Reimbursement 2011
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Transcript Reimbursement 2011
Patient Care Services
Reimbursement: 2011
ROBERT SHESSER M.D. MPH
GEORGE WASHINGTON UNIVERSITY
Patient care services reimbursement
Revenue cycle
Diagnosis coding
Procedure coding
Credentialing
Compliance
Productivity Monitoring
Reports
Revenue cycle I
Chart acquisition
Coding
Data entry
Charge lag- interval between treatment and billing
Billing
Primary and secondary
Charge posting, clean up, reporting
Accounts receivable
everything that has been billed, but not collected
Unit is “days” (total receivables/average charges/day)
Revenue cycle II
Benchmarking performance
No data on charge lag
Coding, Billing should cost 8% of collections
GW MFA data
Charge lag EMR system: 5 days
Charge lag paper charting: 8 days
Chart acquisition, coding, data entry, charge correction,
registration updates
$4.13/chart
3.6% collections
Diagnosis Coding
ICD (International Classification of Diseases)
1853-first International Statistical Congress-classification of mortality
1893 - International List of Causes of Death- adopted by US 1898
1948 WHO took ILCD and developed ICD- included morbidity coding
application in US by National Center for Health Statistics
• branch of CDC
developed ICD 9-CM (clinical modification) (1976)
official system of assigning codes to diagnoses and procedures
associated with hospital utilization in the United States
National Center for Health Statistics
pathologically based
5 digits
E codes, V codes
Diagnosis Coding
ICD 10-CM (1989)
Major change from ICD-9
6882 total codes in ICD-9, 12,420 total codes in ICD-10
Chapters (icd-10); Sections (icd-9)
Letter followed by 4 numbers
Codes reserved for provisional assignment of new diseases
Country-specific clinical modifications- make certain comparisons
difficult
ICD-10 CM in US; implementation date 10/1/13
Includes procedure codes
Diagnosis Coding
ICD-11
Process started in 2002
Attempting to decrease country-specific variations
Web-based, function in an EHR environment
Won’t be presented until 2014
SNOMED-CT (Systematized Nomenclature of Medicine Clinical Terms)
Core of the electronic health record
311,000 active concepts with unique meanings
formal logic-based definitions organized into hierarchies
Hierarchies have multiple levels of granularity
International Health Terminology Standards Organization
(www.ithso.org)
Physician Billing
Common Procedural Terminology (4th edition)
developed and owned by AMA (1966)
Updated three times per year
Three categories of codes
Category I-describe procedure or service
5 digits; series of 2 digit modifiers
used by all 3rd party payers to describe physician work
about 8000 codes
E&M codes versus procedure code
Category II- supplemental tracking codes for performance measure reporting
Category III- tracking codes for new and emerging technologies
On AMA website
Medicare fee schedules
Complete RVU breakdown
References describing commentaries on codes
Resource Based Relative Value Scale
System to measure and compare physician work
developed at Harvard University (Hsiao); 1989
first employed by Medicare as payment basis in 1992
commissioned by HCFA
Medicare keys payment levels to RVU’s
formula includes regional adjuster
three components
physician work (52% of total value on average)
time
technical skill
risk
practice expense (44% on average)
professional liability (4% on average)
Development of RBRVS
Phase I
vignettes of 25 services per specialty developed
definition of time
definition of intensity
physical effort/skill
mental effort/judgment
stress from iatrogenic risk
physician estimates
pre-service, intra-service, post-service
national surveys
small group processes
services in different specialties cross-linked by multiple regression
Resource Based Relative Value Scale
Complex process of updating
Social Security Act mandates review every 5 years
AMA/Specialty society update committee
Relative Value Update Committee (RUC)
receive input from specialty societies
send recommendations to CMS
CMS does final review and makes decisions
Emergency Medicine E and M codes
Physician Credentialing
Process to verify physicians’ licensure, training and experience
Licensure
State medical license
Federal and state DEA numbers
Experience
Residency training
Board certification
Hospital medical staff membership
Medicare
Individual NPI number
Assigned directly by CMS
Started by Medicare
will replace all provider numbers for all payers
Group NPI number- provider group number
Physician Credentialing
Hospitals
governed by JCACO processes (http://www.jcaho.org/)
Third party payers
Medicare (http://www.cms.hhs.gov/)
Carriers (http://www.trailblazerhealth.com/)
Medicaid (http://dchealth.dc.gov/information/maa_outline.shtm)
Managed Care
NCQA (http://www.ncqa.org)
Medical Groups
delegated credentialing
Elements of physician credentialing
Rigorous processes
policies
practitioners can review material and correct if inaccurate
Peer-review multidisciplinary committee
Initial application
primary source verification
license, training, education, board certification, work hx, liability hx
5 years of work history; gaps> 6 month need clarification
National Practitioner Data Bank
Practitioner must attest to
health status, history of loss, limitations of privileges
Elements of physician credentialing
Site visits
managed care plans expected to visit physician offices
Recredentialing
every 36 months
primary source
licensure, board certification, NPDB
Ongoing monitoring
between cycles
quality, complaints, sanctions
Data Banks
Managed by HRSA (health resources and services administration of
HHS)
National Practitioner Data Bank
Created by act of Congress- 1986
alert system to “facilitate a comprehensive review of health care practitioners'
professional credentials”
Includes:
adverse licensure actions by the States
clinical privileges actions by Hospitals
professional society membership actions
paid medical malpractice judgments and settlements
exclusions from participation in Medicare/Medicaid programs; r
Adverse registration actions taken by the U.S. Drug Enforcement
Administration (DEA).
Allied health practitioners added in 2010
Data Banks II
Healthcare Integrity and Protection Data Bank
Mandated in HIPPA (Health Insurance Portability Act-1996)
civil judgments against health care providers, suppliers, or practitioners
related to the delivery of a health care item or service,
Federal or State criminal convictions against health care providers,
suppliers, or practitioners related to the delivery of a health care item or
service,
actions by Federal or State agencies responsible for the licensing and
certification of health care providers, suppliers, or practitioners,
exclusions of health care providers, suppliers, or practitioners from
participation in Federal or State health care programs,
any other adjudicated actions against health care providers, suppliers, or
practitioners
System Performance Monitoring
Cash versus accrual
Net Revenue = Gross Charges minus Contractual Allowances
Allowance- a contractually agreed upon discount
Bad Debt- unpaid balance
Timely filing deadline
Specified in most contracts
Medicare is most forgiving (12 months)
Many commercial plans are 90 or 120 days
DC Medicaid is 180 days
Performance Monitoring
Useful Metrics
Physicians
Patients per physician-hour worked
RVU’s per physician-hour worked
RVU’s per patient
Practice level
Accounts with charges by year and by month
Collected Dollars per closed case
Collected dollars per billed RVU
Total cash collected from the prior month