Medicare Disproportionate Share (DSH)

What it means

Hospitals should be reimbursed for certain uncompensated care. Ruling 97-2 has made recovery of Medicare Disproportionate Share (DSH) funds more straightforward.

The Government's Position on DSH

  • Prior to Health Care Financing Administration (HCFA) ruling 97-2, only "paid" Medicaid days were included in the eligibility test.
  • HCFA ruling 97-2 directs Medicaid proxy to follow Circuit Court decisions.
  • Hospital has the burden of proof that "patient was eligible for Medicaid (for some covered services) during each day" of the hospital stay.
  • Government has changed rules to allow only 180 days from date of finalization to petition for such claims.

The Opportunity

Government Program Specialist utilizes a proprietary, automated process to identify significant opportunities for increased reimbursement. Since 1986, our principals have improved Medicare DSH reimbursement for more than 600 hospitals across the nation. With multiple fiscal years performed at each hospital, they have filed over 2,000 re-openings and/or appeals relating to Medicare DSH, and recovered over $1 billion in DSH monies.

We offer twenty years of national DSH management experience, from point of origin through point of need including:

  • DSH Eligibility Entitlement
  • DSH Qualification and Enhancement
  • Understatement of SSI Ratios
  • Direct and Indirect Medical Education Reimbursement
  • Medicare Audit Support
  • Medicare Appeal Filing
  • Group Appeals
  • Preparation of Jurisdictional Briefs
  • Provider Representation at the Provider Reimbursement Review Board (PRRB)
  • Medicare/Medicaid Cost Reports
  • Prior Period Cost Report Review

How We Do It

  • Our proprietary process captures earned revenue by finding unpaid eligible days.
  • After reviewing DSH adjustments, validating the appropriateness of initial DSH calculations, and all other germane issues, we run an elaborate set of automated functions to compare hospital data to the state's eligibility data.
  • We perform a complete review of all Medicare and Medicaid cost reports that are within current statutes of limitations to either appeal or reopen.
  • After eliminating Medicare Part A patients and non-PPS units we run this data against a programmed set of proprietary algorithms to determine all Title XIX eligible patient days for the MCR DSH calculation.

Prospective DSH

Historically, most hospitals have contracted with consulting firms to handle only the retroactive portion of the Medicare DSH recoveries. We believe that offering the prospective version provides substantial benefits to providers including:

Correct DSH Money

Hospitals receive the correct DSH monies on a more-timely basis, without having to wait years for a Medicare appeal and/or reopening to be addressed and finalized.

No Excessive Fees

Hospitals do not have to pay out excessive fees to consultants to collect the appropriate Medicare DSH reimbursement.

Complete Documentation

Our clients will have complete documentation of Medicaid eligible patients prior to the Medicare audit.

Accurate Reporting

Interim reports will be received during the current fiscal year comparing what DSH payments are being received through the Medicare remittance to what actually should be the Medicare DSH reimbursement based upon eligibility.

Eligible Claims Billing

Once Medicaid eligibility has been established by Government Program Specialists, the hospital can bill these eligible claims to Medicaid for inpatient reimbursement before the billing statute of limitations expires on those claims.

Transfer Diagnosis Related Groups (TDRG)

Government Program Specialists will review your Medicare claims for misapplication of the Post-Acute Care Transfer Policy. Our compliance-driven model will identify those claims with recovery potential. This gives your hospital the opportunity to increase revenues, therefore strengthening your bottom line.

Government Program Specialists has a proven methodology for identifying patients discharged or transferred from your hospital's care where Medicare payment may have been less than what your hospital was entitled to receive. While Centers for Medicare & Medicaid Services and its contractors closely review claims for overpayments relative to this issue, they do not review all claims for underpayments. Therefore, each hospital is responsible for identifying any underpayments.

Government Program Specialists has the technical resources and knowledge to identify and obtain the payments due to your hospital. Our thorough and seamless approach and automated processes allows us to conduct a comprehensive review with minimum impact on your existing operations. Using the our proprietary process, Government Program Specialists will:

Recent Rules Change

New Legislation will allow Center for Medicare and Medicaid Services (CMS) to keep part of your current Medicare payments. The Transfer Diagnosis Related Groups (TDRG) rules are changing. The 27-month window for re-filing these claims will change to 12-months per the Patient Protection and Affordable Care Act (PPACA). The following is the language from the CMS notice:

Timely Filing Requirements for Medicare Fee-For-Service Claims (CMS Message 201004-02)
On March 23, 2010, President Obama signed into law the Patient Protection and Affordable Care Act (PPACA), which amended the time period for filing Medicare fee-for-service (FFS) claims. The time period for filing Medicare FFS claims is specified in Sections 1814(a), 1835(a)(1), and 1842(b)(3) of the Social Security Act and in the Code of Federal Regulations (CFR), 42 CFR Section 424.44. Section 6404 of the PPACA amended the timely filing requirements to reduce the maximum time period for submission of all Medicare FFS claims to one calendar year after the date of service. Under the new law, claims for services furnished on or after January 1, 2010, must be filed within one calendar year after the date of service. In addition, Section 6404 mandates that claims for services furnished before January 1, 2010, must be filed no later than December 31, 2010.

Failure to address this legislative change could result in the loss of potential reimbursements. Gordon Kimberly Partners has created a program to assist hospitals in making the necessary filings prior to the end of the year so this compensation will not be lost.

Contact us today to learn how we can assist your organization.

340B Programs

doctor using laptop

The team at Gordon Kimberly Partners has assisted hospitals in qualifying for and maintaining their status as Medicare 340B providers. A hospital that has a combined Medicare DSH percentage of approximately 27.5% is eligible to enroll in the Medicare 340B discount drug program. This program allows for substantial discounts on purchased pharmacy drugs and selected supplies. Government Program Specialists monitors the Medicare DSH percentage, and attempts to ensure that all Medicaid eligible days are added to the Medicare DSH calculation. Our principals have been involved in Medicare DSH maximization for over 25 years, and have an unparalleled record of success in this area.

If your facility qualifies for the 340B program and is not yet enrolled, Government Program Specialists can assist in making certain that enrollment is completed, and that coordination between the finance and pharmacy departments is appropriate to ensure maximum cost savings from the 340B program.Your facility may already be enrolled in the Medicare 340B drug discount program. This does not mean that your facility is receiving the maximum benefit of the 340B plan.

AR Batch Analysis

One of the reasons Government Program Specialists continues to be the leader in health care reimbursement consulting year after year is because we take great pride in doing things the old-fashioned way; hard work and superior investigative analysis. While we utilize the most technological advanced computer systems in the industry we know that there is no substitute for human intelligence. Employing the highest skilled and experienced data processors is the reason we are able to uncover significantly more reimbursements for our clients. One billion and counting!


The Problem and Our Unique Solution

The current health care environment makes it extremely hard for hospital staff to uncover the proper patient health insurance information with 100% accuracy for three important reasons:

  • Patients do not always reveal the full extent of their health insurance at the time of their registration.
  • Patients obtain retroactive coverage not detectable at the time of registration.
  • And a small but significant percentage of patients have dual coverage even though only coverage from one insurance plan is revealed at the time of registration

Despite the challenges our batch analysis solution determines virtually all possible missed revenue opportunities through the identification of Medicaid, Medicare, Medicaid/Medicare HMOs, Tricare, Commercial Insurance benefits not classified at the time of registration.

Don't Leave Money On The Table


Predominantly, the focus of so-called competitive services has been narrowly fixed upon reviewing aged self-pay accounts under a hefty contingency fee arrangement that inherently reduces the benefit to the provider. This simplistic approach leaves out a slew of compensation that is legitimately recoverable.

Government Program Specialist, on the other hand delivers a more thorough and efficient service for a reasonable flat monthly fee guaranteed to lock in a substantially higher ROI, regardless of the recovery opportunities we uncover. We screen all inpatient discharges and all outpatient visits in a systematic way and on a monthly basis using proprietary algorithms to identify coverage that allow the provider to bill insurance within timely filing.

Benefits of AR Batch Approach

  • Significantly increases net revenue
  • Significantly reduces bad debt and accounts receivable balances
  • Maximize Electronic Health Record (EHR) Incentive Program revenue
  • Uncover additional DSH Medicaid days
  • No contingency fees; reasonable flat fee arrangement typically yields 300% ROI
  • Reports customized to meet the needs of your billing staff

We Are The Leaders In Health Care Reimbursement Consulting

Let Us Help You! Rest assured we are not only the oldest Medicare/Medicaid Reimbursement Consulting Firm in the U.S., we are the most successful because of our commitment to quality in serving our clients. Providing the very best customer support is our mission and we will not rest until you are satisfied. Keep in mind that:

  • We bear the burden of risk associated with achieving results
  • We ensure complete transparency for all claims by providing 100% documentation for proof of every eligible claim
  • We have always found additional monies due the hospital when following the work of other firms providing similar services

Contact us today for more information on how we can assist your organization, or to set up your free demo of our AR batch service today. Have a current vendor already? Let us come behind your internal or third party eligibility processors to see what was missed, or let us have the first pass in order to eliminate or greatly reduce contingency fees paid to current vendor.