Ask For Permission, Not Forgiveness

ask-2341784_1920The expression “It is easier to ask forgiveness than it is to get permission” is attributed to Rear Admiral Grace Murray Hopper. She was a U.S. Naval officer and an early computer programmer who, in 1949, recommended a new programming language be developed using entirely English words. She was told she couldn’t do this because computers didn’t understand English. She did not accept this idea and started work on the process, which later become COBOL, which is the major language used in data processing today.

This tactic is not the one you should use if you are wanting to change the allocation basis on your Medicare cost report. The Centers for Medicare and Medicaid Services (CMS) has a set of standard statistics they have approved for use to allocate expenses on the Medicare cost report. If you decide you want to change the order or use a different statistic, this is permissible but CMS has specific instructions on how and when this is allowed. If you make a change without this request, you are at risk of having your cost report rejected.

Tip #36:

A request to change cost finding methods must be made in writing and submitted to the intermediary 90 days prior to the end of the cost reporting period to which the request for change applies (CMS Pub 15-1, Section 2313).

Further guidance can be found on the CMS website: Provider Reimbursement Manual 15-1

Questions? Please contact Marie White at 612.253.6546 or

“Summertime and the Livin’ is Easy” – Except Unexpected ER Visits

George Gershwin wrote the lyrics “Summertime and the livin’ is easy” in 1934 for the opera “Porgy and Bess.” But summer time generally means extended periods of time spent outdoors which can present ample opportunities to sustain injuries (or hurt others). It is not surprising that Emergency Room visits spike during the summer months. From the first signs of the days getting longer until school is back in session visits to the ER increase by 15 to 27 percent.1 So while the livin’ should be easy, it brings new meaning to the sentiment of enjoying careless summer days when they’re spent in an emergency room.

Hospitals ready for this potential influx of patients by increasing staff, but often it is done through the more flexible route of “on call.” Staff who are on call are paid a flat rate per hour to be available if called to come into work. CMS recognizes the need to have physicians available and in limited circumstances, hospitals can claim this on-call time as allowable expense on the Medicare cost report.

Tip #35:

Time studies are needed to support Emergency Physicians Availability and On-Call Time (Pub. 15-1, §Section 2109).

Further guidance can be found on the Centers for Medicare and Medicaid Services (CMS) website:

Provider Reimbursement Manual 15-1

Questions? Please contact Marie White at 612.253.6546 or


1 ER Visits Peak during the Summer Months, By James Baker, MD, Kaiser Permanente Baldwin Park, California

Exception-al CRNAs: Sometimes the Sole Provider in Rural Areas

According to the American Association of Nurse Anesthetists, nurse anesthetists are the oldest nurse specialty group in the United States and have been providing anesthesia care to patients in the United States for more than 150 years. The CRNA (Certified Registered Nurse Anesthetist) credential came into existence in 1956.

CRNAs are the primary providers of anesthesia care in rural America, enabling health care facilities in these medically underserved areas to offer obstetrical, surgical, pain management and trauma stabilization services. In some states, CRNAs are the sole providers in nearly 100 percent of the rural hospitals.[1]

The services of a non-physician anesthetist (CRNA) generally are paid for by the Part B contractor based on a fee schedule rather than on reasonable cost basis through the cost report.

But for some qualified rural hospitals or Critical Access Hospitals, a request can be made on an annual basis for an exception if the facility employed or contracted with not more than one FTE (2080 hours) non-physician anesthetist. There is also a threshold of 800 or fewer surgical procedures requiring anesthesia services and there can be no professional fee billing for the CRNA.

Tip #33:

Rural and Critical Access hospitals can request an exception to the CRNA Fee schedule if they meet certain criteria (CMS Pub 15-2, Section 4013). Further guidance can be found on the Centers for Medicare and Medicaid Services (CMS) website:

Provider Reimbursement Manual 15-2, Chapter 40

Questions? Please contact Marie White at 612.253.6546 or

[1] American Association of Nurse Anesthetists, “Certified Registered Nurse Anesthetists Fact Sheet.”

How to Apply Your Memory Skills in the Matching Game to Cost Reports

From a very early age, the importance of memory and matching is taught, especially through the use of games such as “Concentration.” The game involved flipping over two cards and trying to find a match. If there were no matches, you flipped the cards back down and it was someone else’s turn or you tried two other cards. The simplest versions had pictures of objects and the more complicated might have numbers, words, colors or some combination.

For Medicare cost reporting, the concept of matching is applied to clinical items or services. In preparing your cost report, the expectation is that clinical service expenses, revenues, and associated statistics will be disclosed on the same cost center (or line).

The importance of this is not widely known, but the Centers for Medicare and Medicaid Services (CMS) does use the cost report and related patient claims to develop standard payment rates for inpatient and outpatient services, as well as other reimbursement related items such as outlier adjustments and various indices.

Tip #30:

Ensure costs, charges and statistics are properly matched across the entirety of the cost report worksheets (CMS Pub 15-1, Section 2203).

Further guidance can be found on the Centers for Medicare and Medicaid Services (CMS) website:

Provider Reimbursement Manual 15-1

Questions? Please contact Marie White at 612.253.6546 or


From Maps to Apps: Advertising Public Info on Hospital May Be an Allowable Cost

Many years ago, the only real way to find your way from one city to another was to use a paper road map that had to be unfolded (and, of course, never folded back up the original way).

Today there are many options to help you navigate from websites such as MapQuest and Google Maps, stand-alone GPS units, and smart phone apps such as Waze or Co-pilot.

A similar situations exists for finding a hospital; many years ago you just had to look for the road sign and easily locate the nearest facility.

Today there are many options that publicize and promote hospitals which not only tell you where to find one, but what services they offer, the operating hours, physicians on staff, and many other things. Nowadays many ads go one step further and seek to differentiate it from other hospitals by citing statistics of quality, patient satisfaction, faster wait times, etc.

Tip #29:

Advertising that can be characterized as public information may be considered an allowable cost (CMS Pub 15-1, Section 2136).

Further guidance can be found on the Centers for Medicare and Medicaid Services (CMS) website:

Provider Reimbursement Manual 15-1

Questions? Please contact Marie White at 612.253.6546 or


The Constitution and CMS Regulations as Foundations: Interpreting Living Documents

US Constitution and FlagIt is generally accepted that the Constitution of the United States is known as a “living document” because its authors intended it to be adapted by future generations. In the past 200 years, the Constitution has been amended 27 times. Additional amendments may be needed in the future. For example, advances in technology may change the way we communicate. Someday, we may be able to vote from our own homes.

The federal regulations that govern the Medicare program can be similarly ascribed as a living document. The regulations themselves don’t change very often, but The Department of Health and Human Services, as well as the Centers for Medicare and Medicaid Services are always interpreting the regulations and issuing guidance in how they apply to health care providers.

Unfortunately, there is no crystal ball to see the future in health care. Therefore, it is often up to the individual hospital to understand and interpret the rules. This is especially true in the evaluation of new services and programs a hospital may choose to offer to its community.

In reviewing a new service, a hospital should use the regulations to provide a framework in deciding whether the new cost center is allowable or non-reimbursable.

Tip #27:

Costs of items or services that bear no relationship to care of hospital patients should be disclosed as non-reimbursable cost centers (Pub. 15-1, section 2328)

Further guidance can be found on the Centers for Medicare and Medicaid Services (CMS) website:

Provider Reimbursement Manual 15-1

Questions? Please contact Marie White at 612.253.6546 or


Right Place at the Right Time

Flight attendant serving mealTaking an airplane flight involves getting you from one place to another, but where you sit and how much you pay widely varies these days. Some airlines offer first class, business class and coach, while others have only one kind of seating. The in-flight services you receive also vary. First class often receives complimentary drinks, food and other perks that the other sections do not. The overall result is you generally get what you pay for.

In receiving care at a hospital, one sometimes runs into a similar experience. Where you are treated influences the care you receive. If a patient presents in a hospital emergency room (E/R) and needs to have IV fluids infused over four hours, the cost of providing that service is different than if a patient had an IV fluid infusion in an inpatient room (I/P). In the E/R, you might be on a gurney with a curtain drawn around and a nurse gives you the infusion while also looking after four or five other patients. In an I/P room, you get a nice bed in a private room and the nurse may only have one to two other patients.

When the service gets billed to Medicare, there is no difference in how you get paid. But for some hospitals it is important to properly identify the costs on the Medicare cost report.

On the Medicare cost report, the B-2 post stepdown adjustment is designed to help CMS appropriately partition and understand the cost of providing care at a hospital, based on the acuity of the service provided, rather than the location.

Tip #26:

Use a B-2 adjustment when outpatient ancillary services are provided in an inpatient area. (Pub. 15-2, §Section 4022)

Further guidance can be found on the Centers for Medicare and Medicaid Services (CMS) website.

Questions? Please contact Marie White at 612.253.6546 or