HCRA Hospital Conference

February 15, 2011

Webinar Q & A´s

Question Number Question Answer
1 Nursing homes are considered to be non-specified payors and are subject to the non-specified surcharge rate. Is there any documentation regarding this that the nursing homes can obtain when they refuse to pay the facility for the surcharges? Revenue a hospital receives directly from a nursing home when providing services directly to the nursing home, is subject to the self-pay/unspecified surcharge rate, currently set at 9.63%, payable by the hospital to the Office of Pool Administration (OPA). The surcharge, if billed, is like any other part of the claim for services, and can be subject to the hospital´s collection procedures if it remains unpaid.
2 What is the higher surcharge of 37.90% and regional GME percentage that was mentioned in the webinar? What does it apply to and what is a hospital´s obligation? Third party payors, as defined in Public Health Law (PHL) Section 2807-j, have the option of filing an election that allows them to pay the OPA directly at a reduced surcharge percentage rate, currently set at 9.63%, when paying for surchargeable claims.

If the third party payor has not filed an election to pay the OPA directly, the provider is obligated to pay to the OPA the non-elector surcharge rate, currently set at 37.90% (plus, if applicable, a regional GME varying percentage on inpatient revenue) on patient services revenue received from non-electors; the hospital is permitted to recoup this expense through billings to their patients and/or non-electors.

Revenue received from non-electors must be included in lines 1, 4 and 7 of the hospital´s monthly Public Goods Pool report and:

Hospitals are obligated to pay a regional GME percentage on revenue received from specified third party payors that meet the following criteria:
  • Are defined in the PHL as being subject to the GME
  • Are non-electors
  • Provide inpatient coverage, and
  • Incur and pay an inpatient claim
Specified third party payors not subject to the regional GME percentage are payors who are providing coverage pursuant to:
  • NYS Workers Compensation
  • NYS Comprehensive Motor Vehicle Insurance Reparations Act
  • NYS Volunteer Firefighters Benefit Law
  • NYS Volunteer Ambulance Workers Benefit Law
The regional GME percentage is based on the region of the state where the hospital resides.
3 Is it possible to get a list of changes to the Elector List by month so that we don't have to look through the entire list to see whose status has changed? Electing payors that have been added or have had a change of status in a given month will be identified by an asterisk in the first column of the Elector List. Providers have the option of sorting the Elector List so that the new or changed electors appear at the top of the list.
4 If a payor is terminated from the Elector List, is the termination date always the end of the month? In most cases, yes. There are exceptions, however, such as a bankruptcy, merger, or closure. In these instances, the termination date is the date in which the bankruptcy, merger or closure occurred.
5 Are non-covered services (i.e., liposuction) subject to the surcharge and if so, would it be the self pay rate of 9.63%? Yes, revenue a hospital receives for non-covered services is subject to the self-pay rate, currently set at 9.63%, and payable to the OPA. The hospital should bill the 9.63% on their claim to the patient.
6 What do filing status letters in the Eector List stand for and can we get the Elector List as an excel file so we can sort by the filing status? The filing status letters in the Elector List pertain to the frequency in which electing payors must submit their Public Goods Pool (PGP) reports, (either "M" for monthly filers, or "A" for annual filers). These status letters are not relevant to a hospital. Please note that the Elector List is available online as an Excel file and can be sorted.
7 Are Lab Capitation payments surchargeable? Revenue a hospital receives for lab capitation services from electing payors is subject to the electing payor rate, currently set at 9.63%, and is payable by the electing payor directly to the OPA.

Revenue a hospital receives for lab capitation services from non-electing payors is subject to the non-elector surcharge rate, currently set at 37.90%, and payable by the hospital to the OPA. Hospitals should assess the 37.90% on their claims to the non-elector or their member.
8 Are there any plans to automate the elector list similar to online insurance eligibility that can help to verify the elector status and appropriate surcharge amount. The manual look up of the elector list is not a good option. Aetna may have 100 entries. The Elector list contained on the OPA´s secure website (www.hcrapools.org) has been recently enhanced to include a search engine that allows a search by payor name or Federal Tax Identification number. We are open to any specific suggestions you may have to further enhance the process. Suggestions can be sent via email to: BIMAMAIL@health.state.ny.us
9 Why do we give payors all these different options? Options lead to confusion and inconsistencies. The Department´s administrative responsibilities are governed by the PHL which, in many cases, does not allow us to mandate how certain issues are handled.
10 What options do electing payors have in the handling of surcharges on deductibles and copayments? Electing payors, who have voluntarily chosen to pay the associated surcharges on fixed dollar patient portions, such as fixed dollar co-pays and deductibles, have two options in which to pay.

Option 1: The payor pays the claim by utilizing the second billing example found on the DOH Website. Hospital pays the surcharge out of the fixed dollar amount and gets reimbursed by the payor.

If the payor chooses Option #1 the hospital must report the patient payment received on lines 1, 4, 7 and 10 of the PGP report. Line 10 calculates the surcharge percentage (currently set at 9.63%) out of the patient payment and calculates the amount due to the PGP.

Option 2: The payor pays the associated surcharge on the fixed dollar co-pay or deductible directly to the PGP via their payor PGP report.

If the payor chooses Option 2, the hospital must have written notice from the payor that they are paying the surcharge directly to the OPA. Upon receipt of written notice, the provider will report the receipt of the patient´s fixed dollar amount on lines 1, 4, 7, and 17 of the PGP report. Line 17 does not calculate a surcharge due to the PGP since the payor is calculating the surcharge due on their PGP report.

Without such written notice, it is the provider´s responsibility to pay the surcharge out of the patient portion received by reporting on lines 1, 4, 7, and 10 of the PGP report.

Written documentation must be kept by the hospital for HCRA audit purposes.
11 Do the auditors have the list showing how various payors are handling the payment of surcharges on deductible and coinsurance, and if not, can you provide it to them and instruct them that they can share with the provider? Yes, the auditors do have the list and are free to share it with providers.
12 Can we get a sample of the letter that we should get from the payors showing how they handle co-pays and deductibles please? There is no standard format for this letter. However, the letter should be detailed and clearly state that the electing third party payor has chosen to pay surcharges on deductibles and copayments directly to the Public Goods Pool along with indicating the time frame involved.
13 If the patient has a $500 deductible and the contracted rate with an electing payor for the service being provided is $400, is the surcharge the responsibility of the patient since adding the surcharge to the $400 does not bring them over their deductible limit? Yes, since the service provided is $400, and the addition of the applicable surcharge at 9.63% does not exceed $500, the hospital should assess the surcharge to the patient, bringing the total bill to $438.52. When the hospital receives the $438.52 from the patient, the hospital is responsible for reporting the revenue on their monthly PGP report, on line 10, of either the Hospital Inpatient Services section or the Hospital Outpatient Services section of the hospital report, where applicable.
14 How should a hospital report surcharges received from non-electors on the PGP report? Revenue received from non-electors must be included in lines 1, 4 and 7 of the hospital´s monthly PGP report and:

15 Is the New York State Medicaid exempt from surcharge? No. The applicable surcharge percentage on New York State Medicaid payments is currently 7.04%. If the hospital has filed DOH form 4405, Provider Election for Medicaid Withholding, all surcharges applicable to payments coming directly from the NYS Medicaid Program are automatically issued to the OPA on the hospital´s behalf. Other NYS Medicaid payors, acting on behalf of the NYS Medicaid Program, either have elected to pay their 7.04% obligation directly, or, if not elected to pay directly, are obligated to pay the hospital, when billed.
16 Is the surcharge paid by ambulance companies? If the ambulance service is billed by the hospital and the revenue remains with the hospital, then the payment for the ambulance fee is subject to the HCRA surcharge, payable by either the electing payor to the OPA, or, by the hospital to the OPA for revenue received from a non-elector or self pay patient. If the latter is the case, the hospital should assess the surcharge on the claim for services rendered. If the service is provided by an outside ambulance company and the revenue is received by the ambulance company, then it is not subject to a surcharge.
17 Will this presentation, including audio, be available for staff to listen into at a later time? The handouts and recording of the HCRA web conference are now available on the HANYS website at: http://www.hanys.org/members_only/financial/.

Please note you will need your HANYS website user ID and password to access this page, and will find the information at the bottom of the web page under the heading "HCRA Basics."
18 If a Medicare-eligible patient receives treatment in the ER, and is subsequently denied by Medicare for Part B, should a surcharge be assessed? Yes. If the patient is not enrolled for Medicare Part B, does not have other secondary coverage for the service, or if the patient´s Medicare benefits are exhausted, the revenue received by the hospital is subject to the HCRA surcharge at the self pay rate currently set at 9.63%. The hospital should assess the 9.63% to the patient.

The hospital is obligated to include this revenue in the Hospital Outpatient Services section of the PGP report on lines 1, 4, 7, and 10.

However, if the patient has secondary insurance for which the service is covered, the applicable surcharge is determined by whether the third party payor has filed an election to pay surcharges directly to the OPA. If the third party payor has not filed an election to pay OPA directly, the hospital should assess the non-elector surcharge currently set at 37.90%. The hospital is obligated to include this revenue in the Hospital Outpatient Services section of the PGP report on lines 1, 4 ,7 and 12.
19 Why are referred lab tests exempt from surcharges? When HCRA was established in 1997, freestanding clinical laboratories were classified as designated HCRA providers. Effective with dates of service October 1, 2000 and forward, the law changed to eliminate Article 5 Title V freestanding clinical labs as designated providers. In an effort to level the playing field for the remaining HCRA providers that operate laboratories and provide similar services, referred (ordered) ambulatory clinical laboratory services provided by hospitals and diagnostic and treatment centers also became exempt from HCRA surcharges for dates of service October 1, 2000, and forward.
20 What is the effective date for the exemption of personal items? There is no effective date for the exemption of personal items. However, if a hospital determines that they have paid surcharges on personal items in the past, the statute of limitations for refund, or the reporting of a prior period adjustment, is 6 years from the end of the calendar year in which the report was due.
21 Can the hospital pursue collection efforts from non-electors on the surcharge that the hospital paid to the OPA but did not collect? Yes, provided the hospital has billed the surcharges. The hospital can pursue collection for any portion of the bill that remains unpaid.
22 If a hospital bills a non-electing third party payor for an inpatient hospital stay a total of $100,000, and the hospital either did not add the surcharge, or the payor did not pay the surcharge what would the applicable surcharge be? Hospitals are obligated to pay surcharges on revenue received from non-electing payors. They are obligated to pay the non-elector surcharge rate (currently at 37.90%) plus, if applicable, the regional GME Percentage (at rates based on the region of the state where the hospital resides) (See question 2 above regarding obligations to the GME).

In this example, the hospital must include the $100,000 revenue received on lines 1, 4 and 7 of the inpatient hospital report, and, either on lines 12a or 12b depending on whether the payor has an obligation to pay the GME. The surcharge is actually carved out of the $100,000 received, and paid to the PGP. If in a subsequent month, the surcharge is received, it must be reported on the same lines as stated above, with the balance due carved out and paid to the PGP.
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