Section 1011: Undocumented Alien Funding for Emergency Care

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Section 1011 Undocumented Alien Funding for
Emergency Care

• Presented by
• American College of Emergency Physicians
• Florida College of Emergency Physicians
• Florida Hospital Association
• Georgia Hospital Association
• Martin Gottlieb Associates

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Part 1 How We Got Here

• Barbara Marone
• Director of Federal Affairs
• American College of Emergency Physicians

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Medicare Modernization Act of 2003 Sec.1011

• ? Provided a legislative vehicle for Sec.1011
  Federal Reimbursement for Emergency Health
  Services Furnished to Undocumented Aliens

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Medicare Modernization Act of 2003 Sec.1011

• Whats significant about Sec.1011?
• Provides 1 billion in funding over four years
  (FY05-08 - 250 million per year)
• Sets a precedent for recognition of uncompensated
  care

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Medicare Modernization Act of 2003 Sec.1011

• Demand is Growing for Emergency Services
• The U.S. Census Bureau estimated 45 million
  uninsured in 2003 The CDC estimates gt 114 million
  ED visits in 2003
• 15 are listed as self-pay (17 million visits)
• 20 are listed as Medicaid and SCHIP (23 million
  visits)

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Medicare Modernization Act of 2003 Sec.1011

• Deteriorating Financial Environment
• Kaiser Commission on Medicaid and the Uninsured
  reported that uncompensated care by hospitals
  grew from 6.1 billion in 1983 to 40.7 billion
  in 2004
• Approximately 35,000 physicians staff EDs
• CMS estimated that 55 of an emergency
  physicians time is spent providing uncompensated
  care
• The AMA estimated that emergency physicians
  provide close to 140,000 of uncompensated
  care each year

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Medicare Modernization Act of 2003 Sec.1011

• Support from Border States
• Hospital and emergency physicians groups
  pressure Congress
• Congressional Champions
• Sen. John Kyl (R-AZ)
• Rep. John Shadegg (R-AZ)

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Medicare Modernization Act of 2003 Sec.1011

• Delays in Program Startup
• 5 months into FY2005, Sen. Kyl questions CMS
  Administrator
• Final guidance released in May 2005

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Medicare Modernization Act of 2003 Sec.1011

• Is it Worth Your While to Participate?
• --CMS will monitor enrollment and expenditures
• --If demand outstrips supply a powerful
  message is sent to Congress

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Determining Eligibility for Covered Services

• Kathy Reep
• Vice President of Financial Services
• Florida Hospital Association

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Eligible Aliens

• Undocumented aliens
• No Green Card, work visa, or travel visa
• Paroled aliens brought to US for temporary period
  due to emergency
• Mexican citizens with laser visa for 72 hour
  access to US

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Determining Eligibility

• No requirement to ask patients directly about
  citizenship or immigration status
• Follow EMTALA rules for financial screening
• Excludes those eligible for Medicaid
• Social Security numbers must be validated
• Maintain documentation of validation

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Determining Eligibility

• Completion of provider payment determination form
• Maintain completed form as provider documentation
• Can use other forms as long as same information
  collected
• Physicians would have to collect and maintain
  patient eligibility information if hospital does
  not participate in 1011

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Determining Eligibility

• Photocopy any relevant documents
• Foreign birth certificate, foreign passport,
  foreign drivers license, expired visa, other
  foreign ID card

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Provider Payment Determination Form

• http//www.cms.hhs.gov/regulations/pra/default.asp
  

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Covered Services

• Otherwise unreimbursed costs of providing
  services under EMTALA to undocumented immigrants
• Services provided by hospitals, physicians, and
  ambulance providers/suppliers
• Excludes non-hospital FQHCs and non-physician
  practitioners
• Applies to services furnished on or after May 10,
  2005

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Covered Services

• Coverage begins when EMTALA obligation begins
• Typically when the patient arrives at the
  hospital emergency department
• Coverage continues until the patient is
  stabilized
• Whether in emergency department or inpatient bed

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Stabilization Defined

• Patients emergency condition must be resolved
• Underlying medical condition may still persist
• Per CMS, most patients stabilized within 2
  calendar days
• Claims covering two days or less will be accepted
  as covered
• Claims covering more than two days may be
  reviewed to determine stabilization

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Claims Submission

• Claims to be submitted electronically
• Must be submitted within 180 days of the end of
  the federal fiscal quarter in which the service
  was provided
• Payments for third quarter 2005 will be issued
  May 28, 2006
• CMS to establish appeals process for payment
  disputes

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FY 2005 State-Level Appropriations

• Florida 8.7 million
• Georgia 5.4 million
• Payment made from allotment for the state where
  the provider is located

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Payment for Services

• Payment base line set at Medicare rate
• For hospitals, DRG reduced to per diem up to full
  DRG
• Additional 10 percent of total approved
  outpatient services
• Covers those aliens who refuse or are unable to
  furnish information needed for eligibility
  determination

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Payment for Services

• Program allows for election by a hospital for a
  portion of on-call payments made to physicians
• Request available at
• http//www.cms.hhs.gov/forms/cms10130B.pdf

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Payment for Services

• Claims for a state accumulated and base line
  payments totaled
• Payment made for claims submitted
• Potential for pro rata reduction if amount due
  exceeds available funds in the state
• Pro rata reduction could vary from quarter to
  quarter and state to state

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First Quarter Calculation (Third Quarter 2005)

• Program effective for services rendered on or
  after May 10, 2005
• Quarter began April 1
• Contractor will calculate, for each provider,
  average covered amount per day from May 10
  through June 30
• Multiply above by days in the quarter to
  determine total first payment

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Designation of 1011 Contractor

• Functions to enroll providers, receive claims,
  calculate and distribute payments
• TrailBlazer announced as national contractor
• Currently serves as both fiscal intermediary and
  carrier
• Expects to accept payment requests by mid-October

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Designation of 1011 Contractor

• Designated Web site
• http//www.trailblazerhealth.com/section1011

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Participation and Enrollment

• Ken Engel
• Compliance Officer
• Martin Gottlieb and Associates

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Participation, Enrollment and Billing Issues

• Agenda
• Hospital Participation Election
• Provider Enrollment
• Billing Issues

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Hospitals Election

• Payment for hospital and physician services
• Payment for hospital and a portion of on-call
  payments made by the hospital for physician
  services

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Election 1 Payment for Hospital and Physician
Services

• All or none proposition
• No physician enrollment is necessary.
• Must submit separate bills for hospital and
  physician services.
• Hospital must pass on payments to physicians in a
  prompt manner at no administrative cost to the
  physician.

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Election 2 Payment for Hospital and Portion of
On-Call Payments

• Hospital will bill for reimbursement of its
  services and any fees it pays to retain on-call
  physicians.
• Physicians must enroll and bill separately for
  their reimbursement.
• Hospital should provide patient eligibility
  information to physicians within 120 days.

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Election 3 No Hospital Participation

• The election of choice for many hospitals
• The unwillingness of a hospital to participate
  will make physician participation difficult.

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Communication with Hospital

• Inquire if the hospitals administrative staff is
  aware of section 1011 reimbursement and establish
  a dialogue.
• Determine the election of the hospital.
• Discuss how the undocumented aliens eligibility
  will be verified, documented and obtained by you.

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Provider Enrollment

• Each provider must submit both a paper and an
  electronic enrollment application to the CMS
  designated carrier.
• Same enrollment application used for hospital,
  physicians, and ambulance providers.
• Physician enrollment individual or group?
• Medicare enrolled versus not enrolled?

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Billing Issues

• Payment Methodology
• Electronic Filing
• Appeal Process

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Payment Methodology

• Section 1011 payments are truly payments of last
  resort.
• Medicaid (section 1011 for only deductible,
  coinsurance or copayment)
• Homeland Security (paid in full-no balance
  billing)
• Workers Compensation (subject to state law-may
  be balance billed)
• Only section 1011 (patient may be balance billed)
• Subsequent third party payment-notify carrier
• Grants and gifts will not be considered.
• Quarterly payments will be issued from carrier.
• Bill-specific payment methodology following
  Medicare rules.

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Electronic Filing

• Electronic filing of claims is required
• X12N 837 version 410A1
• Must be filed within 180 days of end of FY
  quarter
• Electronic payments will be routed directly into
  groups lockbox

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Appeal Process

• Informal appeal process
• No claim adjustments
• Overpayments must be repaid or future payments
  will be withheld

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Question and Answer

• Barbara Marone
• Kathy Reep
• Ken Engel