Presentation on theme: "Provider Based Billing"— Presentation transcript:
1 Provider Based Billing Ann BinaKay MarsylaGundersen Health SystemAnn begins
2 DisclaimerInformation contained in these materials, including all discussion, is not intended to be legal or business advice. The laws and regulations regarding billing and coding are open to interpretation. It is your responsibility to ensure that coding and billing guidelines are being followed and to seek assistance from outside experts on application of those guidelines specific to your circumstances.
3 DefinitionsProvider Based Care benefits patients as all departments of the hospital are subject to strict quality standards and are monitored by The Joint Commission, an independent, not-for-profit organization that accredits and certifies health care organizations and programs throughout United States Joint Commission accreditation and certification is recognized nationwide as a symbol of quality that reflects an organization’s commitment to meeting certain performance standards Provider-Based Billing refers to the process for billing for services rendered in a hospital outpatient clinic or location. This is an industry standard model of practice for large, integrated delivery systems involved in patient care
4 Provider Based Billing (PBB) HealthCare Financing Administration (HCFA)Transmittal No. A Date May 1999Original Publication: A Date May 1998“Provider Based” is an outgrowth of the Medicare cost reimbursement systemIt’s main purpose is to accommodate the allocation of costs where there is more than one type of provider activity taking place within the same facility or organizationAppropriate allocation often results in increased Medicare reimbursement
5 Reimbursement Advantages Provider Based Billing allows for reallocation of cost to a hospital facility resulting in increased reimbursement For example reimbursement for in 2014 Clinic: $ Provider Based Entity Professional: $ Facility: $ Total $169.75
6 Reimbursement Advantages Destruction of Actinic Keratosis (CPT 17000) Clinic: $71.84 Provider Based Entity Professional $50.90 Facility $84.24 TOTAL $135.14
7 Reimbursement Disadvantages Medicare beneficiaries seen in provider based locations are subject to an increased financial liability:The beneficiary (or their supplemental insurance) pays the usual deductible and co-insurance for physician servicesThe beneficiary (or their supplemental insurance) is also responsible for a facility deductible and co-insurance
8 Provider Based Requirements Entire listing of requirements can be found in the Code of Federal Regulations, title 42 CFR :LicensureProvider Based Entity is operating under the same license as the main hospital except when state requirements mandate a separate licenseClinical Services IntegrationProfessional staff must have clinical privileges at the main providerMedical director(s) of the provider based entity maintain a reporting relationship with the Chief Medical Officer of the hospitalMedical records are integrated with those of the hospital
9 Provider Based Requirements Financial IntegrationFinancial operations of the provider based entity are fully integrated with the main hospitalCosts are reported in a cost center of the main hospitalFinancial status of the provider based entity is incorporated and readily identified in the main hospital’s financial reportingPublic AwarenessPatients must be aware they are entering part of the main hospital and that they will be billed accordingly
10 Provider Based Requirements Obligations of Hospital Based EntitiesHospital outpatient departments must comply with Medicare antidumping rulesProfessional services must be filed with the correct place of service indicator (hospital outpatient)Payment for services are subject to the 72-hour rule (PPS hospitals) or the 24-hour rule (PPS exempt hospitals)Provider based departments must meet all applicable health and safety rules for Medicare participating hospitalsLocationMust be located within a 35 mile radius of the main hospitalMust be able to demonstrate that the provider based entity serves the same patient population as the main hospital
11 Decision MakingMaking the decision to move to provider based care, and ultimately provider based billing, cannot be dependent on reimbursement alone:Is this decision good for our patients?Is this decision good for our organization?Will the decision be supported organization wide?Can we meet the necessary Joint Commission requirements?Do we meet the provider based requirements?Can our billing software successfully handle this change?Can we meet the financial reporting requirements?Can we successfully notify our patients of this change?
12 Who….Identify what reimbursements will be increased by submitting both a professional and facility charge:MedicareMedicare Advantage PlansMedical AssistanceContracted PayersCommercial PayersSelf-PayCheck with your contracts to determine reimbursement differencesNotify your contracts with your final decision
13 What…..Determine what locations qualify for provider based billing (i.e. within a 35 mile radius, reporting structure in place, etc.)Within the identified locations, determine what departments will be included in provider based billingService LineProvider TypeReimbursement IssuesImplement appropriate contracts to ensure the space and costs are allocated to the hospital
14 What….Use the Medicare Database (PC/TC indicator) to determine what codes need facility fees:Physician Services Code: Split professional and facilityDiagnostic Tests for Radiology Services: Split 26/TC modifierProfessional Component Only Code: Professional service onlyTechnical Component Only Code: Technical service only
15 Why…..Ensure that all staff is educated on why this change is taking placeImproved patient careNational standard for integrated health care facilitiesAbility to assist the organization in meeting it’s financial goals
16 When…. Determine a timeline Legal Contracts Joint Commission RequirementsInsurance Company NotificationsProvider Enrollment FormsElectronic Fund Transfer FormsSignagePatient EducationSystem BuildMoving to Provider Based is a big decision with lots of work involved. Give yourself plenty of time to ensure successAt least 6 months out from the start date.
17 How…. Create an integrated team to ensure all requirements are met Patient CareLegalFacilitiesHuman ResourcesBillingFinanceComplianceOrganization LeadershipMarketing
18 How…. Create a working document and ensure all updates are recorded Share directoryMeet regularlyDefine the decision making processEducate at every opportunityPatientsStaffCreate talking points and elevator speechesMake sure everyone is on the same pageDecision needs to be supported at all levels, all the timeEnsure all policies and procedures are completed
19 Impact to the Revenue Cycle Provider based billing affects all areas of the Revenue Cycle. Organizations moving in this direction need to be prepared for changes in:RegistrationCharge CaptureCodingBillingPaymentFollow-UpSelf-PayKay starts
20 Registration….Understand what registration forms are required for hospital outpatients:Authorization for treatmentNotice of increased financial liabilityMedicare Secondary PayerPatient Rights and ResponsibilitiesCreate a process to ensure collection of necessary signatures and proof of form distributionBiggest challenges –Additional forms – hospital blanket auth vs clinic blanket auth (daily) vs non PBB SOF (lifetime)Separate check in areas for PBB vs non PBB (split staff)Registration workflow creating a HAR for each visitWorkQ increased volumes - HB and PB don’t’ talk to each other. Visits are not linked.Prepared differentlyFully understanding the workflow impact on staff and patients (one blanket auth for each appt to one per day and communicating that it was already completed)Additional education for staff to understand the reason for the changesEducation for patients as to why there are additional forms to sign and areas to check in
21 Charge Capture…..Ensure the system is built to follow the process defined by the implementation team:Where do professional charges post?Where do facility charges post?Do providers need to change any charge capture processes?Are the fee schedules/chargemaster set up correctly?Will all patients be billed the same total amount?Are the appropriate revenue codes for facility services assigned?How is your billing system set up? Are there separate modules for hospital vs professional?Need to work closely with accounting for the proper flow of data for month end review.Need to analyze the chargemaster to ensure that charges will not be below reimbursement to be impacted by lower of reimbursement or charges.What is the split on reimbursement from the impacted payors? That will help develop the split of the charges between professional and facility.
22 Coding…. Ensure the coding staff understand their new work: Where will they look for charges?How do they make changes?Do they need to pay attention to fees?What if something is posted incorrectly?Where can they escalate questions to?Keep the chain of command intact so problems can be tracked.Do their production standards change?How will they be measured?Are individual meetings needed?
23 Billing…. What should billing staff look for? Consecutive account issuesIncreased claim editsPayer rejects specific to provider based billingDenialsProvider eligibility issuesUnexpected changes in paymentPatient complaintsAre all of the providers properly credentialed with the payors for the location?
24 Payment….Payment staff should escalate the following issues immediately:Noticeable changes in payment frequencyZero payments related to provider based departments/providersPayer phone calls for additional information regarding the PBB changeMost PBB only impacts Medicare, Medicaid, and TriCare unless you have a commercial contract that has specific language. In WI, Medicaid only recognizes provider based for buildings that are physically connected to the main hospital.
25 Follow-Up….The following should be monitored, trended and escalated as needed:All denials related to provider based billingProvider eligibility issuesUnexpected changes in paymentPayer concernsPatient complaints
26 Self-Pay…. Monitor patient concerns over self-pay balances: Ensure staff with patient contact understand the PBB billing rules and what they should expect to seeCan they explain it to the patient?Escalate any patient concern trendsEscalate any unexpected findingsPBB is not patient friendly. Now there will be 2 bills and higher coinsurance. It can be confusing to the patient especially if the facility and professional bill drop at different times. Patient pays the copay/coinsurance on one and then gets billed for the 2nd. Thinking they have already paid for this visit, it may go unpaid.
27 Hidden Identified Costs Joint Commission AccreditationHospital rules apply, i.e. order requirements304b Drugs thru pharmacy (pyxis vs. additional staff)Patient has two charges, professional and facilitySignage72-hour rule reportingAccounting/Finance issuesMedical record documentation changesProvider enrollmentsInternal contractsStaff EducationInitial increase in AR daysThe new hospital based departments will become eligible for 340b the year after the departments are filed on a cost report and then the locations are submitted as child sites with the OPA. Lots of regulations to follow.Signage – patients have to know that they are being seen by the hospital and not a freestanding clinicInternal contracts – where are the physicians employed? Who owns the buildings or rents the space where the clinics are located? All of those costs now need to be the hospitals.Additional:In WI, increased hospital tax as the tax is based on gross charges to the hospital. What used to be clinic revenue and excluded is now included for the facility side.
28 ImplementationThe work does not end at go-live. Part of the implementation plan should be:MonitoringMeasuringTweakingRecordingReporting
29 Monitoring…Monitor the entire revenue cycle for unexpected outcomes and educate staff on how to escalate findingsKeep the implementation team in the loopIs there an increase in patient complaints/concerns?Watch denials and monitor trendsAre the charges being posted? Are the charges routing to the correct departments? Are the right forms being completed?
30 Measuring… Create a process to ensure what you have done is working: Are you capturing the same gross revenue as you did before go-live?Is reimbursement as expected?Increased Medicare reimbursementAre there any barriers to being successful?Monitor the regulations for changes!!To understand impact, need to have compared based on current volumes – Global reimb to expected professional and facility reimbursement. Then actual reimbursement to expected. It is not clean cut or easy depending on how your billing system is set up. How is posting of payments set up.
31 Tweaking… Expect the unexpected and have a change process in place: How can issues be escalated?Where should issues be escalated?How will the changes be recorded?Do policies/workflows need to be updated?How will the implementation team be notified?Changes needed to the chargemaster, is an area not getting the facility charges
32 Reporting… Be prepared to be transparent in all reporting: Not sharing identified issues will likely come back to youThis type of program implementation affects many aspects of the organization and issues are expected to occurCredibility comes with how the issues are handledReport all issues without assigning blameBe prepared for questions on how the issue will be resolvedIf a solution is not readily available, report thatSuccess will be measured as a team…not an individualAfter spending the time and money to set up provider based billing, leadership will want to know if the amount forecasted is what is being realized.
33 ResourcesAlthough the Internet will provide many resources on provider based billing, it is safest to follow CMS (Centers for Medicare and Medicaid Services) published guidanceWhen using industry provider based billing websites, try and tie the information back to Medicare publicationsAsk for assistance when needed:ComplianceConsultantsPeersConfirm all decisions in writing with the implementation team
34 What’s NextProposed changes include a requirement to add a modifier to all PBB servicesExpect continued fee schedule changes included additional bundling of proceduresCCI and black box edits continue to be updated
35 ResourcesSign-up for carrier list serves and monitor proposed and finalized changesMonitor information from healthcare consultantsCreate a peer listing
36 ResourcesResources used within this presentation are noted within each applicable slideOther resources include:Joint Commission.Modern Health Care A.M. Ober| Kaler Payment Matters CMSBecker’s Hospital ReviewKing and Spalding submit contact information to Wisconsin Health News This is a paid subscription but you can get a free trial.Strategic Health CareAmerican Hospital Association AHA News Now