In this episode, we are joined by Jimmy Mendez, Senior Manager on BESLER’s Reimbursement Services team, to discuss compliance issues related to organ acquisition.
Highlights of this episode include:
- What the most common compliance issues are during organ acquisition Medicare cost reporting.
- Reasons why hospitals finds themselves out of compliance.
- Steps hospitals can take to curtail compliance issues.
- How hospitals can use corrective actions when they’ve determined that improper billing has occurred.
- And more…
Mike Passanante: Hi, this is Mike Passanante. And welcome back to the award-winning Hospital Finance Podcast®.
Today, we’re going to be talking about compliance issues with organ acquisition. And joining me to discuss that topic is Jimmy Mendez who is the Senior Manager in our Reimbursement Services Team here at BESLER.
Jimmy, welcome back to the show.
Jimmy Mendez: Thank you, Mike. Good to be here.
Mike: So, Jimmy, in your time as a reviewer of certified transplant programs, what would you say is the most common area in organ acquisition Medicare cost reporting where you’ve seen the most compliance issues?
Jimmy Mendez: Well, the single most common area where compliance issues may arise relates to the treatment of the organ acquisition charges and days information that is used to populate worksheet D-4 Part I.
Mike: Okay. So, we’re going to talk more about that worksheet as we go forward. So we’ll hold off and get into that as we get further along.
And before we discuss specific compliance issues, can you describe the nature and purpose of these organ acquisition charges and days?
Jimmy Mendez: Yes, the purpose is to identify the costs incurred by hospitals for providing organ acquisition services to potential organ recipients and potential organ donors at their own hospital facility. The regulation stipulates that, when a hospital provides organ acquisition services to potential organ recipients or donors, the related charges and days should be accumulated on a cost report cost-per-basis and placed on worksheet D-4 Part 1 or cost-to-charge ratios or cost-per-diems are then utilized to establish the related costs.
Mike: Jimmy, why do hospitals sometimes find themselves out of compliance?
Jimmy Mendez: Well, the compliance issue is typically related to the improper billing of these services. The charges and days we have described should not be billed to Medicare when servicing Medicare beneficiaries. Medicare requires that the necessary cost to validate transplant candidates and prepare a recipient or donor for transplantation be reimbursed via the cost report and a cost reimbursement basis and not be billed to Medicare directly.
Rather than writing them off and capturing them on worksheet D-4 Part 1, hospitals sometimes build the organ acquisition with these charges instead. Even more problematic, some hospitals do both.
Mike: I see, so we’ve discussed services that should not be build. What are some services that should be built?
Jimmy Mendez: Well, this one included billing for the actual transplant event for the recipient, which is reimbursed based on MSDRG’s, any therapeutic interventions or treatments that are necessary to keep the patient healthy. While in the waiting period are to be billed separately to the payer including Medicare in accordance with the provisions of the contract with that payer.
Charges for services occurring subsequent to the transplant event known as post-transplant services should also be billed. These are reimbursed via APC by Medicare.
Conversely, though, the organ donation state for the donor is considered organ acquisition costs and should not be billed to Medicare directly but captured as organ acquisition instead.
Mike: And Jimmy, you stated that the organ acquisition charges and days for Medicare beneficiaries should be captured on worksheet D-4 Part 1. What about other payers?
Jimmy Mendez: Well, Mike, their charges and days should also be captured on worksheet D-4 Part 1. The reason being that, once charges and days are converted to costs via the use of cost-to-charge ratios and per diems, the Medicare ratio is applied to the cost to determine Medicare’s share of these costs.
If you don’t include all payers, then the calculation will underestimate Medicare reimbursement.
Mike: So, Jimmy, given all that we just talked about, what steps can a hospital take to curtail compliance issues?
Jimmy Mendez: Well, most hospitals have a flagging process in place (and if they don’t, they should) where a patient who has been referred to the transplant program is identified and flagged with a unique identifier during the registration process at the hospital.
Ideally, charges and days for these individuals should be held in suspense until someone reviews the data and determines whether the services were organ acquisition-related or medical management/treatment-type services; in other words, determine if the charges would be written off and captured for inclusion on worksheet D-4.
Whether to bill or not is also determined at this point. The challenge has been devoting resources to this process. An additional obstacle has been identifying individuals that have a grasp of both the financial and clinical components of this charge whole process. Often, the process of compiling the organ acquisition logs occurred at the time of the cost report preparation. And by this time, improper billing may have already occurred. Improper steps to rectify the error don’t always take place.
It is our opinion that capable individuals should be identified and trained to handle the charge whole process. And hospitals should allocate the proper resources to this process which, for larger facilities, could mean a fully dedicated FTE.
However, hospitals should consider that the cost of these positions are themselves organ acquisition cost, and therefore, the cost needs to be reimbursed.
Mike: Jimmy what steps should a facility take if they’ve determined improper billing has occurred?
Jimmy Mendez: Well, corrective action will potentially require rebuilding and resolving the cost report and the return of any overpayments. A corrective action plan to avoid a repeat of the issue should be implemented.
CMS requires Medicare Parts A and B healthcare providers and suppliers to report and return overpayments by the later of the date that is 60 days after the date an overpayment was identified or the due date of any corresponding cost report.
One should consult with their compliance officer for specific guidelines to adhere to.
Mike: Thank you, Jimmy. And for those in our audience who may have already guessed, Jimmy is an expert at Medicare organ acquisition reimbursement. And if you do have any questions or would like to understand more about what BESLER might be able to do for you in that area, please feel free to drop us an email at firstname.lastname@example.org.
Jimmy, thanks so much for joining us on the podcast today.
Jimmy Mendez: Well, you’re welcome, Mike. It was a pleasure.