Melinda A. Gaboury, COS-C. Chief Executive Officer. Healthcare Provider Solutions, Inc.

Transcription

1 Session 301 Home Health Services Revenue Cycle Management Melinda A. Gaboury, COS-C Chief Executive Officer Healthcare Provider Solutions, Inc. Intake/Referral Eligibility/Verification & authorization Care Provided Documentation & orders Pre billing audit File Claims Tracking & collections Payment posting & reconciliation Reporting 2 Revenue cycle 1

2 Revenue Cycle Structure Revenue Cycle Manager Billers Collectors Cash Posters Managers/Supervisors Hold to your title Must be able to DELEGATE Require reports at specific time intervals that monitor progress Never take a Verbal everything is fine in place of concrete reports 2

3 Billers Collectors Cash Posters Managers/Supervisors Do you have separate designations or does one person wear all four hats? Does each employee understand his/her responsibilities? Who is the leader/manager/supervisor? Is there required reporting in place to monitor progress? Medicare Cash Receipts Should be Posted on a Daily Basis: If payments are less than the original HIPPS recorded, research reason for difference in DDE/Pricer Differentiate the various types of PPS adjustments in your billing system to obtain statistical data. Make sure adjustments are appropriate. Don t assume anything! 3

4 Develop measures to monitor staff performance Review measures in team meetings Set reasonable expectations/goals Require staff to be accountable Deal with low performance Set limits for time allowed to perform at these levels Reward high performance Require reports to support low performance issues Require monthly details from staff on all claims older than 120/150 days Require weekly reports to monitor progress of billing and cash receipts Allow staff to express concerns & act on issues in a timely manner 4

5 Avoid typical billing problems Inadequate time for collections Lack of adequate supervision/management Unorganized billing/collection tracking Incorrectly paid claims for lack of researching balances Avoid typical billing problems Excessive RAP takebacks/takebacks not being rekeyed Inadequate cash posting reconciliation Inadequate or inefficient pre-billing audits Limited billing training Inadequate knowledge of software/tools 5

6 How many claims are over 150 days on my Accounts Receivable? Require Billers/Collectors give you a detail explanation of each claim that is 150+ days on the A/R as part of your month end close process What is my Average Days in A/R? A/R Balance/(Total Revenues/Total Days) $333,000/($1,850,000/365) = 66 Days in A/R Admissions & Recerts vs. RAPs filed - Review reports to ensure that all admitted and recertified patients have had RAPs created and preferably actually billed by month end # of days to transmit a RAP & Final How many days from date of admission before RAP is transmitted How many days from end of episode or discharge date before Final is transmitted Some effect will be felt from clinical issues 6

7 When do we conduct these audits? End of episode no need to audit prior to end of episode or discharge What do you need for audit? Patient Chart Audit Tool Trial Bill (Pre-bill) Audit 100% of Charts Catch Compliance Issues Catch Issues Associated w/pps Avoid unnecessary denials Who should conduct these audits? Billing or Clerical Staff are sufficient it is not a clinical audit 14 7

8 Quick Review of 485 All Blanks Completed, Signed & Dated by Clinician Signed & Dated by Physician Supplies ordered on 485 Supplemental Orders Signed & Dated by Physician Only exception is Discharge Orders Clinical Note for every visit Frequency & Duration Map out visits and check against orders Disallow visits and supplies as required 8

9 Session 301 Home Health Services Revenue Cycle Management Melinda A. Gaboury, COS-C Chief Executive Officer Healthcare Provider Solutions, Inc. 9

10 2015 Home Health PPS Billing Audit Tool Agency: Patient Name: Audited By: Episode Dates: Review Date: Discharge Date: Documentation Audit Review Does the documentation audit indicate that all orders are back signed? If Applicable does the documentation audit indicate F2F compliance? Does the audit indicate compliance with therapy reassessment requirements? Does the audit indicate OASIS submission "Yes" ADR Reviews Is the HIPPS code 2BGL*, 2CGL*, or 2CHL* with fewer than 16 or greater than 17 therapy visits? is the HIPPS code 1BGP* with fewer than 11 or greater than 13 therapy visits? Is the HIPPS code 5AFK*, 5AGK*, 5AHK*, 5BFK*, 5BGK*, 5BHK*, 5CGK*, 5CHK*with fewer than 20 therapy visits? If you answered yes to any of these questions hold the claim and see your supervisor. YES YES NO NO Status Verification Patient Status Review YES NO Does claim have a 06 Patient Status Code? If yes, confirm that the patient was discharged and readmitted to this or any other agency within this episode HCPCS Code Verification Any nursing visits have the G code G0162? Any therapy visits have the G codes G0159, G0160, G0161? Visit and Supply Verification HCPCS Code Review YES NO N/A Visit and Supply Review YES NO N/A If "Yes" place claim on hold. If "Yes" place claim on hold. Compare the visit and supplies on the current version of the claim to the claim version that was sent with documentation audit. The HiPPS code and all visits and supplies must match the claim copy that was submitted to billing. If "No" place claim on hold. Do the supplies on the claim match the audit? If "No" place claim on hold. If audit indicates supplies used and there are no supplies on claim, place claim on hold. Q Code Compliance Q Code Verification YES NO N/A Does the Q Code on the claim match the audit tool and does the revenue on If "No" place claim on hold. the Q Code line match the revenue code of the first visit in the episode? Q5001=Care Provided at Home, Q5002=Care Provided in an ALF, Q5009=Hold the claim Therapy Re-Assess Compliance Medicare requires a functional reassessment at least once evey thirty days for each discipline of therapy. You must verify compliance for each discipline of therapy individually. Identify the first therapy visit for each therapy discipline on the claim. These visits will have a code of G0151,G0152, G0153 and/or be identified as an Eval or Assessment visit on the visit desciption line. Within thirty days of the first Eval visit for each discipline of therapy there must be at least one other registered therapy visit (G0151, G0152, and G0153). PT OT ST Therapy Reassess Compliance Is there therapy on this claim? (G0151,G0152,G0153,G0157,G0158) Is there at least one other registered therapy visit for this discipline within 30 days of the Eval or last reassess visit? Is there at least one other registered therapy visit for this discipline within 30 days of the Eval or last reassess visit? Is there at least one other registered therapy visit for this discipline within 30 days of the Eval or last reassess visit? YES NO N/A If "Yes", answer all below three questions List the Dx Code on the claim that supports medical necessity for each discipline SN PT OT ST Comments