Revenue Cycle WHCA Spring 2018

Transcription

1 Revenue Cycle WHCA Spring 2018 Revenue Cycle Management in a Changing Business Office 5343 North 118 th Court Milwaukee WI fax Presenter: Mary Petersen, NHA Employed by Specialized Medical Services 29 years in SNF and LTC, 19 at SMS Areas of Expertise Billing all payers Collections and A/R management Mary.petersen@specializedmed.com direct office line Key objectives SNF Revenue Cycle A verified payer = accurate billing Pre-admit Attempt to verify 2 payers: primary and secondary Payer determines billing and collections Reduce denials: save time Improve collections Collections Follow up Monitoring Tools Claim Submission Admit Charge capture Status of many facilities Census decreasing but workload is not decreasing Increased number of payers Speed of admissions (pre-admit time decreasing) Diverse referral sources (not always hospital) Staff reductions Regulation changes Goal be proactive not reactive Time for change Why certain payers only billing at end of month? When is the last time you have reviewed what financial/billing software can do? Payment of a claim does not equal accurate billing Verify payer MORE than on admit 5343 North 118 th Court Milwaukee WI Phone #

2 Revenue Cycle WHCA Spring 2018 Ideal admissions process Intake Get info from referral source Verification usually phone call Payer ID Method of reimbursement Confirmation Paper proof of coverage Authorization in hand Payer ID Medicare assigns a plan number to each Medicare Advantage plan A Payer ID is a unique ID number that is assigned to an insurance company for the purpose of transmitting your claims electronically. Each company has a specific number, and it must be 100% correct in order to collect on each claim. Good practices Good practices Define staff roles in Admission process Don t assume all areas are covered Admission process far reaching to point of scanning updates in on line Set up all involved team in free software systems and do basic training Example Medicaid portal Obtain copy of card: Anthem, UHC, and Humana available on line Obtain Hospital face sheet Software to verify benefits Call insurance company Check Medicare/Medicaid/Family Care benefits in respective portals Good practices Review annually payer contracts Clinical Staff Authorizations Updates needed Rugs vs. levels Billing Staff Method reimbursement New plan changes based on payer id Good Practices Match Payer ID to contracts United Health Care Network Advantage 5343 North 118 th Court Milwaukee WI Phone #

3 Revenue Cycle WHCA Spring 2018 Good practices Review annually payer contracts Compare to software set up Charge structure Compare to payment remits What denials are you seeing with each contract? Timely filing? Payers not contracted Review on going issues Keep notes on things learned Aetna Medicare Advantage example Authorization Anthem contract vs. non contract reimbursement Missed revenue Rate set up in software Therapy Family Care, Medicaid, Partnership Cash posting issues Medicaid liability when hospice or family care some of month Bill for all covered services Missed Revenue Change of Therapy assessments RUG is RUA0d and ARD is 3/6/18 When does payment for RUA start? 7 days back from ARD - See 10 to 15 a month of these that facility software does not take back the 7 days Cash posting is best monitoring tool to revenue cycle Denial management The process for cash posting and opening mail determine success of denial management Many remits on line as well Many have EFT option 5343 North 118 th Court Milwaukee WI Phone #

4 Revenue Cycle WHCA Spring 2018 Cash Posting remit reviews Stamp date received Payments and Denials on same remit, total paid zero Review for charges too low (under billed) Missing co payments, co insurance and deductibles that need to be billed to secondary payer Number of Duplicate denials Insurance tips Anthem ID 3 letter prefix They don t use on authorization Look up in Availity upon admit Anthem ID start with R = Federal All benefits in SNF change 1/1/18 Medicare ID Social is Medicare is D AARP vs. UHC id numbers Common Claim Denials Lost claims vs. Denied claims Incorrect Patient info Coverage terminated Prior Authorization needed Duplicate claim Common Claim Denials Timely Filing Services Excluded Request for Records Coordination of Benefits Missing HCPCS/Revenue codes Common Claim Denials Denial code says Not covered by plan Real issue Room and Board needs to be billed as specific revenue code 0110, 0120, 0192 etc Facility has all private rooms and insurance needs a value code on claim Common denials: insurance based Date of Admit on claim match Authorization Really check as many require new authorization Does software treat discharges as transfer vs. discharge? this can impact what admit date is on the claim 5343 North 118 th Court Milwaukee WI Phone #

5 Revenue Cycle WHCA Spring 2018 Common Denials: insurance based Authorization not go until discharge day only day prior causes denials Authorization is 10/1 to 10/12, resident went home 10/13. Claim is billed 10/1 to 10/13 showing discharge = DENIED Diagnosis match authorization Resident hospice at time of stay Rejected/Lost Electronically Billed Claims EDI language 837 and is file created in billing software to transmit 277 is the file returned from payer to show claims that were accepted by payer or rejected. IS your staff downloading and opening the 277? Many struggle to find a formal to open FREE online to download software Medicare denials Medicare is not primary MSP No 3 night stay Hospice Overlapping stay Medicare B outpatient person not ever d/c from SNF Pitfalls to process Software changes Staff turnover Upon admit one payer and learn a change occurred How often rechecking benefits? Employer plans are pushing Medicare Advantage vs. Supplement plans Enrollment in Family Care whenever is allowed Medicare/Medicaid other portals Pitfalls to process Billing Software may determine some of the denial trends How software handles transfer vs. discharges? Is software updated with correct DEFINITION of status codes? Example 05 Value Code 80 Clinical and Financial/Billing use different software Pitfalls to process Hospital says no three night inpatient stay and later change observation stay to inpatient three night stay Advantage plans Facility never had Authorization or RUGS Medicare or insurance premium not paid QIO overturned and Authorization not extended 5343 North 118 th Court Milwaukee WI Phone #

6 Revenue Cycle WHCA Spring 2018 Solutions/ideas to preventing denials Solutions Review what is pre billing review process? Who reviews claims? Diagnosis Authorization matched to claim Rugs review Claims vs. Payer contracts Solutions/ideas to preventing denials Where claim sent? Sending electronic to where? Sending electronic did claim get there? Paper vs. Electronic is big factor on MUST have admit information Review staffing Number of employees vs. Duties Number claims/invoices track Division of duties Keep like things together Limit retouching of paper Tool attached: edit, add, make your own Factors to always think about Payers Technology Processes People 5343 North 118 th Court Milwaukee WI Phone #

7 Revenue Cycle WHCA Spring 2018 Case Review 1 Admission Case Reviews Facility is told Medicare is primary and UHC is the secondary from hospital. Admitted 1/23/18 from hospital following 3 night stay (yes, inpatient) Facility did not run a Medicare common working file screen Case Review 2 Resident admitted Medicare A with back up on Anthem and pending Medicaid Case review 3 Resident admitted as UHC. Facility did obtain copy of card on line UHC Community Care Kingston NY Case review 4 Resident admitted with Aetna Advantage plan Facility called Aetna and they said no auth needed = AUTH IS NEEDED Aetna is billed and claim denies as person is covered by Hospice Case review 5 Resident Admitted from ER with Medicare and Physician s Mutual Supplement insurance Call PM and determine Mandate benefits Bill Medicare for denial on room and board Bill PM for Room and board with Medicare denial Bill Medicare B for therapy and PM for 20% 5343 North 118 th Court Milwaukee WI Phone #

8 Revenue Cycle WHCA Spring 2018 Case review 6 Resident in hospital 10/4 to 10/17/17, discharges to swing bed from 10/17 to 10/31/17 Admitted to SNF 10/31/17 How many Medicare days are left? Codes 70, 71 and 78 on claims Case review 7 Resident Medicare A 9/30/17 to 11/15/17 went home on 11/16 Hospital calls and person is to return on 1/13/18. Do we need new 3 night stay? How Many Medicare days does the person have? Facility self check list To be handed out at the session on 4/13/18 The materials contained herein include information and facts and the opinions and recommendations of Specialized Medical Services, Inc. (SMS) regarding governmental regulations, statutes and practices, and potential changes to same. Notwithstanding anything to the contrary stated or implied in any of the materials available herein, SMS and its employees cannot and do not make any representation, warranty, endorsement or guarantee, express or implied, regarding (i) the accuracy, completeness or timeliness of any such information, facts or opinions or (ii) the merchantability or fitness for any particular purpose thereof, nor shall any of such materials be deemed the giving of legal advice by SMS or its employees. All participants should consult their own legal advisors, applicable regulatory entities and other sources of legal information and advice for any opinions or recommendations with respect to their own legal situation. Neither SMS nor its employees shall be liable to you or any other person or entity for any loss or injury or any direct, indirect, incidental, consequential, special, punitive or similar damages, or any other damages of any nature whatsoever, arising out of any of the materials (or any portion thereof) contained or not contained herein. BY ATTENDING THIS SEMINAR, YOU HEREBY WAIVE ANY AND ALL CLAIMS AGAINST SMS AND ITS EMPLOYEES ARISING OUT OF YOUR USE OF THE INFORMATION CONTAINED HEREIN. We have provided URL addresses to Internet sites maintained by third parties. Neither SMS nor its employees operates or controls in any respect any information, products or services on these sites, or endorses or makes any representation or warranty regarding these sites. You assume total responsibility and risk for your use of these third party sites. Specialized Medical Services, Inc North 118 th Court Milwaukee, WI fax info@specializedmed.com 5343 North 118 th Court Milwaukee WI Phone #

9 Page # 1

10 CASH POSTING EXAMPLE Page # 2

11 Key Indicator report: SAMPLE Claims and statements per month Cedar Crest Jan-18 Feb-18 Mar-18 Apr-18 May-18 Jun-18 Jul-18 Aug-18 Oct-18 Nov-18 Dec-18 Medicare A Medicare A no pays Medicare B Medicare Advantage A Medicare Advantage B Mandate claims to Medicare Other INS Coinsurance claims A/B Private SNF bills Private other area bills Medicare ADV to Medicare NON SNF private bills TOTAL Referalls and Admissions payer checks done Jan-18 Feb-18 Mar-18 Apr-18 May-18 Jun-18 Jul-18 Aug-18 Oct-18 Nov-18 Dec-18 Referrals - admissions Referrals - not admitted Referal checking therapy cases SAMPLE for 04/13/18 session with Specialized Medical Services, Inc. 4/2/2018 Page # 3

12 BUSINESS OFFICE DIVISION OF DUTIES: SAMPLE WORKING TOOL MODIFY FOR EVERY FACILITY Function Timing Worked performed by Recommendations /notes Census entered to software and checked for accuracy Detailed checking of Medicare and insurance benefits and correct entry to FACILITY software Authorizations for all payers Updates to payers after admission Medicaid care determination (LOC) D/c care determinations and estate recovery notice on Medicaid residents Insurance calls on Medicaid residents (TPL) Medicaid R & B billing Medicaid R & B follow up Medicaid liability review and enter Medicaid HMO/MCO Room billing and follow up (Family Care) Other Medicaid billing: transportation, therapy etc? Private room & board billing & Follow up Medicare A enter Ancillaries: therapy, xray, pharmacy, lab, oxygen, and medical supplies Medicare claims created and checked Medicare claims A sent via electronic Medicare A follow up Medicare A co insurance billing Medicare A co insurance follow up Medicare B enter therapy charges Medicare B claims Medicare B follow-up Medicare B co-insurance Medicare B Medicaid coinsurance Medicare Advantage/Replacement bills room and board Medicare Adv therapy claims ANYTHING ELSE TO ADV ancillary daily daily daily as needed as needed as needed as needed monthly monthly monthly monthly monthly Provided on 04/13/18 by Specialized Medical Services, Inc Page # 4

13 BUSINESS OFFICE DIVISION OF DUTIES: SAMPLE WORKING TOOL MODIFY FOR EVERY FACILITY Function Timing Worked performed by Recommendations /notes Deposits/cash posting/co pay posting Remits download from ability - IMPORT TO software Adjustments in billing software Enter rates in billing software Month end close process and timing Aging review Medicare Credit Balance Report at least weekly and at month end at least weekly and at month end as needed as needed monthly monthly quarterly Vaccine billing BNI Letters issued to residents and families Long Term Care Ins forms assistance for residents Resident Trust account Management Non SNF billing to private pay cover reception area monthly as needed as needed as needed monthly as needed COMPLIANCE BILLING Consolidated Billing late charges to Medicare A FISS on going Medicare No pay bills 1/4ly and upon discharge Medicare advantage bills to Medicare rule eff 1/1/08 Medicare Benefit Exhaust bills on 100 days residents still at skilled Medicare level 10/1/06 rules monthly monthly Medicare Demand bills from ABN as needed Provided on 04/13/18 by Specialized Medical Services, Inc Page # 5

14 Page # 6

15 MAP1752 NATIONAL GOVERNMENT WHCA SPRING SERVICES 2018#06001 ACPFA481 04/02/18 MAP4469 SC ELIGIBILITY DETAIL INQUIRY C201824F 08:49:18 RI 1 MAMMO DT PART B DATA SRV YR 17 MEDICAL EXPENSE BLD DED REM 3 PSY EXP SRV YR BLD DED CSH DED PLAN DATA ID CD H2001 OPT CD C EFF DT CANC DT ID CD OPT CD EFF DT CANC DT ID CD OPT CD EFF DT CANC DT HOSPICE DATA PERIOD 1ST DT PROVIDER INTER OWNER CHANGE ST DT PROVIDER INTER 2ND ST DT PROVIDER INTER TERM DT OWNER CHANGE ST DT PROVIDER INTER 1ST BILL DT LST BILL DT DAYS BILLED PROCESS COMPLETED --- PLEASE CONTINUE PRESS PF3-EXIT PF7-PREV PAGE PF8-CWF INQUIRY COMMON WORKING FILE IN FISS PAGE 2 4/2/2018 8:49:32 AM Page # 7

16 Eligibility Response Response Generated: 4/2/2018 8:44:29 am CT Your Request Payer Medicare (HETS) Last Name Provider ID (NPI) SMS First Name Service Dates 4/2/2017-8/2/2018 Middle Name/Init Member ID DOB Patient Demographics Address Gender F SSN Service Coverage Overview Eligibility Summary Eligible Date Medicare Part A: 8/1/1986 Eligible Date Medicare Part B: 3/1/1992 Medicare Part D Enrollment: 1/1/2018 Contract / Plan #: H Plan Name: SIERRA HEALTH AND LIFE INSURANCE COMPANY, INC. Address: 2720 N. Tenaya Way, Las Vegas, NV Telephone: (877) Status Alert: Medicare Advantage Enrollment: 1/1/2018 Contract / Plan #: H Plan Name: SIERRA HEALTH AND LIFE INSURANCE COMPANY, INC. Message: MCO Bill Option Code - C Address: 2720 N. Tenaya Way, Las Vegas, NV Telephone: (877) Inpatient/SNF/ESRD Go To Top Displaying 1 of 3 sections Edit Display Show All Hide All End Stage Renal Disease Hide No End Stage Renal Disease information available Page # 8

17 Home Health & Hospice WHCA SPRING 2018 Go To Top Displaying 0 of 3 sections Edit Display Show All Hide All Therapy Caps Go To Top Displaying 0 of 5 sections Edit Display Show All Hide All Service Types Go To Top Displaying 0 of 77 sections Edit Display Show All Hide All Preventative Go To Top Displaying 0 of 40 sections Edit Display Show All Hide All Page # 9

18 Page # 10

19 Page # 11

20 Page # 12

21 Page # 13

22 Page # 14

23 Page # 15

24 Page # 16

25 Page # 17