Webcast January 14, 2010

Reference Number Topic Question Answer
1 Testing Can you explain your sampling and testing process?Do you share this with the provider? For the provider HCRA reviews, the entire population of inpatient and outpatient data is tested for all years under review; therefore, there is no sampling. The testing process is communicated and approved by the provider through the testing methodology.
2 Direct vs.Non-Direct Please explain direct versus non-direct?Is this the same as primary versus secondary? These are two entirely different sets of terms. The difference between direct and non-direct payors depends on the electing status of the payor.If a payor has elected to pay the HCRA surcharge to the Public Goods Pool directly, then they are considered a direct payor. If they have not elected, they are considered a non-direct payor, and the hospital is responsible for remitting the enhanced surcharge to the Public Goods Pool. Primary and secondary relates to the order in which the insurers are responsible for payment.
3 Report Without naming a specific provider, approximately how long is a draft report for a single hospital and approximately how long is the draft report for a multi-hospital system? This is truly dependent on the issues at each entity; although a template is utilized to maintain some level of consistency, the specific issues and results generated during the review drive the length of the report.
4 General Review Are reviews planned for all institutions in the State at some point? All HCRA designated providers are subject to a potential review.However, the DOH is appropriated a certain allotment of money every year to conduct HCRA compliance reviews. Although it would be ideal that all entities undergo some level of review, the funds are not available to do so.
5 Testing Can a provider learn which claims and dollar values are under dispute before the Final Report? The milestones have been established to allow for feedback from the reviewee prior to the report stage. In addition to discussion around the payor determinations process, the provider will have an opportunity to discuss preliminary results and provide supporting documentation within a specified timeframe to resolve any disagreements prior to the draft report being issued.
6 General Review If an entity is a KPMG audit client, does that present a conflict? A thorough process has been established to review any potential conflicts of interest. Both KPMG and DOH are involved in this process. If it is deemed that a conflict exists, the Department has another firm it utilizes to complete these reviews.
7 Direct vs. Non-Direct It sounds as though KPMG has software to ease the "process" of categorizing payors. Can this software be offered to the providers? The software utilized is only effective in classifying the data once it has been identified and categorized. Categorizing the payors is done manually by performing an alpha to alpha match to the electing payor list.
8 Questionnaire Can a sample questionnaire be made available? The questionnaire is provided to the entity being reviewed at the same time the audit notifcation package is presented.
9 General Review How many years would a review include, and how far back should we expect you to go? The statute enables us to go back six years. Reviews may range from 1 to 6 years.
10 Administrative Can we receive a copy of this webcast for informational use? The webcast is available for replay and the materials have been posted on DOH's website.
11 General Review Are these reviews targeted more towards hospitals and health centers or any Article 28 facility (i.e., clinics, surgery centers, other treatment centers)?? Currently we are only reviewing hospital providers. However, all HCRA designated providers are subject to review.
12 General Review What is the objective of these reviews? The objective of the HCRA Compliance Review is to assess an entity's compliance with HCRA and ensure that the correct amount of surcharges and assessments have been remitted to the Public Goods Pool.
13 General Review What criteria are used to select providers for review, or is it random? Among the criteria used to determine the list of audit targets are total payments into the Public Goods Pool, taking into account both the high end and low end amounts, along with geographic location.
14 General Review When do you expect these reviews to begin? There are several provider reviews currently in process.A review typically lasts about 11 months.
15 DiscretePhysician Billing Can you speak more to what determines a discretely billed physician? The issue is not just discretely billed physicians, but private practicing and discretely billed. A physician employed by the provider would not be considered private and the related services would be subject to the surcharge.
16 General Review Is there any possibility that as a result of these reviews a more simplified process may be enacted? Through conducting webinars and disseminating pertinent information we will continue to make changes to improve the provider compliance review process.
17 Administrative How do we obtain access to the secured electoral list that is not on the NYS website? Access to the secured elector lists can be obtained by going to the Office of Pool Administration website at www.hcrapools.org. A user id and password is required. If you don't already have one you can obtain it by completing the DOH-4264 - Electronic Filing Userid Application at http://www.hcrapools.org/forms/doh4264.pdf. Please note however a complete elector list without Federal ID number is available at the DOH website at www.health.state.ny.us/regulations/hcra/elector/about.htm
18 Direct vs. Non-Direct If New York State programs are not on the electoral list, such as ADAP, how do we determine the appropriate surcharge rate? There is a chart on the DOH HCRA website that shows the appropriate surcharge rates. It is located at http://www.health.state.ny.us/regulations/hcra/surcharge.htm
19 Testing There are payors that are on the electing payer list, but calculate and process the surcharge using different methodologies. If miscalculations are discovered resulting from lack of information or misunderstanding related to payor processing differences, how would this be reported? Will this be reported exclusively as a provider faulted issue? Electing payors are required to pay the Public Goods Pool directly, as a result providers have no obligation to submit the surcharge on behalf of electing payors.
20 Direct vs. Non-Direct Isn't it true that a payor can elect to be a direct payor or not. Couldn't this result being on the list one year and not another? On the electing payor list, there are fields for effective and termination dates which document the time frame for which a payor maintained electing status. These are taken into consideration during the compliance review.
21 Direct vs. Non-Direct When there is a dispute over whether a payor is a direct payor, and a hospital proves that this payor is indeed a direct payor, does KPMG update the Elector list, and consider this payor as a direct payor going forward? If the provider does not maintain the elector name in their records as it is listed on the DOH list it is quite possible that KPMG won't be able to match it. Once the provider proves that it is indeed a direct payor, KPMG will maintain the payor name as the provider had it listed to use in future reviews when doing the name to name match.
22 Direct vs. Non-Direct To clarify, are you asking providers to identify elector status of each insurance plan with submission of each year's data or does KPMG make the determination as part of the review? KPMG makes its determinations as part of the review, but if the provider maintains its own determinations, then KPMG would request this information when the data is received.
23 General Review If the provider overpaid its assessments will there be a refund provided? If an overpayment is determined on audit the provider will be instructed to take a credit on future Public Goods Pool reports until the total overpayment is offset.
24 Administrative You asked that we not have specific questions. Is there one person that we could contact with specifics? For specific questions related to HCRA, you can contact the Department of Health's HCRA Hotline at (518) 474-1673.
25 Testing Is there data available to compare provider revenue compared to payments submitted as a baseline for comparison? DOH has this information available at it's disposal if the review of such data is necessary.
26 Direct vs. Non-Direct Re:Foreign Insured Patients - Where does the responsibility ultimately lie for assessing the surcharge?In other words, if the hospital fails to list the surcharge on the UB form, is the TPA responsible for charging the international insurer? The hospital is not obligated to segregate the surcharge on the bill. Direct payors are obligated to remit the surcharge directly to the Public Goods Pool. For non-electors, the hospital is obligated to remit the surcharge on revenues collected. The above three responses apply to all claims not just foreign insured patients.
27 Direct vs. Non-Direct Are older elector lists on the website or only the most current one? Although the elector list is updated on a monthly basis, the information contained is historical.
28 Direct vs. Non-Direct Payors that have elected to pay the state directly, are they permitted to pay providers their portion of the surcharge related to the copay/deductible? It would be the insurers choice to pay the provider the portion of the surcharge related to the copay/deductable or use the second billing example on the the DOH HCRA website, which in essence pays a little more on the claim to make up for what the provider loses when they pay the surcharge directly to the Public Goods Pool out of the copay/deductable amount they collected from the patient.
29 General Review You mention Hospitals with regards to Pool reviews, what is review status on Art.28 D & T Centers? Although no Article 28 Diagnostic and Treatment Centers are currently being reviewed, they are subject to review. As such they should insure that all documentation to support their reports submitted to the Public Goods Pool are maintained.
30 General Review If the facility is found to owe, what is the time frame for reimbursing HCRA? Payment is due 60 days from the date of the Delinquent Payment Notification sent by DOH at the conclusion of the review.
31 General Review Where does DOH send the review notification letter? Letters sent to the provider's chief executive may be delayed in getting to the finance staff responsible for the review, especially where finance staff work at an off site location and/or for a network. The review notification letter is sent to the provider's CFO. It is the responsibility of the provider to ensure the information is provided to the hospital staff responsible for the compliance review in a timely manner.