attachment A to
OAC
Occasionally UB 92
Revenue Codes listed in (NOTE: FAQs 6.2 & 6.3 HAVE BEEN ELIMINATED)
6.4
If
an account has gone to collection, or the hospital has gone to court to
enforce collection, and the patient later is found eligible for HCAP on
the date of service, must the hospital write off the collection fees and
court costs? No.
Collection fees and court costs are not considered hospital-level
services and may not be included in an HCAP entry.
They remain the patient’s responsibility, regardless of his/her
eligibility for free care. (4/14/03) 6.5a
Are experimental drugs and procedures covered under HCAP? No. If the principal reason for an inpatient admission or outpatient encounter was the experimental drug or procedure, then the entire admission or encounter would not be considered a medically necessary, Medicaid-covered service. (6/18/03) 6.5b Are routine-care
services delivered in conjunction with a clinical trial covered under
HCAP? Charges for services related to
the clinical trial itself are not covered under HCAP. Per OAC
6.6
Appendix A of OAC 5101:3-2-02 indicates that dental services billed under
UB92 Revenue Code 0512 (Dental Clinic) are covered. Does this mean
all dental services, including routine and preventative dental services,
performed in a hospital-based dental clinic are covered under HCAP? Generally speaking, no.
OAC
5101:3-2-03(A)(2)(h)(i) states that dental services are only
covered in a hospital setting when "the nature of the surgery or
the condition of the patient precludes performing the procedure in the
dentist's office or other non-hospital outpatient setting and the
inpatient or outpatient service is a Medicaid covered service."
As such, HCAP would exclude any diagnostic or preventative dental services
delivered in a hospital setting. (6/18/03) 6.7 How does a hospital determine whether a procedure subject to pre-review by ODJFS—such as elective bariatric surgery—is covered by HCAP? Hospitals are advised to use Medicaid coverage as a proxy for determining whether a particular service would be considered medically necessary, according to OAC 5101:3-2-07.17 (A)(1) [see FAQ 6.1]. For further information regarding conditions and limitations of inpatient and outpatient coverage, please refer to OAC 5101:3-2-03. (7/1/05) Patient
Accounts Logs and Medicaid Cost Report Entries 7.1 Our hospital does not
maintain logs for patient accounts with family incomes above 100% of the
federal poverty income limits. How
should we document HCAP eligibility for these “bad debts?” You must maintain logs for all
categories of entries on the Medicaid Cost Report Schedule F, including
those that represent accounts for families with incomes above 100% of the
FPL. There is no way an
auditor can verify the accuracy of Schedule F in line with ODJFS’
instructions without logs. At
the very least you must maintain four logs of >100% FPL accounts that
represent:
Each log must contain at least the
following data elements:
No log or Medicaid cost report Schedule F entry, below or above 100% FPL, can contain charges for Medicaid-eligible patients. All charges reported in any entry in Schedule F must represent medically necessary, “hospital level” services as defined in Appendix A of OAC 5101:3-2-02. It is also necessary to differentiate all entries in both below and above 100% FPL into "insured" v. "non-insured" categories. Charges for non-Ohio residents may only be included in the Schedule F entries for above 100% FPL. (9/30/04) 7.2a If an inpatient admission or series outpatient encounter crosses two hospital fiscal years, in which fiscal year should the charges be recorded? The General Instructions for Section I of the Medicaid Cost Report (OAC 5101:3-2-23, Appendix A) state: "The data on uncompensated care for people on Disability Assistance... and the data on uncompensated care for patients with family incomes below federal poverty guidelines... may only include inpatient and outpatient accounts with discharge/visit dates that fall within your hospital's fiscal year. You must split-bill any outpatient accounts which cross these dates. Uncompensated care for patients with family incomes above federal poverty income guidelines may be included... regardless of the service dates, so long as the date of the bad debt or charity care write-off fell within your hospital's fiscal year. "
As
such, charges for inpatient DAM admissions and for patients with
family incomes below the federal poverty income guidelines should
be recorded in the fiscal year in which the discharge date
occurred. Charges for
outpatient DAM patients or for patients with
family incomes below the federal poverty income guidelines should
be recorded in the fiscal year in which the date of service occurred.
This will require split-billing any series outpatient claim that
crosses fiscal years.
As noted above,
charges for
patients with family incomes above the federal poverty income guidelines
should be recorded in the fiscal period in which the write-off occurred,
regardless off the date of service. (4/21/04) 7.2b Do hospitals get
“credit” for old patient accounts that are written off to HCAP? However, the Ohio Department of Job and Family Services permits hospitals to report old, <100% FPL accounts as >100% FPL in the Cost Report that covers the year in which they were recorded as bad debts. Remember to report accounts in the correct >100% logs and Schedule F lines, that is, whether they were inpatient or outpatient and whether or not the patient had insurance that covered the services delivered. Hospitals
should log patient accounts for families with income above
the FPL based on the date of write-off.
As such, accounts for patients with family incomes above the FPL
can be included in any Medicaid Cost Report that covers the date of the
write-off, no matter how old the account. (7/8/03) 7.3 If a patient is on
Disability Assistance on the date of service, but later is retroactively
made eligible for Medicaid after the hospital’s Medicaid Cost Report for
that period is filed, can the hospital bill the account to Medicaid? Yes.
OAC
5101:3-2-23, Appendix A, permits a hospital to bill for
accounts that are pending-Medicaid and retroactively made eligible after
the cost report is filed. This
retroactive eligibility determination is no different. (4/14/03) 7.4 How would a hospital log the
recovery of a bad debt once it has been logged on a Medicaid Cost Report? This would depend on
whether the account is for a patient with a family income above or below
the federal poverty-income guidelines (FPL).
Since charges for patients with family incomes at or below the FPL
can only be logged in the specific Medicaid Cost Report that covers the
date(s) the services were delivered, once that Cost Report is filed, no
additional data can be entered. Again,
this includes Disability Assistance Medical accounts.
Should a hospital later find it is able to bill the account to a
third-party payer, there is no way for it to log that recovery and no
additional entry in a log or Cost Report is required. However, since hospitals log
accounts for families with income above the FPL based on the date of
write-off, any recoveries of these bad debts should be reversed in the
year in which the recovery was received, no matter how old the account.
(4/14/03) 7.5a.
When is a patient to be considered “with insurance?” 7.5b Would an self-pay deductible
or coinsurance amount be logged as with or without insurance? While a deductible or co-insurance amount is the patient’s responsibility (s)he is nonetheless insured for the services delivered, so the entry would be logged as “with insurance.” (4/14/03) 7.5c Are self-pay charges for a managed–care patient who has had services out of network considered to be with or without insurance. Assuming the patient is not eligible for Medicaid and enrolled in Medicaid managed care (see FAQs 2.9 & 2.10) any covered self-pay charges for a managed care patient who went out of network would be considered “with insurance.” (3/22/04)7.6
In
some cases payers reimburse hospitals on a “global” fee basis, that
is, the payment represents both the technical and professional portions of
a bill. If a patient is
applying for free care for an unpaid portion of a bill that was paid
globally, how does a hospital determine how much to deduct from the payment to
represent the professional portion? Figure out how much of the total
charges on the bill represent professional services and apply the same
ratio to the payment. (4/14/03) 7.7a
Are
hospitals permitted to include accounts written off as a result of their
internal charity-care programs in the >100% FPL categories of the Schedule F, or are only bad debt accounts allowed to
be included? ODJFS does not recognize a
difference between “bad debts” and “charity care.” Both are eligible to be included in the >100% FPL,
assuming the accounts meet the other requirements of OAC
5101:3-2-07.17.
(4/14/03)RENUMBERED (7/1/05) 7.7b Does the answer in 7.7a also apply to charges a hospital discounts because of an internal policy? Yes,
assuming the discount is granted as a part of a policy to assist an
uninsured or underinsured patient with family income above the FPL.
Employee discounts or prompt-pay discounts are not recognized as charity
care or bad debts for HCAP purposes. (7/1/05) 7.8
How should a hospital report a lump sum, bad debt recovery that cannot be
tracked back to individual patient accounts? Bad debt recoveries should be reported in the cost report year in which the recovery was made, and if at all possible, they should be reversed from the same Schedule F entry as the original write-off. However, if a lump sum recovery cannot be tracked back to the account(s) that were included in the original >100% FPL Schedule F entry, a prorated percentage of the recovery should be taken from each of the four >100% FPL categories. (6/18/03) 7.9
Step 10 of the procedures in OAC
5101:3-2-23, Appendix A permits
hospitals to include charges for pending Medicaid accounts in the <100%
FPL logs and Medicaid Cost Report Schedule F entries. How should
this process be administered? When
should the list of pending accounts be double-checked to ensure they have
not been declared Medicaid-eligible? Hospitals must keep a
separate log of accounts for patients who are <100% FPL and have a
Medicaid application pending with the County Department of Job and Family
Services (CDJFS). When the
determination of each Medicaid application is returned, the hospitals
should remove that account from the “Medicaid Pending” log. If the application is approved, the account can be billed to Medicaid.
If the application is denied, the account should be included in the log and Cost Report entry for <100% or
>100%, with or without insurance, whichever is appropriate.
If a CDJFS retroactively determines a patient to be eligible for Medicaid, the hospital may bill the account to Medicaid. Since the account was reported in a Schedule F entry for <100% FPL, the hospital is not required to treat the Medicaid payment as a bad debt recovery in the following fiscal year. (10/6/03) 7.10
Determination of coverage by auto liability insurers also often
takes a long time. Does the
above “eligibility pending” policy extend to auto liability insurers? No. (10/6/03) 7.10a Does ODJFS require hospitals to bill an auto liability or “Med-Pay” payer prior to writing an account off to HCAP? No. ODJFS has taken the position that auto-liability and “Med-Pay” is not health insurance. In addition, it is often difficult to determine whether a liability or Med-Pay payment is intended to cover health care services, as outlined in 5101:3-1-07.17(C). However, some hospitals have taken the position they want to pursue liability or Med-Pay, because they have the potential to collect full billed charges. ODJFS does not oppose this position, other than to state a hospital must not pursue payment from the patient while an auto liability or Med-Pay insurer is deciding whether to pay, and ODJFS will not grant an exception to the Cost Report timeliness limits if an auto liability or Med-Pay payer denies the claim after the Cost Report that covers the date of service has closed (FAQ 7.10). Conversely, once a hospital decides to write-off an account to HCAP it should stop all collection efforts from the patient or the liability/med pay insurer. OHA recommends that if a hospital decides to pursue a liability or Med-Pay insurer it should complete and pend an HCAP application. That way if it later decides to write the account off to HCAP it has the paperwork on file. Also, OHA recommends the hospital keep these accounts segregated so it can examine them at the point it files its Medicaid Cost Report and decide whether to write the account off to HCAP and abandon the pursuit of a payment from the insurance company, or take the chance it will lose the HCAP write-off and wait for the liability/med-pay insurer to make up its mind. (11/7/05) 7.10b If, after a hospital takes an HCAP write-off and ceases collection activities from a liability or Med-Pay insurer, the insurer pays the account anyway. Can the hospital keep the payment? Yes, but if the Medicaid Cost Report that covers the date of service is still open the hospital must reverse the HCAP write-off. (11/7/05) 7.11
Can Medicare Bad Debts also be written-off to HCAP? No.
The Centers for Medicare and Medicaid Services (CMS) has formally
stated it will not allow a hospital to claim an account as both HCAP and
Medicare Bad Debt. CMS takes
the position that once a patient has applied and been found eligible for
HCAP, the patient has no liability, so there is no bad debt to be
claimed. Further, CMS states
Ohio law forbids the hospital to follow its normal collection procedures
on a patient account found eligible for HCAP, which would procedurally
disqualify it as a Medicare Bad Debt. (10/6/03)
7.12
Can an account be considered eligible for both HCAP and the Ohio
Victims of Crime Compensation Fund? No. The Ohio Court of Claims will not accept a claim for hospital services from any patient with a family income below the FPL. The court takes the position it only makes reparation for medical and other expenses actually paid by crime victims. Since state law requires hospitals to write off covered hospital services for any person with a family income <100% FPL, the Court of Claims maintains there is no patient liability and nothing to repay. (10/6/03) 7.13
Should a hospital treat a payment from a local levy that covers
indigent patients as a bad debt recovery?
7.14
Many hospitals automatically write-off small balance, patient pay
accounts. Can these small balance write-offs be claimed as
uncompensated care and included in the logs and cost report entries for
>100% FPL?
7.15 Can a patient who is eligible for the federal Hill-Burton Program also be counted as eligible for HCAP? Theoretically, yes, since both programs cover patients with incomes below the federal poverty income guidelines. However, the US Department of Health and Human Services determines a patient’s eligibility for Hill-Burton based on the date of application, not the date of service, and it counts the size of a patient’s family differently than HCAP. As such, assuming a hospital can document a patient is eligible for HCAP based on OAC 5101:3-2-07.17, there is nothing to keep it from also applying that account to the hospital’s Hill Burton obligation. (7/1/05)Patient
Payments
8.1
If
a patient is found to be eligible for free care and has already made
payments on an account, must the payments be returned?
Yes.
The hospital must return any payments from the patient for
hospital-level services. Any payment(s) for non-hospital services,
e.g., physician, take home drugs, or home health services, do not have
to be returned, since they were not eligible for free care in the first
place.
(4/14/03)UPDATED (7/1/05) 8.2 Can a hospital apply a patient’s refund from a patient account that is found to be retrospectively eligible for HCAP to another account for the same patient or his/her family that is not eligible for HCAP? No, as long as the payment which caused the refund can be linked to an account that is covered by HCAP. However, if a patient has multiple open accounts, some of which are not eligible for HCAP, and the hospital can document a payment was not specifically intended for an HCAP-covered account, the payment can be applied or re-applied to another account that is not eligible for HCAP. Notification indicating the account to which the payment was applied must be provided to the patient, and the account must be appropriately adjusted or removed from collection. (7/1/05) Hospital-Based
Data Review Guidelines
9.1
Our
hospital does very little DAM with insurance, and yet that is a category of
accounts from which our auditor is required to review a sample of patient
accounts. If there are no
accounts, or an insufficient number of accounts in any category that is
required to be sampled by OAC 5101:3-2-23, Appendix A, how should an
auditor proceed? OAC 5101:3-2-23 requires a specific number of accounts, in specific categories, to be examined by each hospital, depending on the total amount of uncompensated care (UC) without insurance the hospital is reporting. If a hospital has an insufficient number of accounts in any UC category, it should increase the number of accounts randomly selected in other categories until it reaches the total number of accounts it is required to examine. If a hospital has fewer accounts in total than is required by OAC 5101:3-2-23, all accounts reported in Schedule F must be included in the auditor's review. (4/14/03)UPDATED (7/1/05) 9.2
If
a hospital changes the amount reported in the Medicaid Cost Report
Schedule F after the report is reviewed and initially submitted, does the
entire Schedule F have to be re-reviewed by the hospital’s CPA? The answer depends on the nature
and the degree of changes to Schedule F after the initial submission.
If the only change is the addition of some accounts
to the <100% FPL categories for patients who have applied for free care
after the report was initially submitted, the CPA only has to review a
small random sample of the newly approved accounts for compliance with OAC
5101:3-2-07.17. However, if
the hospital has made wholesale changes to Schedule F entries after the
initial submission, it is recommended the entire data review be repeated,
in accordance with OAC
5101:3-2-23. (4/14/03) 9.3 OAC 5101:3-2-23,
Appendix A states the external reviewer shall issue a report to the
hospital that includes required corrective actions.
How should a hospital respond?
Should this report be submitted to ODJFS with the Medicaid Cost
Report? Each
hospital is expected to correct any material errors in the Schedule F data prior to
the Cost Report being submitted. OHA further recommends hospitals prepare a formal response to
the report describing any corrective action being undertaken as a result
of problems identified in the report.
© 2001-2007 OHA. Last updated
December 05, 2007. |
