Transcript Document
Prudent Policies Regarding Billing Procedures and Compliance Presented to: September 19, 2008 Presented by: Timothy Tobin, President Objectives 1. Review current industry trends 2. Examine the “ideal” billing process 3. Present “TOP 10” billing and compliance procedures Industry Trends • • • • • • • Federal/State Regulations Reimbursement Trends Accreditations Guidelines Changes in financial responsibility System interoperability Industry horizontal integration Future AR Cycle Source: www.medical-billing-company.com #1 –Insurance Verification • Check prior to surgery – Obtain pre-certification • Inform patient – Facility vs. professional services vs. anesthesia – Financial policy • Collect prior to surgery • Patient payment options • Payment plan: promissory note Promissory Note On this date of ________,in return for valuable consideration received, the undersigned borrower[s] jointly and severally promise to pay to YOUR FACILITY , the "Lender", the sum of $_______ Dollars, • • • • • • • • Terms of Repayment Payable On Demand Late Fees Default Modification Transfer of the Note Severability of Provisions Choice of Law #1 –Insurance Verification • Online Websites – – – – – Availity www.availity.com Medicare www.wpsic.com Medicaid www.michigan.gov/mdch NEBOS www.nebos.com Clearinghouse • Many offer “real time” eligibility and deductible status #2 – Registration & Charge Capture • • • • • • • Scan insurance card and driver’s license Verify registration information Offer online registration Coordinate with the surgeon’s office Develop charge capture tool Reconcile charges Enter timely #3 – Proper Coding • CPT-4 2008: Current Procedural Terminology • HCPCS Level II 2008: Healthcare Common • Procedure Coding System ICD-9-CM 2008: International Classification of Diseases • • • • Specialty association websites Coding software NCCI edits Medicare Part B resources #3 – Proper Coding • 2008 Changes – 450 non-office based procedures – 360 office-based procedures – More than 3,000 procedures on the CMS final list • Note new billable services • Calculate financial impact #3 - Proper Coding • Gastroenterology – screening colonoscopy vs. diagnostic colonoscopy – Polypectomy • Podiatry – Modifier usage – Bunionectomy – Hammertoe • Orthopedics – Knee arthroscopies – Shoulder synovectomies – Hardware removal #3 - Proper Coding • ENT – Bilateral coding – Impacted earwax – Myringotomy vs tympanostomy • Pain Management – Multiple injections – Diagnostic vs. therapeutic injections – Implant neuroelectrodes Operative Note must match Billing! #3 - Proper Coding Payment for procedures includes: – administrative, housekeeping items and services, recordkeeping – nursing services, services of technical personnel – facility use such as pre-operative areas, OR and recovery room areas – diagnostic or therapeutic items and services – materials and supplies used for anesthesia – blood, blood plasma, platelets, etc., except for those applied to the blood deductible – supplies not on “pass through status” – intraocular lenses (except new technology lens) #4 – Timely Claim Submission • Know your payor contracts – timely filing limitations • Verify electronic claim submission • NPI numbers – Search https://nppes.cms.hhs.gov • Patient “statement” letter • Follow-up on claims #5 – Monitor Payments • Reimbursement – 2008 vs 2009 – 4-year phase-in • • • • • • Load fee allowable in system In-network vs out-of-network Calculate case cost “Re” negotiate contracts Know your “carve outs” Survey your referrals #5 – Monitor Payments • Michigan Prompt Pay Laws Department of Legal & Economic Growth www.michigan.gov/dleg – Clean claim must be paid within 45 days of receipt – If not clean, the facility must be notified within 30 days – Penalty for late payment - 12% annually • Appeal denied claims (use Code violation) • Write a letter to the insurance commissioner Source: http://www.michigan.gov/dleg/0,1607,7-154-10555_12902_35510_36782---,00.html #6 – Manage AR • Follow-up on aged AR – – – – Consistently, not at 365 days Use ATB reports Check status: phone, electronic system, online Staff collection worklist • Involve the patient and/or employer • Contact the provider relations rep AR Indicators Key Billing Performance Indicators KPI GOAL Your Facility AR over 120 days Average 12-15% Best Practice < 11% ? AR Days Average 40-45 Best Practice 30-35 ? Net Collection % Average 95-97% Best Practice > 98% ? AR Indicators AR Liquidation Table Payer Medicare % of Charges 20% % of AR 10% BCBS 35% 30% Commercial 25% 15% Medicaid 15% 25% Self 10% 20% #6 – Manage AR Patient Collections • Implement collections procedures • Statements vs. Letters • “Dial for Dollars” • Fair Debt Collections Act • Use a collection agency • Legal options #7 – Work Denials • • • • Track denials by category Know the payor’s appeal process Pay attention to timeliness Don’t give up! #7 – Work Denials 30% 70% Processed 5 Billion Claims Rejected • Almost 1 out of every 3 claims is denied • 15% never worked • Goal - 7.1% denial rate #7 – Work Denials Top 10 Denials 1. Registration error 2. Eligibility issue 3. Lack of authorization/referral 4. Coding/bundling 5. Medical necessity 6. Untimely filing 7. Duplicate 8. Addition information requested 9. Coordination of Benefits 10.In process #8 – Know Your Contracts • In-network vs. out-of-network • Is the patient getting paid? – Have patient sign a promissory note before the surgery • • • • Monitor reimbursement Note payor requirements Carve-outs Negotiate #9 – Have a Compliance Plan 1. 2. 3. 4. 5. 6. 7. Internal monitoring & auditing Compliance & practice standards Compliance officer or contact person Education/training Respond to offenses Open lines of communications Enforce disciplinary standards #10 – Prevent Internal Fraud Association of Certified Fraud Examiners reports: – Smaller organizations suffer • $127,000 median loss – 6% of total revenues • Based on GNP, 600 Billion or $4,500 per employee – Embezzlers are older • $18,000 with aged 25 or younger • $500,000 aged 60 years or older – 80% of the time – 1 in 4 employees has been employed >10 years #10 – Prevent Internal Fraud 1. 2. 3. 4. 5. 6. 7. 8. Set up rigid protocols Implement system audit trail Perform independent audit Send staff on vacation Look through drawers Review canceled checks and bank statements Sign vendor checks w/matching invoice Purchase insurance #10 – Prevent Fraud 8. 9. 10. 11. 12. 13. 14. Segregate duties/create job description Create checks and balances Use a lockbox Monitor adjustments Create a budget Perform random drug testing Inform staff Conclusions • • • • • Measure KPI Monitor, monitor, monitor Take action Review your information systems Outsource for more efficiency, protection and net bottom-line Websites BCBSM: http://bcbsm.com/ BCBSM EDI Professional Commercial Payer List: www.bcbsm.com/pdf/commercial_payer_list.pdf BCBSM EDI user guide for 837 format: www.bcbsm.com/pdf/edi_userGuide.pdf Medicare CSNAP: www.medicareinfo.com/apps/cms/home.do Medicare: www.wpsmedicare.com Centers of Medicare and Medicaid Services: www.cms.hhs.gov Cofinity (formally PPOM): www.ppom.com/ppomui/index2.aspx HAP: www.hap.org About Medorizon • Operating for over 20 years • Full service medical billing company – Complete revenue cycle management – Practice management system installation – ASP system hosting www.medorizon.com