Worksheet S-10 UCC reporting questions
Can you provide additional explanation for what’s meant by an inferred contractual relationship and how this affects reporting charity related to patients who are covered by an insurance that doesn’t have a contractual relationship with the hospital?
When a provider accepts an amount from an insurer as payment, or partial payment, on behalf of an insured patient this will constitute an inferred contractual relationship. Write-offs for these patients will now be claimed in Line 20, Column 2.
If the write-off is associated with coinsurance, deductible, or copay those won’t be subject to the CCR. If the write-off is associated with non-covered amounts, those will be recorded also in Line 25.01 and subject to the CCR.
What are some example amounts that would be reported on Worksheet S-10, Line 25.01 since non-covered charges for Medicaid or indigent care programs and also patients with a non-contracted payer are reported on Worksheet S-10, Line 20, Column one? Is this the place to report charity related to non-covered charges for commercial insurance, as opposed to Medicaid or indigent care programs, assuming that the financial assistance policy (FAP) allows for charity in this circumstance?
With the new instructions, there will be no more non-contracted payers. If there’s a payment, it will constitute an inferred contractual relationship. Yes, 25.01 will be for non-covered non-Medicaid charity write-offs. Medicaid non-covered will still be reported in Line 20, column 1. Medicaid exhausted limit or length of stay (LOS) limit will still be reported on Line 25.
Does the charity have to be written off to a charity general ledger (GL) account?
There’s no requirement that the charity recorded on Worksheet S-10 has to be written off to a charity GL account. The requirement is that the charity amounts recorded on S-10, Line 20 are written off in accordance with the hospital’s written financial assistance policy or uninsured discount policy.
During the audit, providers will be asked to reconcile the charity GL to the amounts recorded on Worksheet S-10 so in instances where there is charity recorded on S-10 not written off to the charity GL, that information needs to be well documented so that you can support those categories of charity at audit.
What type of charity discounts can be claimed on S-10?
Transmittal 18 includes language requiring charity discounts claimed on S-10 be for medically necessary healthcare services. This will require identifying any discounts that aren’t eligible when compiling charity logs.
Is revenue code detail no longer required for each account?
These templates don’t require revenue code detail, but depending on the hospital’s patient financial system, revenue code detail may be necessary to identify and exclude the professional charges from the charity and bad debt reported on Worksheet S-10. Past audit requests have required revenue code details if the hospital charges and professional charges are commingled on the same system. If those charges are in two different systems, than revenue code detail hasn’t been required.
It’s also important to point out that revenue code detail may also need to be used to complete the new Part II section of Worksheet S-10 as again, depending on your system and how accounts transfer between units, this revenue code detail may be necessary to separate hospital versus sub-acute charges versus professional fee charges. All this adds another layer of complexity to these new templates.
Exhibit 3B includes a write-off date field. Is it a correct assumption that multiple adjustments to a single account will require reporting on separate lines? For example, initial qualification for 50% charity is updated to 90% when more data is received from the patient, which results in two charity postings to one account.
Every Medicare Administrative Contractor (MAC) for audit purposes requires only one account or row for each charity or bad debt write-off. However, as noted in this question, there’s only one write-off date field in the template.
For audits, it’s recommended to provide a supplemental listing that includes all write-offs for that year so the MAC can see if there are multiple write-offs for one account, and we consider this the best approach rather than separating the patient into two rows. If further clarification from CMS or the MACs is provided, we will update this answer accordingly.
Exhibit 3B doesn’t appear to account for open accounts receivable (AR) balances or any credit balance not yet resolved. Is that correct?
Correct, this is where additional information or fields may be helpful to understand each account. It will be interesting to see if MACs at the end of the day take these reports and use them in their S-10 audits or if they’ll request their own auditor’s template that in some cases requires more fields or for the fields to be shown a different way.
Exhibits for charity and bad debt include a lot of patient health information (PHI). Will CMS exclude these exhibits from the electronic cost report (ECR)? Seems like these should be submitted securely via their portal instead.
How the supplemental exhibits are submitted right now in cost reports seems unclear and neither CMS nor MACs have provided clarification. Several providers have addressed the massive amounts of data these exhibits require and if there’s been any thought on different submission alternatives for these templates.
Exhibits 3B and 3C show component CMS certification number (CCN) lines. Do you need a separate exhibit or listing for each sub-provider?
Per the instructions, the answer is yes. Each separate CCN would require its own exhibit. In the charity template instructions, the need for separate exhibits is implied as you’re expected to enter the component CCN value in the header of the exhibit if you have charity for that component so this would require you to separate the hospital CCN accounts from the other CCN accounts.
The bad debt instructions are clearer in that they state, “Complete a separate exhibit for the hospital and each component of the hospital complex (each CCN) and, on each listing, report only the data related to inpatient and outpatient services billed under that CCN.”
Does the new template for total bad debt require or permit consistency with the timing of Medicare bad debt when an outside collection agency is used (when returned instead of when sent)?
The answer depends on when accounts are written off the active Arkansas and placed in bad debt. As seen through the S-10 audits and their bad debt reconciliation templates, MACs are expecting the hospitals to claim total bad debt based on when the account was written off active Arkansas and transferred to bad debt.
This may not necessarily be the same timeline of when a bad debt is returned from the collection agency so you may have different timing with respect to write-off date from a Medicare bad debt versus a non-Medicare bad debt. This inconsistency in timing of claiming the write-off between non-Medicare and Medicare is the product of the S-10 instructions and we don’t expect this to change with the new template.
Does the change in the total bad debt template (Exhibit 3C) affect critical access hospitals, or just DSH?
Critical access hospitals aren’t required to complete the template. The template is only required for IPPS hospitals eligible for DSH and UCC.
Can you report an account on bad debt (Exhibit 3C) and charity care log (Exhibit 3B)?
A provider can report the same account in bad debt and the charity care log as long as they aren’t for the same charges. For example, an account may receive an uninsured discount for a portion of their charges and the remaining amount may be written off to bad debt at a later date. These accounts would then both be included in their respective template.
