Provider Enrollment Data, Data, and more Data Billing Collecting and Applying Payments Denials? Compliance Website links

Transcription

1 So Simple & Easy, Anyone Can Do It, Right!?

2 Provider Enrollment Data, Data, and more Data Billing Collecting and Applying Payments Denials? Compliance Website links

3 God made physicians to heal all of his people. And it was good. On the second day he noticed providers enjoyed medicine, so he created Provider Enrollment with lengthy applications and bureaucracy to rule over providers. On the morning of the 3dd 3rd day, God saw the challenge of paper provider applications so he created PECOS. Now instead of paper applications being misplaced, they are lost in cyberspace. And it was good?

4 Key to getting paid correctly. Medicare = Provider Enrollment, Chain and Ownership System (PECOS), or paper. 855 in all its various forms. Just give them what they want! Allow plenty of time for processing! Once enrolled, make sure billing software is setup to match.

5 Patient calls to schedule an appointment or just shows up. Patient provides demographics and insurance. Patient is seen by the provider.

6 Insurance is billed electronically for services. Insurance pays for all services at 100% of amount billed, right?

7 Does it ever seem like: Medicare & other insurers have focused armies of people using high end computers with sophisticated software on their side of medical billing? This vast array of resources is solely focused on not paying providers?

8 Aside from accurate medical records, it is all about accurate & complete billing data. Whose definition of accurate & complete? Who is typically responsible for collecting the data the receptionist who also greets each patient, answers phones, copies insurance cards, checks the patient t out after treatment, t t etc. Typically held in an EHR or billing software or both which facilitate accurate and efficient billing.

9 Demographics Insurance Patients Referrals & Authorizations Billing codes Payments Details, details, details. Does it all have to be entered correctly?

10 Patient s Name must match the Health Insurance Card (HIC) exactly. Richard C. Papperman vs. Rich Papperman Address DOB Insurance policy(s) & group numbers

11 Providers Provider names Individual & Group # s National Provider Identifier (NPI) numbers Office & facility addresses Zip + 4 CPT, HCPCS, & ICD-9 codes Linking CPT & HCPCS codes with ICD-9

12 How do we report the data in order to get paid? CMS-1500 form Using CPT, HCPCS & ICD-9 codes Maybe some day ICD-10 codes?

13 CPT = Current Procedural Terminology Used to bill: Services of Physicians (MD, DO, DPM) & Allied Health Professionals (PA, NP, APN, Midwife, etc.) for Evaluation and Management, Surgery, Radiology, Lab services, etc. Some codes are composed of Professional and Technical components: Lab, Pathology & Radiology. Professional is what the physician did. Technical is what the facility provided.

14 Used to communicate information to insurers. Example -59 separate and distinct procedure. Example: Excision of 2 separate lesions Common modifiers: 22, 24, 25, 50, 51, 52, 57, 59, 62, 76, 78, 79, 80, 82, AS, AT, GO, GP, GV, GW, LT, RT, Q5, Q6, QW, TC, 26. Podiatry modifiers: TA, T1, T2, T3, T4, T5, T6, T7, T8, T9, Q7, Q8, Q9.

15 HCPCS = Healthcare Common Procedure Coding System Used to bill: Medications (dexamethasone, Celestone, B12, Kenalog) Durable Medical Equipment (DME) equipment and supplies (Wheelchairs, walkers, canes, hospital beds) Orthotics and Prosthetics (Therapeutic shoes & inserts) Surgical Supplies (gauze, ointment, tape) Numerous other medical items & services

16 Often strict coverage policies. For DME and routine ambulance transports requirements for Certificates of Medical Necessity (CMN) signed by a physician or AHP. Common Modifiers: Wound dressings: A1 A9 DME: KX, KA, KH, KI, KJ, MS, NU, UE Ambulance: GM, QL, RH, SH, PH, SI, etc.

17 ICD-9 is used for diagnosis codes. Must be linked to the proper CPT or HCPCS code. ICD-10 set for October 1, 2015.

18 Pairs of CPT or HCPCS Level II codes that are not separately payable except under certain circumstances. Edits are applied to services billed by the: - Same provider for the - Same beneficiary on the - Same date of service. All claims are processed against the CCI tables.

19 Example: (Adjacent tissue transfer, trunk) and (Excision i benign lesion, trunk). Only the will be paid if the was the result of the The should not be billed. Common Software Edits: Age range Sex Units

20 Examples of mismatch edits: Prostatectomy on a female Hysterectomy on a male Well exam, age Invalid for anyone outside that age range Removal of impacted cerumen (ear wax), unilateral. Maximum units is 2.

21 Standard coverage throughout the nation well, almost! Fairly clear policies Not the same as Railroad Medicare

22 For Railroad Retirement beneficiaries Palmetto GBA is the Railroad Specialty Medicare Administrative Contractor (RRB SMAC) and processes Part B claims

23 Part C Covers both Part A (Hospital) & B (Medical) Offered by Private Companies Blue Shield, Aetna, CIGNA, UHC, Humana, etc. Cover all Medicare services Medicare pays a fixed sum of money to the HMO per enrollee Can charge different out-of-pocket of costs & have different rules (referrals, authorizations)

24 Part D Pharmacy Usually offered thru a Medicare Advantage Plan If not offered thru Part C, you can join a Medicare Prescription Drug Plan

25 By definition are 2 to Traditional Medicare and only cover Medicare approved charges and services. Standard plans with the same coverage regardless of the insurer AARP, Blue Shield, etc. Cannot be used to pay Medicare Advantage Plans copayments, deductibles, or premiums.

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27 LCD = Local Coverage Determinations NCD = National Coverage Determinations Indicate what an insurer considers acceptable reasons to pay specific CPT & HCPCS codes often diagnosis code specific. Differences between MAC s Good coders are very valuable!

28 Followed by all MAC s nationwide & covered under 1862(a)(1) of the Social Security Act. Initiated by the Centers of Medicare & Medicaid Services (CMS) if they find: Inconsistent local coverage polices exist The service represents a significant medical advance and no similar service is currently covered by Medicare The service is the subject of substantial controversy The potential for rapid diffusion or overuse exists

29 The alphabetical index can be found at : Common examples: EKG s Blood Glucose Testing Cardiac Pacemakers Colorectal Screening Tests (82270)

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31 Guidance/Guidance/Manuals/Internet-Only- Manuals-IOMs.html Publication Separated into Chapters

32 If no NCD, Medicare MAC s may establish local policies LCD s are administrative and educational tools to assist providers in submitting correct claims Usually include specific requirements for providers to understand Medicare coverage of certain procedures, including specific CPT, HCPCS & covered ICD-9 codes. Will be updated for ICD-10 ~ April 1, 2015.

33 Transthoracic Echocardiography (TTE) Coverage Indications, Limitations, and/or Medical Necessity Covered Indications i Covered CPT Codes ICD-9 Codes that Support Medical Necessity Be sure to link the ICD-9 code to the proper Be sure to link the ICD-9 code to the proper CPT codes.

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38 Payment for services by Medicare must be performed: In accordance with federal laws, regulations and Medicare national payment rules In accordance with Medicare coverage policies (national and local) By a qualified practitioner For a qualified beneficiary Medically reasonable and necessary Coded correctly

39 Paper EOB Paper Check Post $1,000 s in hours hopefully accurately ERA EFT Post $1,000 s in seconds - accurately

40 CMS sets values for each medical procedure (CPT) through h the use of Relative Value Units (RVUs). An RVU for a medical procedure consists of three components: physician work, physician expense and malpractice expense. CMS uses a formula that combines the three components into one unit. The RVU s are then multiplied by a Conversion Factor (CF) to determine how much will be paid for a medical procedure.

41 Types of fee schedules: physician, drug, DME, ambulance. Insurers pay the lower of their allowed fee or the charge. Example 1: Bill at $ Insurer allows $ Payment is based on $50.00 subject to co-pay, co-insurance, and/or deductibles. Example 2: Bill at $85.00, Medicare allows $78.56 so may pay as much as $61.28 (78% of the Allowed). Why not 80%? Incentive is?

42 Resource-Based Relative Value Scale. RVU s part of RBRVS. A system that reflects the relative level of time, skill, training and intensity of a service. RVUs are a method for calculating the volume of work or effort included in the code. Often used to pay providers either by insurers or employers when multiplied by a dollar conversion factor.

43 Many electronic health record (EHR) programs have built-in billing software or provide HL-7 interfaces with billing software. Provider either selects codes in the EHR or indicates on a paper charge form. Some EHR programs do not yet have the ability to output charge data.

44 CMS-1500 vs. UB04 Paper claims it is how healthcare is paid for. CMS-1500 is used for Part B / physician / DME billing. UB04 is Part A / Facility billing Billing is usually now performed electronically Billing is usually now performed electronically via the internet.

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46 Hospital End-Stage Renal Disease Facility Federally Qualified Health Center Histocompatibility Laboratory Home Health Agency Hospice Indian Health Services Facility Organ Procurement Organization Outpatient Facility Physical Therapy Services Outpatient Facility Occupational Therapy Services Speech Pathology Services Religious i Non-Medical Health Care Institution i Rural Health Clinic Skilled Nursing Facility

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48 Used to bill the following types of charges using CPT & HCPCS codes: Physician DME Ambulance

49 All data elements are compared by insurers to ensure they are paying a valid claim only for their insured. Code edits 9 Gender, age, frequency, etc. Data matches & passes coding edits = paid claim! Mismatch = denied claim = more work. Ugh!

50 PQRS = Physician Quality Reporting System Aimed at improving quality of care including readmissions to hospitals. Uses a combination i of incentive i payments (carrot) and payment adjustments (stick) to promote reporting of quality information by eligible professionals (EPs). Code based. $.00 or $.01

51 erx = electronic prescriptions Aimed at decreasing Rx errors which improves the quality of care. Before 2014, used code G8443 to indicate the patient s Rx was sent electronically to a pharmacy. In 2014 is part of Meaningful Use

52 835 vs. manual posting Is someone following up on denials timely? Medicare 1 year from DOS to bill

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54 Yikes! What happened? Patient not covered? Service not covered? Why? Billing error? Wrong or missing i modifiers ICD-9 code not valid for CPT or HCPCS Use of outdated t d codes Billing during global periods

55 Reason and Remit Codes convey why codes paid or denied. MA130 Your claim contains incomplete and/or invalid information M79 Missing / Incomplete / Invalid Charge M76 Missing / Incomplete / Invalid Diagnosis OA22 This care may be covered by another payer per COB

56 Working denials: -Paper EOB - Insurance Report, or - Electronic work queue. Watch timely filing deadlines.

57 Avoiding and correcting mistakes Avoiding the F word - Fraud What is documented in the medical record? What is being billed? Do they match? Close only counts in horse shoes and hand grenades!

58 Fraud Knowingly billing for a service that was not performed. Post-payment audit Pre-payment audit (death by delay?)

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60 Uninsured rate down from 17.1% to 13.4%. Roughly 8-11 million patients. Approximately 1 in 4 who were not insured last Fall now have coverage. Of the 5.4 million enrollees who use to enroll before mid- April, 87% received federal subsidies. To qualify for a subsidy, projected annual income had to be % of the Federal Poverty Level (~ $11,490 - $46,000)

61 High Deductible Plans - $1,000 - $10,000+ The Non-Medicare Paradigm has shifted to greater patient responsibility! Medicare deductible d is $147 in Maximizing patient payments requires strong, written financial policies & procedures.

62 Characteristics of best financially performing practices: Verify insurance when patient calls for the appointment. Use electronic eligibility verification during the call. Remind the patient to bring their co-pay pay. 1-2 days prior to the appointment, re-check eligibility. Always collect the co-pay on the DOS when the patient arrives. Check the billing software for other unpaid patient balances ask the patient how they want to pay? Need a referral or authorization? Receptionists and those staff making appointments are key people! Look for the right characteristics.

63 If not contractually prohibited, collect part of deductible balances on the DOS. Create a spreadsheet of Allowables for each major insurer for the most common CPT/HCPCS codes. Don t give them an option: Do you want to pay by cash, check, or credit card? If an overpayment occurs, promptly refund the balance.

64 Accept and offer: Patient Balances Credit & debit cards, FSA, HSA, & HRA Cash & checks Patient t portals First born child, indentured servitude?

65 Secure online website 24-hour access Providers can communicate with patients Patients can pay their bills without your staff Encourages patients to be more engaged in their care - can check test results, schedule appoints, etc.

66 RVU s: NCCI edits: nalcorrectcodinited/ncci-coding-edits.html Medigap Policies: other-insurance/medigap/whats- medigap.html

67 Railroad Medicare

68 Questions?