When I attested to our organization's ability to meaningfully use electronic health records on April 18, 2011, I thought the really hard part of Phase I was behind me. Talking to colleagues who were at prospective payment system hospitals, their payment process was simple; as soon as they attested for meaningful use, the CMS site locked them for payment, did the calculations of what they were entitled to receive, and three to four weeks later, they had a check.
Critical considerations for critical-access hospitals seeking EHR payments
For a critical-access hospital, it is "Not so fast, Grasshopper."
After our attestation was completed, I did not have long to wait to get some information. A week after attestation, my Medicare administrative contractor contacted our CEO to congratulate him for being its first hospital to qualify—and in fact, we were told we were the first CAH in the nation to qualify. Being the astute CEO he is (and he really is), he told the caller that he would turn the process over to me. So, I called my MAC and asked where the forms were that I needed to fill out—and that is when the fun began.
I was told that there were no forms and that the CMS had not yet written the rules for a CAH to set its payment. I said—and the MAC agreed—that we were entitled to our nondepreciated costs, times our Medicare Cost Share, plus 20%. Simple enough, I thought. We developed a listing of our fixed assets and extracted the information into a spreadsheet, deleted anything that wasn't related to our electronic health record, ran some numbers and things were looking great.
To be on the conservative and careful side, the CFO and I reviewed the asset listing. We thought it was pretty good, reasonable and fair, but because we had a meeting scheduled with our external auditor, we decided to wait and review it with them. We did that in May. Armed with our review and a blessing from our auditor, we went back to our MAC. “Why don't you send us what you have,” they responded. “Let us review it, and we will get back to you.”
We had two to three conference calls with our MAC in which we explained what most of the spreadsheet items actually were and how they fit into the allowed definitions. I was asked to regroup them into categories, which was actually fairly easy. My hospital EHR is CPSI, which we installed in 2004. The initial purchase was fully depreciated; and I did not include that on my list because I was showing only nondepreciated assets. However, I was informed that I needed to show all of the original purchase items, even though they were fully depreciated, to prove that we actually owned a certified EHR. That, too, was easy, and we quickly submitted that information to our MAC.
Our MAC then took our information to a CMS National Audit Conference in mid-June. We were told that our documentation was reviewed there, discussed at length and effectively became a model, since we were the first CAH nationally to submit any documentation. When our MAC returned from that meeting, it told us that some of our items were being disallowed, but the vast majority were accepted. Also, we were advised that everything was subject to cost report filing, desk review and audit.
Also, we were told that it was good we had listed the items that had been disallowed, because that gave us the right to appeal the denial now or at a later date. Had we not listed the items, we would not have been able to go back and add them in a future filing. After reviewing the numbers on the disallowed portion, our decision was to proceed with what was allowed and appeal at a later date. Our feelings were that we would rather get paid sooner and worry about the smaller amounts later, rather than delay the larger payment by pursuing an appeal.
On June 28, our MAC told us that our calculations had been made and our data entered into the FISS system for payment, from which the National Level Repository would take the data and make payment. Its calculation of our Medicare Cost share, including the 20% CAH premium, matched ours very closely (within .01 percentage points), and, after disallowances were deducted, the MAC's base amount calculation matched ours exactly. Finally, it was a simple math exercise to demonstrate that its payment calculation was exactly where we believed it should be, after the disallowances. All that appeared that needed to be done from that point was to wait.
Originally, we were told by our MAC that we should expect a three- to four-week payment horizon, which had been its experience with early qualified PPS hospitals, and it saw no reason for payment to take longer for a CAH hospital. So we waited. The check was received Aug. 29 for the exact amount expected.
So what can you learn from our experience?
A CAH should begin assembling its nonreimbursed cost data as soon as possible, even before attestation. The sooner you have that accumulated, the better off you are going to be.
Regardless of attestation status, contact your MAC and verify the process that it will be following after you are ready. It can't hurt to determine what page it is on at the time you are getting ready. Our experience, although not yet complete, may not be universal, and verifying the MAC's expectations can't hurt.
Be diligent in determining your list of assets. While some may be disallowed, appeal rights depend on their inclusion. On the other hand, be reasonable, and don't try to get overly creative. Refer to the regs, and remember it is computer hardware and software that is allowed.
Remember there is some discussion of prorating resources that are shared with no EHR functions, which may affect your allowable number, after procedures are defined. Deal with what is given at the moment, and reserve for the possible changes down the road.
Know your certification number for your EHR (all components). You can find this on the CHPL site or obtain it from your partner.
All in all, the process was not that difficult. It was a little tedious, because our MAC and we were breaking some new ground, but in the end, we got where we needed to go. Had I known the things I know now, the process could have been faster.
Good luck to all as you move down this road. It is a journey worth taking, but it's not necessarily for the faint of heart.
Stephen StewartChief information officerHenry County Health Center Mount Pleasant, Iowa
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