William T. Cuppett, CPA, Managing Member, The Health Group, LLC Theresa M. Forster, VP for Hospice Policy & Programs, NAHC. NAHC - October 20,

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1 812. Hw t Master Hspice Aggregate CAP Reprting and Financial Management William T. Cuppett, CPA, Managing Member, The Health Grup, LLC Theresa M. Frster, VP fr Hspice Plicy & Prgrams, NAHC NAHC - Octber 20, Hspice Aggregate Cap Aggregate cap: Designed t limit ttal aggregate payments a hspice can receive in a year; t prtect Medicare frm spending mre fr hspice care than cnventinal care at the end f life. First aggregate cap amunt set at $6,500 per beneficiary (1983) determined t be well abve the average cst f caring fr a hspice patient The aggregate payment amunt a hspice may receive under Medicare fr any given cap year is limited t the cap amunt times the number f Medicare patients served NAHC - Octber 20,

2 Hspice Aggregate Cap Tw methds fr cunting the number f Medicare patients The streamlined methd The prprtinal methd Cap histrically has been updated annually by the BLS medical expenditure categry f the Cnsumer Price Index fr all Urban Cnsumers (CPI-U) Beginning with accunting years starting n r after Sept. 30, 2016 (until Oct. 1, 2025) the aggregate cap will be updated by the net hspice market basket index (result f IMPACT Act f 2014) NAHC - Octber 20, Hspice Aggregate Cap MedPAC/CMS have tracked data n hspices that exceed aggregate cap. CMS fund: % % % % Characteristics f ver cap hspices: Predminantly fr-prfit VERY lng length f stay VERY high prfit margin (befre repayment) NAHC - Octber 20,

3 Hspice Aggregate Cap Percent f ver-cap hspices still a minrity f hspices BUT are increasing in number; further, an increasing number f hspices are getting clser t hitting cap (CMS data) Histrically MACs alert hspices f cap liability between mnths after clse f cap year Cngressinal, ther cncerns that verpayments are significantly delayed r g unrecuped NAHC - Octber 20, Hspice Aggregate Cap CMS FY2015 Hspice Wage Index/Payment Rule: Effective fr the 2014 and subsequent cap years, each hspice must calculate its aggregate cap Calculatin made NO SOONER than 3 mnths fllwing clse f cap year (Jan. 31) Cap calculatin must be prvided NO LATER than 5 mnths fllwing the clse f the cap year (March 31) Use pr frma spreadsheet supplied by CMS NAHC - Octber 20,

4 CAP Reprting and Management Prcess (1) Mnitring CAP and any ptential CAP liability thrughut the year (n surprise at the end f the CAP year) The frequency f this activity shuld be dependent n risk f exceeding the CAP Histrical CAP liability Lack f spread between histrical CAP and Medicare payments Increasing average length f stay Certain hspices shuld be mnitring n a mnthly basis. NAHC - Octber 20, CAP Reprting and Management Prcess (2) If apparent that the hspice will, r it is prbable that the CAP will be exceeded, begin t make repayment arrangements Payment is due when the CAP reprt is submitted If a Request fr Extended Repayment Schedule ( ERS ) will be submitted, be prepared t submit the request fr ERS with the CAP Reprt (due March 31 st ) Request fr ERS discussed later. NAHC - Octber 20,

5 CAP Reprting and Management Prcess (3) Prepare CAP Reprt (using template t be prvided) n r befre February 25 th (even thugh nt due until March 31 st ) Yu can submit as sn as cmpleted, r Yu nw have until March 31 st t prvide any additinal dcumentatin, i.e. internal cmputatins r Request fr ERS) Use PS&R infrmatin as f January 31 st (earliest date pssible) t minimize any interim liability. Review alternative ti cmputatin ti (Prprtinal Methd) if CAP still being cmputed n the Streamlined Methd. NAHC - Octber 20, CAP Reprting and Management Prcess (4) Estimate ultimate CAP liability (remember the CAP reprt submitted nly reflects an interim liability) (5) Revisit prir year CAP cmputatins fr ptential liability f increased liability. (5) Begin preparatin fr funding any ultimate liability (6) Begin estimatin f subsequent year CAP and ptential CAP liability (prcess begins again) NAHC - Octber 20,

6 Anticipated MAC Activities Review CAP Reprt submitted n r befre March 31 st Is the CAP Reprt a claim (False Claims Act r False Statement Laws)? Will the MAC mdify r update yur reprt based n mre current infrmatin? Make final CAP determinatins and review prir year cmputatins issuance f Ntice f CAP liability (expected ne year after end f CAP Year) NAHC - Octber 20, CAP Cmputatin (1) Identify methd n which yu CAP is cmputed: Streamlined Methd Prprtinal Methd Once the Prprtinal Methd is elected the Streamlined Methd can never be used again. Understand that if the hspice is still n the Streamlined Methd yu can elect t switch t the Prprtinal Methd. If yu switch cmputatin will revert t Prprtinal Methd back t the 2012 CAP Year (Nvember 1, 2011 thrugh Octber 31, 2012) NAHC - Octber 20,

7 Access IACS Using User Name and Passwrd access IACS me=prviders (2) Get Beneficiary Cunts - Under Miscellaneus Reprts select Beneficiary Cunty (CAP Reprt) Select Streamlined Methd: Beneficiary Perid (September 28, 2013 Octber 31, 2014) (September 28, 2013 thrugh September 27, 2014) Prprtinal Methd (Nvember 1, 2013 thrugh Octber 31, 2014) Payment dates thrugh January 31, 2015 (earliest date available) Run reprts fr the prir perids as well (2012 CAP Year and 2013 CAP Year) If n Streamlined Methd, run reprts fr Prprtinal Methd as well fr cmparisn NAHC - Octber 20, Sample Beneficiary Cunt Streamlined Methd NAHC - Octber 20,

8 Sample Beneficiary Cunt Prprtinal NAHC - Octber 20, Secure Payments Using IACS, PSR secure payment reprt. The reprt will autmatically prduce multiple year reprts. Parameters: Service Dates (initial perid) Nvember 1, 2011 Octber 31, 2012 Yu will nw get multiple year payments NAHC - Octber 20,

9 Medicare Payments NAHC - Octber 20, Cmputatin CAP ON OVERALL MEDICARE REIMBURSEMENT 1. MEDICARE BENEFICIARIES PER IACS PAID THROUGH 7/17/ Nte: These beneficiaries are cunted using the Patient by Patient Prprtinal Methdlgy. 2. STATUTORY CAP AMOUNT FOR THE CAP YEAR ENDED $26, ALLOWABLE MEDICARE PAYMENTS $1,198, ACTUAL PAYMENTS PER THE PS&R PAID THROUGH 7/14/14 $1,910, PAYMENTS IN EXCESS OF THE CAP AMOUNT ($711,992) Payments reflects are net patients, after sequestered Amunts further discussin. NAHC - Octber 20,

10 Check Prir Year Streamlined Methd Having access t IACS, check prir year cmputatins back t the 2012 CAP Year (Medicare can revise CAP fr three years Cmpute any CAP liability under the Prprtinal Methd back t 2012 (2012, 2013, 2014) Medicare cannt g back t years earlier than the 2012 CAP year if yu cnvert Shuld yu cnvert? NAHC - Octber 20, Cnversin t Prprtinal If it is determined in the Hspice s best interest, make yur electin prir t r with the submissin f the reprt fr the 2014 CAP Year. Any cnversin after the Ntice f CAP Liability is issued requires PRRB Appeal t be filed. The PRRB then instructs the MAC t recmpute. (Remember review any ptential liability assciated with the 2013 and 2012 CAP Years under the Prprtinal Methd). NAHC - Octber 20,

11 Over CAP (Liability) Must be remitted with CAP reprt (n r befre March 31, 2015), r Submissin f Request fr ERS (Extended Repayment Schedule): Unknwn: Will they give yu 15 days t respnd t verpayment as in the past If ptentially near r in excess f CAP recmmend making cmputatins in February allwing time t prepare Request fr ERS and submitting with CAP Reprt. NAHC - Octber 20, Extended Repayment Schedules A prvider is expected t repay any verpayment prmptly. If repaying an verpayment within 30 days wuld cnstitute a hardship (10% f annual payments) n the prvider, a request fr an ERS shuld be submitted immediately. Hwever, the prvider may request an ERS at any time the verpayment is utstanding, and the cntractr shall review that request. Instructins n hw t apply fr an ERS shall be available n the cntractrs website fr prvider reference. If a cmplete ERS request is received within 15 days f the date f the demand letter and first payment is included, cntractrs shall nt begin 100% recupment f payments, unless payments are being suspended r withheld fr anther utstanding verpayment r investigatin. During review, the cntractr may reduce recupment t 30% f payments until a decisin is made. If a cmplete ERS request is received after 15 days f the date f the demand letter and first payment is included, during the review, the cntractr may reduce recupment t 30% f payments until a decisin is made. NAHC - Octber 20,

12 Request fr ERS Up t 60 mnths: Infrmatin Needed: Signed amrtizatin schedule Balance sheets, incme statements, cash flw statements, prjected cash flw statements, and surces and uses f funds. (prir year, current year, prjectins may vary) Restricted cash funds Investments Ntes and mrtgages payable Related party transactins and balances Lan applicatin and denial letter frm bank Occupancy First installment payments NAHC - Octber 20, Prjecting Final Liability Using histrical experience t prject final liability due t Medicare prgram: Use last three years distributins f patients based n infrmatin secure thrugh IACS. Give cnsideratin t changes in histrical patient utilizatin (distributins) Update ttal patients fr prjected admissins thrugh end f CAP perid (September 27 th r Octber 31 st depending n methd) NAHC - Octber 20,

13 Estimating Beneficiaries Estimate years prir 0.50% 0.29% 0.35% 0.01% 2 years prir 0.88% 1.28% 0.93% 1.27% 1.03% 1 year prir 12.37% 9.06% 10.98% 12.86% 10.80% Current year 68.34% 67.98% 66.77% 80.58% 67.69% 1st year subsequent 16.11% 20.90% 20.59% 5.28% 19.20% 2nd year subsequent 1.64% 0.33% 0.39% 0.00% 0.78% 3rd year subsequent 0.16% 0.17% 0.17% % % % % NAHC - Octber 20, Estimating Interim CAP At June 30, Estimate d June 1 thrugh Octber 31 estimated years prir 0.50% 0.29% 0.35% 0.01% 2 years prir 0.88% 1.28% 0.93% 1.32% 1 year prir 12.37% 9.06% 10.98% 13.28% Current year 68.34% 67.98% 66.77% 48.11% 67.69% 1st year subsequent 16.11% 20.90% 20.59% 0.00% 2nd year subsequent 1.64% 0.33% 0.39% 37.28% 3rd year subsequent 0.16% 0.17% % % % % NAHC - Octber 20,

14 Settlement Prcess CAP Reprt t be submitted n r befre March 31 st. MAC review f CAP Reprt submitted (?) MAC revisin and update f CAP Reprt submitted (?) MAC review f final CAP (expected smetime arund mnths after end f CAP Year MAC nging review f CAP fr three (3) years. NAHC - Octber 20, Management Summary If yu hspice is substantially under the CAP, the management prcess may be as easy as being alert and filing the annual CAP Reprt. If yur hspice is ver the CAP r appraching the CAP, the management prcess becmes a peridic event addressing estimates, verpayments, and prir year CAP mdificatins. If ERS is currently used r planned t be used, financial recrds must be adequate, pssibly updated t include accrual-basis financial statements fr nging reprting t the MAC. NAHC - Octber 20,