131
Revenue Cycle Billing Does Not Begin At Billing
Revenue Cycle Billing Does Not Begin At Billing
Agenda
California Benchmarks
The Revenue Cycle And Snafus
When To Appeal
Grease Your Applications for Assistance
California Benchmarks Where Do You Stand?
focalPoint® Scope and Reach
focalPoint Data Sets Collects data on
Allowed Amounts
Insurance Payment Amounts
Patient Responsibility
Days To Pay and Days to File
Claims Adjustment Codes (CARCs) which we will refer to herein as denial codes
Remittance Advice Remark Codes (RARCs) which we will refer to as Reason codes
Does not collect data on
Prescribing behavior of providers
Data Sets Herein 2014 for drug codes only
California Only
Limited by billing practices and by insurance data only
May not include all of your payers
Payer Mix--Claims
Payer Mix--Patients
AVERAGE
NOBLE AMA SELECT IPA
SANTE HEALTH SYSTEM AND AFFILIATES
GOOD SAMARITAN MEDICAL PRACTICE ASSOC. (GSMPA)
FIRST HEALTH NETWORK
BROWN AND TOLAND MEDICAL GROUP
HUMANA
GOLD COAST HEALTH PLAN
ANTHEM BLUE CROSS
CALIFORNIA MEDI-CAL
ALLIANCE IPA
CIGNA
CALIFORNIA BLUE CROSS
KEY MEDICAL GROUP
AETNA
HEALTH NET OF CALIFORNIA AND OREGON (CLAIMS)
INLAND EMPIRE HEALTH PLAN
CHAMPVA - HAC
NORTHERN CALIFORNIA MEDICARE
UNITED HEALTHCARE
RETIRED RAILROAD MEDICARE
AKAMAI ADVANTAGE (MEDICARE ADVANTAGE PLAN)
SOUTHERN CALIFORNIA MEDICARE
HAWAII MEDICARE
MEDICARE DME MAC JURISDICTION D
UNIVERSITY HEALTH ALLIANCE - HAWAII
32.0
117.4
95.8
93.3
81.9
75.6
66.8
61.4
44.9
44.7
40.3
40.1
38.9
36.5
36.2
36.0
34.9
33.5
30.0
29.2
29.1
29.1
27.7
26.4
26.3
21.2
Days to Pay From Service 2014
More Info on DTP
DTP Trend CA 2014
Days To File 2014
Top Ten States: Denials
Top Drug Denials CA 2014
Top Denial Codes
Top Denials
Top Denials—Revenue Cycle
Trends In Insurance
* Estimate is statistically different from estimate for the previous year shown (p<.05).
SOURCE: Kaiser/HRET Survey of Employer-Sponsored Health Benefits, 2006-2014.
Percentage of Covered Workers Enrolled in Either a HDHP/HRA or HSA-Qualified HDHP, 2006-2014
* Estimate is statistically different from estimate for the previous year shown (p<.05).
Note: These estimates include workers enrolled in HDHP/SO and other plan types. Average general annual health plan deductibles for PPOs, POS plans, and HDHP/SOs are for in-network services.
SOURCE: Kaiser/HRET Survey of Employer-Sponsored Health Benefits, 2006-2014.
Percentage of Covered Workers Enrolled in a Plan with a General
Annual Deductible of $2,000 or More for Single Coverage,
By Firm Size, 2006-2014
Percent of Covered Workers Enrolled in a Plan with an Out-
Pocket-Maximum Above $6,350 or in a Plan without an Out-of-
Pocket Limit, 2006-2014
* Estimate is statistically different from estimate for the previous year shown (p<.05).
SOURCE: Kaiser/HRET Survey of Employer-Sponsored Health Benefits, 2006-2014.
Percentage of Covered Workers Enrolled in Plans Grandfathered Under the Affordable Care Act (ACA), by Firm Size, 2011-2014
* Estimate is statistically different from estimate for the previous year shown (p<.05).
NOTE: For definitions of Grandfathered health plans, see the introduction to Section 13.
SOURCE: Kaiser/HRET Survey of Employer-Sponsored Health Benefits, 2011-2014.
NOTE: LTSS are long-term services and supports and include home health spending. Premiums include Medicare Part A, B, C, and D and private health insurance premiums. SOURCE: Kaiser Family Foundation analysis of CMS Medicare Current Beneficiary Survey 2009 Cost and Use file.
Out-of-Pocket Health Spending by Medicare
Beneficiaries 65 and Older, by Gender and Type of
Service, 2009
Women Men
Services
$4,844
$4,230
NOTE: Numbers do not sum due to rounding. SOURCE: Kaiser Family Foundation analysis of the Centers for Medicare & Medicaid Services Medicare Current Beneficiary Survey, 2009 Cost and Use file.
Sources of Supplemental Coverage Among
Medicare Beneficiaries, 2009
Total Number of Beneficiaries, 2009: 47.2 Million
No Supplemental
Coverage
Percent of total Medicare population:
NOTE: ADL is activity of daily living.
SOURCES: Income and savings data from Urban Institute/Kaiser Family Foundation analysis, 2011. All other data from Kaiser Family Foundation analysis of
the Centers for Medicare & Medicaid Services Medicare Current Beneficiary 2009 Cost and Use file.
Characteristics of the Medicare Population
5%
13%
15%
17%
23%
27%
40%
50%
50%Per Capita Annual
Income below $22,000
Per Capita Savings below $53,000
3+ Chronic Conditions
Fair/Poor Health
Cognitive/Mental Impairment
Under-65 Disabled
2+ ADL Limitations
Age 85+
Long-term Care Facility Resident
Medicare Enrollment, 1970 - 2030
Number in millions:
SOURCE: 2012 Annual Report of the Boards of Trustees of the Federal Hospital Insurance and Federal Supplementary Medical Insurance Trust Funds.
Historical Projected
Declining Physician Compensation
Source: MGMA Median Compensation Survey
Change in Hem-Onc Salaries
-20.00%
-15.00%
-10.00%
-5.00%
0.00%
5.00%
10.00%
15.00%
2003-2004 2004-2005 2005-2006 2006-2007
Time
Sala
ry C
han
ge
Change
Summary Employers re paying less, which impoverishes people
when they get sick
Out-of-pocket costs cripple patients, but you need them
to stay alive
Medicare patients have supplemental plans, but less
than they did in the past
Physician compensation has been declining for years
Thus, your revenue cycle is more important than ever
Revenue Cycle in Physician
Practices
The Revenue Cycle
Primary Revenue Cycle
Objectives Incremental Cash: Maximize Cash Flow
Incremental Cash: Accelerate cash flow by collecting dollars owed more quickly
Collect dollars at earliest point in the Revenue Cycle
Income Statement Benefit: Minimize Write-offs and Operating Expenses
Reduce administrative and bad debt write-offs
Maximize benefit of internal resources vs. external vendors
Allocate appropriate staffing levels
Allocate staff resources to activities that accelerate cash flow
Shift resources to optimal point in Revenue Cycle
Maximize Customer Service
Improve patient experience throughout contact points of Revenue Cycle
Minimize points of registration while maximizing accuracy of patient registration
Maximize clarity of patient financial information
Minimize event cycle for patient experience
Financial information available at onset of patient event
Maximize information available to Revenue Cycle staff
Eliminate patient “financial anxiety”
Revenue Cycle Principles Measurement: Understanding Key Performance Drivers
Everything that impacts relative financial performance needs to be measured to ensure that activities are providing a positive financial impact
Measurement must be done at all levels:
Organizational level (e.g. A/R Days, write-off %)
Department level (e.g. A/R days in Medical Records)
Unit level (e.g. % surgery patients pre-registered)
Individual level (e.g. staff productivity, quality)
Stratification: “Bang for the Buck”
Direct resources towards tasks and accounts that yield the greatest benefit
Identify break-even performance points within Revenue Cycle
Accountability: Clear Expectations
Clear responsibility for a specific function or task is essential
An organizational structure that stresses accountability for performance at both department and individual levels typically yields optimum performance
Timeliness: Proactive Environment vs. Reactive Environment Actions taken upstream in the Revenue Cycle eliminate required actions downstream
A reactive environment typically requires greater resources and yields a lesser return than a proactive environment
Revenue Cycle Metrics A/R Balance and A/R Days
Measure of overall A/R performance
Benchmark for initial payment by insurance = 30 days as shown previously
Billing Work in Process
Measure of accounts that are prevented from being billed as a result of deficiencies (Denial 16)
Measure for each function (department) that generates a deficiency that prevents a bill from getting out the door
Follow-up Work in Process
Measure of accounts that have been billed but require follow-up steps within your billing function
Ideal area for application of principle of stratification
Measured at unit and individual level
A/R Aging from Discharge
Measure of aging of accounts; stratified by dollar and age
Drug claims should be measured from the date that you pay for your drugs
Analysis of aged accounts can support staff resource allocation and drive management of activities between stratification and timely follow-up
If your focused on accounts at 120+ days, it’s too late to resolve issues in a timely manner
Revenue Cycle Metrics Cash Factor (Cash/3 month Average Daily Revenue)
Measures the cash momentum by accounting for shifts in revenue
Not a good relative measure against other organizations due to contractual differences
Write-Off % (ABCs)
Measure of dollars written off of A/R balance as % of Gross Revenue
Improvement in Revenue Cycle performance should focus on Non-Routine Administrative and Bad Debt write-offs
Administrative Write-offs
Routine Write-Offs: includes discounts, contractual adjustments
Non-Routine Write-Offs: includes write-offs for timely filing, billing, eligibility errors
Bad Debt Write-Offs
Measure of uncollected self pay accounts
Typically written off to a collection agency for follow-up
PAP and Co-pay’ Write-Offs’
Measure of accounts written off based on program guidelines
Analysis of write-offs in conjunction with A/R performance prevents achieving A/R reduction goals through increased write-offs
Scheduling Symptoms
Patient wait times
Patient Care resources are underutilized due to inability to coordinate procedure/resource
scheduling, e.g. patients go elsewhere for lab, imaging, prescriptions, Radiation, or even chemo
Highly manual scheduling functions and tasks
Common Underlying Issues
Multiple points of scheduling and separate scheduling systems may require the duplication of
information gathering and inconvenience for the patient
Lack of technology application may result in a process of manual scheduling and
documentation
Potential solutions
Assess potential benefits for applying technology applications to all points of scheduling
Assess benefits of centralized vs. decentralized scheduling
Assess benefits of cross-functional staff for performing scheduling and registration functions
Patient Pre-Registration and
Registration (Front Desk) Symptoms
High A/R resulting from inaccurate patient demographic and insurance information (Remember our denials??)
Poor coordination of benefits
Denials and write-offs resulting from inaccurate insurance information
Increased delays in patient flow (waiting room time) for services because too much information taken at that time
Common Underlying Issues
Poor intake procedures at the initial point of contact
No conditions of admission obligating the patient to provide accurate information at EVERY encounter
Patient not asked at every encounter whether there have been changes in employment and/or insurance
Taking information from referring physician at face value
Lack of training regarding payer informational requirements or contracts
Lack of appropriate productivity and quality performance measures
Potential solutions
Training, training, training
Feed-back loop from denials to Front Desk
Contract book at front desk
Implement performance measures
96% of scheduled patients verified 48 working hours prior to service (90% unscheduled)
Unit and individual demographic and insurance verification quality measures (“The Data Quality” Project)
Implement patient demographic and insurance verification tools to increase accuracy of patient information
Financial Counseling Symptoms
High Self Pay A/R resulting from inability to collect patient responsibility or many little accounts hanging on forever
Poor insurance information regarding plan ceilings, benefit design, or eligibility dates—electronic versus manual insurance verification
Low levels of co-pay cards or Patient Assistance on Financial Statements
Nurses doing prior authorization
Lots of ADRs following prior authorization
Financial counseling is not ongoing throughout therapy
Common Underlying Issues
Lack of a clearly defined Financial Counseling function with clear responsibilities and staff resources
Lack of involvement by the physicians in therapy choices based on ability to pay
Lack of training for staff regarding available payer resources and guidelines including Drug Assistance
Lack of appropriate productivity and quality performance measures
Potential solutions
Develop a true proactive Financial Counseling function with defined processes and staff to identify payment source for each and every patient provided service within your organization
Every patient has a Financial Plan (and possible assistance) prior to starting new drug regimen
Financial statements track PAP and co-pay assistance
Charge Entry/Physician
Documentation Symptoms
High A/R resulting from inappropriate resources and inaccurate patient care/charge information
Backlogs for charge entry
Denials for medical necessity or diagnosis not matching the procedure
Common Underlying Issues
Department resources have multiple prioritized tasks that may compromise charge entry production
Misinterpretation of services provided by patient care departments may result in inappropriate charges for services (e.g. IV push versus infusion)
Poor interface between EMR and PM system leads to duplication and unnecessary paperwork
Backlog in charge entry may result in charges not billed or late charge write-offs.
Potential Solutions Develop a standard charge entry period of time for charges to be applied to accounts (e.g. within 48
working hours)
Develop a charge entry resource pool to manage volume fluctuations within standards—college kids are great
Monitor Days To File as a key metric
Medical Records/Coding
Symptoms
High A/R resulting from inappropriate resources and inaccurate patient care/charge information
High A/R resulting manual charge entry from outdated coding information
Loss of revenue from lower level coding due to lack of physician documentation/inappropriate interpretation
Practice is not ready to test systems for ICD-10-CM
Practice does not participate in PQRS
Common Underlying Issues
Physicians do not complete medical records so codes cannot be submitted
Hospital visits and consults (for private payers) are a mess
Nurses do not think coding is ‘their job’
Physicians cling to low level codes or bill no visits with chemo because of audit fear
Potential Solutions
Develop backlog reporting of physicians who have unbilled visit reporting
Perform account review to determine appropriateness of assigned coding of diagnoses, drug administration, E/M
Audit every complex chemo regimen bill before it is submitted
Account Billing & Follow-Up
(Insurance) Symptoms
High A/R resulting from inappropriate resources and recurring account follow-up to address same issues
High write-off levels and lack of clarity for source or reasons for write-offs
Volatility and lack of correlation between revenue, A/R and write-offs
Duplicate claims sent due to lack of hands-on follow up to accounts
Claims do not meet individual payer’s guidelines in terms of RARC codes
Common Underlying Issues
Lack of unit and individual performance standards and measurement capabilities results in inability to measure performance
Lack of technology applications results in manual processes and inability to identify and resolve issues
Gaps in functionality may exist:
Lack of ability to address rejections quickly (within 1-2 working days)
Coordinated and focused denial management
Complete A/R payment review and Revenue Recovery function
Potential Solutions
Review potential benefit from separation of functions and tasks
Separate government payers from commercial/managed care payers
Separate billing function from account follow-up and resolution (or denials/appeals)
Customer Service Symptoms
High volume of patient financial complaints
High call wait times or abandonment rates
No one ever talks to a person
Common Underlying Issues
Lack of performance and objective quality metrics for issue identification and resolution
Lack of telephony metrics (rings, answering times for voice mail, numbers of voice mails)
Lack of technology application and training to support staff in resolving account issues
Lack of financial statement clarity or lack of availability of financial information for the consumer
Potential Solutions
Implement unit and individual-level customer service productivity and quality metrics
Call wait times, abandonment rates, call volumes
# of unanswered voice mails
Quality ratings per staff
Determine automated call system capabilities to provide measurement data
Develop capabilities to provide patients with appropriate financial information
Web-site financial information
Patient-Friendly Billing
Develop cross-trained staff
Payment Posting Symptoms
High A/R due to backlog of payments received but not posted
Highly manual processes for review and posting payments—no automated posting
Staff focused on payments posted rather than cash
High credit balances
Common Underlying Issues
Lack of technology application for posting electronic remittances
Lack of resources for meeting high payment volume periods
Lack of unit or individual performance measurements ($0 unposted cash at measurement periods)
Absence of payment review capability coordination
Poor division of duties between cash posting and deposits
Potential Solutions
Maximize capabilities to post electronic remittances
Implement unit and individual-level productivity and quality metrics—daily cash posting
Define unit payment posting target as $0 unposted cash and staff function accordingly
Prioritize refund function appropriately according to risks and benefits
Revenue Recovery (Payment
Review) Symptoms
Absent or incomplete payment review function
Manual review processes or technology
Low cash factor rate (cash as % of revenue)
Common Underlying Issues
Incomplete Revenue Recovery function
Lack of sophisticated technology application to identify appropriate payments per individual contracts
Lack of coordination with Payment Posting/Denial Management/Managed Care Contracting functions
Lack of resources dedicated to ensuring payment accuracy (high ROI area)
Potential Solutions
Develop automated payment review capabilities to identify payment accuracy
Support and train resources focused on Revenue Recovery
Apply timely payment penalties for payers that continue to underpay and link future contracts to correct payment
Utilize payment accuracy in contract negotiations with managed care payers
Common Revenue Cycle Issues Symptoms
Higher A/R Days and Write-offs than industry best performers
Fragmented flow of accounts through the Revenue Cycle. Most current information systems do not support the identification of accounts with deficiencies and push them to the appropriate resource
Common Underlying Issues
Lack of unit performance measurements and process guidelines
Lack of staff training within units to allow them to perform
Lack of “Front-End” patient demographic and insurance verification processes leading to excessive “Back-end” follow-up and write-offs
Staffing levels may be below required levels in key follow-up and collection areas
Potential Solutions
Staffing: Perform staffing level analyses within current environment to evaluate need for increased or decreased staff levels in each area
Training: Increase training and education for both existing staff and new hires
Performance Measurement: Develop performance measures for productivity and quality in all areas of the Revenue Cycle to maximize staff performance
Technology application: Look for opportunities (highly manual processes) to apply technological innovations/systems to improve productivity/quality/cash
Process: Identify opportunities to shift functions “upstream” in the Revenue Cycle
Technology Implications Shared information: New technologies are expected to
connect all areas of the Revenue Cycle both internal and external the organization
New Health Care Provider Revenue Cycle Systems
Workflow Automation using interfaces with EMR, lab systems, and PM system
EMR templates for Prior Authorizations for your top payers
Calculation of Expected Reimbursement
Payer connectivity (Direct or through Third-Party)
Insurance Eligibility transactions (270/271)
Electronic Billing and Remittance transactions (835/837)
Coming Soon: ???
More Specific Oncology
Problems & Solutions
Here’s Where The Problems Are
Pre-Visit
Collect demographic information from the patient or
caregiver
Collect employment and insurance information
Explain conditions of treatment meaning financial terms
Clarify who is responsible for the bill
Verify insurance and benefits
Obtain authorizations and/or referrals for the services you
know about
Insurance Verification Check List
Patient has the insurance they say they do and it is primary with effective date
Insurance address for bill
Plan type: HMO/PPO/other
Deductibles impacting care delivered in the office, e.g. IV drugs, radiology, labs, chemotherapy administration
Episodic patient cost sharing for care delivered in the office, e.g. flat copays for Rx; coinsurance payments, amount
Lifetime, annual or episode out of pocket maximum
Catastrophic coverage (yes/no)
Benefit caps: lifetime or annual or drug-related
If possible, patients’ current status regarding deductibles and out of pocket maximums; current progress toward caps
Insurer requirements: Prior authorization; certification; notification; case management, step therapy
Specialty pharmacy preference for patient costs, pharmacy billing.
Do You Want to Treat?
Insured patients---yes!
Underinsured/ uninsured
Can they get Obamacare?
Do they have $$$ or assets? Will they pay?
Do they qualify for Medicaid?
Do they qualify for other assistance in your community?
Can they be insured by patient assistance or Foundations?
Can they go on a trial?
Remember: Foundations will fund premiums
only if there is a specific request
Process Improvements:
Pre-Visit
If uninsured or underinsured, begin the process before the patient arrives…
“To best serve you at this practice, we need for you to bring in your tax returns for the last three years or another form of proof of income when you come to the office for your first visit. We can try to get funding for your treatment, if you qualify…”
Process Improvements:
Pre-Visit
Deliver a consistent message to patients about their financial responsibility and continually educate them on their specific benefit plan. Each patient that visits should sign a conditions of treatment that includes:
Obligation to pay patient costs
Obligation to obtain referrals
Obligation to inform you of change in insurance, employment or care status
Be party to a collection effort, if they fail to pay their bill.
Process Improvements:
The First VISIT
Provide detailed explanations where appropriate.
Train registration staff on how to present the conditions of treatment forms and create scripts to support the process
Allow time in the registration process for the registrar to more fully review the forms with the patient or consult with the financial counselor.
Have the forms signed and return a copy to the patient.
Use a Patient Financial Obligation Statement or Conditions of Admission that they should sign prior to their first TREATMENT
Tip: Statement content can vary from illustrating co-pay, deductible and coinsurance information to much more complex calculations, such as those that regimen specific and payer-specific (contractual database or use your ERA data).
Process Improvements:
FIRST VISIT
For insured patients, do the following:
Review treatment plan thoroughly (if and when it is available)
Explain treatment alternatives, if there are any.
Calculate out-of-pocket costs if you know them and provide the patient with approximate time frame for these costs
Inform patient of the obligation to pay patient costs at the time of the visit, if possible.
Take a deposit for the first round of chemo if it is occurring that day.
Take credit cards in case bills are not paid or if the patient prefers to pay by credit card
Answer any questions the patient or family may have.
Perform a credit check, if the patient will owe more than benchmark amount (≥ $5000)
Process Improvements:
Patient Financial Counseling
Collecting money from patients can be both a challenge and
a delicate situation if not handled properly.
Remember their care
is a higher priority
than collecting
payment, but
collecting cannot be
ignored
Process Improvements: Financial
Counseling
Sample script with insurance:
“We have verified your benefits. The good news is your insurance company is covering the majority of your bill. Today all you are responsible for is $XX. How would you like to pay today: cash, check, or credit card?”
Increase points of collections----ever thought of putting an ATM outside of your office or in the waiting room?
REMEMBER: Patients with insurance often
think their bills are paid!
Uninsured and Underinsured: The Visit
These patients can be treated in the hospital---but do not give up too easily…they need a financial interview and they need to bring the following: Three years of tax statements or proof of income
Statements of working assets---IRAs, 401K, life insurance, annuities, etc., if you consider them r the programs for the patients do
Bank references for patients who have a high self-pay balances
Credit cards
Proof of Medicaid rejection, if they are going the PAP route
Does Your Patient Qualify? Are they insured?
Have they been ‘rendered uninsured’?
Are they a Veteran?
Do they qualify for Medicaid?
Can they receive an exchange plan with a subsidy?
Do they qualify clinically?
On- versus off-label (varies)
Must have an order or prescription for the drug
Do they qualify financially?
Most programs are 500-600% Federal Poverty levels (FPLs)
Some require proof of income before assistance
HHS Federal Poverty Levels
2014 These numbers may be geographically adjusted
High Balance Patients—The VISIT
Some PAPs besides having an income requirement have an
asset requirement. What is this?
Not the patient’s house or car
Retirement funds: 401K, IRA, SEP
Stocks, marketable securities
Other real estate
Other investment transactions
High Balance Patients—The VISIT
Why do all of this?
Manage the patient and provider expectations
Get patient through the process faster…right now it takes a
long time
Be prepared with next steps for patients who do not qualify
But, bottom line, keep as many folks with you as possible and
manage service to the patient and/or to the caregiver
Financial & Insurance
Verification
Patient is referred to Oncologist and Dx/Tx determined
Locate & Evaluate
Assistance Programs
Call/ascertain Program
Requirements
Entire application submitted
Notification of approval
or denial
Patient completes
patient portion
Practice completes
office portion
32 min 62 min 44 min
33 min
2160 min
(36 hrs)
11400 min
(190 hrs)
(7.9 days)
1% 16% 83%
Percent of Processing Time
Analyze Value Stream Process Map
99% of the Process Time Involves Two Process Steps
Source: E-Expert Reimbursement Partners 2008 PAP Survey
Alternatives for Patients
Other facilities
Clinical Trials
Treat them anyway
Working their assets---what?
Working Assets
Viatical and Other Insurance Settlements
Restructuring Retirement Funds
Payment Plans
Automatic Credit Card Withdrawals
What is a life or viatical settlement?
A life or viatical
settlement is a
proven financial
strategy that enables
eligible policy holders
to sell their life
insurance to a funding
institution and receive
a lump sum of cash.
This also means the
patient does not need
to pay premiums.
Please note that the definitions of these terms vary by state.
What is the difference between a life and a viatical
settlement?
Life settlements generally involve individuals over the age of
65.
Viatical settlements generally involve individuals of any age
who are terminally or chronically ill.
Financial Counseling & collections The financial counseling
process does not end after the first visit.
Any patient with an outstanding balance over 30 days of over $5000 should be counseled.
Alternatives involving credit and assets should be offered.
Also remember that some patients will spend down to Medicaid levels.
Increase your collections Train your staff on how to ask for payment. Introduce
scripts if necessary. Prepared answers for the more
common objections for non-payment will give your staff
the confidence to be more assertive.
PUT INCENTIVES IN PLACE
For lowering patient balances or hard to bill IPAs
For successful PAP applications in less than 3 days
For collection of patient balances over $5-10K
For lowering the number of patients that are sent to the
hospital
For overall reduction in DTF, DTP, or denials
Who Makes A
Good Financial
Counselor
Someone who understands practice
finance and collections.
Someone who is tactful and empathizes
well with patients and caregivers
Someone who can talk about finances
without wincing or being afraid to ask for
what they need.
Someone who does not give up easily.
Someone with astute quantitative skills.
Make Everyone A FC Have a Contract Book at your Front Desk Pictures of Insurance Cards Pre-Auth, Referrals Needed With E-mails or Telephone
Numbers Employers Who Use, if Applicable Contract Copays and Deductibles In-network, Out-of-Network Contracted Rates (for billing) Contracted Pharmacies
Discharge Area with scripts, appointments, and charging the patient, if you missed it up front
Signs in waiting room.
Billing Issues In Oncology Coding
Initial procedure versus sequential
Concurrent infusions: what are they?
Consults
Bone marrow biopsy and aspiration
NPPs
Attending Versus Supervising Physicians for Billing
“Incident to”
Billing Junque
Initial Versus Sequential Infusions
The definition of initial changes with whether you are a
facility versus non-facility
Facility—it is a hierarchy
Non-facility---it is what brought the patient to your office
Only one initial code per day. Period
Not one chemo and one non-chemo
Very few exceptions
Example: Patient comes in for chemo and gets 2 ant-emetics in
one bag over 25 minutes and 1 hour of chemo
96367
96413
Concurrent Infusion (96368)
What is it?
A non-chemo drug given in a Y-connector at the same time as
another drug
Not 2 drugs in a bag
Not billed by facilities
Only one code per day regardless of the length of infusion or
the number of concurrent drugs
Example: Patient given 2 hours of 5-FU and leucovorin
96413 and 96415
96368
Consults Or Not
Medicare does not allow consults
In the office, bill a new or established patient visit (99201-
99215)
In the hospital, bill an initial hospital visit (99221-99223) when
the doc is first asked to see the patient and then 99231-99233
Other payers are all over the map with consults. Use office
and hospital consults (99241-99255) judiciously
Bone Marrow Biopsy and
Aspiration
Modifier -59
CPT 38221 bone marrow, biopsy
CPT 38220 bone marrow, aspiration only
Code both if different anatomic sites same incision do not code and do not use -59
Medicare CPT 38221 and G0364 (bone marrow aspiration performed with bone marrow biopsy through same incision on the same DOS).
Two Different Billing Scenarios
Direct Billing Certain NP Practitioners can be credentialed and can
bill under their own provider number
Nurse Practitioners, Physician’s Assistants, Certified Nurse
Specialists, Clinical Psychologists,
Medicare reimburses on a percentage of the Physician
Fee Schedule
Incident-to Billing Physician directed team
Service is billed under physician’s provider number
Direct Billing Criteria for
Medicare
Non-Physician Practitioner bills services
directly to Medicare
Must meet Medicare’s credentialing
requirements
Can bill in any setting allowable under State
scope of practice (office, inpatient and
outpatient hospital, etc)
Direct Billing Criteria for Medicare
Can provide any services allowed under their scope of
practice, but will only be reimbursed for covered services.
Should have a collaborative agreement with physician or
group of physicians
Refer to Non-Physician Practitioner Direct Billing Guide at
http://www.cms.gov/Outreach-and-Education/Medicare-
Learning-Network-
MLN/MLNMattersArticles/downloads/MM5221.pdf
What Is an Incident-to Service?
When services are provided by auxiliary
personnel under direct physician supervision,
they may be covered as “incident-to” services
Non-physician practitioner bills for services
“under physician’s name”
Incident-to Requirements
Integral though incidental part of physician’s
professional service
Commonly rendered without charge or included in
the physician's bill
Of a type commonly furnished in office/clinic
Furnished under direct supervision of the
physician/group throughout the service Source: Medicare Carrier’s Manual, Part 3, Chapter 2, 2050.1
Part of Professional Service
Service must be medically necessary
Service must follow initial physician service
Supervision alone is not a service
Physician incurs overhead expense for service
Integral though incidental Services and supplies commonly furnished in physician’s
offices are covered
Where supplies are clearly of a type that a physician is not expected to have on hand in his/her office setting, or are of a type no considered medically appropriate to provide in the office, they are not covered under the incident-to provision
Supplies, including drugs and biologicals must be an expense to the physician or legal entity billing.
Example: if patient supplies the drug and physician administers it, only administration can be billed by physician
Service must be medically necessary
Physician performs subsequent service to show active management and participation
Commonly furnished in
Physician’s office or clinic
Place of service MUST be office/clinic
Generally no hospital or other settings
For hospital patients and for SNF patients who are in a
Medicare covered stay, there is no Medicare coverage of
the services of physician-employed auxiliary personnel as
services incident to physicians' services
Direct Personal Supervision
Not part of same day physician service
Not in same room
Physician or other member of group practice must be
present in suite—and the definition of the suite is pretty
vague
Direct Personal Supervision Auxiliary personnel means any individual who is
acting under the supervision of a physician, regardless of whether the individual is an employee, leased employee, or independent contractor of the physician, or of the legal entity that employs or contracts with the physician. Likewise, the supervising physician may be an employee, leased employee or independent contractor of the legal entity billing and receiving payment for the services or supplies.
Direct Supervision If auxiliary personnel perform services outside the office
setting, e.g., in a patient's home or in an institution (other than hospital or SNF), their services are covered incident to a physician's service only if there is direct supervision by the physician.
Example:
nurse accompanied the physician on house calls and administered an injection, the nurse's services are covered.
If the same nurse made the calls alone and administered the injection, the services are not covered (even when billed by the physician) since the physician is not providing direct supervision.
Supervising vs. Ordering
Physician In a group practice, where one physician
orders a treatment/service to be performed
by ancillary personnel under the supervision
of a different physician who is a member of
the group practice, the service should be
billed under the provider number & name
of the supervising physician who was
present in the office when the service was
provided NOT under the ordering
physician.
Supervising vs Ordering (cont’d)
Example:
Oncologist orders chemo to be given by a nurse while
he/she is not present in the office, but under supervision of
another physician member of the same group.
Service should be billed under the name of the supervising
physician
Supervising vs. Ordering (cont’d)
Example #2
Patient with high blood pressure. At first visit, treatment plan
is established that the patient will come in once per week
for a BP check. Patient sees a nurse for these weekly visits.
This service is billed under the physician supervising the day
that the patient is seen in the office.
Per Chapter 14 of Medicare
Carriers Manual
A Nurse Practitioner, Physician Assistant, Nurse Midwife or
Certified Nurse Specialist can bill any E&M service (99210-
99499) per MCM 15501G
Other employees must bill 99211
Cannot bill based on counseling time per MCM 15501C
Incident-to vs Direct Billing Incident To
No New Patients
No New Problems
Physician In Suite
Not at Hospital or SNF
Physician Initiates/Directs Patient Care
Full Payment
Code at Any Level
Direct Billing
Any Patient
Any Problem
Who cares where Dr is?
Any Place of Service
NPP Initiates/Directs Patient Care
85% of Physician Fee
Code Any Level
Private Insurance and Managed Care
Companies may have different policies
and requirements!!
Some insurance companies do not allow incident-to or
billing under the doctor
NPPs may not be accredited to treat by private payers
Know your most common payer requirements
“Junque” Billing
“Junque” billing is billing for stuff you very rarely get paid for.
The decision to bill them must be based on whether you
make more $$ billing them than writing them off. Examples
include
IV fluids used to transport drugs
Needles and syringes
Drawing blood from the port or PICC 36591-36592 when
another service is performed
Facility fees when there is no agreement to pay for them
PART A & PART B APPEAL PROCESS
(Non-Expedited)
Beneficiary receives the service
Medicare contractor (fiscal intermediary or carrier or MAC) issues initial determination explaining whether Medicare will pay for a service already received.
Beneficiary has 120 days to request redetermination by contractor. Provider may also request redetermination Appeals will be consolidated Time frame may be extended for “good cause”
Contractor has 60 days to issue redetermination
PART B APPEALS
(cont.)
If redetermination is unfavorable can request a“reconsideration” by Quality Independent Contractor (“QIC”)
120 days to request reconsideration
Beneficiary & provider appeals will be consolidated
Time may be extended for good cause
Must fill out a reconsideration form which is available at http://www.cms.hhs.gov/cmsforms/downloads/cms20033.pdf
QIC must issue decision within 60 days.
Parties may request escalation to ALJ if time frame not met
60 days to request review by ALJ
ALJ HEARINGS Hearings conducted by Medicare ALJs in DHHS Office of
Medicare Hearings and Appeals
Minimum amount disputed must be ≥ $140 in 2014
ALJs are in 4 regional offices, not local offices
Must fill out the ALJ request form (http://www.cms.hhs.gov/cmsforms/downloads/cms20034ab.pdf)
For Part A and Part B claims, ALJ must issue decision within 90 days – with exceptions and there is a backlog right now
No time limit if request for in-person hearing granted
ALJ HEARINGS (cont.)
For ALJ hearings under Parts A, B, C & D
Amount of claim must be at least $ (changes annually)
Subject to annual increase
Can aggregate certain claims
Hearings conducted by video teleconferencing (VTC) if
available, or by telephone
ALJ assigned to case has discretion to grant request for in-person
hearing
APPEALS PROCESS – BEYOND THE ALJ
HEARING
If ALJ decision is unfavorable, have 60 days to request an
Appeals Council review (address will be in the rejection
letter)
Must be in writing within 60 days after the ALJ decision,
Appeals Council reviews the record concerning only those issues,
unless unrepresented beneficiary requests.
If Appeals Council decision is unfavorable, have 60 days to
request review in federal court
Must meet amount in controversy requirement
Amount may increase each year (≥ $1430 in 2014)
CALCULATING TIME FRAMES Time frames are generally calculated from date of
receipt of notice
5 days added to notice date
Time frames sometimes extended for good cause, examples include: Serious illness Death in family Records destroyed by fire/flood, etc Did not receive notice Wrong information from contractor Sent request in good faith but it did not arrive
MEDICARE ADVANTAGE APPEALS
“Organization determination” is initial determination
regarding basic and optional benefits
Can be provided before or after services received
Issued within 14 days
May request expedited organization determination if delay
could jeopardize life/health or ability to regain maximum
function.
Plan must treat as expedited if requested by doctor
Issued within 72 hours
MEDICARE ADVANTAGE (MA)
Request reconsideration w/i 60 days of notice of the organization determination.
Reconsideration decision issued within
30 days for standard reconsideration.
72 hours for expedited reconsideration.
Unfavorable reconsiderations automatically referred to independent review entity (IRE).
Time frame for decision set by contract, not regulation
Unfavorable IRE decisions may be appealed
to ALJ
to MAC
to Federal Court
MEDICARE ADVANTAGE (MA)
Fast-Track Appeals to Independent Review Entity (IRE)
before services end for
Terminations of home health, SNF, CORF
Two-day advance notice
Request review by noon of day after receive notice
IRE issues decision by noon of day after day it receives appeal request
60 days to request reconsideration by IRE
14 days for IRE to act
MEDICARE ADVANTAGE
GRIEVANCE PROCEDURES
Grievance procedures to address complaints that
are not organization determinations.
60 after the event or incident to request grievance
Decision no later than 30 days of receipt of grievance.
24 hours for grievance concerning denial of request for
expedited review.
PART D APPEALS PROCESS-
OVERVIEW
Each drug plan must have an appeals process
Including process for expedited requests
A coverage determination is first step to get into the appeals process
Issued by the drug plan
An “exception” is a type of coverage determination
Next steps include
Redetermination by the drug plan
Reconsideration by the independent review entity (IRE)
Administrative law judge (ALJ) hearing
Medicare Appeals Council (MAC) review
Federal court
PART D APPEALS PROCESS –
COVERAGE DETERMINATION
A coverage determination may be requested by
A beneficiary
A beneficiary’s appointed representative
Prescribing physician
Drug plan must issue coverage determination as expeditiously as enrollee’s health requires, but no later than
72 hours standard request
Including when beneficiary already paid for drug
24 hours if expedited- standard time frame jeopardize life/health of beneficiary or ability to regain maximum function.
EXCEPTIONS: A SUBSET OF
COVERAGE DETERMINATION
An exception is a type of coverage determination and gets enrollee into the appeals process
Beneficiaries may request an exception
To cover non-formulary drugs
To waive utilization management requirements
To reduce cost sharing for formulary drug
No exception for specialty drugs or to reduce costs to tier for generic drugs
A doctor must submit a statement in support of the exception
PART D APPEALS - COVERAGE
DETERMINATIONS ARE NOT AUTOMATIC
A statement by the pharmacy (not by the Plan) that the Plan will not cover a requested drug is not a coverage determination
Enrollee who wants to appeal must contact drug plan to get a coverage determination
Drug plan must arrange with network pharmacies
To post generic notice telling enrollees to contact plan if they disagree with information provided by pharmacist or
To distribute generic notice
PART D APPEALS PROCESS
NEXT STEPS
If a coverage determination is unfavorable: Redetermination by the drug plan.
Beneficiary has 60 days to file written request (plan may accept oral requests).
Plan must act within 7 days - standard
Plan must act within 72 hrs.- expedited
Then, Reconsideration by IRE
Beneficiary has 60 days to file written request
IRE must act w/i 7 days standard, 72 hrs. expedited
ALJ hearing
MAC review
Federal court
PART D GRIEVANCE PROCESS
Each drug plan must have a separate grievance process to address issues that are not appeals
May be filed orally /in writing w/in 60 days
Plans must resolve grievances
w/i 30 days generally
w/i 24 hrs if arise from decision not to expedite coverage determination or redetermination
USEFUL WEBSITES
www.medicare.gov
www.medicareadvocacy.org
www.healthassistancepartnership.org
Private Insurance Appeals
Appeals process must be outlined in the contract.
Sometimes, it is outlined on the payer’s web site.
Do not contract with a payer unless you know their appeals
process.
Appeals Process: Internal
Assess the denial and damage
Gather data
Draft letter
Follow up
Guerilla tactics
Assess Denial and Damage Is this a rejection or denial? Know your reason codes!
Reason Code 16—Get the info to the payer
Some are ‘game over’ Reason Code 27—Services rendered after coverage
terminated
Did the patient sign an ABN?
Does this require an appeal? Or is it unanswerable? No pre-authorization
No coverage for product or service
Not eligible
Duplicate claim, unless a drug or admin unit problem
Assess the Denial/ Damage
Requiring a response
Insurance limit reached, if cap is high
Off-label, if supported by legitimate sources, like approved compendia
Medical necessity supported by literature or community standard
Pre-existing conditions, checking state law or ACA
Contract violations
Draft Letter
Thoroughly review the record to ensure documentation, legibility, and medical necessity support are there.
Collect data
Clinical literature
Medicare laws, NCDs, LCDs, or local articles
Coding books and literature
Patient’s policy or benefit manual from employer
Paid EOBs from your own or neighboring practices
Agenda from KOL clinical meetings
Draft Letter Using chart documentation and data sources draft a
letter.
Use Medicare forms as necessary.
Review (unless it is an admin issues) the full content of the letter with the provider and, if necessary with the patient or caregiver.
Make corrections as necessary.
Always have the provider sign the letter, if clinical issues are involved.
Follow Up
Send by signed mail and ensure that the package was
received.
Mark in patient accounting file the date of receipt and who
signed the claim.
Medicare--Follow up per policy.
Commercial--Follow Up per contract or every thirty days.
Guerrilla Tactics Involve a lawyer---if only a cc
Employer/ Union
For Medicare or Medicaid
Local representation
HHS Regional Office
State Insurance Commissioner
State Medical Society
The Press
Stop the Bleeding
Do you have a denial management strategy?
Do you have an ERA (835) Analyzer?
What are your top five denials by payer? by dollar
amount? by type?
How do you prioritize denials? How long does it take to
address them?
How many claims are improperly paid?
What is your plan to improve your denial rate?
Find The Bleeding
Front Desk
Poor demographics
No payer contact information
Insurance changes not tracked
Change of patient address
Wrong guarantor
No signature on financial commitment form
Find the Bleeding
Insurance verification/ Billing
Lack of authorization
Patient not eligible
MA not Medicare
Insurance ceiling not identified
Deductible fulfillment not tracked
Coordination of benefits
MSP
Catastrophic coverage
Find the Bleeding
Charge capture/billing
Coding
Billing for supervising physician
Medical necessity
Support for unlisted codes
Timely filing
Duplicate claims
Inability to write off small amounts
Find the Bleeding
Clinicians
Change of diagnosis
Poor charge capture
Off-label use with no ABN
Dictation delays
No submission of hospital charges
A Fantastic Resource
Solutions Front Desk/ Financial Counseling Technology Eligibility/verification products On-line eligibility verification
Insurance company websites
Establish standardized registration polices, procedures, processes and performance levels
Ensure that registration staff is thoroughly trained Insurance plans and requirements prior to treatment Plan requirements, e.g., referrals, authorizations Importance of correct demographics
Solutions
Charge Posting
Computerized coding tools, particularly ICD-10-CM
Updated charge capture/Superbills
Claims editors
Claims “scrubbers”
Online access to Medicare policies for all providers
Strategies Benchmark yourself against what we have shown today
Remember that the more work done up front, the more will pay off in the long run
Advanced Financial Counseling is a real key to success…
Co-pay cards and Foundations are key to your solvency—track your revenue
Every person in the Revenue Cycle should have incentives—pay, PTO, pizza, etc.
Invest in systems to track, work and report denials, e.g. 835 data and benchmarking
Develop standards for reporting types of denials and communicate this information
Assign responsibility for denials and reward people for improvements in denial rates
Measure improvement on an ongoing basis
