Instructions by Table: Table 9D - Patient-Related Revenue (Scope of Project Only)

Table 9D must be completed by all BPHC grantees covered by the UDS. It is included only in the Universal Report. This table collects information on charges, collections, retroactive settlements, allowances, self-pay sliding discounts, and self-pay bad debt write-off.

ROWS: PAYOR CATEGORIES AND FORM OF PAYMENT

Five payor categories are listed: Medicaid, Medicare, Other Public, Private, and Self Pay. Except for Self Pay, each category has three sub-groupings: non-managed care, capitated managed care, and fee-for-service managed care. Note that while similar data elements on Table 9C exclude dental-only or mental health-only managed care plans, information reported on table 9D includes these charges, collections and allowances on the managed care lines.

Medicaid - Lines 1 - 3. Grantees should report as " Medicaid " all services billed to and paid for by Medicaid (Title XIX) regardless of whether they are paid directly or through a fiscal intermediary or an HMO. For example, in states with a capitated Medicaid program, where the grantee has a contract with a private plan like Blue Cross, the payor is Medicaid, even though the actual payment may have come from Blue Cross . Note that EPSDT (the childhood Early and Periodic Screening, Diagnosis and Treatment program which has various names in different states,) is a part of Title XIX and is included in the numbers reported here - almost always on line 1. Note also that S-CHIP, the State based Children's Health Insurance Program, which also has many different names in different states, is sometimes paid through Medicaid. If this is the case, it should be included in the numbers reported here. Also included here will be "cross-over" charges that are reclassified to Medicaid after being initially submitted to Medicare

Medicare - Lines 4 - 6. Grantees should report as " Medicare " all services billed to and paid for by Medicare (Title XVIII) regardless of whether they are paid directly or through a fiscal intermediary or an HMO. Specifically, for patients enrolled in a capitated Medicare program, where the grantee has a contract with a private plan like Blue Cross, the payor is Medicare, even though the actual payment may have come from Blue Cross . If a patient is covered by both Medicare and Medicaid, or by Medicaid and a private payor, some portion of the charge will be reclassified to these other payment sources.

Other Public - Lines 7 - 9. Grantees should report as " Other Public " all services billed to and paid for by State or local governments through programs other than indigent care programs. The most common of these would be S-CHIP, the State based Children's Health Insurance Program, which has many different names in different states, when it is paid for through commercial carriers. (See above if it is paid through Medicaid.) Other Public also includes family planning programs, BCCCP (Breast and Cervical Cancer Control Programs with various state names,) contracts with correctional facilities, and other dedicated state or local programs as well as state insurance plans, such as Washington's Basic Health Plan or Massachusetts' Commonwealth Plan. Other Public does not include state or local indigent care programs. Patients whose only payment source is one of these other public programs are reported as "uninsured" on Table 4.

NOTE . Reporting on state or local indigent care programs that subsidize services rendered to the uninsured is as follows:

•  Report all charges for these services and collections from patients as "self-pay" (line 13 of this table);

•  Report all amounts not collected from the patients as sliding discounts or bad debt write-off, as appropriate, on line 13 of this table; and

•  Report collections from the associated state and local indigent care programs on table 9E . State/local indigent care programs are now reported on a separate line (line 6a - "state/local indigent care programs") on that table.

Private - Lines 10 - 12. Grantees should report as " Private " all services billed to and paid for by commercial or private insurance companies. Specifically, do not include any services that fall into one of the other categories. As noted above, charges etc. for Medicaid, Medicare and S-CHIP programs which use commercial programs as intermediaries are classified elsewhere. Private insurance includes insurance purchased for public employees or retirees such as Tricare, Trigon, the Federal Employees Insurance Program, Workers Compensation, etc.

Self pay - Line 13. Grantees should report as " Self Pay " all services and charges where the responsible party is the patient, including charges for indigent care programs as discussed above. NOTE: This includes the reclassified co-payments, deductibles, and charges for uncovered services for otherwise insured individuals which become the patient's personal responsibility.

COLUMNS: CHARGES, PAYMENTS, AND ADJUSTMENTS RELATED TO SERVICES DELIVERED (Reported on a cash basis.)

Full Charges This Period (Column A) - Record in Column a the total charges for each payor source. This should always reflect the full charge (per the fee schedule) for services rendered to patients in that payor category. Charges should only be recorded for services that are billed to and covered in whole or in part by a payor, the patient, or written off to sliding fee discounts.

Example : Optometry charges should not be included in Medicare charges, since Medicare provides no coverage for these services. If a patient has both Medicare and Medicaid coverage, charges for optometry would be included in "Medicaid charges." If a patient has only Medicare coverage, charges for optometry would be entered under "self-pay."

Charges that are generally not billable or covered by traditional third-party payors should not be included on this table. For example, a charge for parking or for job training would not normally be included. WIC services are not billable charges. Charges for transportation and similar enabling services would not generally be included in Column a, except where the payor (e.g., Medicaid) accepts billing and pays for these services.

Charges for pharmaceuticals donated to the clinic or directly to a patient through the clinic should not be included since the clinic may not legally charge for these drugs. Charges for standard dispensed pharmaceuticals, however, are to be included.

Charges which are not accepted by a payor and which need to be reclassified (including deductibles and co-insurance) should be reversed as negative charges if your MIS system does not reclassify them automatically. Reclassifying these charges by utilizing an adjustment and rebilling to the proper category is an incorrect procedure since it will result in overstatement of both charges and adjustments.

NOTE: Under no circumstances should the amount paid by Medicaid or any other payor be used as the actual charges. Charges must come from the grantee's CPT based fee schedule.

Amount Collected This Period (Column B) - Record in Column b the amount of net receipts for the year on a cash basis, regardless of the period in which the paid for services were rendered. This includes the FQHC reconciliations, managed care pool distributions and other payments recorded in the columns C1, C2, C3, C4. Note: Charges and collections for deductibles and co-payments which are charged to and due from patients are recorded on Line 13.

Retroactive Settlements, Receipts, or Paybacks (Column C) - In addition to including them in Column B , details on cash receipts or payments for FQHC reconciliation, managed care pool distributions, payments from managed care withholds, and paybacks to FQHC or HMOs are reported in Column C.

Collection of Reconciliation/Wrap Around, Current Year (Column C1) - Enter FQHC cash receipts from Medicare and Medicaid that cover services provided during the current reporting period .

Collection of Reconciliation/Wrap Around, Previous Years (Column C2) - Enter FQHC cash receipts from Medicare and Medicaid that cover services provided during previous reporting periods .

Collection of Other Retroactive Payments Including Risk Pool/Incentive/Withhold (Column C3) - Enter other cash payments including managed care risk pool redistribution, incentives, and withholds, from any payor. These payments are only applicable to managed care plans. (Note: While table 9C includes co-payments in a similar data element, this column does not include co-payments. They are recorded on line 13 as self pay collections.)

Penalty/Payback (Column C4) - Enter payments made to FQHC payors because of overpayments collected earlier. Also enter payments made to managed care plans (e.g., for over-utilization of the inpatient or specialty pool funds).

NOTE : If a center arranges to have their "repayment" deducted from their monthly payment checks, the amount deducted should be shown in Column (C4) as if it had actually been paid.

Allowances (Column D) - Allowances are granted as part of an agreement with a third-party payor. Medicare and Medicaid, for example, may have a maximum amount they pay, and the center agrees to write off the difference between what they charge and what they receive. Allowances must be reduced by the net amount of retroactive settlements and receipts reported in the columns C1, C2, C3, C4, including current and prior year FQHC reconciliations, managed care pool distributions and other payments. This will often result in a negative number being reported as the allowance in Column D.

If Medicaid, Medicare, other third-party, and other public payors reimburse less than the grantee's full charge, and the grantee cannot bill the patient for the remainder, enter the remainder or reduction on the appropriate payor line in Column d at the time the Explanation of Benefits (EOB) is received and the amount is written off.

Example : The State Title XIX Agency has paid $40 for an office visit that was billed at a full charge of $75. The $75 should be reported on Line 1 Column A as a full charge to Medicaid. After payment was made, the $40 payment is recorded on Line 1 Column B. The $35 reduction is reported as an adjustment on Line 1 Column D.

Under FQHC programs, where the grantee is paid based on cost, it is possible that the cash payment will be greater than the charge. In this case, the adjustment recorded in Column d would be a negative adjustment. (Financial adjustments received under FQHC are reported in Columns C1 and C2)

NOTE : Amounts for which another third party or a private individual can be billed (e.g., amounts due from patients or "Medigap" payors for co-payments) are not considered adjustments and should be recorded or reclassified as full charges due from the secondary source of payment. These amounts will only be classified as adjustments when all sources of payment have been exhausted and further collection is not anticipated and/or possible.

Because capitated plans typically pay on a per-member per-month basis only, and make this payment in the current month of enrollment, these plans typically don't carry any receivables. For Capitated Plans (lines 2a, 5a, 8a, and 11a, ONLY! ) the allowance column should be the arithmetic difference between the charge recorded in Column A and the collection in Column B unless there were early or late capitation payments (received in a month other than when they were earned) and which span the beginning or end of the calendar year.

Also note that Line 13 Column D is blanked out because up-front allowances given to self-pay patients are recorded as sliding fee discounts and valid self-pay receivables that are not paid should be recorded as self pay bad debt.

Sliding Discounts (Column E) - In this column, enter reductions to patient charges based on the patient's ability to pay, as determined by the grantee's sliding discount schedule. This would include discounts to required co-payments, as applicable.

NOTE : Only self-pay patients may be granted a sliding discount based on their ability to pay. All other cells are blanked out. For this reason, "Column E" is a "virtual column" on the electronic version of the UDS, appearing below line 14 on the screen. When a charge originally made to a third party such as Medicare or a private insurance company has a co-payment or deductible written off, THE CHARGE MUST FIRST BE RECLASSIFIED TO SELF-PAY. TO RECLASSIFY, first reduce the third-party charge by the amount due from the patient and increase the self-pay charges by this same amount.

Bad Debt Write Off (Column F) - Any payor responsible for a bill may default on a payment due from it. In the UDS, only self pay bad debts are recorded. In order to keep responsible financial records, centers are required to write off bad debts on a routine basis. (It is recommended that this be done no less than annually). In some systems this is accomplished by posting an allowance for bad debts rather than actually writing off specific named accounts. Amounts removed from the center's self-pay receivables through either (but not both!) mechanism are recorded here.

Reductions of the net collectable amount for the Self-Pay category should be made on Line 13 column F. Bad debt write off may occur due to the grantee's inability to locate persons, a patient's refusal to pay, or a patient's inability to pay even after the sliding fee discount is granted.

Under no circumstances are bad debts to be reclassified as sliding discounts, even if the write off to bad debt is occasioned by a patient's inability to pay the remaining amount due. For example, a patient eligible for a sliding discount is supposed to pay 50 percent of full charges for a visit. If the patient does not pay, even if he or she later qualifies for a 100 percent discount, the amount written off must still be reported as bad debt, not sliding discount. At the time of the visit, it was a valid collectable from the patient.

Only bad-debts from patients are recorded on this table. While some insurance companies do, in fact, default on legitimate debts as they go bankrupt, centers are not asked to report these data. For this reason, "column F" is a "virtual column" on the electronic version of the UDS, appearing below line 14 on the screen.

Total Patient Related Income (Line 14) - Enter the sum of Lines 3, 6, 9, 12, and 13. Be sure to include only these "subtotal" lines and not the detail for each of the subtotals.

Questions and Answers for Table 9D

•  Are there any changes to this table?

There are no changes to Table 9D for 2007.

2. Are there any important issues to keep in mind for this table?

Payments received from state or local indigent care programs subsidizing services rendered to the uninsured are not reported on this table. All such payments, whether made on a per encounter basis or as a lump sum for services rendered, shall be recorded on Table 9E. See Table 9E for specific instructions. Grantees receiving payments from state/local indigent care programs that subsidize services rendered to the uninsured should:

•  Report all charges for these services and collections from patients as "self-pay" (Line 13);

•  Report all amounts not collected from the patient as sliding discounts or bad debt, as appropriate, on Line 13 of this table;

•  Report collections from the state/local indigent care programs on Table 9E . State/local indigent care programs are now to be reported as a separate category (Line 6a - state/local indigent care programs).

•  Are the data on this table cash or accrual based?

Table 9D is a 'cash' table in as much as all entries represent charges, collections, and adjustments recognized in the current year. All entries represent actual charges and adjustments for the calendar year and actual cash receipts for the year.

4. Should the lines of the table "balance"?

No. Because the table is on a 'cash' basis, the columns for amount collected and for allowances will include payments and adjustments for services rendered in the prior year. Conversely, some of the charges for the current year will be remaining in accounts receivable at the end of the year. The one exception is on the capitated lines (lines 2a, 5a, 8a, and 11a) where allowances are the difference between charges and collections by definition, provided there are no early or late capitation payments that cross the calendar year change.

5. If we have not received any reconciliation payments for the reporting period what do we show in Column C1 (current year reconciliations)?

If you have not received a check during this reporting period for current year services, enter zero (0) in Column C1.

6. We regularly apply our sliding discount program to write off the deductible portion of the Medicare charge for our certified low-income patients. The sliding discount column (Column E) is blanked out for Medicare. How do we record this write off?

The amount of the deductible needs to be removed from the charge column of the Medicare line (Lines 4 - 6 as appropriate) and then added into the self-pay line (Line 13). It can then be written off on Line 13. The same process would be used for any other co-payment or deductible write-off.

7. Our system does not automatically reclassify amounts due from other carriers or from the patient. Must we, for example, reclassify Medicare charges that become co-payments or Medicaid charges?

Yes - regardless of whether or not it is done automatically by your PMS the UDS report must reflect this reclassification of all charges that end up being the responsibility of a party other than the initial party.

Reporting Period: January 1, 2007 through December 31, 2007 OMB No. 0915-0193 Expiration Date:

TABLE 9D (Part I of II) -

PATIENT RELATED REVENUE (Scope of Project Only)

Reporting Period: January 1, 2006 through December 31, 2006                                                                  

TABLE 9D (Part II of II) -

PATIENT RELATED REVENUE (Scope of Project Only)