Presentation on theme: "Improving Your Patient Revenue While Ensuring Integrity and Compliance"— Presentation transcript:
1 Improving Your Patient Revenue While Ensuring Integrity and Compliance Region II Annual Primary Health Care ConferenceJune 1 - June 3, 2010Presented by:Peter R. Epp, CPA, Healthcare Practice Leader, Managing Director, RSM McGladreyGil Bernhard, CPA, Managing Director, RSM McGladreyRSM 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 ComplianceSetting the Health Center up for Success – operationally and complianceRegular Reports and MonitoringIntervening 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 goalsMaintaining a balance of financial, operational and regulatory requirementsMaintaining the overall financial health of the health center and its revenue streamsDeveloping and monitoring processes; intervening where appropriate
4 The Revenue Cycle Patient Enters Facility/greeted at reception Patient RegistersClaims sent to payor (non-capitation)Denials Investigated and CorrectedPatient Seen By ProviderProvider Completes Encounter FormPatient Released at Front DeskClaim Report PreparedEncounter Form ProcessedRemittance Received with PaymentBilling Department Reconciles and PostsResubmission of Denied ClaimsMonth Ending Journal Entries Posted
5 Objectives when Reviewing Billing/Revenue Cycle Strong internal control procedures/compliance with policiesCollection of proper billing informationProper recording of revenueMaintenance of subsidiary accounts receivableCollection of information for management reportingSatisfy Federal reporting requirements
6 Establishing Policies and Procedures Set of expectationsMany health centers are strong in policies and weak in proceduresSteps for revising policies & procedures:Board and management affirm commitment to processIdentify goals and implementation dateDevelop internal committeeDevelop appropriate policies and proceduresBoard of Directors approves policiesImplement; distribute written policies and proceduresReinforce that compliance with policies and procedures is central to health center missionReinforce through regular education and trainingMonitor & 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 BurnsReview all Policies and ProceduresHaving a well-established compliance plan can reduce risk of fraud and abuse, as well as potential penaltiesCompliance plan also goes beyond Policies and Procedures by:Defining appropriate behavior and helping improve employee behaviorPromoting self-evaluation, problem detection and resolutionPromoting 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 DescriptionsCharge-Master is tied to CPT CodesUse International Classification of Disease (ICD) Codes – 9th version – Clinical ModificationReferenced as ICD-9-CM codesBill 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 PracticeStatement Date:04/06/2009123 Any StreetDate Due:05/06/2009Anytown, IA 88888STATEMENT OF ACCOUNTJesse James234 One Way StreetAnytown, IADATEDESCRIPTIONCHARGESCREDITSACCOUNT BALANCEBalance brought forward$56.0004/01/09Intermediate Office Visit - Dr. Jones$75.00$131.00Basic Metabolic Panel$125.00$256.00Potassium$20.00$276.00Co-Pay$15.00$261.0004/03/09Filed Ins. - $205.00($205.00)
11 Types of Health Center Reimbursement All-inclusive RateMedicare (Cost-Based Reimbursement)Medicaid (Prospective Payment System)Fee-For-ServiceCommercial carriersCapitationMedicareMedicaidContract RevenuePatient Self-Pay Revenues
12 FQHC - Getting StartedWhat 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 FormForm 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 licensesCLIA licensesPharmacy licensesLegal Action documentsEDI AgreementsArticles of Incorporation/Corporate chartersIRS DocumentsNotice of Grant AwardGo toClick 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 toNurse Practitioner and Physician Assistant services and services/supplies incident toClinical Psychologist and clinical social worker services and services/supplies incident toVisiting nurse servicesNurse-midwife servicesDiabetes 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 ServiceIOM , Chapter 18, Sec 120 = Billing requirements
16 FQHC Medicare Services (Billable and Covered) FQHC Medicare Services (Billable and Covered). Preventive Primary Care ServicesServices required under Section 330 of PHS ActFurnished by providers listed in previous slideMedical social servicesNutritional assessment and referralPreventive health educationChildren’s eye and ear examinationsPrenatal and post-partum carePerinatal ServicesWell Child careImmunizationsFamily planning servicesTaking patient historyBlood pressure measurementWeightPhysical ExamETC
17 Medicare Cost Principles Social Security Act§1861(aa)(4) Statutory Requirements§1833(a)(3) = Payment provisions1832(a)(2)(D) =Managed Care provisions1861(v)(1)(A) = FQHC Services & IOM ,Chap 13Regulation (RHC/FQHC)General MethodologyThe 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 RateNo Medicare $100 Annual Deductible for visits to FQHCs100% Reimbursement for Pneumococal and Influenza Vaccines and AdministrationMedicare Bad Debt RecoverySliding Fee Scale Applicability62 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 PlanMA plan must pay FQHCs an amount similar to what it pays other non-FQHC providersFQHC must accept MA payment and wraparound as payment in fullCovers FQHC services onlyDoes 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 intermediaryFQHC will receive payment for each wraparound bill it submits to fiscal intermediaryNACHC Issue Brief # 86 dated June, 2006
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 benefitsOptional benefit; enrollees will need to sign upDual eligibles will receive coverage through Medicare Part D, not MedicaidHealth centers with pharmacies will need to contract with PDPs to receive reimbursement for Medicare pharmacy patientsNo 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/RHCExamples:Dental and pharmacyEnabling Services, i.e., transportation, case mgmt., translationEPSDT servicesCertain inpatient servicesNursing 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 methodologyCurrent FQHCsNew FQHCsPPS rate-setting for the futureMedicaid 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 orin the absence of such a center, in accordance with Medicare FQHC regulations and methodology, orbased on other tests of reasonableness as the Secretary may specifyThe MEI will be applied to the new FQHC’s rate for each year following the baseline year.
32 PPS CHANGE IN SCOPE OF SERVICES “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; andThe 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.
33 PPS CHANGE IN SCOPE OF SERVICES Cost Per Visit Analysis:19992000Avg.Trended2008Medical50.0055.0052.5057.7560.00Ancillaries10.0011.0020.00Enabling15.0016.50AdministrationCapital12.5013.7525.00TOTAL$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 methodologyMust 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 2000Reimbursing 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-AroundStates 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.
37 TRADITIONAL FEE-FOR-SERVICE BASICS OF MANAGED CARECultural Changes Required to Participate in Managed CareTRADITIONAL FEE-FOR-SERVICEMANAGED CAREPROVIDER OF SERVICEMANAGER OF CAREVISITSREVENUENO CHANGE IN REVENUEREVENUE MAXIMIZATIONCOST MANAGEMENT
38 BASICS OF MANAGED CARE Forms of Reimbursement Under Managed Care Fee-For-Service:Based on CPT CodesEarn More Revenue by Performing More ServicesDifferent 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 CAREContracts with Both Capitation and Fee-For-Service ComponentsIn these cases two separate sets of entries should be booked in the general ledger:Capitation payments received for month’s capitationGross charges for capitation services rendered during monthGross 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 ServicesReimbursement Based on CPT Code at Fees Established by Third PartiesAmount of Revenue Earned Is Based on the Number and Type of Billable Services ProvidedFee-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 proceduresProperly code encounter forms to ensure all services provided are billedUtilize a comprehensive encounter form to ensure all billable procedures are includedHave a system of collections
43 Ensuring Proper Coding – High Level Overview Collect data on provider visits (E&M Codes)By individual ProviderIn the aggregate for the health centerPrepare graphs to show frequency of codes usedShow increasing intensity of visit from left to rightOverlay Health Center providers and aggregate data in national averagesInclude payor-source specific graphs
45 How Can You Recognize Improper Coding? When we add payer-based coding information, the differencesmay become even clearer:
46 Tracking Productivity and Performance based on Relative Value Units (RVUs) Each procedure code has an associated value – an RVUThe RVU compares services against one anotherThe more intense the service, the higher its RVUThree components to the RVUWork RVU which measures effort of the providerPractice Expense RVU which measures support staff and overhead costs associated with providing the careMalpractice RVU which translates the cost of average malpractice coverage attributable to the codeWork RVU is the important component for provider productivity
47 Billing and Revenue Strategies – Understanding Contracts Eligibility/preauthorizationClaims timelinessComplete informationAccurate informationOn appropriate formsIn compliance with managed care contract/from provider manual
48 Compliance ProgramsA 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 expectationsCommunicates uniform work procedures to assure the corporate standards and expectations will be metDescribes the methods for monitoring standardsIdentified to ‘go-to’ person(s) for staff when compliance issues ariseProvides corrective action processesRequired in Healthcare Reform Bill
49 Benefits of a Compliance Program Establishes and promotes awareness of federal and state regulationsDefines the standard of organizational values and expectationsCreates the framework for meeting regulations by providing the necessary parameters and protocols for staff to followCan help to identify organizational vulnerabilities/weaknessesIn 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 PracticesDesignating a Compliance Officer or ContactsConducting Internal Monitoring and AuditingDeveloping Written Standards and ProceduresConducting Training and EducationResponding Appropriately to Detected OffensesDeveloping Open Lines of CommunicationEnforcing Disciplinary StandardsNew York has eightPolicy 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 governingInternal controlsGrants managementCommunity Health Center programOther (Ryan White, state & local grants)Tax filings and complianceNew IRS Form 990Cost report filings and compliance (Medicare and Medicaid)Billing and coding compliance (Medicare and Medicaid)Internal auditing and monitoring
52 ObjectivesThe 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 providersDocumenting services…collecting and recording data to support your claim for reimbursement…on paper, or in the computerCoding accuracy…making sure that your providers properly code the diagnoses of your patients and the care they deliverChecking 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 needsservices providedpayer requirementsAnd 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 MatrixRevenue IntegrityOperational PerformanceFinancial PerformanceQuality ImprovementCorporate ComplianceRevenue 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 ScanThere is increasing pressure on all providers of care to ensure revenue integrity due to:Limitations of Federal and State reimbursement, with current budget concernsIncreasing scrutity by Federal and State agencies on proper claims submissionsDevelopment 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 providersIncreasingly, 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 SystemPerformanceProperCodingDefine Scope of CareAcurateChartingMonitoringFeedbackThis 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.BoardClinicansStaff
57 Foundation of Revenue Integrity Program SystemPerformanceProperCodingDefine Scope of CareAcurateChartingMonitoringFeedbackThe 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.BoardClinicansStaff
58 Foundation of Revenue Integrity Program Strategies for Success:Include in job descriptions the specific activities of each person as it relates to revenue integrityKeep job descriptions general and refer to following policies and procedures which are frequently updatedProvide formal training during on-boarding of new people of their expected performanceExplain that revenue integiry is an important component of the organization’s corporate compliance programProvide periodic reviews of mission critical performance activitiesReview quarterly or annually the policies and procedures which are most important or have been problemmaticProvide feedback on individual and team performanceStress that achieving revenue integrity is a combination of individual and group performanceThe 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 BoardCliniciansStaffParticipates in training on Revenue Integrity, Compliance, and Quality AssuranceIncludes revenue integrity as a goal of it’s charge to management in developing and implementing a compliance and quality assurance programReceives periodic performance reports on revenue integrity as part of compliance or quality assurance programAllocates 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 accuratelyMaintains awareness of coverage status of common visits, tests and procedures by common payers.Documents care provided according to center’s standardsDocuments coding to center’s standardsDates and signs all documentation accurately.Writes clearly and legibly.Electronically signs and locks all electronic documentation properlyParticipate 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 integritParticipate 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 SystemPerformanceProperCodingDefine Scope of CareAcurateChartingMonitoringFeedbackThe 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.BoardClinicansStaff
61 Define Your Scope of Care Strategies for Success:Outline the clinical services needed by your patient populationConsider the age groups you serve, health status of your population, and preventive care requirementsIdentify the place of services that are requiredConsider if you serve children who may need school based programs, or elders who may need nursing home or home based visitsReview Medicare, Medicaid, and Commercial Payer requirements for services and place of careFor 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 serviceWhile 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 regsClinical ServicePlace of ServiceAppropriate ProviderCovered by MedicareCovered by MedicaidCovered by Managed CareApplicable Utilization LimitsAnnual PhysicalCenter or Home CareMD, NP, PAYesYes (This is State Specific and need to check State regs)Medical NecessityPsychology ServicesPhD (Psych), or LCSWVaries by contract or plan—list separatelyMedicaid 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 ProviderFor each service provided, know the appropriate provider for that serviceE.g. Primary care by MD, DO, NP, or PAE.g. Mental Health services by PhD (Psychologist) or LCSWAlso make sure each provider is appropriately credentialedLicense and education verificationEmployment contract or agreementValidation that they are not on either a federal or state banned provider list
64 Utilization LimitsMedical necessity is required for Medicare clinical servicesMany Medicaid programs, as well as commercial and managed care plans, may have utilization limitsCoverage limits by type of serviceLifetimeCoverage yearMonth
65 Ensure Adequate Documentation of Care (Charting) SystemPerformanceProperCodingDefine Scope of CareAcurateChartingMonitoringFeedbackThe 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.BoardClinicansStaff
66 Ensure Adequate Documentation of Care Strategies for Success:For each service provided, create documentation guidelines for providers to followConsider 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 documentationProviding cues for required documentation can improve compliance, but make sure that documentation is individualized to patient and not templatedReinforce policies and procedures for dating and signing clinical documentationInclude standards for when signing/locking must occurAlso, include procedures for making changes or additions to documentation at a later dateWe 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.
68 Ensure Proper Use of Billing Codes SystemPerformanceProperCodingDefine Scope of CareAcurateChartingMonitoringFeedbackThe third component we are discussing today is proper coding.BoardClinicansStaff
69 Ensure Proper Use of Billing Codes Strategies for Success:For each service provided, create coding guidelines for providers and staff to followDefine the appropriate CPT or payer specific codes required to describe the service providedDefine the appropriate place of service codes for each setting in which care is providedFor each service encounter, provide a mechanism (either on paper or in electronic health record) for provider to assign code based on care providedEach year, review codes for continued applicability and for any changes in definition or requirmentsDesign a process where coding is checked during the claims submission processThis may be done by manual review of each or a sample of claims, or by electronic billing edits / reportsThe 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 FQHCsFQHC 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 claimsubmitted withinallowableTimeframe?Was care givenin a coveredplace of service?ProperBilling Code?Do providersmatch?Claim #Date of ServiceDate Claim FiledSubmitted Place of ServiceAudited Place of ServiceSubmitted Billing CodeAudited Billing CodeSubmitted ProviderAudited Provider
72 E&M CodesE&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 serviceHistory, Examination, and Medical Decision MakingUnderstand how Contributory Factors effect your level of serviceSuccessful linking of CPT and ICD-9-CMThe 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:HistoryExaminationMedical Decision MakingCounselingCoordination of careNature of presenting problem; andTime
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 codeWhen to code for signs and symptomsChoosing the primary diagnosisCoding to the highest level of specificyPrepare for the immanent mandated change to the ICD-10-CM.
75 Ensure Proper System Performance CodingDefine Scope of CareAcurateChartingMonitoringFeedbackBoardClinicansStaff
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 processesThis strategy should be performed during initial set up, and updated annually or after any process changeTest a sample of automated claims against a manual claims submission processAgain, perform this during initial system implementation, after any modification to system, and at least quarterlyBe sure to include a sample of all claim typesReview user performance with system to identify issuesCheck that providers are electronically signing and locking notesCheck reports of timeliness of claims processing, and whether edits are unnecessarily holding up submissionElectronic 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 payerE.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 trackedClaim denials are tracked and appealedClaim denial trends are analyzed and systemic issues identified for performance improvement
78 Sample System Performance Management DateSoftware Upgrade, or “switch” turned on or offPost system change testing completedComparison of post system change testing to hand coded sample of clinical documentation6/1/2010Rates updated in system6/3/2010100% correlation
79 Ongoing Monitoring Activity SystemPerformanceProperCodingDefine Scope of CareAcurateChartingMonitoringFeedbackBoardClinicansStaff
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 servicesLow volume, but complex servicesServices that are the focus of government or payer auditsServices for which claim submissions have been problemmatic in the pastDesign and implement a monitoring program for the high risk areas identifiedDevelop review tools and define frequency of implementationAnalyze results of these reviews and identify root causes and develop corrective action plansTrack corrective action plan implementation and check for improvementThe 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 SystemPerformanceProperCodingDefine Scope of CareAcurateChartingMonitoringFeedbackBoardClinicansStaff
82 Provide Continuous Feedback Strategies for Success:Communicate findings of revenue integrity monitoring activity to board, providers, and staffInclude these reports in regular board, provider, or staff meetingsDon’t report raw data– first conduct root cause analysis and develop recommendations for improvementBe 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 issuesProvide on-going education to providers and staffAs requirements, policies, and procedures change, it is critical to update written procedures and guidelines to reflect themAll changes should be communicated to providers and staffA record of training should be maintainedRemember 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 followedExample of monitoring in a paper based environment might be checking that there is a encounter sheet signed by a provider for each claim being submittedExample of monitoring in an electronic enviroment might be an electronic notification if a claim lacks an electonically signed and locked clinical noteAuditing is a retrospective process where a sample of claims is selected and tested to see if the expected outcome matches the actual performanceExample 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 DoStudyActPlanPlan. 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 yearPlan 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 improvementsWhen strategies for improvement are identified, plan and implement ongoing monitoring activities to make sure the gained improvements are sustained.
86 Benchmark MonitoringKey benchmarks of revenue integrity performance should be established and monitored by management and the governing bodyExamples include:Net collection ratioRate of claim denials by payer classDays from service to claim by payer classDays receivable by payer classIf data shows performance decline, closer review is indicated
87 McGladrey Pyramid of Revenue Integrity SystemPerformanceProperCodingDefine Scope of CareAcurateChartingMonitoringFeedbackBoardClinicansStaff
88 Self Assessment of Your Organization’s Revenue Integrity StandardYesMaybeNoFor 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.
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