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
1.
Are there any changes to
this table?
There
are no changes to Table 9D for 2008.
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).
3.
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.
Payor Category
|
Full Charges This Period
(a)
|
Amount Collected This
Period
(b)
|
Retroactive Settlements,
Receipts, and Paybacks (c)
|
Allowances
(d)
|
Sliding Discounts
(e)
|
Bad Debt Write Off
(f)
|
Collection of
reconciliation/wrap around Current Year
(c1)
|
Collection of
Reconciliation/wrap around Previous Years
(c2)
|
Collection of other
retroactive payments including risk pool/ incentive/ withhold
(c3)
|
Penalty/ Payback
(c4)
|
1.
|
Medicaid
Non-Managed Care
|
|
|
|
|
|
|
|
|
|
2a.
|
Medicaid
Managed Care (capitated)
|
|
|
|
|
|
|
|
|
|
2b.
|
Medicaid
Managed Care (fee-for-service)
|
|
|
|
|
|
|
|
|
|
3.
|
Total Medicaid
(Lines 1+ 2a + 2b)
|
|
|
|
|
|
|
|
|
|
4.
|
Medicare
Non-Managed Care
|
|
|
|
|
|
|
|
|
|
5a.
|
Medicare
Managed Care (capitated)
|
|
|
|
|
|
|
|
|
|
5b.
|
Medicare Managed Care (fee-for-service)
|
|
|
|
|
|
|
|
|
|
6.
|
Total Medicare
(Lines 4 + 5a+ 5b)
|
|
|
|
|
|
|
|
|
|
7.
|
Other
Public including Non-Medicaid CHIP (Non Managed Care)
|
|
|
|
|
|
|
|
|
|
8a.
|
Other
Public including Non-Medicaid CHIP (Managed Care Capitated)
|
|
|
|
|
|
|
|
|
|
Payor Category
|
Full Charges This Period
(a)
|
Amount Collected This Period
(b)
|
Retroactive Settlements,
Receipts, and Paybacks (c)
|
Allowances
(d)
|
Sliding Discounts
(e)
|
Bad Debt Write Off
(f)
|
Collection of
reconciliation/wrap around Current Year
(c1)
|
Collection of
Reconciliation/wrap around Previous Years
(c2)
|
Collection of other
retroactive payments including risk pool/ incentive/ withhold
(c3)
|
Penalty/ Payback
(c4)
|
8b.
|
Other
Public including Non-Medicaid CHIP (Managed Care fee-for-service)
|
|
|
|
|
|
|
|
|
|
9.
|
Total Other Public
(Lines 7+ 8a +8b)
|
|
|
|
|
|
|
|
|
|
10.
|
Private
Non-Managed Care
|
|
|
|
|
|
|
|
|
|
11a.
|
Private
Managed Care (capitated)
|
|
|
|
|
|
|
|
|
|
11b.
|
Private
Managed Care (fee-for-service)
|
|
|
|
|
|
|
|
|
|
12.
|
Total Private
(Lines 10 + 11a + 11b)
|
|
|
|
|
|
|
|
|
|
13.
|
Self
Pay
|
|
|
|
|
|
|
|
|
|
14.
|
TOTAL
(Lines 3 + 6 + 9 + 12 + 13)
|
|
|
|
|
|
|
|
|
|
|