FHCA 2014 Annual Conference & Trade Show

Transcription

1 FHCA 2014 Annual Conference & Trade Show CE Session #32 Precision Solutions for Reimbursement Challenges Wednesday, July 9 5:30 to 7:00 p.m. Crystal N/J2 Finance/Development Upon completion of this presentation, the learner will be able to: identify three common problems encountered in successful collection of third party receivables; describe their role and its interface with clinicians in assembling complete and pertinent medical records for audit by Recovery Auditors, ZPICs and other third party contractors; and describe how to investigate collection problems and outline an effective action plan when accounts receivable billing and collection practices are ineffective. Seminar Description: This session will stress practical solutions to address common barriers to successful billing and collection in the current SNF environment. Topics will include ensuring good admission data for billing, insurance verification, resolution of problem claims and interfacing with payers. The importance of interdisciplinary cooperation and effective data collection will be a focus area, as will tips to facilitate accurate identification of the underlying cause of collection issues to assist management in problem resolution. Presenter Bio(s): Felice Landry, Senior Consultant with, is a Senior Healthcare Consultant with over 25 years of experience in management of accounts receivable in long term care. She has conducted operational assessments of billing and collection processes to improve efficiency and to minimize avoidable write-offs due to untimeliness of claims or non-compliance with payer requirements.

2 This image cannot currently be displayed. 5/27/2014 Precision Solutions for Reimbursement Challenges Presented to Florida Healthcare Association (FHCA) July 9, 2014 By: Felice Landry, Senior Billing Consultant Precision Solutions for Reimbursement Challenges UB04 your road-map to reimbursement 1

3 Precision Solutions for Reimbursement Challenges Agenda: Identify the payer Accurate Data Collection Insurance Verification Reconciling Problem Medicare Claims Best Practices Communicate with the TEAM Questions and Answers Identify the payer Who pays first? Traditional Medicare Medicare Part C Commercial Insurance Other payer primary to Medicare 2

4 Identify the payer Traditional Medicare Check entitlement for A & B Days available in benefit period Enrolled in hospice? Skilling service Therapy Limits Identify the payer Medicare Part C What type of MAP is the plan? Health Maintenance Organization (HMO) Preferred Provider Organization (PPO) Private Fee for Service (PFFS) 3

5 Identify the payer Commercial Insurance Auto insurance Long term care insurance Worker s Compensation Insurance Identify the payer Other insurances primary to Medicare Group Health Auto Liability Worker s Compensation 4

6 Accurate Data Collection Regardless of the Payer: Request and make copies of ALL available insurance cards Verify entitlement/eligibility Compose a script of questions to assist in compiling the correct information Complete insurer tool to determine primary payers to Medicare Accurate Data Collection Audit input in software Ensure that anyone who enters information into the software is properly trained Conduct periodic checks for errors or problems Review and analyze software reports 5

7 Insurance Verification Copy front and back of ALL available insurance cards. Insurance Verification Develop a system Each patient record should have relevant information identified Effective date Deductible Copay Contact information 6

8 Insurance Verification Utilize online insurance data bases Availability and ease of use Determine if they provide the desired information Current Problems by Payer Medicare Is the health insurance claim number (HIC) correct? Is the name spelled correctly according to social security s information Is the date of birth (DOB) correct? Is Medicare the primary payer? 7

9 Current Problems by Payer Medicare Advantage Plans (MAP) Part C What type of MAP is the plan? Do I need to be contracted with the plan? How will I be reimbursed? Current Problems by Payer MediGap/Supplemental Coverage 1. Does the plan pay days ? 2. Does the plan pay the 20% of Part B services? 3. Is prior authorization required? 8

10 Current Problems by Payer Medicaid Is the patient eligible for institutionalized Medicaid? Am I set up to bill the Managed Care Organization (MCO) for the patient? Reconciling Problem Medicare Claims UB04 Examples 9

11 Reconciling Problem Medicare Claims Medicare System Errors Reason Code V8024 Occupational therapy expenses limit over applied. Reconciling Problem Medicare Claims Medicare System Errors Reason Code This is a SNF, and the occurrence span code 70 (qualifying stay) thru date is greater than the claim admission from date. 10

12 Reconciling Problem Medicare Claims Medicare System Errors Reason Code C7123 A COVERED SNF CLAIM (21X) WHERE THE CLAIMS'S ADMISSION DATE AND FROM DATE EQUALS THAT DOES NOT MEET THE QUALIFYING STAY CRITERA. Reconciling Problem Medicare Claims Medicare System Errors Reason Code DIAGNOSIS IS AN EXACT MATCH OR WITHIN THE FAMILY OF CODES AND THERE IS NO EVIDENCE IT WAS SENT TO WORKERS COMPENSATION, AND THE SERVICE IS WITHIN THE 120 DAY PROMPTLY PERIOD. 11

13 Best Practices Financial Department Processes Month End Close Discuss any snags encountered Census Reconciliation Billing issues resulting from incorrect data Triple Check Is it producing the desired affect Best Practices Communicate Request a list of monthly billing errors by payer Identify the areas affected Provide training where applicable 12

14 Precision Solutions for Reimbursement Challenges Questions and Answers 13