Denial & RAC Appeals Financial Impact & how to calculate
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1 Denial & RAC Appeals Financial Impact & how to calculate Michael Snyder Anchor Provider Solutions, LLC. 1 1
2 Patient #1 Patient discharged 3/31/2013 Location: Charlotte, NC major teaching hospital DRG #340 Appendectomy w/o CC/MCC was denied CPT #44970 Laparoscopy, surgery, appendectomy Additional labs that would have been paid under fee schedule not included 2 2
3 Patient #1 (cont d) Operating DRG Payment assumed originally paid on claim: Labor related portion $3, (from FFY 2013 PPS regulations) Wage index.9011 (from FFY 2013 PPS regulations) Labor related $2, Non-Labor related portion $1, (from FFY 2013 PPS regulations) Am t before DSH and IME $4, IME factor (.09) $ (hospital-specific provided by MAC/FI) DSH factor (.15) $ (hospital-specific provided by MAC/FI) Operating DRG rate after adjusts $5, DRG weight (DRG #340) (from FFY 2013 PPS regulations) Operating DRG payment $6,
4 Patient #1 (cont d) Capital DRG Payment assumed originally paid on claim National capital rate $ (from FFY 2013 PPS regulations) Geographic adjust factor (Charlotte).9312 (from FFY 2013 PPS regulations) Subtotal $ Capital IME factor (.03) $11.89 (hospital-specific from MAC/FI) Capital DSH factor (.07) $27.74 (hospital-specific from MAC/FI) Capital rate after adjusts $ DRG weight (DRG #340) Capital DRG payment $
5 Patient #1 (cont d) APC Payment calculation for CPT code #44970 Payment rate per Addendum B $3, (per FFY2013 OP PPS regs) Labor proportion 60% Labor portion of rate $2, Wage index.9011 Subtotal $1, Non-labor proportion 40% Non-Labor proportion of rate $1, APC Payment $3,
6 Patient #1 (cont d) Operating DRG Payment $6, Capital DRG Payment Total Inpatient Payment $7, APC Payment $3, Difference $4,
7 Patient discharged 1/19/2013 Patient #2 Location: Charlotte, NC major teaching hospital DRG #227 Cardiac defib implant w/out cardiac cath w AMI/HF/Shock as PD w/o MCC CPT #33249 Insertion or replacement of permanent pacing cardioverter-defibrillator system with transvenous lead(s), single or dual chamber Additional labs that would have been paid under fee schedule not included 7 7
8 Patient #2 (cont d) Operating DRG Payment assumed originally paid on claim: Labor related portion $3, (from FFY 2013 PPS regulations) Wage index.9011 (from FFY 2013 PPS regulations) Labor related $2, Non-Labor related portion $1, (from FFY 2013 PPS regulations) Am t before DSH and IME $4, IME factor (.09) $ (hospital-specific provided by MAC/FI) DSH factor (.15) $ (hospital-specific provided by MAC/FI) Operating DRG rate after adjusts $5, DRG weight (DRG #227) regulations) (from FFY 2013 PPS Operating DRG payment $29,
9 Patient #2 (cont d) Capital DRG Payment assumed originally paid on claim National capital rate $ (from FFY 2013 PPS regulations) Geographic adjust factor (Charlotte).9312 (from FFY 2013 PPS regulations) Subtotal $ Capital IME factor (.03) $11.89 (hospital-specific from MAC/FI) Capital DSH factor (.07) $27.74 (hospital-specific from MAC/FI) Capital rate after adjusts $ DRG weight (DRG #227) Capital DRG payment $2,
10 Patient #2 (cont d) APC Payment calculation for CPT code #33249 Payment rate per Addendum B $30, (per FFY2013 OP PPS regs) Labor proportion 60% Labor portion of rate $18, Wage index.9011 Subtotal $16, Non-labor proportion 40% Non-Labor proportion of rate $12, APC Payment $28,
11 Patient #2 (cont d) Operating DRG Payment $29, Capital DRG Payment $2, Total Inpatient Payment $32, APC Payment $28, Difference $3,
12 Use of this information Hospital obtains better feel for change in reimbursement due to RAC activity. Hospital will make more informed decisions on whether to appeal (cost to appeal vs. change in reimbursement) Hospital will be able to better support RAC reserve on financial statements 12 12
13 Anchor Provider Solutions, LLC Provides the following services: Reimbursement services for almost all provider types Managed care modeling impacts Compliance reviews and analyses Litigation support & damage calculation Financial impact of new regulations, adding, deleted new service/units, etc. Revenue cycle charge capture, denial management, etc. ICD-10 assessment/preparation 13 13
14 Contact information Michael Snyder, MHA address: Phone #:
15 Questions??? 15 15
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