Transcript Patient Access and MSP

Patient Access: Leading
the Way
2012 Revenue Cycle Fall Workshop
WV Chapter, HFMA
Presented by:
Sandra J Wolfskill, FHFMA
President
Wolfskill & Associates, Inc.
[email protected]
Agenda
• Registration Accuracy – Getting it
right the first time!
• Medicare Secondary Payer
• Closing Thoughts
2
Opening Exercises …
• Survey question 1: how many
hospitals have formal quality
assurance programs in patient
access?
• Survey question 2: how many
hospitals have informal QA review
activities performed by supervisors or
leads?
3
What Do You Value Most?
Your Perspective
As Evidenced By
Staff’s Perspective –
Staff will …
5.
4.
3.
2.
1.
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Why Formal QA Programs Work
• QA programs are designed to track and
report accuracy rates in order to:
• Reduce/eliminate denials
• Ensure compliance with government
regulations
• Identify patterns of poor work
• Identify training needs
• Demonstrate compliance with corporate
integrity agreements
• Hold staff accountable for established
performance outcomes
5
Automated vs. Manual Programs
• Recent surveys suggest that majority of
programs are manual and daily
• Automated options include:
• DaVincian
• AHIQA
• AccuReg
• CPSI
• Emdeon Denial Management
• Compass and Epic
• McKesson
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Building Accountability
• Moving beyond simple error tracking
• Knowing consequences to
performance failures
• Clearly documenting the
organization’s tolerance for error and
rework
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If 99% is good enough …
• Do you want to be on the airplane
serviced by the mechanic whose
performance standard was 99% right?
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Implementing an Effective QA
Program
• Set standards and expected outcomes
• Establish disciplinary steps to support seriousness of
expectations
• Embark on comprehensive training program to bring
all staff to expected level of expertise and set=up staff
to succeed:
• Identify what staff doesn’t know
• Review registration errors identified in your QA
program
• Using variety of resources, TRAIN staff
•
•
•
•
Webinars
Intranet
CHAA Certification resources from NAHAM
CRCR Certification resources from HFMA
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Implementing an Effective QA
Program
• Start program
• Report results on regular basis
• Enforce consequences for failure to
perform to standards
• Retool as issues change (dynamic
nature of program)
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Trick or Treat?
The “trick” with MSP is to get it right;
The “treat” is that you get a passing report from the MSP Auditors!
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MSP: Common Errors
• Patient’s insurance as registered is in
conflict with the MSPQ answers
• Incorrect payer/plan information recorded
during registration
• Missing required information (addresses for
“other” payer)
• Failure to record occurrence code and date
for codes 18 and 19
• Information on MSPQ does not match how
the account was actually billed
• Incorrect subscriber identification
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MSP
• MSP audits – did you go through an
audit?
• What were the lessons learned for
your hospital?
• What changes have you implemented
as a result of the audit experience?
13
MSP – Test Your Knowledge
• Source: Medicare Secondary Payer
Manual available at :
http://www.cms.gov/Regulations-andGuidance/Guidance/Manuals/InternetOnly-Manuals-IOMsItems/CMS019017.html
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MSP
• Do you know the details?
• List the only MPS provision included in the
1965 Medicare law:
• In 1980 the MSP provisions were redefined to
include group health plans, worker’s
compensation, liability or no-fault. What other
payers are primary to Medicare and for which
does Medicare pay secondary benefits?
15
MSP
• List details of the Liability rule:
• List details of the ESRD rule:
• List details of the Disability rule
• List details of the Working Aged rule
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The Answer Is …
• True or false: The primary payer may decline to
make a primary payment based on its contract
which calls for Medicare to pay first.
• True or false: Employer group health insurance
plans for retirees are primary to Medicare.
• True or false: The coordination period for
beneficiaries covered under ESRD provisions
begins three (3) months after the beneficiary
begins Medicare eligibility.
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The Answer Is …
• True or false: If a group health plan denies
payment for services because they are not
covered b y the plan as a plan benefit for all
covered individuals, Medicare plays as primary if
the services are covered by Medicare.
• True or false: The claim for a 66 year old
disabled Medicare beneficiary whose spouse is
employed by an employer with 250 employees is
an example of a disability MSP claim.
18
The Answer Is …
• True or false: If the failure to take proper and
timely action results in a loss of work
compensation benefits, Medicare benefits are
not payable to the extend that payment could
reasonably have been expected under Work
Compensation.
• If a beneficiary receives a Work Compensation
settlement that includes funds for future medical
expenses, Medicare will pay for those future
expenses.
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The Answer Is …
• True or false: Medicare is not secondary to all
types of no-fault insurance.
• True or false: Medicare will not make a
secondary payment if the provider accepts the
primary plan as full payment or full satisfaction
of the patient’s responsibility.
• True or false: in the Medicare manuals, the term
Work Comp (WC) includes Federal WC programs
such as the US Department of Labor.
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The Answer Is …
• Case: A Medicare beneficiary with GHP coverage
was a hospital inpatient for 20 days. The
hospital's charges for Medicare covered services
were $16,000. The inpatient deductible had not
been met. The gross amount payable by
Medicare for the stay in the absence of GHP
coverage is $11,500. The GHP paid $14,000, a
portion of which was credited to the entire
inpatient deductible. How much will Medicare
pay?
21
The Answer Is …
• True or false: With regard to WC insurance and
no-fault insurance, prompt or promptly means
payment within 90 days after receipt of the
claim.
• An individual who has not met any part of the
Part B $140 deductible incurred $140 in charges
for which the GHP paid $70. The Medicare fee
schedule amount was $140.
• How much is credited to the Part B deductible?
• How much will Medicare pay?
• How much will the patient owe?
22
The Answer Is …
• True or false: A Medicare beneficiary may not
reject employer coverage for self or spouse.
• True or false: If an individual becomes entitled
to Medicare based on age or disability after
being entitled based on ESRD, the coordination
period automatically ends on the date of the
disability or age eligibility.
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The Answer Is …
• Case: William Moneypenny, age 75, is a Medicare
beneficiary with coverage under Part A and Part B. He
retired from the Acme Tool Company in 2003 and
received retirement health insurance coverage that is
secondary to Medicare. His wife, Mary, age 64, has been
employed continuously with the local police department
since 1977 and since that time has received coverage for
herself and her husband under the department's GHP.
The priority of payment for John's medical expenses is as
follows:
• Primary payer is __________________
• Then what happens? ________________________
____________________________________________
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The Answer is …
• For the same case as on the previous slide:
If the retirement plan is permitted to pay after the GHP under
the private coordination of benefits, the order of payment will
be as follows:
• Case: Chris Kringle, age 67, is a Medicare beneficiary with
coverage under Part A and Part B. He has been employed
continuously by XYZ Bolt Company since 2002 and has GHP
coverage through his employer. His wife, Glenda, age 62, has
been retired from the local police department since 2000 and
received retirement health insurance coverage for herself and
her husband that is secondary to Medicare. The order of
payment for Chris' medical expenses is as follows:
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Summary
• Foundation for success is a strong QA program
with known and enforced rewards and
consequences
• There is NO excuse for anything less than 100%
accurate compliance with MSP rules
• The road to continued success is paved with the
motto: Train Train Train for Success!
• Patient Access should always lead the way to the
highest level of quality and accuracy within the
revenue cycle
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Contact Information
Sandra J Wolfskill, FHFMA
Wolfskill & Associates, Inc.
[email protected]
440-285-4094
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