In this episode, we welcome back Cody Bales, Senior Reimbursement Consultant at BESLER, who’s here to discuss the Disproportionate Share Hospital, affectionately known as DSH survey for New Jersey.
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Highlights of this episode include:
- What is the Medicaid DSH survey
- What is the reimbursement impact
- Tools and knowledge needed to complete
- Tips for completing the survey
- Common pitfalls
Kelly Wisness: Hi, this is Kelly Wisness. Welcome back to the award-winning Hospital Finance Podcast. Today we’re joined by Cody Bales, a Senior Reimbursement Consultant at BESLER, who’s here to discuss the disproportionate share hospital, affectionately known as DSH, survey for New Jersey. Welcome to the show, Cody.
Cody Bales: Hey, Kelly. Thanks for having me.
Kelly: So, we’re just going to jump right in today with this very important topic for our New Jersey folks. What is the Medicaid DSH survey, and why does it have to be completed?
Cody: Most hospitals in the state are eligible to receive DSH payments – again, DSH is short for disproportionate share hospital – eligible to receive those payments from the Medicaid program. And this is an entirely different payment mechanism than Medicare DSH payments, which comes to mind for most people when they hear DSH. So, while Medicare DSH payments or adjustments are calculated through the Medicare cost report and supplemental reporting, the Medicaid DSH payments are, again, a different stream of payments that are paid by the state to hospitals that serve certain patient populations, namely Medicaid or Medicaid-eligible patients as well as uninsured individuals. So the DSH survey itself comes in as a reporting requirement for any hospital that receives DSH funding during the year. Without going into the specifics too much, the survey is basically an accounting of the uncompensated cost of services provided to Medicaid and uninsured individuals. The state of New Jersey, in turn, has a statutory requirement to report to CMS not only their DSH hospitals and the funding paid out but also several other elements that are collected through the DSH surveys that are completed by hospitals.
Kelly: Okay. That makes sense. And how often must the DSH survey be completed?
Cody: Good question. The state’s report is submitted on an annual basis. So basically, a DSH survey must be completed each year by the hospital. Now, because of how the UCC, which is the acronym for uncompensated care cost, that you’ll hear quite often– because of how UCC gets realigned from a hospital’s cost report year to the state’s fiscal year, which in New Jersey is a 6/30 year-end, there are scenarios where a hospital would have to submit multiple surveys for each reporting cycle or each year. So think in the cases of when you have a cost-report year end change or a short cost-report period, that scenario could come up. But for the vast majority of cases, now that the DSH survey reporting cycle has been up and running for several years, it’s one survey due per year.
Kelly: Okay. That makes sense. Thank you. And, Cody, what is the reimbursement impact?
Cody: The primary concern for this process is the measure of DSH funds received during the year versus the amount of uncompensated care that’s incurred by the facility in providing services. So if the hospital doesn’t take proper care in obtaining the necessary documentation and timely submitting the survey with the most accurate information, then the hospital’s DSH payments may be subject to recoupment or more recoupment than otherwise would be necessary. So that’s kind of the primary concern. But additionally though, even with that being said, the hospital should carefully complete the survey and ensure that all of the uncompensated care is properly being reported and claimed on the survey because as we’ve seen time and time again, even if some specific survey or data is not used for sort of an ancillary purpose today, that may not necessarily be the case in the future.
Kelly: Okay. Thank you for that. That makes a lot of sense. What tools or knowledge does someone need to complete the survey?
Cody: The DSH survey should be assigned to someone at the facility with a high degree of reimbursement knowledge as well as revenue cycle knowledge and probably hospital operations in general. It’s essential to have a basic understanding of the Medicare cost report, how cost-to-charge ratios work, and then probably the most important thing to understand is how to identify the appropriate patient populations and gather patient claims detail. The survey requires a high degree of detailed patient claims reporting, scrubbing, research, analysis, validation, all of that. So, this will often involve multiple individuals in the organization, those from decision support, information systems, revenue integrity, or other groups, just depending on how the organization is structured.
Kelly: So very knowledgeable people on the team for sure is needed for this, right?
Cody: Yes. Yes, absolutely.
Kelly: Yeah, that’s what it sounds like. And do you have any tips for completing the survey?
Cody: I’m glad you asked because yes, of course I do. Generally, hospitals can get a lot of benefit and kind of save a lot of headaches by properly and, just as importantly, efficiently validating the data that’s included on the survey prior to submission. Not only can this minimize audit questions but could potentially limit additional audit sampling, testing procedures, and all that sort of thing. And so not to go off in the weeds too much, but I’ll give you a few examples. One obvious one is to compare Exhibit A, which is a listing of your uninsured patients, to Exhibit B, which is a record of patient payments received during the year. So, if a patient is identified in Exhibit A and matched in Exhibit B with payments that are classified as insured, then obviously, that doesn’t make any sense and you’d want to go and determine what happened there.
And then speaking of Exhibit B, I would also add to specifically review the range of service dates that are included in the detail. If oldest service dates only go back a few years from the cost report year in question but you as an organization are still collecting on patient accounts from many years back, then there’s a disconnect there. And so prior to submitting, you would want to determine the cause for that, be it missing legacy transaction data, older transaction codes not being picked up in the report, or whatever the cause may be. And another check I would recommend is to look at the calculated cost of services as a percentage or a ratio of charges. This will clue you into any potential issues with the mapping or allocation of revenue codes and the claims data to the cost center lines on the DSH survey so you can perform this review across patient populations, so Medicaid dual eligible, uninsured, etc., as well as between survey years to identify and review that ratio. So performing this additional check may even help you identify issues with your current reporting that are leading to underreporting of uncompensated care.
Kelly: Wow, those are some great tips. Thank you. And are there any common pitfalls to watch out for?
Cody: Yeah, I’ll just mention a quick one, which is to not kind of check out of the process after everything’s done and the survey is submitted. You’ll likely receive an adjustment report back, and it’s very important to zero in on the high-impact adjustments on the report and confirm either that the adjustments are valid or that maybe further information can be provided to the auditor to potentially negate the adjustment. So, take a look at that adjustment report for sure and keep it kind of front and center even after you submit the survey because when you look at that, the impact of the adjustments may not appear to be significant and aggregate, but you would want to still do that review to make sure that you have a handle on all the adjustments.
Kelly: Definitely. That’s good advice. Thank you. We are so appreciative of all this great information you shared with us today, Cody.
Cody: Yeah, absolutely. Thank you. Thank you for having me.
Kelly: And you can learn more from Cody on this topic on the related webinar he’s presenting live on July 27th. You can register for that webinar on our website, besler.com. The webinar recording and corresponding slides will also be available on our website after the webinar. Thank you for joining us on the Hospital Finance Podcast.
[music] This concludes today’s episode of the Hospital Finance Podcast. For show notes and additional resources to help you protect and enhance revenue at your hospital, visit besler.com/podcasts. The Hospital Finance Podcast is a production of BESLER, SMART ABOUT REVENUE, TENACIOUS ABOUT RESULTS.
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