Webcast October 22, 2010

Question Number Topic Question Answer
1 Capitation Agreements Should the vetting approach to surcharge, regarding capitation arrangements with DOH, occur contemporaneously or retrospectively in preparation for audit? Regardless of when the evaluation of surcharge obligations on capitation arrangements occurs, payors are responsible for remitting the appropriate amount on such arrangements to the Public Goods Pool. Any deficiencies in paying the surcharge that payors discover should be addressed as soon as possible to avoid large underpayments.
2 General Will all insurers in NY be audited? All electing payors, regardless of physical location are subject to potential audits under the HCRA statute.
3 Discrete Physician Billing for Private Practicing Physicians As KMPG has gathered letters throughout HCRA reviews, would it be possible to compile a listing of facilities for which DBPPP related letters have been received and publish it for the carrier community? As part of the review there is constant communication with the Reviewee during the entire engagement through the use of the status tracker and scheduled status calls. A primary contact is assigned during the offsite pre-entrance conference to assist with any Reviewee questions. The period from day 75 through day 115 is reserved for testing, therefore there will be limited discussion during this time. This demonstrates the importance of communication during the first 74 days of the review. The preliminary results meeting is the formal vehicle for communication of any variances noted during the testing phase.
4 Discrete Physician Billing for Private Practicing Physicians Why are not all professional claims for private practicing physicians excluded? Some hospitals structure their organization so that all or most physicians are not employees of hospitals. When reviewing professional claims it can be difficult for the reviewee to distinguish between a private practicing physician using the discreet billing mechanism of an article 28 facility and a salaried physician. Services provided by salaried physicians are surchargeable.
5 Discrete Physician Billing for Private Practicing Physicians Are there any recommendations for correctly identifying a claim as a DBPPP claim as the claim is received? For a claim to be identified as a DBPPP claim, an identifier that distinguishes between the professional and institutional component is needed, in addition to support that the physician is truly in private practice.
6 Membership Data Do all assessable and non assessable subscriber members need to be included in the membership data provided? Yes, both the assessable and nonassessable populations must be included in the membership data provided.
7 Membership Data How should retroactivity be treated in the membership data? How does that affect remittance of the assessment? Historical data is usually retained in the form of a snapshot by month of all active membership during each month. This would support the summary forms the payors submit to the Pools Administrator to pay the covered lives assessment. The process used by a reviewee to document retroactivity should be maintained and available for review.
8 Membership Data How should we account for members without addresses? A person does not have to provide an address to be insurable; payors can have enrollment without addresses. If a member's address information is not available that member will be assigned to the highest assessment region in which the entity has enrollment.
9 Membership Data Do we have to restate enrollment after one of these audits? The HCRA audit performed would ultimately assess the accuracy of the payments remitted to the Pool Administrator by the payor. Any overpayments or underpayments that result will be resolved through DOH billing the entity at the conclusion of the audit or instructing the entity how to recoup an overpayment.
10 Membership Data Could KPMG publish a record layout with the membership data requirements and the information that is needed historically? If so, carriers could make the necessary changes. Since system layouts vary from entity to entity, there is no one layout that KPMG can provide to satisfy all situations. Per the HCRA statue, entities should retain all fields necessary to support the remittance of assessment payments made to the Public Goods Pool.
11 Membership Data What is the impact to the review if the historical data is not available? If historical data is not available, there is the potential for civil penalties to be assessed. In certain instances, alternative procedures may be utilized to determine the assessment obligation. However, the use of alternative procedure may not prevent the assessment of the civil penalty.
12 Data Retention How long does an entity subject to the HCRA review need to keep the data for (i.e., record retention)? Any entity subject to the HCRA review should retain support for payments remitted to the Pool's Administrator for a period of 7 years after submission.
13 Medicare Claims How should records related to instances of Medicare be identified within the data? Does the payor need to include a field for Medicare primary indicator or just a field that indicates if the member is eligible for Medicare? All criteria used by a reviewee during the surcharge calculation process should be included in the claims data, including all Medicare related fields.
14 Medicare Claims How can Medicare covered services and situations of Medicare exhaustions of benefits be identified? Medicare eligibility must be supported, which would include procedures to indentify non-covered services and instances of exhaustion of benefits.
15 Surcharge calculation Should surcharge be based on the charge the provider submitted or the allowance based upon the contracted rate? Surcharges owed by electing payors are determined by the amount paid to the provider by the payor, and may also included asociated surcharges on payments their members paid to the provider. For details about the surcharge calculation and related examples, refer to the DOH website at: http://www.health.state.ny.us/regulations/hcra/examples.htm
16 Copays and Deductibles Could you clarify deductible responsibility? Is the patient responsible for the surcharge? Who is responsible for applicable surcharges on copays and deductibles? Where a member's liability is limited to fixed dollar amount, as in a fixed dollar copayment, the billing provider cannot assess a surcharge to the patient on the fixed dollar amount, if by doing so it would exceed the limit of the member's contractually stated obligation. If the electing payor chooses to pay the associated surcharge on a fixed dollar copayment, they have two options by which they can pay it. They may choose to pay the associated surcharge directly under their PGP report, or, model their payment methodology after the second billing example found on the DOH HCRA website. The second method requires the provider to pay the surcharge to the PGP out of the amount received by the member, but when using this method, the payor is actually reimbursing the provider for the amount they paid to the PGP. If the payor wishes to pay the associated surcharge directly via their PGP report, they must notify the provider in writing of such choice. By doing so, the provider will not be obligated to pay the surcharge out of the amount received by the member. If the payor chooses neither option, the provider must pay the surcharge to the PGP out of the amount received by the member. In a deductible situation where the deductible has not been met for the plan year, the provider should calculate the surcharge and add it to the bill of the member. Since the surcharge is considered part of the total bill for services, the surcharge amount paid should be applied towards the member's deductible for the plan year. In a deductible situation where the member has met their deductible amount for the plan year, the payor has the same options as in the copay options above.
17 Copays and Deductibles What level of documentation should be maintained to support the determination of responsibility? Payors should be able to produce contracts, plan descriptions, or claim processing protocols indicating whether they pay the applicable surcharge on copay and deductible directly to the Public Goods Pool on behalf of the insured or not. Payors should also be prepared to produce letters they have provided to NYS Article 28 providers indicating to them whether they pay the surcharge on copays and deductibles on behalf of the insured directly to the Pool or not.
18 Service line exclusions What are the service line exclusions that are recognized by DOH and how should records related to these services be identified within the data? Hospice, home health and skilled nursing facility have been identified as exclusions. The criteria used by a reviewee should be supported by documentation that demonstrates how each criteria is applied.
19 Referred Outpatient Lab. What are the criteria that need to be met to establish a claim as referred outpatient lab service? Referred (ordered) ambulatory care laboratory services are defined as "clinical laboratory services provided to non-registered patients upon the order and referral of a qualified physician, physician's assistant, dentist, or podiatrist to test or diagnose a specimen taken from a patient." For purposes of the specific service being ordered, the physician ordering the service may not be employed by or under contract to provide direct patient care for the facility. The lab service can not be part of preadmission test work for an impending procedure.
20 Capitation Agreements How is risk transfer treated? For example a health plan globally capitates a hospital and transfers full risk for all of the inpatient and outpatient care. How do you determine the value of services that are surchargable? Is it the capitation payment? Is it the proxy price value of the service performed? Electing payors are obligated to pay surcharges on all capitation payments allocated to surchargeable services, rather than on the value of the underlying service performed. Any portion of the capitation payment that contractually covers non-surchargeable services would be exempt. Detailed supporting documentation of the transfer arrangement and the payment made to the PGP must be maintained and supplied on audit.
21 Ambulance Are ambulance services surchargeable or nonsurchargeable? If the ambulance service is billed by the provider and the revenue remains with the provider, then the ambulance service is subject to the surcharge. If the service is provided by an outside ambulance company and the revenue is received by the ambulance company, then it is not subject to the surcharge.