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I.COMPLIANCE & THE DIRECTORS II.UPDATE ON THE 3PB REVENUE ENHANCEMENT PROJECT III.OPERATIONS AND THE REIMBURSEMENT SYSTEM BEST PRACTICES IV.DASHBOARD FOR.

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Presentation on theme: "I.COMPLIANCE & THE DIRECTORS II.UPDATE ON THE 3PB REVENUE ENHANCEMENT PROJECT III.OPERATIONS AND THE REIMBURSEMENT SYSTEM BEST PRACTICES IV.DASHBOARD FOR."— Presentation transcript:

1 I.COMPLIANCE & THE DIRECTORS II.UPDATE ON THE 3PB REVENUE ENHANCEMENT PROJECT III.OPERATIONS AND THE REIMBURSEMENT SYSTEM BEST PRACTICES IV.DASHBOARD FOR MANAGING THE REIMBURSEMENT SYSTEM

2 HEALTH CARE COMPLIANCE

3 Deliberate ignorance

4 COMPLIANCE PROGRAMS Voluntary in 2000…..Mandatory now Evolved into Compliance and Ethics Programs Affordable Care Act - Indian Health Care programs are deemed Essential Community Providers therefore ACO’s must include. ACO membership mandates the implementation of a compliance program

5 DUTY OF CARE - BOARD RESPONSIBILITY Must demonstrate good faith judgment Must act in a manner an ordinarily prudent person would exercise under similar circumstances Must act in a manner believed to be in the best interest of the corporation Must perform reasonable inquiry – Is compliance program reporting and information system adequate from an oversight not operational perspective

6 REASONABLE INQUIRY  Ask knowledgeable and appropriate questions  Structural Questions – designed to explore the adequacy of program breadth, reporting relationships and resources to implement the program  Operational Questions – directed to an evaluation of the adequacy and vitality of the compliance program

7 2 CATEGORIES OF QUESTIONS ARE SUGGESTED FOR DIRECTORS: Operational Questions – directed to an evaluation of the adequacy and vitality of the operations compliance program Structural Questions –scope of the organization’s compliance program; designed to explore the adequacy of program breadth, reporting relationships and resources to implement the program

8 STRUCTURAL QUESTIONS Compliance Infrastructure How is the compliance program structured and who are the key employees responsible for its implementation and operation? Do the personnel have sufficient authority, autonomy and resources to perform assessments and respond appropriately to misconduct to implement the compliance program? Are employees held accountable for meeting these compliance-related objectives during performance reviews?

9 STRUCTURAL QUESTIONS M easures to Prevent Violations What is the scope of compliance-related education and training across the organization? Has the effectiveness of such training been assessed? What policies/measures have been developed to enforce training requirements and to provide remedial training as warranted? How is the Board kept apprised of significant regulatory and industry developments affecting the organization’s risk? How is the compliance program structured to address such risks?

10 STRUCTURAL QUESTIONS Measures to Respond to Violations What is the process by which the organization evaluates and responds to suspected compliance violations? Does the organization have policies that address the appropriate protection of “whistleblowers” and those accused of misconduct?

11 SMALL GROUP PRACTICE GUIDANCE OIG KEY COMPONENTS 1. Conducting internal monitoring and auditing 2. Implementing compliance and practice standards 3. Designating a compliance officer or contact 4. Conducting appropriate training and education 5. Responding appropriately to detected offenses and developing corrective action 6. Developing open lines of communication 7. Enforcing disciplinary standards through well publicized guidelines

12 BOARD ACTIONS Peer Review and Credentialing & Privileging Policy and Procedures with controls for risk areas Periodically evaluate the effectiveness of the compliance program Ensure access to resources

13 OPERATIONAL RISK AREAS Coding and Billing Errors Safety for patients and staff Quality of Care Contracting Accuracy of reporting Conflict of interest Privacy and Security Rules Harassment or intimidation Culture of business environment Social Networking

14 RESOURCES Participate with local hospital or physicians association programs Health Care Compliance Association American Academy of Professional Coders American Health Information Management Association Office of Inspector General Center for Medicare and Medicaid Services

15 3PB REVENUE ENHANCEMENT PROJECT

16 3 RD PARTY REVENUE ENHANCEMENT UPDATE VISITED SITES HOSTED 2 GATHERINGS HOSTED 7 WEB-EX TRAININGS 1 MORE TO DO 8 WEB-EX INTENSIVE SERIES FOR CODING PLANNED IMPLEMENTING 3PB SYSTEMS AT 14 SITES SUPPORTED SITES WITH FQHC APPLICATIONS DEVELOPMENT OF SLIDING DISCOUNT SCHEDULES ASSIST COORDINATION OF AREA OFFICE SUPPORT

17 COMING UP ACCOUNTS RECEIVABLES MANAGEMENT INTENSIVE CODING SERIES INTENSIVE MEDICARE SERIES ICD-10 IMPLEMENTATION PLANNING COMPLIANCE PROGRAM DEVELOPMENT

18 FINDINGS Need consistent support Need for Electronic Health Record & Meaningful Use support Need for regular coding and billing training Need assistance processing Medicare/Medicaid FQHC applications Practice Management systems being retired

19 DASHBOARD REAL MEANING OF ALL CAUGHT UP PRODUCTIVITY MEASURES – Provider, Coder/Auditor, Biller AGED RECEIVABLES – COLLECTIONS AND REASONS FOR WRITE OFFS SCHEDULE COLLECTION GOALS MANAGE WARNING SIGNS AS ALERTS BALANCE WITH FINANCE TRAINING REQUIREMENTS DIRECTORS 3 RD PARTY REIMBURSEMENT MANAGEMENT WORKSHOP

20 CONTRACT CAUTIONS……… What is your reimbursement under this contract? And when are rates renegotiated? Can the health insurer unilaterally change the terms? Is the health insurer obliged to pay you promptly? How is medical necessity defined? Who qualifies? Does the contract or manual designate all services and procedures that are subject to prior authorization requirements? Are electronic 837 claims accepted in the 5010 format (now)? Are electronic remittance 835 available now and do they include adjustments with payments How is eligibility determined? Online or by phone?

21 AGE IS MORE IMPORTANT Balance A/R Balance $212,245.60$77,823.39$56,598.83$7,074.85$0$353, %22%16%2%0%

22 WHERE IS REVENUE MADE AND LOST? Revenue MadeRevenue Lost Training is ongoingWhen rules change and no-one notices Proactive practicesFall behind – timely filing ~ A/R Follow up – Denial ManagementNo A/R management - Rebilling Front desk skilled interpreting benefits and promoting enrollment Ineffective front end management Tracking and measuring the right thingsAccountability is lacking Policies, Procedures and Tasks are doneEveryone is doing their own thing

23 RADAR ICD-10 Terminology & Anatomy/Physiology 10/01/ ICD-10 compliance date Process Improvements Improve denial management process I10 coding training for providers, support and coder/billers MEANINGFUL USE OF E H R Stage 1 requirements Stage 2 requirements Stage 3 requirements ACA Hospitals outcome based payment (10/01/12) “Value Based Payment – VBP” Payment bundling for outpatient with inpatient Insurance Exchanges & 133% Newly Eligible's Paying physicians based on “value” not volume

24 ELIGIBLE PROFESSIONALS: MEDICARE INCENTIVE PAYMENT EXAMPLE Amount of Payment Each Year of Participation Calendar Year EP Receives a Payment CY 2011CY 2012CY 2013CY2014 CY 2015 and later CY 2011 $18,000 CY 2012 $12,000$18,000 CY 2013 $8,000$12,000$15,000 CY 2014 $4,000$8,000$12,000 CY 2015 $2,000$4,000$8,000 $0 CY 2016 $2,000$4,000 $0 TOTAL $44,000 $39,000$24,000$0

25 ELIGIBLE PROFESSIONALS: MEDICAID INCENTIVE PAYMENT EXAMPLE Amount of Payment Each Year if Continues Meeting Requirements 1 st Calendar Year EP Receives a Payment CY 2011CY 2012CY 2013CY 2014CY 2015CY 2016 CY 2011$21,250 CY 2012$8,500$21,250 CY 2013$8,500 $21,250 CY 2014$8,500 $21,250 CY 2015$8,500 $21,250 CY 2016$8,500 $21,250 CY 2017$8,500 CY 2018$8,500 CY 2019$8,500 CY 2020$8,500 CY 2021$8,500 TOTAL$63,750

26 Focus points… Fundamentals Change Goal Similarity of processes 3 rd Party revenue Work to do It’s why we are already here


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