1. Information Integrity in the Revenue Cycle
Information Integrity in the Revenue Cycle! Order Entry, All Subsystems and The Charge Description Master
I dropped new year!
Presented by:
Jessy Huebner, MAT, CHFP
President
MedCompliance Services, Inc.
2011

2. Our Philosophy: We are a firm believer in information integrity
Our Philosophy: We are a firm believer in information integrity. Therefore we perform on or off site a full review of the hospitals Order Entry, Subsystems and CDM for accuracy and compliance while performing education and problem solving with all department heads and key staff during and after the interview process. We further believe “On Going Education and Daily Reconciliation” is key to the hospitals financial success. Educate and validate that the hospital personnel are completely knowledgeable in their documentation and charge capture and to insure the integrity of hospital compliance and billing. As we call it “Hand Holding” and at a reasonable price.
I dropped new year!
2011

3. Introductions and Background Jessy Huebner, MAT, CHFP Conceived and developed: “The Healthcare Financial and RAC Editor” “The Information Integrity Editor” “The Healthcare Department Modeler” First to merge CDM applications into one system. Over 30 years of onsite healthcare validation reviews. Author and speaker for HFMA and MedLearn with over 3,000 hours logged at the podium.

4. The Revenue Cycle CHARGE Revenue Integrity Claims Adjudication
Management
Patient
Access
Scheduling
Medical Necessity Determination/ Orders
Pre-Registration
Registration and Demographic/ Insurance Validation
Insurance Verification
Pre-Certification
Financial Counseling
POS Collections
Claims Preparation
Claims Submission
Third Party Follow up
Self Pay Follow up
Rejection Processing
Payment Posting
Payment Validation
Medical Case Management
Denial and Appeal Management
Revenue Cycle KPI’s
Contracts
Physician Credentialing
EMR data from Clinical Care documentation & transcription
Health Information Management
Coding
Charge Capture
Charge Entry
Billing System(s)
CHARGE
MASTER
Appendix Support

5. Revenue Issues Facing Hospitals Today -Confusion due to new rules -RAC Audits are increasing -The risk of fraud is escalating -Staffs need more education to document & charge accurately -Order Entry, all Subsystems and CDM are not synchronized -Incorrect CPT/HCPC and Diagnosis coding is taking place -Modifiers are not being correctly applied or missing -An understanding of the Medicare Rules and Regulations is lacking, especially how the Correct Coding Initiative (CCI) Editor & Medically Unlikely Editor (MUE) works -Difficult to stay current with CMS Addendum A & B -Improper packaging and bundling is an issue -Reporting needs simplification that can be easily customized -Internal controls and daily reconciliation, that will withstand scrutiny, are often missing

6. Did you know? A good CPT code can be linked to a good procedure and still be wrong. Coding must not create a fraudulent situation. Compliance is required throughout the process, necessitating a complete understanding of all aspects, from the front end to bill drop. A clean and accurate CDM, not one that creates problems and causes lost revenue, is essential A clean claim is the key Clean code + a clean CDM + a clean bill drop = more cash

7. Our Solution includes: Clean up and synchronization of Order Entry through all Subsystems to the Charge Master Reimbursement problem solving: On-the-job training, technical support, and on going maintenance

8. “The Healthcare Financial and RAC Editor”

9. The Healthcare Financial and RAC Editor Merges Data from: - CDM - Revenue & Usage - Order Entry - All Sub-systems Audits and Evaluates the Data for Issues in the following major areas: - Descriptions - Revenue Codes - CPT/HCPC Codes - Modifiers - Pricing - RAC Issues

10. There is 113 Columns of Data In The Healthcare Financial & RAC Editor The main areas are: Hospital Two Years of Usage (IP & OP) Hospital CDM Item, Order Entry & Subsystem Numbers Hospital CDM Description and AMA/CMS Descriptions Hospital Revenue Code plus 3M & Ingenix Revenue Codes Hospital CPT/HCPC Code and AMA & CMS CPT/HCPC Codes Hospital Modifier and AMA & CMS Modifiers All Reference Tables, Issues & Files Hospital Charge and AMA & CMS APC & Fee Schedules RAC Issues by Region A few of the columns of data are: AMA CPT Codes, CMS HCPC Codes, AMA & CMS Long, Medium and Short Descriptions, 3M & Ingenix Revenue Code tables, CMS CCI & MUE Edits, CMS Addendums A & B (SIC, APC, Payment and Co-Insurance Amounts), CMS Fee Schedules (Lab, Pro Fee, Ambulance, DME), Medicaid Fee Schedules, Pharmacy Crosswalk Tables, RVU Tables, AMA Appendix Rules, AHA Type of Service Table, MedLearn Interventional Radiology File, CMS Part B Drug Schedule and all RAC issues by Region

11. “The Information Integrity Editor”

12. “The Information Integrity Editor” Merges files and reviews:
“The Information Integrity Editor” Merges files and reviews: Order Entry, All subsystems, The Charge Description Master Regardless of the type of system in place at the hospital into one Excel Worksheet

13. The Healthcare Information Integrity Editor
MedCompliance
Financial Revenue
Usage
Charge Description Master
Physicians Services
Order Entry
Radiology
Pharmacy
Pulmonary
Cardiology
Lab
(Cerner)
Central Supply
(Lawson)
One Platform -- Bridging Information
Data Integrity
Optimizing Reimbursement
Compliance
Clean Accurate Billing

14. “The Healthcare Department Modeler”

15. Modeling We take a unique, more intimate approach than others, who still employ hard-coded logic that works off good code vs. bad code methodologies. Modeling enables overlay of each department’s CDM, to its respective model, thereby revealing services not found in the department’s CDM….increased revenue! Built on nationals standards; enhanced through our work in hospitals. Modeling is run for several reasons: -to perform impact analyses before departments or services are added. -to build Ad Hoc Reports to research “what ifs”. to compare and assess, by department, to identify missing services for increased revenue. Models are consistently well received due to their level of detail and revenue has ALWAYS been identified, regardless of departmental size.

16. Example1 of Modeling
1While characterized as an example, this is actual data from a client assignment.

17. MedCompliance Demo of Editor (Todays demo is of a 170 Bed Hospital in Dallas, Texas)

18. Output of the Initial Review
MedCompliance Services Inc.
"Healthcare Financial Editor" Summary Report of Findings
''Healthcare Financial Editor'' Copyright Protected
Hospital Name :
Medical Center - Dallas, Tx
Report Compiled at:
October 7th 2011
Prepared by:
Jessy Huebner, CHFP, MAT
Number of Lines in Charge Master:
8661
Number Of Lines in CDM with Possible Alerts
20353
Number Of Lines in CDM with Alerts
5540
63.96%
CRITICAL INDICATOR - EVALUATE
Total of All Issues:
8793
101.52%
Number Of Lines in CDM With No Usage in Year 1
2356
27.20%
Number Of Lines in CDM With No Usage in Year 2
2569
29.66%
Number Of Lines in CDM With No Usage in Year 1 & 2
1589
18.35%
Total of Revenue Code Issues: 15
0.17%
Total CPT/HCPC Code Issues:
498
5.66%
Total Description Issues: 18
0.20%
Total Modifier Issues:
790
8.98%
Total Status Indicator Code (SIC) Issues
2728
31.02%
Total Hospital Price Issues:
4685
53.28%
Total Special Issues: 59
0.67%
Revenue Code Issues
Revenue Code Incorrect - Evaluate 13
86.67%
Revenue Code Missing - Evaluate
0.00%
Revenue Code is for Professional Fee - Evaluate
Revenue Code is for Patient Convenience Item - Evaluate
Revenue Code is '999' for Statistics Only - Evaluate 2
13.33%
CPT/HCPC Code Issues
CPT/HCPC Code Invalid - Evaluate
CPT/HCPC Code Missing - Evaluate
380
76.31%
CPT/HCPC Code is SIC - D (Per AMA & CMS Code Deleted) - Evaluate 6
1.20%
Revenue Code is for Implant That Has Missing CPT/HCPC - Evaluate
111
22.29%
Revenue Code is for Drug That Has Missing CPT/HCPC - Evaluate 1
Description Issues
Description Missing - Evaluate
Description Issue - Evaluate
100.00%
Modifier Issues
Modifier Invalid - Evaluate
174
22.03%
Modifier Missing - Evaluate
616
77.97%
Status Indicator Code (SIC) Issues-Not Covered by OPPS
CPT Code is SIC - B (Codes Not Recognized by OPPS) - Evaluate
0.48%
CPT Code is SIC - C (Inpatient only) - Evaluate 23
0.84%
CPT Code is SIC - E (Not Covered - Get ABN) - Evaluate 12
0.44%
CPT Code is SIC - N (Bundled/Packaged) - Evaluate
2680
98.24%
CPT Code is SIC - M (Codes Not Billable to FI) - Evaluate
CPT Code is SIC - Y (Non-Implantable Durable Medical Equipment - Not Paid Under OPPS) - Evaluate
Hospital Price Issues
Hospital Price is less than CMS Fee Amt - Evaluate
Hospital Price is less than HOPPS APC Rate - Evaluate 31
0.66%
Hospital Price is ZERO - Evaluate
102
2.18%
CPT/HCPC Code Same with Different Prices - Evaluate
3245
69.26%
Hospital Price Gtr than OPPS Benchmark - Evaluate
1307
27.90%
Special Issues
Department # Missing - Evaluate
DME Item Found - Evaluate 30
50.85%
F & A Alert Found - Evaluate
RAC Alert Issue Found - Evaluate 29
49.15%

19. Typical Example of Recommended Changes Note : This is a 350 bed hospital in New Jersey that we audited January 2011 that had been audited by a National CPA firm in August The client was not happy with the August results.

20. Resulting Financial Impact Note : This is a 350 bed hospital in New Jersey that we audited January 2011 that had been audited by a National CPA firm in August The client was not happy with the August results.

21. What Makes MedCompliance Different in the Industry Philosophy: We are a firm believer in information integrity. Technology: Utilizes Excel and the clients information to merge and audit their order entry, subsystems and CDM information into one Excel spreadsheet…..a Soft Coded Logic approach not the Hard Coded Logic approach as utilized by others in the industry Merging of Data: Ability to merge data from all client sources into one Excel spreadsheet Modeling: Able to take hospital departmental models that contain AMA, CMS and AHA data and overlapping that information with the hospital data to show missing services the hospital can add for increased revenue Reports: Standard plus Customer designed at no additional charge Printing: Easy to print using Excel format Multiple Facilities: Able to overlap and merge multiple facility hospitals and multi-tier physician groups CDM into one Excel spreadsheet which will show discrepancies and consistencies in coding, compliance, pricing and other features that may effect the Order Entry System, Subsystems and the CDM accuracy Web-based & Support: Yes, we are Web Based with 24 hour phone and support under our monthly maintenance contract

22. Competitor Systems Hospital Hospital Hospital
CDM electronically sent via Black Box
to hard coded logic editor at
providers location
CDM, Order Entry, Sub-system and Usage Reports sent to MedCompliance Services
Providers location runs CDM through
editor and sends results back to
hospital.
Note: results are not
reviewed by the provider.
MedCompliance consultants run all files through MedCompliance editors
MedCompliance consultants run all reports, assesses the data, provide recommendations which require corrections and alerts for further clarification. Reports are in Excel format and sent back to hospital.
Hospital goes to "Black Box"
to run reports and figure out
what needs to be corrected.
Reports are not in Excel format
but in a format designed by provider.
Together, Hospital staff and MedCompliance consultants review all findings and corrections
Hospital gets limited assistance
regarding issues found in editor reports

23. Benefits of Partnering with MedCompliance Services Inc
Benefits of Partnering with MedCompliance Services Inc. -We provide cleanup of Order Entry, all Subsystems and the CDM -We use unique Modeling to reveal missing services, by department -We find missing revenue to drive immediate cash flow improvement -We reduce erroneous charging – thereby reducing your risk of fraud -We improve documentation/charging by hospital staff and physicians through on-the-job and formal training programs -We provide real-time updates

24. Partnering Benefits, Cont’d -We use software applications, tools, education and personal on-site services to produce Clean Claims -Based on our reviews, you can reduce the risk of non-compliance and increase your confidence when you’re faced with outside audits -Unlike others, our reviews project expected Return on Investment (ROI). Our average ROI is 150:1 therefore we can guarantee our results -Our Reporting has the capability to deliver customer-specific information, to guide each staff member, in each department

25. Partnering Benefits, Cont’d -Our Educational Services help turn around inefficient departments -Documentation and tools are used to help drive a deeper understanding of a customers billing factors -Ongoing maintenance assures that your CDM stays current, accurate and clean -We are accessible in person, by phone, or via , within 24 hours

26. Thank You For Attending!
Jessy Huebner, MAT, CHFP
MedCompliance Services Inc.
800 West Ave - Suite 1001
Miami Beach, FL 33139
&
129 Club House Road - Box 3520
Breckenridge, CO 80424
Clinical Education & CDM Cleanup