Transcript The Dynamics of Implementing HIPAA in the AR

Skills for the New
Healthcare Internal Auditor
Revenue Cycle
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WELCOME TO MY WORLD!
What is the “Revenue Cycle?”
It is the entire process: From scheduling,
to pre-admission, to registration, to charge
capture, to HIM coding, to patient financial
services/business office’s claims submission, to
insurance resolution, to payment in full—with or
without financial counseling –or bad debt.
Each component has potential for audit.. But first
let’s learn some of the basics.
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Outlining
The
Revenue Cycle
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Definition of basic terms
Admitting-Central Registration-Patient Access
Scheduling – central scheduling vs each dept does
their own
Charge capture – the process of the revenue
generating departments marking charge tickets or
order entry.
Health Information Management/HIM – medical
records
Business Office – Patient Financial Services
Hold days - # of days hold before dropping off
the computer (usually 4-7 after d/c. Need to wait 72
hours for all Medicare accounts.)
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More Terminology Help
CPT- procedure codes that outline
what procedure was done. (updates Jan
yearly) CPT=# 0-9999
HCPC – a 2nd type of procedure coding
– but alphabetical. J/pharmacy; G &
C/usually temporary Medicare only
codes (updates April yearly)
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Health Information Management/
Medical Records
All visits require an ICD/diagnosis code
before the claim will be processed by the
payer
HIM coders take the physician
dictation/notes and assign ICD as well as
CPT codes, where appropriate
Coding backlog occurs due to physician
delays, record delays and coder shortages=
cash delays.
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How are charges submitted to
payers?
IT creates billing
document.
UB-04/837I form is for
hospital charges sent to
payer.
1500/837P form is for
physician/professional
charges.
Forms are sent
electronically (65%) or
hardcopy to payers/health
plans
HIPAA Transaction Sets
dictated standardization 7
What is an AR Day?
An indicator of how fast the cash is moving
Different ways to count an AR Day:
From Final bill to paid in full
From Discharge to paid in full
Gross vs net days
Gross – without deductions
Net – with allowance/reductions for
different items: bad debt, contractuals,
etc.
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Redesign Revenue Cycle Opportunities - WIN
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How Medicare’s Common
Reimbursement Systems Work
Inpatient: Diagnostic Related Groups/DRG
Uses Dx, procedures where an end coder groups
into payment categories (1 payment/1 stay)
Outpatient: Ambulatory Payment
Classification/APC (Each CPT could be paid)
Uses CPT and HCPC codes to group clinically and
financially related codes into APC payment groups
Skilled Nursing facilities – Resource Related
Group (a # of days = 1 RUG payment)
Home Health – Home Health Related Groupers (1
HHRG $ for each 60 day care plan)
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Reimbursement Systems
Remittances –payment document from the payers
What type of payment arrangements are hospitals
experiencing thru contracting as well as federal
and state mandated:
Prospective payment systems – payment based on
something besides charges: Diagnosis, CPT codes, care
plans. (EX: Medicare PPS: Inpt/DRG; Outpt/APC)
Fee for service – payment based on charges
Per Diem – payment based on a per day rate
Capitation – payment based on covered lives, per member,
per month
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Charge
Description
Master Challenges
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National Issues with CDM/Charge
Description Masters
Congress Sub
Committee/Ways
and Means focusing on hospital
charge structure
Under/Uninsured –
focusing on how
hospitals charge
and collect
MILLION DOLLAR
QUESTION—can
you explain how
your charges were
created to your
community?
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Golden Rule for Charging
Use Medicare Guidelines for all payers
No care team/charge capture staff
member can even tell who the payer is for
the pt.
Question: How are charges to be
created?
Answer: Cost plus a reasonable mark
up
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The Road Ahead
MedPAC survey of
hospital chargesetting practices (904; 6/05):
CDM-lgr/complex
No systematic
relationship: cost to
charge
Mark-ups vary by
service:
low cost items=higher
markup; pharmacy,
supplies and new
services
Payer’s Bill of Rights
Ca Assembly Bill 1627 (eff
7-1-04)
Hospitals have a written or
electronic copy of their
CDMs available on location
Clear and Conspicuous
notice required in the ER,
admission and billing office
List of 25 most commonly
charge services available
upon request
CDM submitted to the
state on an annual basis
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The Charge Description Master
Welcome to the charge master – CDM
It houses all charges that are billable
It houses all stats-only items
It houses all hard coded CPT codes
It houses all activity used for productivity
It requires at least yearly updating with
changes in the CPT and HCPC manuals
It houses all regulatory billing requirements
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Revenue Opportunities within the CDM
Key to success is department ownership
Key to success is understandable charge
descriptors. The MOM TEST!
Key to success is ongoing CDM Integrity
Team work in identifying revenue
opportunities, changing regulations and
teaching to all effected individuals.
Key to success is automation for
research,etc—but only with the above
elements!!
“Computers are useless. They can only give you answers” Pablo Picasso
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Charge Protocol
Manual
Explore how charges are being created.
Who, within each department, is inputting
charges? Charge tickets, order entry, bar
coding?
Interview staff – all 3 shifts – to
determine who/how inputting of charges.
Use actually billing documents – UB04 and
itemized statements to ‘see’ the actual
charge capture.
Develop written protocol on HOW TO!
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Patient Financial
Services/Business
Office
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Hot Spots Within Patient Financial
Services/Business Office
Credit Policy/CP – easily
understood by the patients
& the staff.
Communicated to the
patients early and
throughout the process
Documentation in the
patient’s history shows CP
used.
If not resolved within CP
and not eligible for charity,
turn to bad debt.
EX) Inpt/120 days from
D/c; Outpt/90 days d/c
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More Uglies with PFS
Lost charges –sent to
the floor, never
charged for; charted,
never charged
Late charges – claims
dropped off IT, then
charges submitted.
Cost of both – if
identified, adjusted
bills sent to the
payers.
Patient receive 2
statements –from
payers and facility.
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Let’s Look at the Billing Documents:
UB-04s and itemized Statement
UB-04 = sent to the payers; hardcopy and
electronic
Itemized statement = usually sent to
the patient. Payers, on request only.
Tells the story of the CDM with billable
services.
Roll the itemized to the UB –without
manual intervention
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UB92
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Tracking and Trending
Last but not least,
keep the focus:
PREVENT REPEAT
REWORK.
PFS has a massive
amount of
information.
Sample: Trend late
charges by dept;
eligibility denials
by area; Medical
necessity denials
by CPT code;
manual ‘touching’ to
the UB-92 prior to
submission, etc.
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AR System’s Contact Info
Day Egusquiza, President
[email protected]
208-423-9036
Free Info Line – informal updates,
process ideas, etc.
HAVE FUN!
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