Your Revenue Cycle It s not just billing anymore. Presented by: Candy Edie, MBA, CRCE-I

Transcription

1 Your Revenue Cycle It s not just billing anymore Presented by: Candy Edie, MBA, CRCE-I

2 POSITIONS Staff Accountant Chief Financial Officer Financial Systems Analyst Patient Access Director Patient Financial Services Director Revenue Cycle Administrator Senior Consultant FACILITY TYPES Hospice Skilled Nursing Facilities Critical Access Hospitals Inpatient Psychiatric Facilities Inpatient Rehabilitation Facilities Primary Care and Specialty Clinics Sole Community Hospitals About the Presenter EDUCATION Associates Degree in Accounting BA in Healthcare Management MBA in Healthcare Management Certified Revenue Cycle Executive (AAHAM) SYSTEMS CPSI Meditech Passport SSI epremis

3 Why are you here? How comfortable are you that you are charging appropriately? How sure are you that you are billing correctly? How determined are you to collect every penny that you can? How aggressive are your payer contracts? How useful are your denial management reports? How much progress have you made in improving your revenue cycle? Are you knowledgeable enough about the revenue cycle to fix any of these? It is not enough to trust that you have the right people in place. You need to have enough knowledge about the process to support their efforts.

4 What to consider when evaluating your Revenue Cycle Payer contracts Customer/Patient satisfaction Quality measures Repeat visits enhanced reimbursement Reduce retro review recoupments Scheduling/Registration Practices ABN Authorizations Eligibility No shows/waitlists POS collections IT S NOT JUST BILLING ANYMORE! Clinical Staff Timeliness of charting Completeness of record no charge visits? Medical Records Verifying charges Validating diagnoses Chart reviews/audits Billing Knowledge of staff (CRCS?) Use of automation Follow up procedures/documented?

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6 Payer/ Insurance Patient Accounting Clerk Medical Records Clinical Departments Registration Clerk Revenue Cycle Basic Process/No Gaps Identified/No EDI Transactions in Use START Obtain patient demographic, payer, and procedure info Determine Authorizaiton/ Coverage/ ABN? Collect Copay &/or Evaluate for Charity Care Capture Charges/ Documentation Verify Charges/ Record Dx Does patient have ins? No a Send statement to patient Yes Collection Process Self Pay b END Send claim to ins-assume contractual adj at time of billing Is there a balance? No END Yes Is there a secondary Ins? No a Yes Correct claim b Is claim appropriate for payment? No Yes Send check/ EFT to provider Send denial to provider

7 Privacy Security What is HIPAA? Health Insurance Portability and Accountability Act 1996 COBRA Portability Part C Standard Transaction Data Sets?? 2003 some extensions to October 2004

8 What are EDI Transactions Eligibility Inquiry and Response (270/271) Claim Submission or Equivalent (837I/837P) Payment and Remittance Advice (835) CARC (claim adjustment reason codes) CAS segment Claim Status inquiry and Response (276/277) Functional Acknowledgement (277CA formerly 997) Referral Certification and Authorization Inquiry and Response (278) Enrollment and Disenrollment in Health Plan

9 Payer/ Insurance Patient Accounting Clerk Medical Records Clinical Departments Registration Clerk Revenue Cycle Basic Process START Obtain patient demographic, payer, and procedure info Determine Authorizaiton/ Coverage/ ABN? Collect Copay &/or Evaluate for Charity Care 270/271 Capture Charges/ Documentation Verify Charges/ Record Dx Does patient have ins? No a Send statement to patient Yes Collection Process Self Pay b END Send claim to ins-assume contractual adj at time of billing Is there a balance? No END Yes Is there a secondary Ins? No a Yes Correct claim b Is claim appropriate for payment? No Yes Send check/ EFT to provider Send denial to provider

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12 Contract Management/Negotiation Don t succumb to pressure Local Employer with 20 Employees insures staff with a new payer to area with low premiums Pressure for local providers to contract with new payer Provider signs payer contract accepting low reimbursement for services Local Employer with 200 Employees replaces insurance plan that reimburses higher rate to providers with new payer to area with lower premiums and reimbursement OOPS! there goes the budget

13 Contract Management/Negotiation Deal Breaker list # of covered lives Record review criteria (timeliness of request, max # per request, age of accts requested) Electronic transactions Timely filing limits Interest if not paid within 45 days HMO and PCP Know your reimbursement Accepting less than other major payers? Lower reimbursement = lower rates = area employers switch = decrease to you % of Medicare does not necessarily mean % of your Medicare reimbursement Split billing (APC plus prof fee schedule vs. global fee schedule) Incentive programs (Fidelis, Humana, ASK?) Manage renewals don t allow contracts to evergreen

14 Contract Management/Negotiation Contract In Network MultiPlan or similar contract Rate agreement only Processed at higher allowable, but out of network Patient Responsibility Cost to Collect for Self Pay vs. Insurance Potential Bad Debt Payer for professional charges must be participating Use locums (must replace someone) Some payers disallow locums once application submitted

15 Understanding Medicare Reimbursement APC for G0463 is $92.53 (national unadjusted) Professional Fee from Jurisdicion K, Area 99 from Place of service 22 on 1500/837P (not POS 11) Example of reimbursement for established patient level 3 office visit (99213): APC $92.53 plus pro fee $49.90 = Medicare Reimbursement $ Global fee schedule reimbursement $70.15 If contracted for 150% of Medicare fee schedule ($70.15 x 150%) = $ which is less than your Medicare payment

16 Understanding Medicare Reimbursement APC for G0463 is $92.53 (national unadjusted) Professional Fee from Jurisdicion K, Area 99 from Place of service 22 on 1500/837P (not POS 11) Example of reimbursement for established patient level 3 office visit (99213): APC $92.53 plus pro fee $49.90 = Medicare Reimbursement $ Global fee schedule reimbursement $70.15 If contracted for 150% of Medicare fee schedule ($70.15 x 150%) = $ which is less than your Medicare payment

17 Provider-based Services In 2014 Proposed Rule, CMS requested public comments about the increasing practice of hospitals purchasing office practices and making them provider-based OP departments Looking for opinions on how to collect data for services provided in off-campus provider-based departments CMS is concerned about combined professional and technical payments for provider-based services being more than the same service billed in an office setting Also, patients owe separate coinsurance amounts when service is billed this way CMS has proposed use of a new modifier to be attached to both technical and professional components on both UB and 1500 (837I and 837P), but not consensus that is best way to capture data. In the CMS 2015 Final Rule and clarified in release CR9097: Use of Modifier PO voluntary for 2015 and required 1/1/16 Services, procedures and/or surgeries furnished at off-campus provider-based outpatient departments

18 START Revenue Cycle starts with getting patients to use your services Use of payer incentives such as Fidelis required services list Review previous labs APG costs Article 28 facilities order appropriate tests Annual visit reminder Many payers cover in full for preventive health Correct coding for preventive annual visits On-line patient portal Requires well built scheduling system Schedule follow up/preventive/chronic illness testing at discharge from visit No show maintenance Reminder calls Wait lists Secret shopper

19 Obtain patient demographic, payer, and procedure info Capture demographics at EACH visit Script registration Has anything changed? Is your address xxx? Do you still have BC? Scan ins card and picture ID Identity proof Skip tracing Verify PCP for HMO 270/271 file Not enough to send and receive file, train staff Denial Management Reports user correct, trend, retrain

20 Determine Authorizaiton/ Coverage/ ABN? Know your payer contracts Manage web sites and denials management for changes to medical policies Vendors offer web scrubbing service to manage changes specific to your practice Advanced Beneficiary Notification Medicare Local Coverage Determinations (previously Local Medical Review Policies) National Coverage Determinations Procedure/Diagnosis Combination or Frequency No blanket notifications Select Jurisdiction then Medical Policy Center

21 Collect Copay &/or Evaluate for Charity Care Facilitated enrollment, Certified Application Counselor Point of Service Collections Discount for prompt pay? Copay/Deductible per 271 or insurance card Cost to collect? Collect previous visit balances Health care loan options, Vendors extending credit, Early out options

22 Capture Charges/ Documentation Are providers (doctors, nurses, therapists, etc.) knowledgeable about reimbursement and charity care/sliding fee schedules Avoid no charge visits Ensure additional services are not performed at a visit without authorization Document/charge for all reimbursable services Are you fully utilizing EMR to generate charges from documentation Are charges and documentation done timely to ensure all are captured The longer between visit and documentation/charging, the less is remembered

23 Verify Charges/ Record Dx Diagnoses Preventive codes for annual visits as payers require PQRS/Incentive Programs such as Fidelis Medical Necessity Procedures Documentation review for appropriate CPT DNFB Discharged Not Final Billed # days in unbilled

24 Does patient have ins? Yes: Process account No Really? Are you sure? 270 files up to 3 months after date of service (NYS Medicaid) Should there be coverage? What about reform? Case Management/CAC to ensure all patients Calls to uninsured patients

25 Send statement to patient Collection Process Self Pay END Patient Friendly Statements Guarantor vs. Patient Medical Record vs. Visit Detail vs. Summary (Balance Forward) Early-out Programs Auto Dialers Follow up (hours of collection) Point of Service for prior balance/include with Scheduling reminders Bad Debt Agencies Returned? Cost report? % of collection (compare agencies)? FDCPA (Fair Debt Collections Practices Act)/Title VIII/Sept 30, 1996

26 Send claim to ins-assume contractual adj at time of billing Format (UB, 1500, 837I, 837P) Electronic provides record, avoid lost/delayed paper Provides electronic remit for COB info on secondary Use of claims vendor with edits Schedule based on payer cycles Assume contractual at time of billing to automate contract payment management Non-par payers courtesy bill immediate patient responsibility no assignment 277CA - If this is not processed, untimely filing denials

27 Is claim appropriate for payment? Send check/ EFT to provider Full Denial vs. Line Item Denial CLP 4 vs. CAS segment in will return pending/paid for line item denials No Yes Send denial to provider Electronic 835 vs. Paper Remits Timeliness of posting Balancing daily cash Determine components of remit to post (adjustment such as sequestration) Line Item Denials Adjustment process auto adjust with remit? Specific CAS/Remit codes only?

28 Is there a balance? No END How do you know if the balance on account after posting remit is correct? Does CAS group PR = balance? Do staff understand contracts? Or APC and APG reimbursement calculations? Do balances drop automatically with payment to secondary payer or patient? How is this calculated? one payment per claim, any payment, PR only? Does anyone verify this? Exception reports or every payment

29 Is there a secondary Ins? If no, begin patient collection process Crossover claims Identifying by CLP 19 or assume per payer Process to follow up if secondary not paid timely Avoid duplicates and recoups 270/271 to check for coverage Timely filing for secondary claims per contract

30 A/R Follow Up Procedure Written? Workflow Priority Claims Acknowledgement, Denials, Correspondence, Aging Based on payer cycles Hierarchy Web site, status request, telephone call Adjustment Authorization Protocol

31 Software vendor optimization audit Outside audit Coding Payer audits CDM (chargemaster) Revenue cycle/billing/collections Audit Revenue Cycle Self Audits Zero pay accounts Payment to Claim to Coding to Documentation

32 Tools Coding Books - HCPCS, CPT, and ICD-9/10 Claim Editor (UB Editor) NUBC subscription (nubc.org) Peer Networks Professional Organizations Regular meetings with major payer reps Revenue Cycle team meetings List Serves (CR, emedny, payers, software vendor to review and specific articles) Annual conference regarding OPPS and FFS updates/changes Outsourcing cost to collect, liability

33 Executive Reports Aged A/R (by insurance, by provider, by location) AR days is dangerous measure without other indicators Denials Management (by reason, by insurance, by provider, by location) Monthly comparison Appeals won Revenue Comparison Miscellaneous Quality Indicators

34 Is Revenue Cycle Fiscal?

35 Questions?