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Improving Your Patient Revenue While Ensuring Integrity and Compliance

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1 Improving Your Patient Revenue While Ensuring Integrity and Compliance
Region II Annual Primary Health Care Conference June 1 - June 3, 2010 Presented by: Peter R. Epp, CPA, Healthcare Practice Leader, Managing Director, RSM McGladrey Gil Bernhard, CPA, Managing Director, RSM McGladrey RSM McGladrey Inc. is a member firm of RSM International – an affiliation of separate and independent legal entities.

2 Improving Your Patient Revenue While Ensuring Integrity and Compliance
Establishing a culture of Revenue Maximization and Integrity and Compliance Setting the Health Center up for Success – operationally and compliance Regular Reports and Monitoring Intervening When Necessary

3 Impact of Executive Management and Board
While the day to day processes of the revenue cycle are performed by dedicated health center staff, executive management and the Board play a large role in determining the success of the process by: Establishing the proper culture of billing and collection: health centers that have a clear mandate from the board through management to bill correctly and maximize reimbursement as an organization priority do a better job of billing and collection than those who do not. This mandate plays out in management and staff goals Maintaining a balance of financial, operational and regulatory requirements Maintaining the overall financial health of the health center and its revenue streams Developing and monitoring processes; intervening where appropriate

4 The Revenue Cycle Patient Enters Facility/greeted at reception
Patient Registers Claims sent to payor (non-capitation) Denials Investigated and Corrected Patient Seen By Provider Provider Completes Encounter Form Patient Released at Front Desk Claim Report Prepared Encounter Form Processed Remittance Received with Payment Billing Department Reconciles and Posts Resubmission of Denied Claims Month Ending Journal Entries Posted

5 Objectives when Reviewing Billing/Revenue Cycle
Strong internal control procedures/compliance with policies Collection of proper billing information Proper recording of revenue Maintenance of subsidiary accounts receivable Collection of information for management reporting Satisfy Federal reporting requirements

6 Establishing Policies and Procedures
Set of expectations Many health centers are strong in policies and weak in procedures Steps for revising policies & procedures: Board and management affirm commitment to process Identify goals and implementation date Develop internal committee Develop appropriate policies and procedures Board of Directors approves policies Implement; distribute written policies and procedures Reinforce that compliance with policies and procedures is central to health center mission Reinforce through regular education and training Monitor & take action against violators

7 Ensuring Compliance with Policies and Procedures – Compliance Review
Good Policies and Procedures without follow up are worthless “Even the best laid plans of mice and men oft go awry.” – Robert Burns Review all Policies and Procedures Having a well-established compliance plan can reduce risk of fraud and abuse, as well as potential penalties Compliance plan also goes beyond Policies and Procedures by: Defining appropriate behavior and helping improve employee behavior Promoting self-evaluation, problem detection and resolution Promoting open communication

8 Billing and Revenue Strategies
Billing and revenue strategies are intended to improve the billing and collections process in the Health Center and encourage the effective use of staff who perform these functions. Common goals and objectives achieved through billing and revenue strategies: Increased patient revenue. Improved collections rates. Reduced medical coding errors. Cost savings of doing it right the first time.

9 Typical Medical Billing for Primary Care Services
Use Current Procedural Terminology (CPT) Codes and Descriptions Charge-Master is tied to CPT Codes Use International Classification of Disease (ICD) Codes – 9th version – Clinical Modification Referenced as ICD-9-CM codes Bill visit to insurance and patient is responsible for balance. Patient may have deductible and pays 100% until it is met.

10 Typical Medical Billing for Primary Care Services
Family Medical Practice Statement Date: 04/06/2009 123 Any Street Date Due: 05/06/2009 Anytown, IA 88888 STATEMENT OF ACCOUNT Jesse James 234 One Way Street Anytown, IA DATE DESCRIPTION CHARGES CREDITS ACCOUNT BALANCE Balance brought forward $56.00 04/01/09 Intermediate Office Visit - Dr. Jones $75.00 $131.00 Basic Metabolic Panel $125.00 $256.00 Potassium $20.00 $276.00 Co-Pay $15.00 $261.00 04/03/09 Filed Ins. - $205.00 ($205.00)

11 Types of Health Center Reimbursement
All-inclusive Rate Medicare (Cost-Based Reimbursement) Medicaid (Prospective Payment System) Fee-For-Service Commercial carriers Capitation Medicare Medicaid Contract Revenue Patient Self-Pay Revenues

12 FQHC - Getting Started What is the difference between a FQHC and a Community Health Center? Must apply for FQHC status. FQHC Medicare Provider Billing numbers are by delivery site. Medicaid may be different depending on your state. For FQHC Medicare, must complete and submit CMS-855A form in order to enroll in the FQHC program. For FQHC Medicaid, your state may require FQHC Medicare status before awarding FQHC Medicaid status. Again, depends on your state. Approval timeline may be 2-4 months.

13 CMS 855A Form Form requires completing information on health center’s identification (locations, address, etc.), legal history (including adverse rulings), ownership interest (sheet per board member with SSN), practice locations, etc. Copies of all: Professional/business licenses CLIA licenses Pharmacy licenses Legal Action documents EDI Agreements Articles of Incorporation/Corporate charters IRS Documents Notice of Grant Award Go to Click on Medicare; then CMS Forms

14 What are Billable FQHC Medicare Services?
Medicare FQHC Services, as defined in Regulation are: Physician Services and services/supplies incident to Nurse Practitioner and Physician Assistant services and services/supplies incident to Clinical Psychologist and clinical social worker services and services/supplies incident to Visiting nurse services Nurse-midwife services Diabetes Self-Management Training (DSMT) Medical Nutrition Therapy (MNT) Preventive primary services

15 DSMT & MNT Services Effective January 1, 2006
Section 5114 of Deficit Reduction Act of 2005, FQHC definition of face-to-face encounter is expanded to include encounters with qualified practitioners of Outpatient Diabetes Self-Management Training (DSMT) services and Medical Nutrition Therapy (MNT) Program requirements for provision of such services set forth in Part 410, subpart H (DSMT) and Part 410, subpart G (MNT) IOM , Chapter 15, Sec 300 = Accreditation from American Diabetes Assn. or Indian Health Service IOM , Chapter 18, Sec 120 = Billing requirements

16 FQHC Medicare Services (Billable and Covered)
FQHC Medicare Services (Billable and Covered). Preventive Primary Care Services Services required under Section 330 of PHS Act Furnished by providers listed in previous slide Medical social services Nutritional assessment and referral Preventive health education Children’s eye and ear examinations Prenatal and post-partum care Perinatal Services Well Child care Immunizations Family planning services Taking patient history Blood pressure measurement Weight Physical Exam ETC

17 Medicare Cost Principles
Social Security Act §1861(aa)(4) Statutory Requirements §1833(a)(3) = Payment provisions 1832(a)(2)(D) =Managed Care provisions 1861(v)(1)(A) = FQHC Services & IOM ,Chap 13 Regulation (RHC/FQHC) General Methodology The reasonable cost of any services shall be the cost actually incurred, excluding any cost found to be unnecessary in the efficient delivery of needed health services

18 Medicare Payment Provisions
Pay FQHCs/RHCs 80% of All-Inclusive Rate No Medicare $100 Annual Deductible for visits to FQHCs 100% Reimbursement for Pneumococal and Influenza Vaccines and Administration Medicare Bad Debt Recovery Sliding Fee Scale Applicability 62 ½ % Reimbursement for treatment of mental, psychoneurotic, and personality disorders (phase in of increase over next 5 years) Medicare Part B for non-covered services

19 Medicare FQHC Billing-Outpatient Mental Health
Outpatient Mental Health Treatment Limitation (Rev. 1843, Issued: , Effective: , Implementation: ) The limitation has been 62.5 percent since the inception of the Medicare Part B program and it will remain effective at this percentage amount until January 1, However, effective January 1, 2010, through January 1, 2014, the limitation will be phased out as follows: January 1, 2010 – December 31, 2011, the limitation percentage is 68.75% January 1, 2012 – December 31, 2012, the limitation percentage is 75% January 1, 2013 – December 31, 2013, the limitation percentage is 81.25% January 1, 2014 – onward, the limitation percentage is 100%

20 FQHC Medicare Medicare Advantage Plans
The Medicare Prescription Drug, Improvement, and Modernization Act of 2003 renamed the Medicare+Choice plan and made other changes including regional PPOs, special needs plans for dual eligibles, and others, and created private drug plans effective 1/1/06. Rates paid to managed care companies were also increased in many cases. Overall HHS target is to increase Medicare enrollees in managed care to 30% by 2013 from 12% in ,609,264 are enrolled as of January, 2009, which is approximately 25%. Also includes supplemental wrap-around payments to FQHCs who contract with Medicare Advantage (MA) plans. Includes HMOs, PPOs, and PFFS’. All are known as MA Plans. Created also were Special Needs Plans (SNP) which restricts enrollment only to dual eligibles , those residing in institutional settings, or those with multiple chronic conditions.

21 FQHC Medicare Medicare Advantage Plans
Health centers with MA plan contracts will be paid based on the contract. In addition, will qualify for a supplemental wrap-around payment when it provides FQHC Services. With PFFS plans, health center is entitled to 80% of its reasonable costs (up to the cap), plus 20% of its actual charges, less the plan’s co-pay.

22 FQHC Medicare Wrap-Around Provisions
Three contractual requirements between Plans & CMS: Must be written contract between FQHC and MA Plan MA plan must pay FQHCs an amount similar to what it pays other non-FQHC providers FQHC must accept MA payment and wraparound as payment in full Covers FQHC services only Does not include certain Part B services such as lab and x-ray. Does not include pharmacy costs under Part D. Part B services should be billed directly to the MA plan

23 FQHC Medicare Wrap-Around Provisions
System changes made to accept payment on 6/3/06 (bill type 73x and revenue code 0519) For first 2 rate years, FQHC submits an estimate of MA payments to fiscal intermediary FQHC will receive payment for each wraparound bill it submits to fiscal intermediary NACHC Issue Brief # 86 dated June, 2006

24 FQHC Medicare Wrap-Around
Proc Code Procedure Description Estimated Units Plan Rate Weighted 99211 Est. Office Visit 38 $ 21.16 $ 99212 411 62.25 25,585 99213 3,596 72.04 259,056 Totals Per-Visit-Rate 5,200 $ 309,388 $ 59.50

25 FQHC Medicare Wrap-Around
AGE PMPM Annualized Capitation/100 Estimated Visits/100 Per-Visit Rate 1-12 $13.32 $15,984 299.38 53.39 13-18 $27.55 $33,060 620.38 53.29 19-36 34.35 $41,220 765.60 53.84 37+ $46.42 $55,704 990.64 56.23 Per-Visit Rate $ 54.19

26 FQHC Medicare Part D Pharmacy
Starting 1/1/06, prescription drug plans (PDPs) will be the primary mechanism for Medicare enrollees to receive prescription drug benefits Optional benefit; enrollees will need to sign up Dual eligibles will receive coverage through Medicare Part D, not Medicaid Health centers with pharmacies will need to contract with PDPs to receive reimbursement for Medicare pharmacy patients No statutory provisions preventing health centers with 340B programs from participating in Part D

27 FQHC Medicaid Services
FQHC/RHC Services, as defined in Section 1902(a)(10)(A) and 1905(a)(2)(C) of the Social Security Act, and any other ambulatory service in the State Medicaid plan provided by the FQHC/RHC Examples: Dental and pharmacy Enabling Services, i.e., transportation, case mgmt., translation EPSDT services Certain inpatient services Nursing home or home care services

28 Prospective Payment System for FQHCs
“Beginning with fiscal year 2001 with respect to services furnished on or after January 1, 2001….” New Section § 1902(aa)(1) of the Social Security Act “The new Medicaid PPS requirements are effective in all States with respect to services furnished by FQHCs on or after January 1, 2001.” January 19, 2001 State Medicaid Director Letter (SMDL)

29 Prospective Payment System
Who are the FQHCs? Initial PPS rate-setting methodology Current FQHCs New FQHCs PPS rate-setting for the future Medicaid managed care shortfall payments (“wraparound”)

30 OVERVIEW OF PPS Payment calculated on a per visit basis.
States required to pay current FQHCs 100 percent of the average of their reasonable costs of providing Medicaid-covered services during FY1999 and FY2000. Adjusted to take into account any increase (or decrease) in the scope of services furnished during FY2001 by the FQHC and inflated by the MEI (Medicare Economic Index) for 2001.

31 OVERVIEW OF PPS New FQHCs After 2001:
PPS baseline rates will be calculated using one of the following methodologies. This varies by state. the rates established for the fiscal year for other centers or clinics located in the same or adjacent area with a similar case load or in the absence of such a center, in accordance with Medicare FQHC regulations and methodology, or based on other tests of reasonableness as the Secretary may specify The MEI will be applied to the new FQHC’s rate for each year following the baseline year.

“Change in Scope” per CMS Q & A Document: A change in scope shall occur if : The center has added or has dropped any service that meets the definition of FQHC/RHC services; and The service is included as a covered Medicaid service under the Medicaid state plan. A change in the “scope of services” is defined as a change in the type, intensity, duration and/or amount of services. In making such an adjustment, state agencies must add-on the cost of new services even if these services do not require a face-to-face visit with a provider.

Cost Per Visit Analysis: 1999 2000 Avg. Trended 2008 Medical 50.00 55.00 52.50 57.75 60.00 Ancillaries 10.00 11.00 20.00 Enabling 15.00 16.50 Administration Capital 12.50 13.75 25.00 TOTAL $100.00 $110.00 $105.00 $115.50 $135.00

34 Alternative Payment Methodologies
States may opt to pay FQHCs using a methodology other than PPS (“alternative payment methodology”) only if the methodology selected meets the following conditions: Must be agreed to by the State and each individual FQHC to which the state wishes to apply the methodology Must result in a payment to the center or clinic that is at least equal to the amount to which it is entitled under PPS. Must be described in the approved State plan. Many states have adopted alternative methodologies. Examples of such methodologies include: Continuing to use cost-based reimbursement or some version of it. Allowing states to select as their base year costs the higher of 1999 or 2000 Reimbursing for full capital costs. How capital is defined also differs amongst states. Varying when during the calendar year the MEI goes into effect. For more information on a state-by-state basis, please review the NACHC report at

35 PPS Wrap-Around States required to make supplemental payments to FQHCs that subcontract (directly or indirectly) with managed care organizations (MCOs) – particularly important in Section 1115 States where managed care is statewide. Supplemental payment is the difference between the payment received by the FQHC for treating the MCO enrollee and the payment to which the FQHC is entitled under the PPS. IMPORTANT - Incentive payments, e.g. risk pool payments are excluded from the wraparound calculation. Also, whether payments for non-direct medical services such as case management and administration will be figured into the wraparound calculation will also vary on a state-by-state basis. FQHCs are entitled to be paid at least as much as any other provider for similar services.

36 Commercial Insurance Payers HMOs, PPOs, Indemnity Coverage


38 BASICS OF MANAGED CARE Forms of Reimbursement Under Managed Care
Fee-For-Service: Based on CPT Codes Earn More Revenue by Performing More Services Different Charges for Different Types of Services

39 BASICS OF MANAGED CARE Forms of Reimbursement Under Managed Care
Capitation: Revenue is based on a prepayment of a fixed periodic amount per member per month (PMPM). The amount of revenue earned is based on the number of members enrolled - not on the number of visits. To earn more, control utilization and provide fewer and/or less costly services.

40 BASICS OF MANAGED CARE Contracts with Both Capitation and Fee-For-Service Components In these cases two separate sets of entries should be booked in the general ledger: Capitation payments received for month’s capitation Gross charges for capitation services rendered during month Gross charges and associated contractual allowance for all specialty services (if a co-payment is required, then an entry to self pay receivable and revenue is required) NOTE: Under this type of contract, it is essential that centers track the different types of services rendered to each patient.

41 Fee-For-Service Fee-For-Service (FFS) Methodology:
In a FFS environment, reimbursement is based on Current Procedural Terminology (CPT) code. Different Charges for Different Services Reimbursement Based on CPT Code at Fees Established by Third Parties Amount of Revenue Earned Is Based on the Number and Type of Billable Services Provided Fee-for-service procedures include, but are not limited to, laboratory, radiology, etc.

42 Maximizing FFS Revenue
To generate more revenue, a health center can: Provide more procedures Properly code encounter forms to ensure all services provided are billed Utilize a comprehensive encounter form to ensure all billable procedures are included Have a system of collections

43 Ensuring Proper Coding – High Level Overview
Collect data on provider visits (E&M Codes) By individual Provider In the aggregate for the health center Prepare graphs to show frequency of codes used Show increasing intensity of visit from left to right Overlay Health Center providers and aggregate data in national averages Include payor-source specific graphs

44 How Can You Recognize Improper Coding?

45 How Can You Recognize Improper Coding?
When we add payer-based coding information, the differences may become even clearer:

46 Tracking Productivity and Performance based on Relative Value Units (RVUs)
Each procedure code has an associated value – an RVU The RVU compares services against one another The more intense the service, the higher its RVU Three components to the RVU Work RVU which measures effort of the provider Practice Expense RVU which measures support staff and overhead costs associated with providing the care Malpractice RVU which translates the cost of average malpractice coverage attributable to the code Work RVU is the important component for provider productivity

47 Billing and Revenue Strategies – Understanding Contracts
Eligibility/preauthorization Claims timeliness Complete information Accurate information On appropriate forms In compliance with managed care contract/from provider manual

48 Compliance Programs A set of procedures and processes instituted by an organization to regulate its internal processes and train staff to conform to and abide by applicable local, state and federal regulations. Defined corporate standards and expectations Communicates uniform work procedures to assure the corporate standards and expectations will be met Describes the methods for monitoring standards Identified to ‘go-to’ person(s) for staff when compliance issues arise Provides corrective action processes Required in Healthcare Reform Bill

49 Benefits of a Compliance Program
Establishes and promotes awareness of federal and state regulations Defines the standard of organizational values and expectations Creates the framework for meeting regulations by providing the necessary parameters and protocols for staff to follow Can help to identify organizational vulnerabilities/weaknesses In the event that a violation occurs, an effective compliance program can serve as a mitigating factor in determining penalties.

50 Seven Recommended Elements of a Compliance Program
From OIG Compliance Voluntary Program Guidelines for Individual and Small Group Physician Practices Designating a Compliance Officer or Contacts Conducting Internal Monitoring and Auditing Developing Written Standards and Procedures Conducting Training and Education Responding Appropriately to Detected Offenses Developing Open Lines of Communication Enforcing Disciplinary Standards New York has eight Policy of non-intimidation and non-retaliation for good faith participation in the compliance program

51 Basic Elements of the Finance Portion of Your Compliance Program
Accounting policy and procedure manual (Including Patient Revenue and Receivable recording and reporting) Policies and procedures governing Internal controls Grants management Community Health Center program Other (Ryan White, state & local grants) Tax filings and compliance New IRS Form 990 Cost report filings and compliance (Medicare and Medicaid) Billing and coding compliance (Medicare and Medicaid) Internal auditing and monitoring

52 Objectives The essential components of a revenue integrity program and introduces you to the tools to build one. Topics covered include: Defining your scope of care…delivering the right services in the right setting with the right providers Documenting services…collecting and recording data to support your claim for reimbursement…on paper, or in the computer Coding accuracy…making sure that your providers properly code the diagnoses of your patients and the care they deliver Checking system performance…checking regularly to make certain your automated systems are not automating an error! Monitoring revenue integrity results…establishing an ongoing program for reviewing and monitoring the critical elements of your claims process, from point of care through posting of payment. The responsibility for revenue integrity rests with all center staff. This applies to clinical staff who provide care, business office staff who bill for the care, and those in positions of leadership or governance.

53 Revenue Integrity Defined
Revenue Integrity is the state of accurately coding or classifying care provided based on: patient needs services provided payer requirements And collecting, recording, and storing the data required to support the claims. Revenue integrity is about being paid for the services you provide– nothing more and nothing less. It is a disciplined approach to making sure that the services provided were medically necessary and appropriate, within parameters for reimbursement, provided by the appropriately credentialed providers, documented appropriately, and submitted for payment properly.

54 The Heart of the Matrix Revenue Integrity Operational Performance Financial Performance Quality Improvement Corporate Compliance Revenue Integity interfaces with both the quality assurance and improvement process of the organization, but also with the corporate compliance plan for it as well. Health centers exist to provide health care services, but in order to ensure their sustained viability and continued access to them by their patients, they need to have effective processes to collect the revenue that those care activities reflect. Therefore, the operational processes of how a center works includes providing data input into the revenue cycle to initiate the revenue collection process. Therefore, revenue integrity is affected by the care giving processes as measured by the quality improvement process. In other words, quality improvement activities will legitimately include reviewing operational aspects of revenue integrity. For example, when patients are registered, was accurate demographic and insurance information obtained? Likewise, revenue integrity touches the corporate complaince process which is focused on making sure that the organization is appropriately billing for services it actually provided. For example, for each claim submitted, is there clinical documentation showing the services provided, their medical necessity, and that they were provided and documented by an appropriate medical provider?

55 Environment Scan There is increasing pressure on all providers of care to ensure revenue integrity due to: Limitations of Federal and State reimbursement, with current budget concerns Increasing scrutity by Federal and State agencies on proper claims submissions Development of a “revenue recovery” mentality by Federal and State governments (e.g. RAC audits, State Medicaid Audits, etc.) Half of health care reform is expected to be funded by reducing fraud, waste, and abuse by providers Increasingly, the Department of Justice and Medicare’s Office of Inspector General are moving from a “pay and chase” approach to preventing fraud, waste, and abuse by providers, to a model that involves concurrent monitoring of claims submission data for signs of potential misadventure. In order to prevent being flagged for further review, it is important that providers submit claims in their proper format and with an awareness of utilization patterns.

56 McGladrey Pyramid of Revenue Integrity
System Performance Proper Coding Define Scope of Care Acurate Charting Monitoring Feedback This is the McGladrey pyramid of revenue integrity, and is the framework for our discussion today. Like any process, by having an organized framework to base the activity on, you ensure a disciplined, comprehensive approach that can be replicated over time in the organization. This means that changes in performance over time can be compared. And by using a framework which encompasses the major components of the revenue cycle, you decrease the chances of missing a factor that could be affecting performance. The framework includes not only the four major components of revenue integrity, but shows the people of the organization as the foundation of the process, and that success is dependent on monitoring and feedback. We will explore each piece of this model in more detail in the rest of this presentation. Board Clinicans Staff

57 Foundation of Revenue Integrity Program
System Performance Proper Coding Define Scope of Care Acurate Charting Monitoring Feedback The foundation of the revenue integrity program is the people of the organization. This ranges from the governing body, to the providers of care, to the non-clinical and support staff. Each of these groups plays an important role in a successful revenue integrity program. Board Clinicans Staff

58 Foundation of Revenue Integrity Program
Strategies for Success: Include in job descriptions the specific activities of each person as it relates to revenue integrity Keep job descriptions general and refer to following policies and procedures which are frequently updated Provide formal training during on-boarding of new people of their expected performance Explain that revenue integiry is an important component of the organization’s corporate compliance program Provide periodic reviews of mission critical performance activities Review quarterly or annually the policies and procedures which are most important or have been problemmatic Provide feedback on individual and team performance Stress that achieving revenue integrity is a combination of individual and group performance The people of your organization provide the foundation of your revenue integrity program. It is critical to have their engagement, support, and involvement in the building of the pyramid in whatever areas relate to their individual jobs. In order for you to achieve high levels of engagement, support, and involvement, you must develop and implement a planned strategy for success. This includes everyone from the governing body, to providers and clinicians, to administrative and support staff.

59 Role Differentiation for Revenue Integrity
Board Clinicians Staff Participates in training on Revenue Integrity, Compliance, and Quality Assurance Includes revenue integrity as a goal of it’s charge to management in developing and implementing a compliance and quality assurance program Receives periodic performance reports on revenue integrity as part of compliance or quality assurance program Allocates resources and ensures follow through for development of systems and processes to correct or improve revenue integrity issues identified. Participates in training on proper documentation of care provided, and on coding accurately Maintains awareness of coverage status of common visits, tests and procedures by common payers. Documents care provided according to center’s standards Documents coding to center’s standards Dates and signs all documentation accurately. Writes clearly and legibly. Electronically signs and locks all electronic documentation properly Participate in problem solving focus groups when issues are identified.. Participates in training on supporting revenue integrity by properly preparing and filing documentation, collecting and verifying insurance coverage information on residents, and maintaining an awareness of coverage status of common visits, tests and procedures by common payers. Implement all procedures and processes in support of revenue integrit Participate in problem solving focus groups when issues are identified. The table on this slide shows the different roles and responsibilities of each of the three groups of people making up the FQHC.

60 Define the Scope of Care
System Performance Proper Coding Define Scope of Care Acurate Charting Monitoring Feedback The first element of the McGladrey pyramid of revenue integrity that we are going to discuss is “define the scope of care. Scope of care includes the various clinical services provided by the center, the populations served, and the settings in which care will be provided. Board Clinicans Staff

61 Define Your Scope of Care
Strategies for Success: Outline the clinical services needed by your patient population Consider the age groups you serve, health status of your population, and preventive care requirements Identify the place of services that are required Consider if you serve children who may need school based programs, or elders who may need nursing home or home based visits Review Medicare, Medicaid, and Commercial Payer requirements for services and place of care For each service you plan to provide (e.g. primary care, podiatry, maternal/child, substance abuse) find the regulation or provider manual reference that shows coverage requirements, designated provider, and place of service limitations. File supporting documents for each service While each segment of the revenue integrity pyramid is critical, the definition of the scope of care is a primary step. This is where you determine what activities needed by your patients and provided by your staff meet the requirements of coverage by your payers. It also includes a definition of who the appropriate providers of these services are. It is important to remember that these payer requirements will vary between Medicare, your individual state’s Medicaid program, and commercial payer requirements.

62 Sample Documentation of Scope of Care Discussion Purposes Only– Must be individualized for each FQHC based on state regs Clinical Service Place of Service Appropriate Provider Covered by Medicare Covered by Medicaid Covered by Managed Care Applicable Utilization Limits Annual Physical Center or Home Care MD, NP, PA Yes Yes (This is State Specific and need to check State regs) Medical Necessity Psychology Services PhD (Psych), or LCSW Varies by contract or plan—list separately Medicaid limits to two visits per month. This slide shows and example of documentation of the scope of care of the organization, and the financial coverage of those services by payer class. For each “yes” in coverage columns, attach copy of regulation or coverage memo

63 Appropriate Provider For each service provided, know the appropriate provider for that service E.g. Primary care by MD, DO, NP, or PA E.g. Mental Health services by PhD (Psychologist) or LCSW Also make sure each provider is appropriately credentialed License and education verification Employment contract or agreement Validation that they are not on either a federal or state banned provider list

64 Utilization Limits Medical necessity is required for Medicare clinical services Many Medicaid programs, as well as commercial and managed care plans, may have utilization limits Coverage limits by type of service Lifetime Coverage year Month

65 Ensure Adequate Documentation of Care (Charting)
System Performance Proper Coding Define Scope of Care Acurate Charting Monitoring Feedback The second element we are going to discuss is accurate charting. Increasingly, this function is moving from a paper based process to an electronic one– with a new set of challenges. Board Clinicans Staff

66 Ensure Adequate Documentation of Care
Strategies for Success: For each service provided, create documentation guidelines for providers to follow Consider the required documentation to support the medical necessity of the service, the level of coding, as well as any requirements for quality of care incentives under managed care contracts. Validate that clinical forms or electronic health record templates support the required documentation Providing cues for required documentation can improve compliance, but make sure that documentation is individualized to patient and not templated Reinforce policies and procedures for dating and signing clinical documentation Include standards for when signing/locking must occur Also, include procedures for making changes or additions to documentation at a later date We have all heard the adage, “If you didn’t write it, you didn’t do it.” Ensuring adequate documentation is more involved than documenting clinical care. Specific requirements for payment may depend upon documentation, and providers need to know them. For example, some visits may require documentation of a face-to-face encounter with a provider, even if the majority of care is given by staff. And if E&M coding is used for determining the level of reimbursement, then the required charting is needed as well.

67 Sample Documentation Guidelines

68 Ensure Proper Use of Billing Codes
System Performance Proper Coding Define Scope of Care Acurate Charting Monitoring Feedback The third component we are discussing today is proper coding. Board Clinicans Staff

69 Ensure Proper Use of Billing Codes
Strategies for Success: For each service provided, create coding guidelines for providers and staff to follow Define the appropriate CPT or payer specific codes required to describe the service provided Define the appropriate place of service codes for each setting in which care is provided For each service encounter, provide a mechanism (either on paper or in electronic health record) for provider to assign code based on care provided Each year, review codes for continued applicability and for any changes in definition or requirments Design a process where coding is checked during the claims submission process This may be done by manual review of each or a sample of claims, or by electronic billing edits / reports The services provided, the provider of those services, and the place of service are represented in codes on the claim for each encounter. If the proper codes are not utilized, payment may be provided for services for which the center is not entitled. For example, if a provider encounter for follow-up of CHF is performed in a hospital rather than in the center, if the place of service is coded for the center and not the hospital, the center may be paid for a non-covered FQHC service.

70 Coding and FQHCs FQHC providers are not required to submit a HCPC code on a claim however operationally many FQHC providers need to include  a charge amount and HCPC to allow a claim to be created in their practice management systems (PMS).  An FQHC commonly includes the E&M code only for the Medicare threshold visit (regardless of what other services were provided) and includes the total charge amount associated to that visit to the E&M code line item/HCPC.  Type of Bill (TOB) is used on Institutional claims which is required for FQHC providers seeking reimbursement from Medicare for threshold visits, similar to place of service on a professional claim.  Centers should ensure they are using the appropriate TOB and revenue codes to ensure claims are not denied.  For example certain mental health visits with certain diagnosis codes need to be submitted with a revenue code of 0900 whereas medical visits are submitted with a 0521. 

71 Coding and Billing Reviews
Was claim submitted within allowable Timeframe? Was care given in a covered place of service? Proper Billing Code? Do providers match? Claim # Date of Service Date Claim Filed Submitted Place of Service Audited Place of Service Submitted Billing Code Audited Billing Code Submitted Provider Audited Provider

72 E&M Codes E&M codes may be required by certain state Medicaid programs, or by commercial or managed care plans that centers may contract with. Even though E&M coding does not affect Medicare Part A reimbursment for FQHCs, it is a good idea to promote acurate E&M coding for these patients as well. This helps to ensure provider coding acuracy for patients with payers where coding does matter. The clinical documentation needed to support E&M coding helps to demonstrate medical necessity of the visit

73 Evaluation and Management Documentation Guidelines CPT
Documentation and Coding are driven by the nature of the presenting problem. Key Components of the note. Understanding the basics of choosing the correct level of service History, Examination, and Medical Decision Making Understand how Contributory Factors effect your level of service Successful linking of CPT and ICD-9-CM The descriptors for the levels of E/M services recognize seven components which are used in defining the levels of E/M services. These components are: History Examination Medical Decision Making Counseling Coordination of care Nature of presenting problem; and Time

74 Evaluation and Management Documentation Guidelines ICD-9-CM
The importance of consistent, complete documentation in the medical record cannot be overemphasized. Without such documentation accurate coding cannot be achieved. The entire record should be reviewed to determine the specific reason for the encounter and the conditions treated. Selecting the correct ICD-9-CM code When to code for signs and symptoms Choosing the primary diagnosis Coding to the highest level of specificy Prepare for the immanent mandated change to the ICD-10-CM.

75 Ensure Proper System Performance
Coding Define Scope of Care Acurate Charting Monitoring Feedback Board Clinicans Staff

76 Ensure Proper System Performance
Strategies for Success: Validate that all definitions, edits, and templates in your electronic health system are consistent with your policies, procedures, and processes This strategy should be performed during initial set up, and updated annually or after any process change Test a sample of automated claims against a manual claims submission process Again, perform this during initial system implementation, after any modification to system, and at least quarterly Be sure to include a sample of all claim types Review user performance with system to identify issues Check that providers are electronically signing and locking notes Check reports of timeliness of claims processing, and whether edits are unnecessarily holding up submission Electronic health systems have tremendously improved the efficiency and effectiveness of claims submission and reconciliation…but they also have introduced a new area of concern for breaches in revenue integrity. The electronic system only formats claims in the way it is set up to do, and using data provided to it in an appropriate manner. If the definitions or edits that have been programmed into the system are incorrect, then the error is perpetuated through the automated process…and it may not be noticed for awhile.

77 Other Systems Considerations
Systems are set to appropriately select payer E.g. Medicare should always be primary payer for dual eligibles, no-fault insurance is primary for auto accidents, etc. Co-payments and co-insurance amounts are billed for and tracked Claim denials are tracked and appealed Claim denial trends are analyzed and systemic issues identified for performance improvement

78 Sample System Performance Management
Date Software Upgrade, or “switch” turned on or off Post system change testing completed Comparison of post system change testing to hand coded sample of clinical documentation 6/1/2010 Rates updated in system 6/3/2010 100% correlation

79 Ongoing Monitoring Activity
System Performance Proper Coding Define Scope of Care Acurate Charting Monitoring Feedback Board Clinicans Staff

80 On-Going Monitoring Activity
Strategies for Success: Conduct an annual risk assessment for revenue integity to identify monitoring focus areas, based on: High volume services Low volume, but complex services Services that are the focus of government or payer audits Services for which claim submissions have been problemmatic in the past Design and implement a monitoring program for the high risk areas identified Develop review tools and define frequency of implementation Analyze results of these reviews and identify root causes and develop corrective action plans Track corrective action plan implementation and check for improvement The monitoring activities of both your center’s corporate compliance program, and quality/process improvement program should support the goals of your revenue integrity strategy. Since revenue integrity is important to demonstrate compliance with Federal and State regulations and prevention of fraud, waste and abuse, and it is critical for the financial success of your organization, all of these programs inter-relate. Successful revenue integrity strategies will lead to success in compliance and meeting financial goals.

81 Provide Continuous Feedback
System Performance Proper Coding Define Scope of Care Acurate Charting Monitoring Feedback Board Clinicans Staff

82 Provide Continuous Feedback
Strategies for Success: Communicate findings of revenue integrity monitoring activity to board, providers, and staff Include these reports in regular board, provider, or staff meetings Don’t report raw data– first conduct root cause analysis and develop recommendations for improvement Be sensitive to compliance or legal issues when reporting results– use data summaries and only characterize problems as performance issues and not as compliance or legal issues Provide on-going education to providers and staff As requirements, policies, and procedures change, it is critical to update written procedures and guidelines to reflect them All changes should be communicated to providers and staff A record of training should be maintained Remember that the foundation of your revenue integrity program is made up of your board, your providers, and your staff. It is critical that all three of these groups get feedback from your monitoring activity. If the information on program performance is collected, but not shared, then any opportunity for process and outcome improvement is lost. The feedback loop is two-way, and ideas and suggestions from the board, providers, and staff should go back to the revenue integrity team as well.

83 Monitoring Verses Auditing
Monitoring is a process of gathering data during the revenue cycle process to ensure that procedures are being followed Example of monitoring in a paper based environment might be checking that there is a encounter sheet signed by a provider for each claim being submitted Example of monitoring in an electronic enviroment might be an electronic notification if a claim lacks an electonically signed and locked clinical note Auditing is a retrospective process where a sample of claims is selected and tested to see if the expected outcome matches the actual performance Example of auditing is a review of 300 claims submitted against a checklist of requirements, such as signed note, documentation of medical necessity, etc.

84 PDSA Performance Improvement Cycle
Do Study Act Plan Plan. Recognize an opportunity and plan a change. Do. Test the change. Carry out a small-scale study. Study. Review the test, analyze the results and identify what you’ve learned. Act. Take action based on what you learned in the study step: If the change did not work, go through the cycle again with a different plan. If you were successful, incorporate what you learned from the test into wider changes. Use what you learned to plan new improvements, beginning the cycle again.

85 Plan for Performance Monitoring
Develop an annual plan for quality assurance audits of revenue integrity, with a calendar of audits to be done throughout the year Plan should be based on high volume claim submissions, high risk, things that have been problemmatic in the past, etc.) Feed findings of audits into PDSA cycle to facilitate process improvements When strategies for improvement are identified, plan and implement ongoing monitoring activities to make sure the gained improvements are sustained.

86 Benchmark Monitoring Key benchmarks of revenue integrity performance should be established and monitored by management and the governing body Examples include: Net collection ratio Rate of claim denials by payer class Days from service to claim by payer class Days receivable by payer class If data shows performance decline, closer review is indicated

87 McGladrey Pyramid of Revenue Integrity
System Performance Proper Coding Define Scope of Care Acurate Charting Monitoring Feedback Board Clinicans Staff

88 Self Assessment of Your Organization’s Revenue Integrity
Standard Yes Maybe No For each service or activity which we submit claims for, we have copies of regulations or billing guidance showing that it is appropriate for an FQHC to bill for in our state and settings. We have written clinical documentation guidelines to ensure our providers understand how to show medical necessity and to suppor appropriate coding based on patient services provided. We regularly review the coding of services, provider, and location of service for accuracy and appropriateness. After initial implementation and each software change, and at least once annually, we review the billing generated by our electronic system for accuracy and appropriateness. We maintain a system for concurrent monitoring and retrospective auditing of revenue cycle processes and accuracy and appropriateness of claims submitted. The results of our monitoring and auditing activities are appropriately shared with board, providers, and staff.

89 Questions???

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