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
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Diagnosis Coding
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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
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National Center for Health Statistics
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pathologically based
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5 digits
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E codes, V codes
Diagnosis Coding
 ICD 10-CM (1989)
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Major change from ICD-9
6882 total codes in ICD-9, 12,420 total codes in ICD-10
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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
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Hierarchies have multiple levels of granularity
International Health Terminology Standards Organization
(www.ithso.org)
Physician Billing
 Common Procedural Terminology (4th edition)
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developed and owned by AMA (1966)
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Updated three times per year
Three categories of codes
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Category I-describe procedure or service
 5 digits; series of 2 digit modifiers
used by all 3rd party payers to describe physician work
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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
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On AMA website
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Medicare fee schedules
Complete RVU breakdown
References describing commentaries on codes
Resource Based Relative Value Scale
 System to measure and compare physician work
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developed at Harvard University (Hsiao); 1989
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first employed by Medicare as payment basis in 1992
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commissioned by HCFA
Medicare keys payment levels to RVU’s
formula includes regional adjuster
three components
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physician work (52% of total value on average)
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time
technical skill
risk
practice expense (44% on average)
professional liability (4% on average)
Development of RBRVS
 Phase I
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vignettes of 25 services per specialty developed
definition of time
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definition of intensity
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physical effort/skill
mental effort/judgment
stress from iatrogenic risk
physician estimates
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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
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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
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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
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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
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Elements of physician credentialing
 Site visits
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managed care plans expected to visit physician offices
 Recredentialing
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every 36 months
primary source
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licensure, board certification, NPDB
 Ongoing monitoring
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between cycles
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quality, complaints, sanctions
Data Banks
 Managed by HRSA (health resources and services administration of
HHS)
 National Practitioner Data Bank
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Created by act of Congress- 1986
alert system to “facilitate a comprehensive review of health care practitioners'
professional credentials”
Includes:
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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
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Mandated in HIPPA (Health Insurance Portability Act-1996)
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civil judgments against health care providers, suppliers, or practitioners
related to the delivery of a health care item or service,
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Federal or State criminal convictions against health care providers,
suppliers, or practitioners related to the delivery of a health care item or
service,
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actions by Federal or State agencies responsible for the licensing and
certification of health care providers, suppliers, or practitioners,
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exclusions of health care providers, suppliers, or practitioners from
participation in Federal or State health care programs,
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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
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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
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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
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