Protect and Improve Profitability in Your Practice. Positioning Your Organization for a RAC Audit

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1 Protect and Improve Profitability in Your Practice Positioning Your Organization for a RAC Audit 2011 Annual Educational Seminar March 9, 2011 Presented By: Cindy Tipton-Cain, Exec. Director Physician Services-Coding & Compliance

2 Understanding RAC The RAC program has already proven to be a financial boon to the Centers for Medicare & Medicaid Services (CMS). Anyone who bills Medicare could face scrutiny. Consider setting aside a reserve for estimated overpayment amounts. Undertake an office self assessment to uncover possible overpayments. Prepare for timely response to record requests

3 Preventing Billing Errors Standardize language in medical charts and coding departments 1. RAC s look for inconsistencies between what the physician documents and what is billed to the payer. 2. Mistakes occur when translating written ICD-9 codes.

4 Preventing Billing Errors Implement an internal audit process 1. Randomly conduct internal audits 2. 3 rd party audit to determine coding accuracy and possible risk areas.

5 Preventing Billing Errors Provide rewards 1. Positive reinforcement over negative reinforcement for physicians and staff that comply with good practices in Clinical documentation Coding Billing

6 Preventing Billing Errors Institute a clinical documentation improvement program 1. Verify that all clinical staff are following the same documentation guidelines. i.e. vitals, medications 2. Internal random audits to verify accuracy

7 Preventing Billing Errors Be ready for RAC auditors 1. Every provider who bills Medicare is subject to a RAC audit. 2. RAC auditors are reimbursed a percentage based on what is identified as billing errors.

8 Preventing Billing Errors Consider EHR 1. Installing a system that will assist with improving medical documentation can help minimize the incidence for billing errors 2. Eliminate the possibility of being subject to penalities 3. Capture missing revenue opportunities 4. Compliance

9 Charge Capture Get Paid For What You Do! 1) Ensure there is a reconciliation process through the practice management system or daily schedule to ensure all office charges have been entered. 1) Use scheduler in practice management system or daily schedule 2) Office charges should be entered daily no lag time! 3) Ensure encounter form is representative of commonly used procedure codes 2) PDA s can be used for daily inpatient charges, if this is not an option print daily census and use as reconciling tool. 1) Inpatient charges should be turned in daily 2) Ensure practice staff have appropriate access for patient demographics, test results, etc. 3) Surgery charges should be reviewed by a certified coder to ensure all services are billed for. 1) Surgery charges should be entered as soon as the dictated operative report is available for coding. 2) Surgery schedule can be put into practice management system to ensure no missing surgery cases!

10 Managing the Revenue Cycle INDICATOR CALCULATION BENCHMARK Days in Accounts Receivable: how many days on average does it take to liquidate a receivable item? 12 months gross charges/365 Primary Care: <50 days Specialty Care< 60 days % of Accounts Receivable >120 days: the older the receivable, the more difficult it is to collect Net Collection Percentage: how much money was collected on the money that could have been collected? Denial Percentage: why are claims not being paid? Total Accounts Receivable/Total Accounts Receivable +120 days Payments/(Charges+ Contractual Adjustments) Total Zero Payments-Denials/Total Payments <20% >95% <7% Bad Debt Total bad debt adjustments (one year)/total charges (one year) <2%

11 Importance of the Front Desk/Check In First Impressions of your office The collection of accurate demographic and insurance information. Registration staff should be well educated with the various insurances your practice participates with. Insurance verification process should be established for your practice.

12 Policies, Procedures and Education of Staff Keeping your staff informed is critical to the AR process Should have established policies and procedures to ensure standardization Have meetings with staff to keep them educated of changes with insurances, processes etc.

13 Charge Capture and Claim Submission Importance of Clean charges Charges should be entered timely (even hospital charges) Scrub charges before they are submitted to the carriers Claims should be sent electronically and daily Clearing House or vendor should provide reports of claims sent and status of claims

14 Accounts Receivable Process How does your staff monitor un-paid claims? When does your staff review un-paid claims? Do you post denials, and how do you track your top denials? Do you have a standard set of monthly reports for the practice? Do you review the reports with your staff and use them as educational tools? Does your current billing system provide the necessary reports to work the AR? Do you monitor staff productivity? Do you have thresholds set for your practice?

15 Information and Reports Turning Data into Information for Improvement Identify Strengths and weaknesses Provide objective, measurable information Establish trends Improve performance

16 Top 5 Reports A/R Reports Unpaid Claims Lag Time Denial Productivity

17 Accounts Receivable Reports Days in AR A/R over 120 days

18 Unpaid Claims Review at days Follow-up with payer

19 Lag Time Submission of claim within hrs. of service Improve cash flow Faster Submission = Faster Payment

20 Denial Denial reason Patient detail

21 Productivity Benchmarks Track trends

22 Checklist for Improving Accounts Receivable What is the 1 st impression of your office Insurance verification Updated Policy & Procedures monthly staff training on updates Staff informed of the A/R process Scrub charges prior to submission Send claims daily Send hospital and/or nursing home claims daily or weekly Review reports from clearing house on denied claims work daily Review monthly reports

23 TOP TEN Most Common Professional Fee Billing Errors Always assigning same level of service Misinterpreted abbreviations No chief complaint listed for each visit Billing of service(s) included in global period Inappropriate or no modifier used No documentation for services billed No signature on documentation Unbundling of procedure services Billing Consult vs. New Patient Visit Invalid codes billed-due to charge ticket not being updated with new/revised codes

24 Frequently Used Modifiers 22 Unusual Procedural Service 53 Discontinued Service 24 Unrelated E/M service during post-op 57 Decision for surgery 25 Separately Identifiable E&M 59 Distinct procedural service same day as a procedure service 26 Professional Component 76 repeat procedures 50 Bilateral Procedure 80 Assistant Surgeon 51 Multiple Procedures 91 Repeat clinical test 52 Reduced Service

25 At the End of the Day, It s Outcomes that Matter! Outcomes for your Practice: Enhanced Revenues Operating Efficiency Stable, Integrated System Ability to Focus on Patient Care Outcomes for your Patients: Increased Accessibility of Practice Recalls and Reminders for Needed Care Evidence-Based

26 Questions?

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