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Hospital receipt format for Operations

welcome my name is gary kaufman i want to thank you for watching this webcast on critical access hospital we're going to talk about reimbursement with us for this webcast is mr david passetti who's the senior executive for critical access hospital before we dive into the questions maybe we should just take a step back and and define what a critical access hospital is the critical access hospital programs were started in the late 1990s and last time i looked there were over 1300 critical access hospitals in 45 states so they're everywhere but a lot of respiratory therapists may not know about them because they work in the traditional you know larger acute care hospital so dave let's start the conversation can you tell us what is a critical access hospital uh critical access hospital critical access is a federal designation um generally for smaller hospitals that are geographically removed from uh other hospitals or or bigger hospitals there's certain um levels of confinement that come with that in that you can only have up to 25 beds um the average length of stay while that's currently under waiver due to covid normally would be 96 hours you have to have a relationship with the tertiary care center and generally they're they're they're kind of known as as rural hospitals they're they're they have to be geographically positioned so far away from other hospitals so in our case uh you know we're positioned between uh two uh kind of metropolitan areas that are that are a fair distance away uh it sounds like critical access hospitals play a very valuable role and at the kind of a niche role that provides much better access to folks particularly in the more rural areas let's talk about hospital reimbursement how are critical access hospitals reimbursed and and if you just talk a little bit about is it different by the different payers whether it be medicare or medicaid or commercial insurance yeah it's totally different the the payment platform um through through medicare is all cost based it's all based on an annual cost report that you know is usually done by the cfo of the company um and the the medicare payment for inpatient care is based on a per diem rate that's established through the cost report uh medicaid a little bit different uh method in our state you know it's supposed to be cost based but the actual payment is not cost based and that's sort of reimbursed by an annual wraparound payment that comes once a year that's supposed to make up that difference or that gap between what you got paid and what the cost to provide that care was and then does commercial insurance or or private insurance that they play a role in your reimbursement uh certainly we you know we take care of patients that have commercial insurances and they're largely based on contract just like they would be in other facilities and they're all a little bit different um you know unfortunately it seems sometimes you know because there's very little leverage from a small hospital with an insurance company the contracts are not always so favorable for uh for critical access hospitals when it comes to the commercial insurances so you know i sometimes feel like we get a little bit penalized not you know not having that quote unquote big stat big corporate status with the insurances dave you mentioned that medicare is a cost plus model medic medicaid is a different model and then you said there's all kind of different contracts with commercials or private is there any one particular type of methodology for reimbursement is that capitated cost plus charge for the commercials they're they're all a little different there are to my knowledge there are none that we no commercials that we have away from medicare advantage plans you know which are commercialized but the other commercial products as far as i know we have none that are cost based reimbursement they're all they're all individual contracts um they quite often unfortunately there are some that never cover the costs um so the answer to that is is largely no no cost based commercials you mentioned this is how reimbursement is today it's different from medicare medicaid and maybe many different ways for private insurance are you anticipating or have there been any announcements for changes for critical access hospital reimbursement um in our state there's there's been a shift to attempt to go to a global payment system um and we were one of the pilot hospitals in our state uh where by the payment platform especially it started out with medicare and medicaid were flattened out if you will they took a a look basically like a three-year rewind looking at your volumes and your payments so on and basically what they've done is they've flattened out our payments so we received a monthly payment from medicare um 112 each month for for the amount that we should be receiving throughout the year it stops the peaks and valleys of the reimbursement that are sometimes a hardship to critical access hospitals now we talked about reimbursement at the global hospital level how is that at the department level whether that be lab or imaging or in our case respiratory therapy do the rts or the rt department bill or charge and does that play a role into your actual final reimbursement yeah like with with medicare everything is cost based so you know those doesn't matter what the service might be it all rolls into the overall cost to take care of an inpatient for you know by the day and we do get a per diem rate based on that and all those costs all those applicable costs whether they be respiratory therapy or physical therapy or occupational therapy or nursing service so on that that all rolls into that cost that you know the the the respiratory therapy in in those a lot of critical access hospitals is done a little bit differently than it is in big hospitals and that some some cause or critical access hospitals don't even have a respiratory department per se um you know it's mostly run by nurses and some of the smaller ones and we're one of those dave you mentioned that the medicare medicaid and commercials pay in different or many different ways for labor supplies pharmaceuticals etc but what about capital equipment are you able to get reimbursement for on a depreciation scale for the use of ventilators or bi-level or high flow systems it is run through depreciation scale um you know basically it it's it's more difficult for cause in general to and you know do large capital projects through you know of equipment or improvements to a facility for that matter just because you know it's uh you're you're paying for it up front it takes a long time to recover that through a cost-based depreciated scale okay now i want to circle back to something else you said it just struck me let's say a breathing treatment you can reimburse for the labor and for the pharmaceuticals what about the disposable costs does that all go into that uh total cost basis whether it be a vent circuit or a humidifier high flow or even a nasal cannula for that matter yeah it does that all goes into the costs it's not it's not nothing is reimbursed you know by the item on this uh cost-based reimbursement model it's it basically it's all the costs you know in speaking overly simple you take all those costs and divide it by patient days and you get the cost to take care take care of a patient per day and that's where the per diem rate essentially comes from for the medicare and the reason the reason that strikes me as important is that far too frequently we hear from respiratory therapists i'm not permitted to utilize the best device supply item protocol whatever because it's more costly and with a few exceptions like hospital acquired conditions where you might select a soft cannula over a hard canva to avoid the hack if there's a lot of pushback from that that kind of leads me in the next question do critical access hospitals receive higher reimbursement for one therapy over another and does this vary by the different payers yeah as go say again referring to medicare everything would roll into cost all those services and supplies and pharmaceuticals and so on would roll into the cost when you get into the commercial payers for us again it's very very contract dependent and some of them are certainly a little bit more friendly than others um you know based on on codes and so on what is going to be reimbursed and what is not and i certainly can sympathize with what you're saying that there are certain things that are not reimbursable and you know makes it makes it tough to use a supply that is very very expensive when you know there's going to be no reimbursement for it and many times you know we don't even know you know like the the end user the nurse or the doctor making the order they certainly many times have no idea knowing if a supply or a service is reimbursable when they order it so basically we usually just do what's best for the patient based on the physician order and sometimes we suffer on the back end with reimbursements bye