Archive for the ‘Employment Records’ Category

Patients that have similar clinical characteristics and similar costs are assigned to an MS-DRG. The MS-DRG will be associated with a fixed payment amount based on the average cost of patients in the group. Patients are assigned to a MS-DRG based on diagnosis, surgical procedures, age and other information. Medicare uses this information that is provided by hospitals on their bill to decide how much they should be paid. Hospital Compare shows information for each hospital on selected MS-DRGs from October 2007 through September 2008. If a MS-DRG has “Complications” or “Comorbidities” in its title, it means the hospital may have treated more complicated patients.

Because MS-DRGs are highly technical, patients and other consumers may need to work with a doctor or other healthcare provider to understand these terms as well as the payment and volume information. ‘CC’ refers to complications or comorbidities. MCC refers to major complications or comorbidities. When Medicare pays a hospital based on the MS-DRG, it takes into account the following (case mix):

  • How bad the illness is or if the patient dies (severity of illness)
  • How likely it is that the patient will get better or get worse (prognosis)
  • What would happen if the patient does not receive immediate or continuing care (need for intervention)
  • How much and what type of service the hospital needed to provide, such as lab work, X-rays or physical therapy (resource intensity)

The payment and volume information is for acute care hospitals. “Critical access hospitals (CAH)”, “Acute Care – VA Medical Centers” and “Children’s Hospitals” are not included because they are paid using another method.

Median Medicare Payments

Median Medicare payments for the same MS-DRG can vary. The median payment refers to the midpoint of all payments to the hospital for a particular MS-DRG, that is, half the payments were lower and half the payments were higher than the median payment. A hospital can get a higher payment for any or all of the following reasons:

  • It is classified as a teaching hospital
  • It treats a high percentage of low-income patients (disproportionate share)
  • It may treat unusually expensive cases (outlier payments)
  • It pays its employees more compared to the national average because the hospital is in a high-cost area (wage index). Note: The hospital’s wage index is calculated using the hospital’s payroll records, contracts and other wage related documentation

Range of Payments 25th – 75th Percentile

Hospital Compare lets you compare the hospitals you select with other hospitals in your state and in the nation. The state and national amounts are shown as a range of payments (between the 25th percentile and the 75th percentile). This is the range of payments for the most typical cases treated for the MS-DRG. The information doesn’t include unusually low payments for cases, such as when a patient was transferred to another facility before being fully treated. It also doesn’t include unusually high payments for cases that are more complex and costly to treat. Only one number appears in this field when the 25th and 75th percentiles are the same.

Source :

NEW JERSEY: In the final days of the 2009 session, the legislature passed a bill requiring managed care organizations to remit direct payments to out-of-network providers. Aetna, along with the business community, trade unions and other health plans, unsuccessfully opposed this legislation. Despite this setback, the chairman and members of the committee found arguments concerning egregious out-of-network reimbursement and network deterioration sufficiently compelling to commit to drafting legislation addressing this issue in the 2010 session. 

The legislation was amended to delay its effective date for 12 months and provide carriers the option of issuing a check requiring dual endorsement. Also, the Assembly took up legislation requiring ambulatory surgical centers to report clinical and financial data to the state. Similar legislation passed unanimously in the Senate.

A Medigap policy is health insurance sold by private insurance companies to fill the “gaps” in Original Medicare Plan coverage. Medigap policies help pay some of the health care costs that the Original Medicare Plan doesn’t cover. If you are in the Original Medicare Plan and have a Medigap policy, then Medicare and your Medigap policy will pay both their shares of covered health care costs.

Insurance companies can only sell you a “standardized” Medigap policy. These Medigap policies must all have specific benefits so you can compare them easily.

You may be able to choose up to 12 different standardized Medigap policies (Medigap Plans A through L). Medigap policies must follow Federal and State laws. These laws protect you. A Medigap policy must be clearly identified on the cover as “Medicare Supplement Insurance.” Each plan, A through L, has a different set of basic and extra benefits.

It’s important to compare Medigap policies because costs can vary. The benefits in any Medigap Plan A through L are the same for any insurance company. Each insurance company decides which Medigap policies it wants to sell.

Generally, when you buy a Medigap policy you must have Medicare Part A and Part B. You will have to pay the monthly Medicare Part B premium. In addition, you will have to pay a premium to the Medigap insurance company.

You and your spouse must each buy separate Medigap policies. Your Medigap policy won’t cover any health care costs for your spouse.

For additional information on Medigap policies, including why you would want to buy a Medigap policy and information about what Medigap policies cover, please read our publication, Choosing a Medigap Policy: A Guide to Health Insurance for People with Medicare.

On February 17, 2009, President Obama signed the American Recovery and Reinvestment Act (ARRA), which delayed the phase-out of the hospice wage index budget neutrality adjustment factor (BNAF) for FY 2009. Therefore we are posting a revised copy of the FY 2009 wage index (see Downloads section below), which includes a full (unreduced) BNAF. Please also see CR 6418 (Transmittal 1701, dated March 13, 2009 ) (see Downloads section below) for more information on the revision to the FY 2009 wage index.


According to Section 1861 (dd) of the Social Security Act, the term “hospice care” means the following items and services provided to a terminally ill individual by, or by others under arrangements made by, a hospice program under a written plan (for providing such care to such individual) established and periodically reviewed by the individual’s attending physician and by the medical director (and by the interdisciplinary group described in paragraph (2)(B)) of the program—

(A) nursing care provided by or under the supervision of a registered professional nurse,

(B) physical or occupational therapy, or speech-language pathology services,

(C) medical social services under the direction of a physician,

(D)(i) services of a home health aide who has successfully completed a training program approved by the Secretary and

(ii) homemaker services,

(E) medical supplies (including drugs and biologicals) and the use of medical appliances, while under such a plan,

(F) physicians’ services,

(G) short-term inpatient care (including both respite care and procedures necessary for pain control and acute and chronic symptom management) in an inpatient facility meeting such conditions as the Secretary determines to be appropriate to provide such care, but such respite care may be provided only on an intermittent, nonroutine, and occasional basis and may not be provided consecutively over longer than five days,

(H) counseling (including dietary counseling) with respect to care of the terminally ill individual and adjustment to his death, and

(I) any other item or service which is specified in the plan and for which payment may otherwise be made under this title.

The care and services described in subparagraphs (A) and (D) may be provided on a 24-hour, continuous basis only during periods of crisis (meeting criteria established by the Secretary) and only as necessary to maintain the terminally ill individual at home.

Manufacturer reporting of Average Sales Price (ASP) data: A manufacturer’s ASP must be calculated by the manufacturer every calendar quarter and submitted to CMS within 30 days of the close of the quarter.  Each report must be certified by one of the following: the manufacturer’s Chief Executive Officer (CEO); the manufacturer’s Chief Financial Officer (CFO); an individual who has delegated authority to sign for, and who reports directly to, the manufacturer’s CEO or CFO.

Manufacturers must report the ASP data to us in Microsoft Excel using the template provided in Addendum A, the ASP Data Form.  Both this and the ASP Certification Form (Addendum B), are available in the ‘Downloads’ section below.

When sending ASP data to CMS via first class mail, federal express mail, or overnight delivery, please use the following address:

Centers for Medicare & Medicaid Services
Hospital and Ambulatory Policy Group
Division of Ambulatory Services
ATTN: Medicare ASP Data
Mail Stop No. C4-01-26
7500 Security Boulevard
Baltimore, MD 21244
Phone: 410-786-0548

Please send any questions to:

Medicare Contractor Reporting Template for Medicare Part B Drugs – (Located in the “Downloads” section below)

As indicated in CR 4140, dated February 15, 2006, Medicare contractors shall use the Medicare Contractor Reporting Template for Part B drugs to report information on all Medicare Part B drugs not paid on a cost or prospective payment basis when payment limits are not listed in the quarterly drug pricing files, or in the OPPS Pricer. Contractors shall also use the template to report pricing information for the NOC drug billing codes. This information must be sent to CMS on a monthly basis to e-mail address:

New Information Regarding Medicare Payment and Coding for Drugs and Biologics (See Downloads section below for the message)

Section 303(c) of the Medicare Modernization Act of 2003 (MMA) revised the payment methodology for Part B covered drugs that are not paid on a cost or prospective payment basis. In particular, section 303(c) of the MMA amended Title XVIII of the Act by adding section 1847A, which established a new average sales price (ASP) drug payment system.  Beginning January 1, 2005, drugs and biologicals not paid on a cost or prospective payment basis will be paid based on the ASP methodology, and payment to the providers will be 106 percent of the ASP.  There are exceptions to this general rule which are listed in the latest ASP quarterly change request (CR) document.  The ASP methodology uses quarterly drug pricing data submitted to the CMS by drug manufacturers.  CMS will supply contractors with the ASP drug pricing files for Medicare Part B drugs on a quarterly basis.

What if my card is lost or stolen?

You can replace your card or your child’s card for free if it is lost or stolen. However, you are limited to three replacement cards in a year and 10 during your lifetime. Legal name changes and other exceptions do not count toward these limits. For example, changes in non citizen status that require card updates may not count toward these limits.

Also, you may not be affected by these limits if you can prove you need the card to prevent a significant hardship.

To get a replacement card, you will need to:

  • Complete an Application For A Social Security Card (Form SS-5);
  • Present a recently issued document to show your identity;
  • Show evidence of your U.S. citizenship if you were born outside the United States and did not show proof of citizenship when you got your card; and
  • Show evidence of your current lawful non-citizen status if you are not a U.S. citizen.

Your replacement card will have the same name and number as your previous card.

What if my immigration status or citizenship changed?

If your immigration status changed or you became a U.S. citizen, you should tell Social Security so your records can be updated. To get your immigration status or citizenship corrected, you need to show documents that prove your new status or citizenship.

Double Check Your Documents

Only certain documents can be accepted as proof of citizenship for new and replacement cards. These include your U.S. passport, a Certificate of Naturalization or a Certificate of Citizenship. If you are not a U.S. citizen, Social Security they ask to see your current immigration documents.

How do I make sure my records are accurate?

Each year your employer sends a copy of your W-2 (Wage and Tax Statement) to Social Security. They compare your name and Social Security number on the W-2 with the information in their files. They add the earnings shown on the W-2 to your Social Security record.

It is critical that your name and Social Security number on your Social Security card agree with your employer’s payroll records and W-2 so that they can credit your earnings to your record. It is up to you to make sure that both Social Security’s records and your employer’s records are correct. If your Social Security card is incorrect, contact any Social Security office to make changes. Check your W-2 form to make sure your employer’s record is correct and, if it is not, give your employer the accurate information.

Over Age 25 and Not Receiving Benefits

If you are a worker age 25 and older and not receiving benefits, you receive a Social Security Statement every year that summarizes your earnings. Review this Statement to make sure that all your earnings are included. If your Statement does not include all your earnings, let your employer and your Social Security office know about any incorrect information.

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