T.Giovanis & Company - - - -

Health Policy and Advocacy

T. Giovanis & Company is the best firm to represent your interests on Medicare and Medicaid issues. Our firm provides specialized quality strategic services to health care organizations that need dependable, clear, and concise information well in advance of that information becoming generally available, or that need assistance in policy making or technical issues.

Health care organizations turn to us when they want to find out what policy makers are thinking, planning, or doing. By maintaining close relationships with health care decision makers we are intimately familiar with policy developments at extremely early stages. Therefore, our clients are in the best strategic position relative to policy changes.

Sometimes it is necessary to intervene in the health policy legislative and regulatory development process. Often we are called upon to develop or analyze policy proposals. The results of our analyses help to facilitate needed changes to the pending proposals. We have broad experience in the areas of health insurance, managed care, Medicare, and Medicaid.

Examples of Health Policy and Advocacy Services

Design, development, and evaluation of prospective payment systems
Evaluation of Medicare and Medicaid regulatory or legislative proposals and related impact
Development and evaluation of pilots or waivers
Assistance with state based legislative proposals for consistency with federal Medicare or Medicaid rules and policy principles
Expert witness testimony and analysis
Advocacy of policy changes with Congress and regulatory agencies
Evaluation of the impact of Medicaid hospital specific limits
Medicaid spending evaluation - upper limit, payment system design and changes
Securing appropriate levels of federal matching for states/providers
Evaluation of the impact of Medicaid hospital specific limits

Reimbursement Services

T. Giovanis & Company's policy and analytic background makes us very qualified to represent organizations on issues involving reimbursement. Our firm has provided strategic reimbursement services and technical assistance to health care organizations in both the Medicare and Medicaid areas.

Our practice includes many client specific strategies and services such as: working with fiscal intermediaries; filing appeals; special status applications like Sole Community Hospital (SCH) and Critical Access Hospital (CAH); resolving wage index issues; outpatient payment reviews; TEFRA limit appeals; and Medicare cost report preparation. In addition, we have developed several service lines that have more general application such as: reimbursement strategy evaluations; Medicare/Medicaid disproportionate share reviews; and Psychiatric Prospective Payment System evaluation and implementation.

Sometimes it is necessary to intervene in the health policy regulatory development process. Our firm's close contacts with decision makers and health policy expertise help facilitate these changes.

Examples of Reimbursement Services

Prospective Payment System impact evaluation and implementation assistance
Disproportionate Share Payment qualification, quantification, and retention
Indirect Medical Education quantification
Geographic reclassifications
Appeals - PRRB, TEFRA, other
Medicare bad debt recovery
Resolving issues with Medicare
Attaining SCH, RRC, and CAH status
Identifying and resolving area wage index issues
Assuring appropriate inpatient, physician, and outpatient billing as well as coding and documentation issues
Charge structure reviews
Review of outpatient payment areas
Reimbursement related compliance reviews
Home office cost structure development
Cost report preparation

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Reimbursement Strategy Review (RSR)

What is the T. Giovanis & Company RSR?

The RSR is a systematic review of all aspects of a provider's reimbursement position. It examines the interactive nature of many reimbursement changes or strategies providers pursue. The review is performed via a systematic process.

Why is the T. Giovanis & Company RSR Needed?

Providers/Systems tend to evaluate reimbursement issues/decisions in isolation. This means decisions about how to implement any particular new program are made one at a time. However, there is no review with a panoramic perspective that views the interactive aspects of various reimbursement issues.

Examples of how issues can be missed when done in isolation include:

Providers can make changes to the hospital's benefits, which adversely affect the hospital's average hourly wage and accordingly its potential for geographic reclassification. Hospitals may change their computer system and negatively impact the counting of Medicaid days for DSH. Also, combining hospitals into a single provider may initially appear to increase payments, but the actual result is a net decrease.

Why is the RSR Unique?

The T. Giovanis & Company approach is based on a copyrighted questionnaire process. The principals of the firm are the individuals who perform the review, and accordingly the services are performed by individuals with broad reimbursement expertise.

Disproportionate Share Hospital (DSH) Review

What are T. Giovanis & Company DSH Services?

The review encompasses both the Medicaid day and SSI portions of the criteria, uses a multi-disciplinary technique, identifies additional reimbursement by identifying new areas, and deploys unique data bases to help identify opportunity areas.

What is the T. Giovanis & Company Approach to DSH Services?

The review approach uses a copyrighted questionnaire, uses interviews with the hospital personnel, deploys proprietary data bases, uses sophisticated analytic techniques, and integrates information from the hospital, fiscal intermediary, and Medicaid plan.

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Why are there opportunities?

Regulatory complexity, changing rules, intermediary issues, and lack of thorough understanding of all the issues tend to have a lowering effect on Medicaid day and SSI percentages. A systematic review using sophisticated analytic techniques leads to improvement.

What is unique about T. Giovanis & Company's qualifications and approaches?

T. Giovanis & Company uses a "principals-only" approach coupled with unique data bases and sophisticated analytics, a broad base of experience with this issue, and experiences in over half the States.

Result of DSH Review

This process results in improved, but appropriate, increases in payment. The hospital will be able to track its own data in the future, and the T. Giovanis & Company approach can produce results even after other consultants have worked on the issue.

Psych PPS Evaluation

What is the new Psych PPS system?

The Medicare program began phasing in a new PPS system for psychiatric hospitals and units during 2005. Hospitals/Units are currently being paid on a per discharge system but will change to a per diem system. This will entail changes in the payments and the processes to be followed in obtaining payment. Evaluation of the PPS payment implications can assist with planning or lead to ideas about restructuring the provision of services.

Why is T. Giovanis & Company's PPS review needed?

The new per diem system includes area wage and case mix adjustments, among other changes, which substantially differ from those under the present system. The new tiered per diem system will offer altered incentives for reducing stays. Related to the PPS implementation is an evaluation of the existing payment system, which can assist providers during the transition to PPS. This review can lead to the identification of billing and coding as well as documentation changes necessary to obtain payment and related education for staff and physicians.

T. Giovanis & Company's Unique Approach

During 2001, 2002, and 2003, our firm worked with a national psychiatric association modeling the new system. These efforts have allowed T. Giovanis & Company to acquire unique data bases and an understanding of the new system from the ground up. This knowledge meshed with our reimbursement and billing/coding experiences has enabled us to develop approaches for assisting providers with evaluation, implementation, education, and transitional issues.

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Inpatient Psychiatric Prospective Payment System Evaluation and Implementation

Analysis of the Impact of the New System

It is important that every provider have an initial evaluation of how the new IPPP system will impact them from a payment perspective. Thereafter and depending on the results of the initial evaluation, other more detailed evaluations could include how the hospital/unit compares based on components of cost within the national rate, per group comparisons, and whether it is prepared from a billing and coding perspective.

Review of TEFRA Based Payments

Some providers desire a limited scope review of their present position under the existing TEFRA based system. This is important because the provider will be paid on this system throughout the transition.

Chart Review

In the course of the financial evaluation, it is helpful to perform a sample chart review. Through this process, we can identify documentation issues that are or will directly relate to the providers performance under PPS and potentially under the existing system. Sometimes it is also beneficial to re-examine charts after training has occurred to gauge its effectiveness.

Financial/Clinical staff and physician education about the new PPS

In this area, our consultants conduct educational seminars for the hospital's financial/clinical staff and physicians.

Billing and Coding Education and Instruction

This education focuses on provider billing and coding personnel to assure they are ready for the new system. While not directly part of this component, we have the capability to be an ongoing resource for the provider on these issues in the future.

In depth cost structure analysis of the component costs and a peer group comparison

Sometimes when the provider's cost structure is an issue, there is the need for further analysis. In this area, we can "drill down" through the provider's component cost per day, evaluate these components, and/or compare them to a peer group of providers selected by the hospital.

Review and evaluation of patient treatment plans and related matters

Often times it is clear that the issues at the provider involve its mix of services (chemical dependence verses mental illness), the existence of other programs (such as partial hospitalization), patient flows, etc. In this area, a psychiatrist and/or clinician as well as financial personnel review these areas and make recommendations for changes.

Implementation consulting involving patient flow changes

This area involves the implementation of changes related to the recommended changes in treatment plans, patient flows, service changes, etc.

Sample of T. Giovanis & Company Engagements

We have pursued a wide variety of engagements on behalf of clients. Examples of engagements include:

Challenge:		Results:
1	The six hospitals in a county were faced with competition for labor from an adjacent Metropolitan Statistical Area (MSA) aggravated by a significant Medicare payment differential.	We developed and deployed a legislative and regulatory strategy, which resulted in the county's hospitals receiving $15 million per year in increased Medicare payments.
2	A small hospital was placed at a disadvantage when a hospital located 30 minutes away received sole community hospital (SCH) status.	We developed a regulatory strategy and related analyses, which was used to pursue SCH status for the target hospital using a unique approach. This resulted in the hospital being designated SCH.
3	A group of hospitals in an MSA were faced with a decrease in Medicare payments caused by errors in the data used to calculate Medicare's area wage index.	We analyzed the data and interviewed the hospitals to ascertain the facts in the situation. Through research, dialogue with Medicare, and other activities, we were able to develop an approach that resulted in the hospitals getting appropriate level of payments in a manner that was acceptable to the hospitals and the Medicare program.
4	A small rural heavily Medicare dependent hospital was faced with shrinking Medicare payments and non-Medicare volumes with no apparent regulatory remedy.	We successfully advocated legislation, creating a provision for rate relief. We then filed the regulatory appeal on behalf of the provider, which resulted in a $1.7 million annual increase in their Medicare payments.
5	Several hospitals were competing for labor with hospitals in an adjacent MSA while receiving substantially less per Medicare discharge, due to the use of MSAs that were not modified for changing labor markets.	When HHS denied that they had statutory authority, we pursued a legislative change resulting in the creation of a separate Medicare Appeals Board to review such appeals. We filed an appeal on behalf of the hospitals resulting in an increase in Medicare payments in excess of $1,000 per Medicare discharge.
6	A hospital that was part of a system was faced with Medicare costs in its psychiatric unit that were over its Medicare TEFRA Limit. While believing their costs were at the appropriate level, the hospital could not identify any appropriate solution.	We analyzed the history of the unit and identified a framework for requesting an appeal. Then we developed data to support the claim and also worked with the intermediary and Medicare, which resulted in a $3 million retroactive payment and increased payment for each subsequent period by $1.3 million.
7	A health system of several hospitals was concerned that it was not receiving the appropriate level of its Medicare Disproportionate Share Hospital (DSH) payments and feared that proposed changes would adversely affect them.	We analyzed all aspects of the DSH payment at the two providers already qualified for DSH, developed a request for increased payments yielding $700,000 for two fiscal years, and demonstrated to the providers how to continue developing needed data for future periods.
8	The Interim CEO of a hospital was faced with cost overruns, the threat of insolvency, concerned employees and medical staff, and the threat of violating the hospitals bond covenants.	We advised the Interim CEO on the departments where costs could be cut, implemented ways to improve cash flow, and negotiated with the state rate setting agencies and bond rating authorities. The hospital sufficiently increased its cash flow to meet its bond covenant; the medical staff was co-opted into the process; and the hospital established a long term strategy toward stability.
9	A county owned and operated nursing facilities in a state were faced with reduced Medicaid payments in the wake of a payment system reform.	We evaluated the structure of the Medicaid plan and county expenditures and then developed a Medicaid plan amendment that created $200 million more federal matching dollars for the state which were in turn used to support payments to nursing facilities.
10	A major professional association was faced with Medicare reform of its payments from a unit rate to a relative value basis, involving $1.5 billion in annual Medicare outlays.	We successfully developed and advocated a payment methodology with the Medicare program in conjunction with the association's counsel.
11	A small hospital was faced with decreasing Medicare payments and increasing cost per stay which threatened the hospital's existence.	We performed a review and identified that with only minor operational changes the hospital would quality as a Critical Access Hospital. We assisted the hospital in applying for and obtaining CAH status with its related increase in Medicare payments and operational flexibility.
12	A $100 million primary health care organization was responsible for the risk associated with a capitated payment related to the state prison system. The organization and staff had failed in their attempts to negotiate with providers for selective contracts.	Our firm developed a bidding process and a related request for proposal to initiate the bidding process and worked with the state and organization to gain control over the flow of potential inpatients to various providers resulting in substantial decreases in annual outlays.

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