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Medicare Disproportionate Share

Medicare Disproportionate Share hospital (DSH) payments are a vital source of funding for hospitals that serve low-income populations. DSH payments reimburse treatment costs that are not covered by other payers and typically range from $250 to $400 for each eligible patient day.

Aggregating and integrating the patient data needed to qualify for Medicare DSH is a complex process, and many hospitals lack the internal resources and/or technology to accurately determine eligible DSH reimbursement.

STINGRAYTM, Healthcare Payment Specialists’s proprietary software platform, ensures that hospitals maximize their DSH reimbursement. STINGRAY integrates multiple data sources to identify all DSH eligible patients and patient days.

Driven by superior technology, staff expertise and a commitment to quality, Healthcare Payment Specialists delivers its DSH logs to clients quickly and accurately.

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STINGRAY’s Medicare Disproportionate Share module has received the prestigious Peer Reviewed designation from the Healthcare Financial Management Association (HFMA).

HPS Solution

  • Performs a thorough scrubbing of patient encounter data to ensure maximum match results with Medicaid eligibility data
  • Utilizes sophisticated regressive matching techniques to identify all mom/baby matches
  • Matches the Medicare PS&R to the final Medicaid log to remove any paid Medicare claims
  • Cross-references results against the Medicare Common Working file in all nine regions to reconcile any eligible but not paid Medicare records from the Medicaid fraction
  • Delivers results with full documentation required for submission to Medicare
  • Delivered as either a consulting service (with HPS performing the analysis), or as a SaaS solution (with HPS implementing STINGRAY for the hospital to use to perform its own analysis)

Case Study

108-bed Independent Hospital — Recovered $1.5MM over 4 years

A Midwestern, 108-bed, independent hospital that serves a seven-county area and admits approximately 3,500 inpatients per year.

Opportunity / Challenge

Medicare DSH is an important source of supplemental income that helps offset the costs for providing needed care to indigent patients. Despite a concerted effort by the hospital’s internal accounting department, the hospital found that it had not identified a sufficient number of days to qualify for DSH payments. The hospital was aware of some of the issues that made the process complex — such as newborns, partially paid accounts or accounts where the patient did not provide key payer or eligibility information. They knew that these challenges had inhibited their ability to identify all of the days that were available to be counted. Given the hospital’s previous experience with HPS on other reimbursement issues, as well as favorable feedback from other HPS clients, the hospital engaged HPS to conduct a review of the hospital’s data to assess their DSH opportunity.

Solution

HPS used STINGRAYTM to reconcile 100% of the client’s inpatient accounts with several independent data sources to identify DSH opportunities. Specifically, STINGRAY screened the client’s patient accounts to verify Medicaid and Medicare eligibility, confirmed all eligibility segments that overlapped with patient stays and reconciled all account payments. This automated process provided highly accurate results to show which patients should and should not have been included in the DSH calculation, a process that would have been exceedingly challenging and time consuming to identify through a manual data review.

HPS’s review uncovered a sufficient amount of Medicaid days to qualify the client for DSH payments. Quality assurance checks by HPS ensured that supporting documentation was in order for all submitted claims and that the package submitted to CMS was organized to facilitate the auditor review. In addition to reimbursement due from CMS, HPS also identified a Medicare Advantage private plan that provided DSH reimbursement and collected additional DSH reimbursement for the client from this Part C plan. HPS supported both the traditional and Medicare Advantage DSH claims through audit, achieving 99.7% audit success rates for traditional DSH and 100% for Medicare Advantage DSH.

Results

  • Qualified the client for DSH reimbursements
  • Recovered ~$1.5MM over a period of 4 years in DSH payments (traditional and Medicare Advantage), based on FY03-06 recoveries
  • Continuing multi-year relationship on DSH and transfer DRG reimbursement issues

BROCHURE

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