Information Integrity in the Revenue Cycle! Order Entry, All Subsystems and The Charge Description Master
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1 Information Integrity in the Revenue Cycle! Order Entry, All Subsystems and The Charge Description Master 2011
2 Our Philosophy: We are a firm believer in information integrity. Therefore we perform on or off site a full review of the hospitals Order Entry, Subsystems and CDM for accuracy and compliance while performing education and problem solving with all department heads and key staff during and after the interview process. We further believe On Going Education and Daily Reconciliation is key to the hospitals financial success. Educate and validate that the hospital personnel are completely knowledgeable in their documentation and charge capture and to insure the integrity of hospital compliance and billing. As we call it Hand Holding and at a reasonable price. 2011
3 President of MedCompliance Services Jessy Huebner, MAT, CHFP Conceived and developed: The Healthcare Financial and RAC Editor The Information Integrity Editor The Healthcare Department Modeler First to merge CDM applications into one system. Over 30 years of onsite healthcare validation reviews. Author and speaker for HFMA and numerous hospitals with over 5,000 hours logged at the podium.
4 The Revenue Cycle Patient Access Revenue Integrity Claims Adjudication Management Scheduling Medical Necessity Determination/ Orders Pre-Registration Registration and Demographic/ Insurance Validation Insurance Verification Pre-Certification Financial Counseling POS Collections EMR data from Clinical Care documentation & transcription Health Information Management Coding Charge Capture Charge Entry CHARGE MASTER Billing System(s) Claims Preparation Claims Submission Third Party Follow up Self Pay Follow up Rejection Processing Payment Posting Payment Validation Medical Case Management Denial and Appeal Management Revenue Cycle KPI s Contracts Physician Credentialing
5 Revenue Issues Facing Hospitals Today -Confusion due to new rules -RAC Audits are increasing -The risk of fraud is escalating -Staffs need more education to document & charge accurately -Order Entry, all Subsystems and CDM are not synchronized -Incorrect CPT/HCPC and Diagnosis coding is taking place -Modifiers are not being correctly applied or missing -An understanding of the Medicare Rules and Regulations is lacking, especially how the Correct Coding Initiative (CCI) Editor & Medically Unlikely Editor (MUE) works -Difficult to stay current with CMS Addendum A & B -Improper packaging and bundling is an issue -Reporting needs simplification that can be easily customized -Internal controls and daily reconciliation, that will withstand scrutiny, are often missing
6 Did you know? A good CPT code can be linked to a good procedure and still be wrong. Coding must not create a fraudulent situation. Compliance is required throughout the process, necessitating a complete understanding of all aspects, from the front end to bill drop. A clean and accurate CDM, not one that creates problems and causes lost revenue, is essential A clean claim is the key Clean code + a clean CDM + a clean bill drop = more cash
7 Our Solution includes: Clean up and synchronization of Order Entry through all Subsystems to the Charge Master Reimbursement problem solving: On-the-job training, technical support, and on going maintenance
8 The Healthcare Financial and RAC Editor
9 The Healthcare Financial and RAC Editor Merges Data from: - CDM - Revenue & Usage - Order Entry - All Sub-systems Audits and Evaluates the Data for Issues in the following major areas: - Descriptions - Revenue Codes - CPT/HCPC Codes - Modifiers - Pricing - RAC Issues
10 There is 113 Columns of Data In The Healthcare Financial & RAC Editor The main areas are: Hospital Two Years of Usage (IP & OP) Hospital CDM Item, Order Entry & Subsystem Numbers Hospital CDM Description and AMA/CMS Descriptions Hospital Revenue Code plus 3M & Ingenix Revenue Codes Hospital CPT/HCPC Code and AMA & CMS CPT/HCPC Codes Hospital Modifier and AMA & CMS Modifiers All Reference Tables, Issues & Files Hospital Charge and AMA & CMS APC & Fee Schedules RAC Issues by Region A few of the columns of data are: AMA CPT Codes, CMS HCPC Codes, AMA & CMS Long, Medium and Short Descriptions, 3M & Ingenix Revenue Code tables, CMS CCI & MUE Edits, CMS Addendums A & B (SIC, APC, Payment and Co-Insurance Amounts), CMS Fee Schedules (Lab, Pro Fee, Ambulance, DME), Medicaid Fee Schedules, Pharmacy Crosswalk Tables, RVU Tables, AMA Appendix Rules, AHA Type of Service Table, MedLearn Interventional Radiology File, CMS Part B Drug Schedule and all RAC issues by Region
11 The Information Integrity Editor
12 The Information Integrity Editor Merges files and reviews: Order Entry, All subsystems, The Charge Description Master Regardless of the type of system in place at the hospital into one Excel Worksheet
13 The Healthcare Information Integrity Editor Radiology Pharmacy Order Entry Pulmonary Physicians Services Charge Description Master MedCompliance Cardiology Lab (Cerner) Financial Revenue Usage Central Supply (Lawson) One Platform -- Bridging Information Data Integrity Optimizing Reimbursement Compliance Clean Accurate Billing
14 The Healthcare Department Modeler
15 Modeling We take a unique, more intimate approach than others, who still employ hard-coded logic that works off good code vs. bad code methodologies. Modeling enables overlay of each department s CDM, to its respective model, thereby revealing services not found in the department s CDM.increased revenue! Built on nationals standards; enhanced through our work in hospitals. Modeling is run for several reasons: -to perform impact analyses before departments or services are added. -to build Ad Hoc Reports to research what ifs. to compare and assess, by department, to identify missing services for increased revenue. Models are consistently well received due to their level of detail and revenue has ALWAYS been identified, regardless of departmental size.
16 1While characterized as an example, this is actual data from a client assignment. Example of Modeling
17 Our Proven Results
18 Typical Example of Recommended Changes Note : This is a 350 bed hospital in New Jersey that we audited January 2011 that had been audited by a National CPA firm in August The client was not happy with the August results.
19 Resulting Financial Impact Note : This is a 350 bed hospital in New Jersey that we audited January 2011 that had been audited by a National CPA firm in August The client was not happy with the August results.
20 What Makes MedCompliance Different in the Industry Philosophy: We are a firm believer in information integrity. Technology: Utilizes Excel and the clients information to merge and audit their order entry, subsystems and CDM information into one Excel spreadsheet..a Soft Coded Logic approach not the Hard Coded Logic approach as utilized by others in the industry Merging of Data: Ability to merge data from all client sources into one Excel spreadsheet Modeling: Able to take hospital departmental models that contain AMA, CMS and AHA data and overlapping that information with the hospital data to show missing services the hospital can add for increased revenue Reports: Standard plus Customer designed at no additional charge Printing: Easy to print using Excel format Multiple Facilities: Able to overlap and merge multiple facility hospitals and multi-tier physician groups CDM into one Excel spreadsheet which will show discrepancies and consistencies in coding, compliance, pricing and other features that may effect the Order Entry System, Subsystems and the CDM accuracy Web-based & Support: Yes, we are Web Based with 24 hour phone and support under our monthly maintenance contract
21 Hospital CDM electronically sent via Black Box to hard coded logic editor at providers location Hospital CDM, Order Entry, Sub-system and Usage Reports sent to MedCompliance Services Providers location runs CDM through editor and sends results back to hospital. Note: results are not reviewed by the provider. Hospital goes to "Black Box" to run reports and figure out what needs to be corrected. Reports are not in Excel format but in a format designed by provider. Hospital gets limited assistance regarding issues found in editor reports MedCompliance consultants run all files through MedCompliance editors MedCompliance consultants run all reports, assesses the data, provide recommendations which require corrections and alerts for further clarification. Reports are in Excel format and sent back to hospital. Together, Hospital staff and MedCompliance consultants review all findings and corrections
22 Benefits of Partnering with MedCompliance Services Inc. -We provide cleanup of Order Entry, all Subsystems and the CDM -We use unique Modeling to reveal missing services, by department -We find missing revenue to drive immediate cash flow improvement -We reduce erroneous charging thereby reducing your risk of fraud -We improve documentation/charging by hospital staff and physicians through on-the-job and formal training programs -We provide real-time updates
23 Partnering Benefits, Cont d -We use software applications, tools, education and personal on-site services to produce Clean Claims -Based on our reviews, you can reduce the risk of noncompliance and increase your confidence when you re faced with outside audits -Unlike others, our reviews project expected Return on Investment (ROI). Our average ROI is 150:1 therefore we can guarantee our results -Our Reporting has the capability to deliver customerspecific information, to guide each staff member, in each department
24 Partnering Benefits, Cont d -Our Educational Services help turn around inefficient departments -Documentation and tools are used to help drive a deeper understanding of a customers billing factors -Ongoing maintenance assures that your CDM stays current, accurate and clean -We are accessible in person, by phone, or via , within 24 hours
25 Contact Information: Jessy Huebner, MAT, CHFP MedCompliance Services Inc. 800 West Ave - Suite 1001 Miami Beach, FL & 129 Club House Road - Box 3520 Breckenridge, CO [email protected] Clinical Education & CDM Cleanup
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