I would like to turn the program over to our speakers to get us started this morning on behalf of Forbis. And I think I'm going to turn the program over to Mr. Chad Tisdall to introduce his team and get us started. Thank you for being here with us this morning. All right. Thank you, Lindsay. Good morning, everyone. Yes. Thank you for joining us today. My name is Chad Tisdall. I'm a director with Forbis. I spend most of my time working with Wage Index, Wage Index projects, but also helping providers prepare Medicare cost reports and other various reimbursement type projects. Previous to joining Forbis, I did spend six years working for a MAC. And I will say that that MAC was not Palmetto. I'm joined by two colleagues today, Brian Green and Matt Ortiz. Brian is a director with over 20 years experience and previous Wage Index leadership roles at RSM and DHG and continues his leadership role here at Forbis. Matt is a senior managing consultant and joined us about nine years ago, started in on Wage Index pretty much right away, and also has some previous experience working in the hospital provider setting. So a little bit about Forbis, who we are. We are a newer created firm, I would say coming up on two years in June, created by a merger of equals, if you will, from legacy firms, BKD and DHG. We are a full service firm from audit, tax, consulting, various types of strategic projects, operations, strategy finance, healthcare reimbursement. If there's a certain healthcare component out there, we do it. We are the ninth largest consulting firm in the country, and we are quite proud of our 92 net promoter score. So we appreciate the opportunity, again, to speak on a very timely and important topic of structuring contracts with the Medicare Wage Index. And I'll say today's focus is really a subset of Wage Index with a deeper dive and attention on contracts and support specific to contract labor and physicians. So our agenda here, I'll kick us off talking about the role of the Wage Index just to give a little bit of background and really how the Wage Index plays into your Medicare reimbursement. I will say that the content was initially developed more for the non-regulatory person who may not be familiar at all with cost reports or Wage Index, and so why we thought important to talk a little bit about some of that, the Wage Index basics, and really try to set the stage for really a link between how Wage Index can be impacted by contract labor and physicians. So Brian will then talk about contract labor requirements and some best practices, and then Matt will discuss requirements for contract and salaried physicians, as well as some physician time study requirements, and then I'll wrap us up with some summary comments. We have allowed, tried to allow some time for questions, and feel free to add those into the chat as we proceed. So with that, we'll get us going here with really the role of the Wage Index that obviously a lot of components make that up, but our two key areas again today will be focused on contract labor and physicians. For those of you, again, not as familiar with it, you may be thinking, well, what is Wage Index and how does that translate to contracting and physicians? So hospitals are essentially paid for their inpatient services based on a prospective payment system, or known as the PPS. So they're paid a predetermined amount based on the diagnosis for that patient. So as a PPS hospital, the Medicare Wage Index determines approximately 60 to 70% of a hospital's Medicare reimbursement, depending on in or outpatient, and possibly even higher for inpatient services, depending on if that Wage Index is above a 1.0. So the Wage Index data obviously is establishing not just the inpatient and outpatient reimbursement, but it also plays a big factor for the non-acute provider types, such as the SNF and the home health, any psych or rehab sub-provider units. The Wage Index plays a factor there as well. So a diagnosis-related group, or that DRG, is really the payment mechanism for a short-term acute hospital, and besides that diagnosis and treatment, the operating payment incorporates a variety of other factors before getting to that final federal payment, and one of those are the wages that are paid in a hospital's specific geographic area. So Wage Index is the portion of that DRG formula that adjusts the Medicare payments by accounting for the differences in wages paid to the hospital personnel. So really the method to calculate the Wage Index is comparing the national wage data to hospitals in a specific geographical region. Those are known as the core-based statistical areas, or CBSAs, as we've listed here. That individual hospital's wage data calculates an average hourly wage, or a rate, and that data is then included with the rest of the hospitals in that same CBSA. So the adjusted rate for the CBSA is divided into the national rate, which then becomes the Wage Index factor, or ratio, for a certain CBSA at a certain hospital. So keeping in mind that the goal for the hospital is to have the highest adjusted rate it can when it's compared to the national rate. So what factors go into the Wage Index? Well, it starts with the employed personnel, total salaries and total hours at the facility. It takes off any excluded areas, the salary and hours for any excluded areas comes off. It does include Physician Part A, or that administrative time, such as the best example would be a medical director performing non-patient care services. It would not include the patient care physician time, since that is considered Part B, and those physicians would be billing Medicare separately for those services. Wage-related costs, or the benefit expense, those are included, would include some of the bigger ones, such as health insurance, retirement plan expense, and FICA, and then a variety of contract labor services ranging from, you know, those hands-on direct patient care services down to contracted housekeeping that Brian will elaborate more coming up on. So the impact of really just 50 cents, the final, excuse me, the final 24 national average rate was just above 50 bucks, 50 bucks and 34 cents, and that, that final adjusted rate incorporates, you know, all of the factors that I mentioned just previously, along with a few other calculations, obviously, that gets us to that average adjusted rate. And so we've taken it and kind of just shown here what an increase of 50 cents would be, would look like. So an increase of 50 cents would be a .01 change to the wage index, and then that .01, how that can translate to some pretty big reimbursement dollars for hospitals that you can see here. estimated impact from our wage index analyzer of what that .01 change would do for a few states around the country. So you can, you can see it can be quite, quite significant. So really the opportunity, you know, as it relates to wage index and in our discussion today specifically for physicians and contract labor is significant with, with potential for, you know, millions of loss reimbursement for a certain state or hospital when that data is not presented accurately. So on this slide here, so, you know, why would a hospital have misstated data or why would they have included incorrect data on the cost report? Unfortunately, and really not all that uncommon, there are some reasons that this could happen. First one, maybe the biggest one is just simply due to timing. For those of you, again, not familiar, a cost report can be a daunting report to get completed accurately and timely. It includes many different, many different components, expenses, revenues, Medicare specific data, certain statistics that have to be accumulated and reported during their fiscal period. And really, you know, a cost report is essentially like a tax return for Medicare. And it is a often a lengthy report that tries to true up what Medicare paid a hospital during a period compared to what they put that hospital should have been paid for that same period. So a regulatory department or a cost report department may just have ran out of time, you know, within that five-month period that CMS allows for a cost report to be completed and filed. The second one there, the complicated rules that keep changing. Yeah, without a doubt there, the guidelines for the wage index data to be included on the cost report can be challenging. It can be extensive and quite complicated, especially when those regulations and guidelines never seem to stop changing. So third one, missing data needed to claim the expense. There just could unfortunately could be missing data, or it may be available, but not able to be received timely or obtained in a quick enough manner to be able to, you know, really confidently include that data on the cost report and with the wage index data. Next one there, the Medicare administrative contractor or the MAC, that is the government contracted entity, as I assume many of you know, which performs the audits on the wage index data that is included on each cost report. And really the results of those audits many times will result in adjustments that are made by a MAC because of a lack of support. So there are other reasons exist for why data could be misstated, but again, our focus is really on the missing data and adjustments that occur because of a lack of support. So thinking about, you know, what needs to be done and what process changes should be occurring to really fully support the contract labor and the physician part A expenses getting incurred so that those higher paid or higher rate components ultimately remain as an allowable expense in the wage index. Chad, let's pause there for just a second. I see that the folks online, can you, before we get to the next slide, I think it'll be an interesting question. Has anyone on the call had any issues with supporting contract labor within the state of Georgia this last audit cycle? So you just raise your hand. You can, of course, type a comment in the chat as well. Yep, yep. We're getting to the good stuff, folks. We're getting to the good stuff. All right. So we've got a couple answers here. Not surprising. It was an issue this year. So here's some numbers to back that up, Chad. Sorry to take your spot there. That's a perfect segue, a good question to kind of lead into this. So on top of all the other issues that the MAC can come across, we definitely saw that it was further magnified this past fall with the emphasis on the contract labor, specifically the patient care contract labor. And we can see here how much patient care contract labor dollars were lost. We only stopped at the states that were above $100 million, but the total did get to $5.4 billion in lost patient care contract labor. And unfortunately, you can see the second one there, Georgia, way up towards the top, was hit, definitely hit pretty hard. So I'm going to talk a little bit further now with handing it off to Brian on why that is and really how to, steps to take to prevent that in future wage index audits. So I'll go ahead and hand it off to you, Brian. All right. Thanks, Chad. I guess feel free to comment in the chat. Is anyone surprised by that $828 million disallowance? I mean, we are here for Georgia. Is anyone surprised by that? Is it shocking anyone? If it doesn't, the next couple slides are going to be, I think, important to pay attention to because in my opinion, this is the new normal. This is what's going to be happening going forward with MACs. There's a focus on this. They found an opening, and they're going to continue to do this. I think you're going to see these numbers nationwide go up unless people can really start digging in. So in the next couple slides, we'll talk about what's allowable, what's not allowable. And then we'll get to what are some best practices. You know, lost the battle, lost the battle for this last audit cycle, but we don't want to lose the war. So what can we do prospectively going forward when we file cost reports in this next wage index cycle? What can we do to be more prepared? I forgot to advance the slides. Okay. So category is contract labor, right? You got patient care, and then you got management A and G. Patient care is anyone that does hands-on patient care. It's self-explanatory, RNs. You will have lithotripsy, dialysis, wound care. Anything that has that labor service component is going to be patient care in a contract that's going to be allowed under the wage index. Management administrative services, A and G, contract labor. You've got department directors. Anything that's except in excluded areas. And then you also have your law firms, your legal expense, your accounting and auditing. Everyone receives an audit at the end of the year. Those are all allowable, and they're typically on the higher average hourly wage end. So an example of lawyers you couldn't do is around fighting the government and battles with OIG, stuff like that. But anything that's a general, and just know that that also has to be mapped to line five on worksheet A if it's going to be captured as management administrative. So dig a little further here. We've got some more examples I just mentioned. A and G in a contract. You've got your legal, accounting, consultant, strategy. Anything with a service and labor component that can be tied and is exclusive of meals, lodging, anything else has got to be down in the labor component and supported as labor component. Dietary under contract. Housekeeping under contract, as Chad said. So the MAC has taken a stance that if you don't have housekeeping aligned where you have them in house, then they know you have to have housekeeping being done. So they're going to force you into the main housekeeping under contract, but there is a labor component to that. General guidelines. So again, we're getting down to the labor component and related hours providing the service. No equipment, supplies, per diems, no travel expenses at all. It is assuming that the person is just providing that hour of work. You've got the source of written contract. It does not matter how it's paid. It's about how you can support it. Per click contingency, can it be supported? You can work with your vendors to get down to what the real labor cost was at. It's just going to take some time and some effort. No longer attestations and declarations allowed and emails where they were. It was loose in the past. They're not going to be allowed anymore. The best situations where you have the dollars and the hours on the physical invoice. If you want to have a summary from the provider at the end, or from the provider of services, that's typically okay. But that is a little gray area. The best way is to have hours and dollars on the invoice when the check is paid. Contracting words to avoid. These are general brushstrokes. We want to stay away from those when writing contracts. Maximum, minimum, approximate, estimate. Then there's vendors, which we all saw a lot of this year of all-inclusive rates. When that all-inclusive rate, when the max is all-inclusive rate, they're going to automatically toss it. That's what we're working on. This is sort of building a story to how to deal with those all-inclusive rates here because we have seen them allowed in other parts of the country. Terms to clarify. The labor component separate from travel and per diems meals. Then anytime there's a rate change, you need an addendum or another type of trigger to address any rate changes or increases. Here's contracting terms that you want to have in there. Labor dollars and hours required for the service. Best practice is that is required in order to pay the bill. When you set up with that vendor, make them known, I need the hours on the invoice in order for me to process your bill. Functioning contract labor cycle. This is really, to boil this down, this is 365 days a year. Once you get an inventory of where your contracts are, you get the RFP, the language, got to put the language in there as we just covered a couple slides. Again, best practice. No support, no payment. Spot checking those to make sure everything's in compliance with the methodology. Then after year end, you got the cost report, you have everything ready from the invoices in order to accurately file the cost report, and you can support everything on the wage index. That is a best practice life cycle. Hard to find people that do this perfectly, but this is a process that's just, once you get it going, it's just maintaining it and getting everybody on board for this. Some of y'all may be sitting here going, well, again, it's going to be a long process to get everything in order for that functioning contract life cycle. What can we do now? What can we do in preparation of this next wage index audit that'll be due or revisions that will be due September 1st or the first Monday in September? Until we can get to the RFP and contracting, you know, these source contracts, interim steps. Start contacting your vendors now. Vendors know what they pay for labor. It's a burden on them, and some people just don't want to do it. We're past pandemic times, but back in there, there was a lot of shuffling around and trying to find contracting, and it was rough. But now, if you start having these conversations now, you should be able to have everything for every one of these vendors allowable for this next cycle. Then, I mean, if they're saying we can't give you our payroll, it's knock the names off. All of them want summaries. I don't care how much we paid you. It does not matter. Any professional services provider, which I would throw all this contract labor and A&G and everything all in this bucket, they can tell you how much they pay the people. You just got to work hard at it. And then again, it doesn't matter how you pay for the service. It's can you get down to the labor dollars and associated hours. So with that, I'll pause. Do we have any questions? Feel free to put them in the chat. I don't see any at this time, but for all of our attendees, you can type your questions into that Q&A option at the bottom of your Zoom window, or of course, you can type them into the chat as well. Perfect. Brian, I would just add that just the all-inclusive rate that you mentioned, that AAR, that was really the biggest thing that popped up this past fall at the audit as those samples were selected on the invoices. A variety of things were noted at the bottom in the small print or up towards the top or possibly in the contracts. To me, that was the biggest thing. And a big takeaway from this is to really identify that in the contract or on the invoices, and then it may take some work with the vendor to really understand, are the hospitals even paying for those incidental expenses, the travel, the meals? Sometimes we found out they weren't, and that was the best case. It was a fairly, well, an easier appeal, I would say, as far as getting some of that data allowed. I'm not for sure on the reasons why Georgia had such a high dollar amount, other than we know that the MAC in the southeast really hit it hard. If you recall from the top, there were quite a few Palmetto states. But that's the biggest takeaway for me, is really understanding those incidental expenses. Yeah, thanks for that, Chad. So, I mean, as Chad just said, I'll say it a third time. Start working now to support your expenses that were actually incurred. Start working with those vendors now, because sometimes it can take a little while to get all that documented. And then as you're following this next cost report, try and get all that on the front end. Start working. Maintain and constant communication with your vendors. Sometimes if you're not getting answers as a reimbursement department or contracting department, have the department that's actually utilizing the services and has that direct relationship with the vendor, have them call and email and maybe do some education internally about why this is important and what the hospital is losing if we cannot support these. So with that, I'll turn it over to Matt with the positions. Yeah, and I'd also add to that last point, you know, if you reach out to your vendors, they're going to say no. You know, first off, their first response is going to be no. Well, we don't track that information. Don't get discouraged by that. Keep at them. Help them understand what it is you're looking for. You're not trying to get sensitive salary or wage payroll information from them about their employees. You're just trying to figure out, you know, how many hours were at your hospital just so that you can report that to Medicare, make it clear that it's for just reporting purposes only. It'll go into a lump total on the cost report. That's the only public data. Everything else is then summarized by a vendor and cost center and so on. As long as you can educate them, the contractor, then you'd be a little more likely to get that information out of them. Because I've been on several phone calls, reached out to vendors, cold calls on working with hospitals before, and that's just, that's number one. Some of them are, they want to help and will be open to working with you, but usually the very first thing is out. We don't track that. Don't accept that and move on. Just keep pushing on them and I'm sure you'll have some success there. And Brian also mentioned a little bit about, you know, scrambling, trying to find a contract, trying to find workers to be able to come in. And in some cases you may not have had a contract or subcontract, you know, right away and you just were trying to fill the need and would fill that in later. And I can remember even, you know, in my, as Chad said, almost nine years here working in wage index, you know, used to be that if you would get pulled for a wage index or a contract labor review, it was not uncommon to hear, well, we don't really have, you know, a hard set contract with them. It's, you know, we mostly just go off invoices, you know, even at that time, if it was set up as an implied contract, that's really not the case any longer. You know, you were really starting to see like there has to be a contract in order for you to be able to claim that. And the same is true of positions. Even back then, you know, you've got to have a contract. There's really no option. The risk involved with having someone come in and perform patient care at the physician level, you know, you've got your malpractice involved, you've got other tail coverage that needs to be considered and really working out. Plus they're very expensive whenever you get your positions. And as I'm sure you're all very keenly aware how expensive physicians can be. So a contract really isn't an option. And as Chad said earlier, you know, most for the most part, the default for physicians is patient care. You know, what they're coming in, you're not going to bring in a physician to, you know, to come mop your floors or to just help with pick insertions or, you know, anything that a nurse can do. You're going to have them come in specifically for patient care. But physicians can do other things as I'm sure, you know, we've talked about a little bit and as I'm sure you've seen. But the patient care is that part B that Chad was talking about earlier. The opposite, of course, is part A. And that's time that the physicians are spending doing anything that's related to administrative, something that benefits the hospital as a whole that's not patient care related. And there's a number of reasons why they may want to take that up. If they just want to see the hospital succeed, or if they have a desire for their patients to have a more well-rounded experience when they come into the hospital. And it could be just that they're the kind of person who wants to have a position of leadership. In either of those, any of those cases, there's usually a part A role for them to serve, an administrative role that they can jump into. Some examples here, your medical directorships, you know, they're spending time developing your staff. They're improving the efficiency of their one department, making sure everything comes in and rolls out. The patients are all being taken care of and everything, all the T's are crossed, denies are dotted. And then if anything else, it really scratches that leadership itch. If that's what they want is just a position of leadership, something that they can feel like they're controlling and making sure that they can take ownership of something outside of just their patients, then, you know, that's a great option for them to get into a medical directorship over their departments. Here, you've got committee meetings. The question around committee meetings is how do we track that? Make sure that you've got a secretary set up for all of your committees. Take that attendance, make sure whoever is there is getting credit for being there. Log whenever the start meeting start time is, the meeting ending time is, and then to track that, continue to keep a hold of that. And then once you've got that, you can figure out how many hours the physicians would spend in that, and then assign whatever their hourly rate is to that committee time. Because as long as the committee is benefiting the hospital as a whole, then it's usually an allowable thing. If it's specifically for one department or just the physician group, sometimes it can get a little questionable as to whether or not that's really, truly administrative in nature, if it's just for, you know, the betterment of providing patient care. But if you've got infection control, med staff credentialing, that sort of thing, that's usually a committee that you can track and try and get included as part A, especially as long as that position is getting compensated while they're attending those committee meetings. So usually if it's during hospital, you know, office hours. And then, you know, anything else that's related to administration, I'm sure you've got specifics at your hospital. If you can think of something that a physician is doing in the hospital that benefits the hospital, that could be, you know, even a CMIO, a chief of staff, someone sitting on a chair of any given board, then that's something that you can generally count as long as they're actually doing physician work also, in which case they're still classified as a physician, but it would need to be split between part A and part B, or if it's 100% part A, make sure that it's designated as such. The only other one that's here is the ER availability. You've got your physicians are required to be on site. CMS recognizes that. And so anytime you've got ER physicians on site waiting for patients, that availability time is going to be regarded as part A as well. And that's generally another thing that's grabbed in your contracts. Sometimes if you've got your ER physicians are doing their own part B billing, and you're technically only paying them to be available, you may need to work out in your contract how to get that worded to where it says you're paying for availability time, and then anything that's going to be part A billing related to what's going through on the hospital side is being captured. But seeing ER at 100% part A, you will likely get some pushback on. So if you've got a contract wording to support that, then you may see some success there as well. And the next slide has a little bit of guidance here. It's going to be somewhat related or similar to what we saw for the contract labor. Of course, like I said, you've got to have that written agreement. It has to be in writing. And if it's if it's going to have part A included in like if the if this physician's duties are going to include part A, if you set up a medical directorship right at the beginning, or if they're doing some other kind of administrative function, you need to make sure that that's included on the contract in order for you to be a little more watertight whenever it comes to wage index audit. And again, you're going to want to avoid maximums and minimums. When you hit maximum, then the question becomes, did they continue to get paid if you're reporting more hours than that? If not, how many hours were extra? And can you support how many hours that the what the total hours were that they spent doing part A time? And then you're still in the same situation of you may as well not have even had hours listed. Minimum is the same way. If they didn't hit their minimum, did they not get paid? And that's the big question is what you can support. If that minimum is is listed there, it's like, well, yeah, we would we would expect them to do that much. But if they didn't actually do that much, then technically they shouldn't pay. And then the burden still falls on you to try and support the number of hours that are being that are being claimed for your wage index. So it's really best to just get away from minimums and maximums because they're still going to be regarded as an estimate, which is another word you don't want to use estimate approximate around, you know, about number of hours that burden of proof still falls on you in order to try and grab that. And if you're not keeping a time study, then you won't have it supported and it's all going to get treated as part B and you won't get any credit for any of the administrative functions that that physician is doing. So if you're going to be including hours and a dollar amount or a rate, it's it's important that you get specific in your contract. And I understand that, you know, sometimes you know, there's some flux around it. That's where a rate would be good. But then it's still trying to figure out how many hours are you saying that this person is spending? So if you put an exact number, generally speaking, that's what that's going to be pretty well supported during during an audit. But if it's going to be in flux and they're being paid a rate, then you're going to have to try and track those those hours. And a quick word of caution against not quite done there. A quick word of caution against including part or patient care. If you've got a 100 percent part A contract only, it's just a director. It's just a chair, just a CMO. It's going to be very tempting to put a clause in there that says, well, you are a talented physician, and we don't want your abilities to go to waste. So if there's some kind of catastrophe, if there's some kind of an issue or emergency at the hospital, we can call on you to come in and perform patient care if we have to. Because it's a perfectly good physician, why would you let a perfectly good physician go to waste doing 100% Part A? Well, be careful with that, because the MAC can latch onto that and say, OK, well, show us how much Part B time that they were actually doing. How many times did you call on them to come do an emergency surgery? And if you can't support that, then that's all that they need in order to get that 100% Part A physician removed from your wage index. And you, again, won't get that. You won't get that credit. I've seen it in audit in the past, where there was someone who was 100% Part A. And they said, if we have a need for an emergency cardio something surgery, then we can call on you. And it didn't matter what kind of support we gave. That wasn't a time study. That amount got thrown out because we couldn't prove, you know, we couldn't give them a time study with a bunch of zeros on it that said that there was zero Part B time. So, again, if you're not intending for that physician to actually do patient care, maybe just steer clear of that or set up a different agreement that does require specific documentation for it to get paid out. And then on time studies, should you include them? Maybe, maybe not. The next slide will give a little bit of guidance on that as well. If it's a medical director only, you know, you might not need a time study, but you might still need one if there's not a rate or the hours aren't clear in the contract. Recording it in payroll isn't always 100%. I had another audit where a physician was recording all of their time under job code medical director. But when we got the contract, it stated it was kind of a strange wording. It was two. Two days were going to be patient care out of five and three days were out of five were patient care instead of giving a percentage. It was kind of strange, but that's how it was worded. But it turned out that they weren't 100% medical director, even though that they were recording their time in the payroll system as a medical director 100% of the time. That wasn't the case. And so there was an audit adjustment related to that as well. So if it's a medical director, make sure that you've got that in the time study and specific and consider whether or not the contract and then consider whether or not a time study really should be used. On the flip side of position is doing only patient care, then you probably don't need to include any wording for a time study. It just adds burden. If they're coming in and just doing their work and leaving, then there's really not any good reason to to track the the hours in a time study. Again, if it's if it's all zeros for part A, then there's really no value to giving a time study. Keep in mind, you do need to track the total hours. I mentioned the payroll physician earlier need to track the total hours for your employed physicians because the the part B does get reported for the wage index, but the contracted does not. So contract part B is just it doesn't go anywhere. We only pick up the party for the wage index. So if the physician is doing both administrative and patient care, then yes, you need to have a time study. Again, even if you list a total or if you list again, if you if you don't fix the bad wording of minimums and maximums or estimates or whatever, you really need to have that time study in order to get that well supported. And then it's kind of obvious if the contract says a time study will occur, make sure you're getting that time study. It just needs to be performed because, again, even if you say, oh, well, that physician always does this or that or they devote one day a week to their medical directorship, you know, it's still just not enough. And it has to be in paper, it's got to be signed in order for it to get counted towards the wage index. So I'm sure there's a whole litany of other examples of of what situation is at the hospital, whatever you are observing your physicians do that may. I wonder if that makes you think I wonder if there's a time study being tracked for what that for what that doctor's doing. I wonder if they know what percentage of their time is spent doing this thing instead of spent doing patient care. And and when you confront the physicians about that, a lot of times they'll get a little defensive towards, you know, productivity and RBU's trying to make sure that that you're not looking at them to say, well, is this physician being productive enough and bringing in that patient revenue? Maybe we should get a different position. And that's the sort of thing that you want to avoid when bringing up time studies to your physicians, because, again, you want your physicians to cooperate with you, help them understand that, hey, it's just for reporting. We're trying to get better reimbursement for the hospital. And this is how this is one great way for you to help us with that. And whether it's part a administrative or part a teaching, all of that needs to be tracked so that it can get properly reported. A little more information on time studies here on this next slide. Looking at the frequency, we always see that the best practice is two weeks every quarter. So, you know, eight weeks out of the year. And you want to rotate those weeks, the first two weeks of the first month of the quarter and then the next two weeks, like the middle two weeks of whatever month of the second quarter in the last two weeks. If you. You know that there's going to be a patient care flux, depending on what part of the year it is based on the seasons, the weather, the sports seasons. If you talk to your nurses, the moon phases will have an impact on on when patients are coming in. So be sure that you're you're timing those appropriately to get a good a good representation of part A, part B time, not necessarily looking at heavy part B times and heavy part A times. Try and get a good mix. During the public health emergency, there was there was some leniency regarding time studies. And one of those that started out the MAC would accept a two week time study done just twice a year. We would caution you against that with the ending of the PHE. It could this could very easily go away. And that goes even without the PHE, this third one, the MAC reserves the right to require more. It's usually a good idea or it's it's more. Recommended that you contact your MAC to see what is it that you expect out of a time study. And I'll let you decide if you want to ask for permission or for forgiveness when it comes to that, because it could be as much as once a month and and they don't necessarily have a mind for what your positions are like and the fact that you have to be the ones that deal with them. I mentioned earlier that you've got to have your time to be signed, usually within three months is timely enough. What you want to avoid is getting all of your time studies at the end of the year and having your position sign them at once, because then it will just look like an attestation or an estimate again, similar to the the contract labor and you may run into issues with that being supported as well. It's important to note that you also cannot rely on your time studies to impute your total hours. So if you've got eight time studies for the year and you multiply that out to be 52 weeks, then you, you can't use that to say, well, these are my total part A hours and these are my total part B hours because of my time studies and we extrapolate that to the to the whole year. That's still going to be considered an estimate and it's still going to get rejected because you have to have the total hours tracked. In your payroll, I would expect it to be 2080 hours, just one FTE. The same really could be true of your contract positions, but really try and get a total out of them every year and then you can apply the part A, part B percentages from your time studies for that. And then looking at a few other strategies. You, of course, want to evaluate what's the value of the part A services being provided. When you're writing your contract and trying to get in that specific wording. Really, really think about, you know, what, what would it take if I had to hire a consultant to come in and do this analysis that a physician would be doing during their medical directorship. What would it cost for me to go out and hire a director from a temp agency or what it would, what it would cost to hire someone in addition to the physician to come and run this department and really get a good accurate value on that. And make sure that it's called out in the contract. And then again, make sure that you're specific on on the hours. And then if you, if you decide to include time studies on your contract, just make sure that that gets provided. If you're going to do so, do so, implement a gatekeeper. Make sure that someone is receiving that time study before you pay that. Believe it or not, there are hospitals out there who will not pay a physician unless they receive their time study. I know of one instance where a physician was not turning in their time studies and didn't get paid that medical director fee and didn't realize for several months that they hadn't been paid for that, that service. And then when they came in and figured out that what the problem was, they got their affairs in order and ended up getting paid. And you can be sure that they were, they were more mindful of that going forward. Accountants, lawyers, you know, we're used to tracking our time. It might take, it might take an hour out of our week to do the entire week at a quarter hour at a time, accounting for every quarter hour of our week. You look at a time study, trying to remember every day, a general percentage or the number of hours that they were doing medical directorship versus patient care work, you know, that might take, that might take five minutes out of their day. You extrapolate that out to the whole year, you're looking at, you know, less than two hours for the whole year to remember. When I was at the hospital, we had one physician do a time study. It was sent via interoffice mail and paper. And when we would get it back, we'd have a 10 and a 90, and that was our percentages or an 80 and a 20, just down the line, or a zero and 100. And that was it. And who could challenge that physician as to whether that was true. So that's the, when you think about the value of a time study, no one's going back to the physician saying, hey, what are you doing? Unless you're seeing something that, if you're seeing all 100 part B, then maybe challenge that, say, aren't you supposed to be doing medical directorships? And then you have that conversation with your physician. But once it's done and signed, you know, you've got your amount supported, and there's really not, that's kind of where the buck stops. If you are still doing it on paper, I would recommend getting, updating that to something newer. And even if you're doing it in Excel, I would say that there's few things that physicians hate more than a good spreadsheet. By the time they get it in their email, they open it, get it to the desktop, open it, figure out what they, what it is that you want them to do with it, get it completed and sent back to you. They don't want to do it. By the time they get it opened and try and figure out what you want them to do on it, they don't want to do it. And who knows what level or what accuracy of the information you're going to get by. There are other options out there, time study apps. I know we have one. I know that there are others out there where you can get on your phone, get on the computer, get on your smart TV, whatever it is that you've got and complete it. There's reminders that come through the app that says, hey, you haven't done your time study. It sends a reminder to administration that says, hey, this physician didn't do their time study. Follow up with them and then that can get done in it. Boop, boop, boop on your phone and you're done. So if you're still using in our office mail or you're using Excel time studies, I would, I would recommend trying to get that updated. And then you're some of your call to action here. Take a look at your contracts. Make sure that they reflect what's actually happening. Look at what's happening. Make some observations about your positions and make sure that's in your contracts. And if you see that there's any voids there, go ahead and make that update. Get it. Start, start in on on trying to get new wording included. Look at when those contracts are going to sunset. And if it's out for a couple of years, then there's nothing that would hold you back from doing an addendum. Adding an addendum to medical directorship, part A, whatever, requiring a time study, getting rid of a time study, however, whatever is needed. You can take care of an addendum and then get it into the body of the contract the next cycle. I also encourage using the CMO, whoever is advocating for physicians, make sure that they understand what you need, what you're asking and what's, what's really needed for the support. Make sure you have their backing because then they will help you with the physicians to make sure that the doctors don't think that you're just attacking them. And then I'm going to push it one more time. Modernize your time study process because that's the easier you can make it, the more participation you'll have. And the same is true for education. With that, I believe it will go back to Chad. All right. Thank you, Matt. So the goal overall, you know, getting credit for the, for the expenses that have been incurred for contract labor and the physicians, you know. Both of those are expensive. Both of those come with quite high rates. We, we, we want to keep that, that data in there. Wage index is budget neutral. I don't think we mentioned that from the beginning. That, that's big. Some are, some are going to benefit. Some will lose out. So, you know, really for, for us, you know, a goal for, for you all should, should not be penalized because of missing data or because you're unable to support your patient care contract labor or the physician Part A. We know other hospitals are, are implementing those process improvements. They're looking at their contracts. They're assessing the contract language. Many of them, as Matt mentioned, they're, they're working with their vendors to, to change the support they get to, to get the support they need that will, that will hold up, come on at time. And, you know, it has that support is hopefully determined allowable. It could pull reimbursement from other hospitals that are, that don't have good support, that are not taking those steps. So with that, I think we've got a couple of minutes left for, for some questions or any other comments from, from Brian or Matt. I don't see any coming in yet. Yeah, I don't see any pending questions. So, as Chad mentioned, we do have just a few moments left in our allotted time for today's presentation. If you do have any questions, please go ahead and be typing those into the Q&A option there at the bottom of your zoom window, or, of course, there in the chat. I do see a question here. And Brian, thanks for answering that, asking if the slides will be presented. And we will have that available for all, all registrants in an email that will go out tomorrow morning. And I'll go over all of those details in just a few moments. And then I'll turn it back to you guys. If you have any kind of closing comments. I will just say one thing regarding the appeals. Obviously, not sure who all is listening today, but if, if you had Wage Index appeals this past couple of months, the MACs have until tomorrow. By now, they've essentially transmitted any changes or the new data to CMS. But if you are, if you're planning to continue the appeal, if your data did not get updated as you requested that the next official CMS deadline is April 3rd. So, it's a, it's a pretty quick turnaround time for that for that next appeal. So, just wanted to make sure folks were aware of that. And then just thanks everyone for your time. We do this all day, every day around the nation. So, we see different perspectives. So, you know, it's a pleasure to present a little bit of relevant content to your association. Thank you. Perfect. Thank all three of you for joining us today and for sharing Georgia's perspective with our, with our members. We greatly appreciate you taking the time to do so. I did want to say a couple of things.

Medicare wage index

contract labor

physicians

hospital reimbursement

calculating wage index

contract labor requirements

tracking physician time

reimbursement accuracy

contract language update