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DSH COMPONENT - MEDICARE SSI PERCENTAGE

 

The two components that make up the Medicare Disproportionate Share Hospital (DSH) reimbursement amount are the Medicaid Percentage of total days and the Supplemental Security Income (SSI) Percentage. 

 

After many years of appeal and litigation, we arrived at our current state for the Medicaid percentage component, where a provider has to prove eligibility in order for the days to be part of the calculation.  


 

SSI PERCENTAGE

 

One component of the DSH calculation, SSI Percentage, is enthralled in various appeals and litigation. Presently, hospitals are required to rely on the SSI fraction of the DSH formula that is provided to them by the Centers for Medicare and Medicaid Services (CMS).  However, the detail of how CMS determines the SSI Percentage that considerably dictates a hospital’s reimbursement is not readily available to the hospital. Basically, it would be as if the hospital submitted their Medicaid days and told the fiscal intermediary/CMS to just accept it.

 

However, based upon recent favorable court decisions and if hospitals appeal, CMS will release their supporting documentation. Therefore, hospitals will have the ability to review and challenge the accuracy of the SSI fraction used in the calculation of their Medicare DSH payments.

 

 

Hall Consulting Services (HCS) has reviewed CMS’s SSI data for many of our clients, and we have identified numerous errors such as:

  • Unidentified Medicare beneficiaries who have exhausted their Part-A coverage

  • Varied treatment of Medicare beneficiaries who are covered under Medicare Part-C

  • Medicare Part-A beneficiaries in the SSI Percentage who are not included on the Medicare PS&R

  • Medicare beneficiaries who are receiving SSI benefits but are not treated as such in the SSI Percentage

  • The use of incorrect health insurance claim numbers for matching SSI recipients

  • The total Medicare days reported in the denominator of the SSI ratio are often under reported

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    For all hospitals, this involves a significant amount of additional Medicare DSH reimbursement, and relates to any cost reporting period that is subject to a reopening or has a PRRB appeal. If a provider has an appeal before the PRRB, it may request the detailed SSI Percentage information from CMS. 

     

    Once HCS receives CMS’s SSI Percentage information along with other provider and Medicare information, we will perform all the necessary work to re-calculate the provider’s SSI Percentage.

     

     

     

    Back to Medicare Disproportionate Share Hospital Analysis