[PDF]Trifecta Tips - Rackcdn.comf45ebd178a369304538a-da09e9363888411f910f2103a3cb9db6.r58.cf2.rackcdn.co...
7 downloads
117 Views
2MB Size
Trifecta Tips
Dash for Cash
Compliance Plans and Audits
Money Walks and Money Talks
Sponsored by:
American Academy of Physical Medicine and Rehabilitation AAPM&R Annual Assembly 2015 Boston, Massachusetts Presented by:
Karen Zupko
Karen Zupko President and Speaker Advising physicians on how to improve their practices has been the focus and passion of Karen Zupko for more than 30 years. Karen founded KarenZupko & Associates, Inc. in 1985 and has built the company into a team of more than 24 professional staff whose goal it is to help physicians:
Improve profitability Reduce expenses Reduce risk Increase patient satisfaction Establish a better work environment for physicians and staff
In collaboration with national specialty societies, KZA developed the first specialtyspecific coding courses over 25 years ago. These programs have established a reputation for providing excellent comprehensive and accurate advice to physicians and their staff. Karen participates in practice management programs sponsored by societies at their annual meetings. She has earned positive evaluations for her practical advice, delivered with humor and wit. As consultants, Karen and her group have worked with medical groups nationally – from solo practices to academic departments – sharpening business systems, improving the revenue cycle and delivering improvements in coding and reimbursement. They also advise on hospital employment, physician compensation, technology, and coding compliance.
Karen is the author of articles that have appeared in The Journal of Medical Practice Management, Plastic Surgery News, AAOS Now, and Medical Economics.
Text and Format © 2015 KZA, Inc. 305 2015 AAPMR_Trifecta Tips (KZ) 080415
1 All Rights Reserved
Dash for Cash
Text and Format © 2015 KZA, Inc. 305 2015 AAPMR_Trifecta Tips (KZ) 080415
2 All Rights Reserved
Key Questions on A/R 1. How does our practice compare to national statistics? 2. What percentage of our accounts receivable is owed by patients? Deductibles Co-insurance Co-pays Uncovered services 3. How old are the patients’ balances? Are the dates accurate? 4. How have the totals and percentages changed in the last two years? 5. How have our internal systems changed to improve patient collection balances? A/R as of 12/31/12
What is your percentage goal for improvement? 10%
15%
20%
Text and Format © 2015 KZA, Inc. 305 2015 AAPMR_Trifecta Tips (KZ) 080415
3 All Rights Reserved
25%
30%
Adjustments
Non-Contractual Adjustments •Bad debt write off
•Bankruptcy
•Deceased patient
•Missed appeal deadline
•Missed filing deadline (or
Timely filing adjustment)
•No precertification •No referral authorization •Non-covered service •NSF check •Payment plan default •Preexisting condition not covered •Recovered from collection agency •Risk management •Sent to collection agency •Service recovery •Small balance write off (under $5.00) •Risk management adjustment •Service recovery •Professional courtesy
Contractual Adjsutments •Contractual Amounts (plans for which the practice is contracted with) •List carriers individually •Adjustments from NonContracted/ Out-ofNetwork Plans •List carriers individually
Treated as Non-Contractual •Bundling denial – appeal denied •Bundling denial – not appealable •Charity care •Financial hardship discounts (these are discounts and not full charity care) •Global period •Medicaid secondary contractual adjustment •Multiple procedures (-51 and -59 modifiers) •Professional courtesy adjust (other physicians, medical community) •Self-Pay discounts (i.e. prompt pay discounts) •Surgical assistant not covered
** Absolutely, positively, no use of Miscellaneous, General, Other or Administrative Adjustment Codes. Everything has a specific reason!** Text and Format © 2015 KZA, Inc. 305 2015 AAPMR_Trifecta Tips (KZ) 080415
4 All Rights Reserved
Sample H.E. Plans What plans are you on?
In or Out?
“All products clauses.” Beware! What are the allowable for these plans?
Can eligibility be verified online?
Text and Format © 2015 KZA, Inc. 305 2015 AAPMR_Trifecta Tips (KZ) 080415
5 All Rights Reserved
Improving Point of Service Collections (POS) 1.
New patient pre-registration is the first step.
2.
Patient re-registration is mandatory.
3.
Know About Insurance Coverage Before Patients Arrive.
4.
Verification of Eligibility and Benefits – Benefits You!
Ask your clearinghouse vendor: “What can you do to help us verify benefits more effectively?”
Text and Format © 2015 KZA, Inc. 305 2015 AAPMR_Trifecta Tips (KZ) 080415
6 All Rights Reserved
Use Claim Estimators 5.
Use Claim Estimators
Who Offers? How to Get info? www.Availity.com. Free! Single source sign on! Includes Aetna, Cigna, and most Blues Plans. Or www.navinet.com. Or direct from plans: United Health Care.
Text and Format © 2015 KZA, Inc. 305 2015 AAPMR_Trifecta Tips (KZ) 080415
7 All Rights Reserved
Patient Estimators Work! 6.
Implement Recurring Payment and Reduce A/R! You can add a card‐on‐file contract
08/30/2013
01/20/2013
Three ways (plus one!) to handle recurring payments: 1. Debit Card 2. Credit card 3. Checking account withdrawal 4. HSAs
Text and Format © 2015 KZA, Inc. 305 2015 AAPMR_Trifecta Tips (KZ) 080415
8 All Rights Reserved
Patient Estimators Work! 7.
Collect at Check-In and Check-Out!
Text and Format © 2015 KZA, Inc. 305 2015 AAPMR_Trifecta Tips (KZ) 080415
9 All Rights Reserved
Money Walks and Money Talks
Text and Format © 2015 KZA, Inc. 305 2015 AAPMR_Trifecta Tips (KZ) 080415
10 All Rights Reserved
Audit Controls for PMRs Check Up
■
I review the income and expense statement monthly.
■
The report is clear and understandable to me.
■
I receive timely financial reports. As an example, I review the February month-end report no later than the 2nd week in March.
■
Revenue expense + categories are detailed and broken out.
■
I review write offs and adjustments.
■
I know and approve staff overtime.
Text and Format © 2015 KZA, Inc. 305 2015 AAPMR_Trifecta Tips (KZ) 080415
11 All Rights Reserved
Audit Controls for PMRs Risk Area: Cash Handling Action Steps
■
Establish a set of written policies and procedures for the following: The receipt of money received: Always generated by the computer system. Steps in the daily close process. Require two people, at a minimum, to be involved in the process. Charge Capture o Timely submission o Reconciliation process
■ ■ ■ ■ ■
Review “Credit Balance Report” monthly
■ ■
Collection at the time of service.
Cash handling protocols Petty cash Change fund Financial policy regarding bad debt and referrals to a collection agency. Run small balance report monthly.
Text and Format © 2015 KZA, Inc. 305 2015 AAPMR_Trifecta Tips (KZ) 080415
12 All Rights Reserved
Audit Controls for PMRs Risk Area: Cash Handling Action Steps
■
Require background checks on all new employees who handle money.
■
Set up credit card machine to automatically submit transactions to the bank.
■
Monitor inventory.
■
Generate “Missing Ticket” report. Monitor “no shows.”
■
Number charge tickets/encounter forms.
■
Signup for electronic remittance.
■
No delegation of check signing.
■
Bond all employees with cash handling responsibilities or check your office umbrella policy.
Text and Format © 2015 KZA, Inc. 305 2015 AAPMR_Trifecta Tips (KZ) 080415
13 All Rights Reserved
Audit Controls for PMRs Banking Services 1. Private Banker 2. Credit Card Processing 3. EFT (ERemittance) 4. Remote Check Deposit 5. MMF – Practice 6. Line of Credit 7. Lock Box
Text and Format © 2015 KZA, Inc. 305 2015 AAPMR_Trifecta Tips (KZ) 080415
14 All Rights Reserved
Compliance Plans and Audit Avoidance
Text and Format © 2015 KZA, Inc. 305 2015 AAPMR_Trifecta Tips (KZ) 080415
15 All Rights Reserved
The Alphabet Police Roles of Various Medicare Improper Payment Review Entities Acronym
How selected All claims where hospital submits an adjusted claim for a higherweighted DRG Expedited Coverage Reviews requested by beneficiaries
Volume of Claims Very small
All Medical Claims
Randomly
Small
All Medical Claims Randomly
Randomly
Medical Review Units* at MACs
All Medicare FFS Claims
Targeted
Medicare Recovery Auditors*
All Medicare FFS Claims
Targeted
PSC/ZPICS
All Medicare FFS Claims
Targeted
QIO
CERT*
PERM*
OIG
Types of Claims Inpatient Hospital claims only
All Claims
Type of Review Prepay & Concurrent (Patient still in hospital) Complex Only
Postpay only Complex only Postpay only
Small
Automated & Complex
Targeted
Depends on number of claims with possible improper payments for this provider
Prepay & Postpay
Depends on number of claims with possible improper payments for this provider
Postpay
Depends on number of potentially fraudulent claims submitted by provider
Prepay and Postpay
Depends on number of potentially fraudulent claims submitted by provider
Postpay
Automated, & Complex
Automated and Complex
Automated and Complex
Complex
*Overseen by OFM/PCG
Source: https://www.cms.gov/CERT/downloads/Overview_Review.pdf .
Text and Format © 2015 KZA, Inc. 305 2015 AAPMR_Trifecta Tips (KZ) 080415
16 All Rights Reserved
Purpose of Review To prevent improper payments through DRG upcoding To resolve discharge disputes between beneficiary and hospital
Other Functions Quality Reviews
To measure improper payments
None
To measure improper payments
None
To prevent future improper payments
Education
To detect and correct past improper payments
None
To identify potential fraud
----
To identify fraud
----
Appeals
Tip: Private payors are also increasing their audit efforts. Pay particular attention to medical policies related to coding and your specialty.
Meet the Public Sector Auditors • FY2013: $3.65 billion in overpayments, $102.4 million in underpayments identified. • Incentive to RAC for recoupments.
RAC
• The new RAC contract period is to extend from 2014 to 2018 • Contractors make public the “issues” list. For example, physician issue is E&M during global (pre- or post-op period).
• Measure error rates by reviewing randomly selected claims.
CERT
• Signatures, physical therapy and E&M codes are big issues! • 2012: 8.5% $29.6 billion • 2013: 10.1% $36.0 billion
Incentive for money collected.
MAC
HEAT
• Interagency team to combat criminal fraud.
• Investigate areas of overpayment.
OIG
• Highlight areas for payor audits. • Publish audit targets (work plan) each year.
Text and Format © 2015 KZA, Inc. 305 2015 AAPMR_Trifecta Tips (KZ) 080415
17 All Rights Reserved
• Focus on billings that are higher than the majority of providers and noncompliance with LCD’s (medical necessity).
• Also conduct pre and post payment audits.
OIG Workplan Physicians and Suppliers — Noncompliance with Assignment Rules and Excessive Billing of Beneficiaries
Read the entire 2015 document at: http://oig.hhs.gov/reports-andpublications/archives/workplan/201 5/WP-Update-2015.pdf
Billing and Payments. We will review the extent to which physicians and suppliers participated in Medicare and accepted claim assignment during 2012. We will also assess the effects of their participation and claim assignments on the Medicare program (such as noncompliance with assignment rules) and on beneficiaries (such as excessive billing of beneficiaries’ share of charges). Context—Physicians participating in Medicare agree to accept payment on “assignment” for all items and services furnished to individuals enrolled in Medicare. (Social Security Act, § 1842(h)(1).) CMS defines “assignment” as a written agreement between beneficiaries, their physicians or other suppliers, and Medicare. The beneficiary agrees to allow the physician or other supplier to request direct payment from Medicare for covered Part B services, equipment, and supplies by assigning the claim to the physician or other supplier. The physician or other supplier in return agrees to accept the Medicare-allowed amount indicated by the carrier as the full charge for the items or services provided. (OEI; 07-12-00570; expected issue date: FY 2014; work in progress) Physicians — Place-of-Service Coding Errors Billing and Payments. We will review physicians’ coding on Medicare Part B claims for services performed in ambulatory surgical centers and hospital outpatient departments to determine whether they properly coded the places of service. Context— Prior OIG reviews determined that physicians did not always correctly code nonfacility places of service on Part B claims submitted to and paid by Medicare contractors. Federal regulations provide for different levels of payments to physicians depending on where services are performed. (42 CFR § 414.32.) Medicare pays a physician a higher amount when a service is performed in a nonfacility setting, such as a physician’s office, than it does when the service is performed in a hospital outpatient department or, with certain exceptions, in an ambulatory surgical center. (OAS; W-00-11-35113; various reviews; expected issue date: FY 2014; work in progress)
Text and Format © 2015 KZA, Inc. 305 2015 AAPMR_Trifecta Tips (KZ) 080415
18 All Rights Reserved
Ancillaries on the “Hit List” Part B Imaging Services—Payments for Practice Expenses. We will review Medicare payments for Part B imaging services to determine whether they reflect the expenses incurred and whether the utilization rates reflect industry practices. For selected imaging services, we will focus on the practice expense components, including the equipment utilization rate. Practice expenses are those such as office rent, wages, and equipment. Physicians are paid for services pursuant to the Medicare physician fee schedule, which covers the major categories of costs, including the physician professional cost component, malpractice costs, and practice expenses. Diagnostic Radiology—Medical Necessity of High-Cost Tests. We will review Medicare payments for high-cost diagnostic radiology tests to determine whether they were medically necessary and the extent to which the same diagnostic tests are ordered for a beneficiary by primary care physicians and physician specialists for the same treatment. Medicare will not pay for items or services that are not “reasonable and necessary.
Prepare for 2015 IRF Final Rule Changes – Mediware http://www.mediware.com/rehabilitation/blog/item/irf-2015-final-rule-decisions-cms-1608-f
Is the 2015 OIG Plan for IRF Actionable? – Mediware http://www.mediware.com/rehabilitation/blog/item/irf-incidence-of-adverse-and-temporary-harm-on-oig2015-plan
Proposed Fiscal Year 2016 Payment and Policy Changes for Medicare Inpatient Rehabilitation Facilities (CMS-1624-P) – CMS.gov https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2015-Factsheets-items/2015-04-23.html Text and Format © 2015 KZA, Inc. 305 2015 AAPMR_Trifecta Tips (KZ) 080415
19 All Rights Reserved
Ancillaries on the “Hit List”
Text and Format © 2015 KZA, Inc. 305 2015 AAPMR_Trifecta Tips (KZ) 080415
20 All Rights Reserved
Ancillaries on the “Hit List”
Text and Format © 2015 KZA, Inc. 305 2015 AAPMR_Trifecta Tips (KZ) 080415
21 All Rights Reserved
E&M Utilization: Why You Should Care PMR Practice Physcial Medicine and Rehabilitation – 2013 CMS Data
Text and Format © 2015 KZA, Inc. 305 2015 AAPMR_Trifecta Tips (KZ) 080415
22 All Rights Reserved
E&M Utilization: Why You Should Care Evaluation and Management Profile Analyzer Dr. Smith Pain Management - 2013 CMS Data
Text and Format © 2015 KZA, Inc. 305 2015 AAPMR_Trifecta Tips (KZ) 080415
23 All Rights Reserved
E&M Utilization: Why You Should Care Evaluation and Management Profile Analyzer Dr. Doe Physical Medicine & Rehabilitation - 2013 CMS Data
Text and Format © 2015 KZA, Inc. 305 2015 AAPMR_Trifecta Tips (KZ) 080415
24 All Rights Reserved
Private Health Insurer Retrospective Audits: What You Need to Know Based on paid claims—you already have the money and have typically spent it! Goes back several years. Defies the “well, they always pay me” and “everyone else gets paid” philosophies. Do not ignore these notices as an inconvenience. Call a health care attorney. The American Health Lawyers Association.
Why Might You Be Selected? Level of code; E&M especially. Do you use 1995 or 1997 guidelines? High service volume compared to peers. High volume of modifier 25. Non-conformity—congenital unbundling. Whistle blower complaint file. Former staff, former partners.
Text and Format © 2015 KZA, Inc. 305 2015 AAPMR_Trifecta Tips (KZ) 080415
25 All Rights Reserved
Sample Compliance Plan for Physician Practices (Your Practice Name) voluntarily implements a compliance program aimed at fraud, waste, and abuse prevention while at the same time advancing the mission of providing quality patient care. Our compliance efforts are aimed at prevention, detection, and resolution of variances. The eight elements of (Your Practice Name) Compliance Plan are: 1. Commitment to Compliance A. Standards of Conduct B. Reasonable and Necessary Services C. Coding, Billing, and Claims D. Reliance on Standing Orders E. Compliance with Applicable HHS Fraud Alerts F. Marketing G. Anti-Kick-Back/Inducements H. Retention of Records/Documentation 2. Designation of a Compliance Officer/Committee 3. Conducting Training and Education Programs 4. Communication 5. Disciplinary Guidelines 6. Auditing and Monitoring 7. Corrective Action 8. Response to Government Investigator or Auditor Copyright © 2013 Medical Risk Institute
Text and Format © 2015 KZA, Inc. 305 2015 AAPMR_Trifecta Tips (KZ) 080415
26 All Rights Reserved
