Third Party Reimbursement Training

Julia Hidalgo, ScD, MSW, MPH Positive Outcomes, Inc. Harwood MD www Julia Hidalgo, ScD, MSW, MPH Positive Outcomes, Inc. Harwood MD www.positiveoutcomes.net julia.hidalgo@positiveoutcomes.net (443) 203 - 0305

HRSA HAB Project Officers Planning Committee Aubrey Arnold Gayle Corso John Eaton Theresa Fiano William Green Deidre Kelly Syd McCallister AHCA Heidi Fox HRSA HAB Project Officers Johanne Messore Yukiko Tani TPR Trainers Curt Degenfelder Marilyn Massick Michael Taylor

Ground Rules I do not represent HRSA, CMS, or AHCA Let me know if you do not understand We can share our feelings at the end of each section You will be rewarded for staying awake Shut off your electronic devices A 15 minute break means 15 minutes!

Overview of Today’s Session Overview regarding organizing patient/client charts, basics of billing, developing billing systems Additional training modules and materials are available on website Real life examples will be used Resources for more in-depth information are identified Each section includes training and discussion Train the trainer approach is used Please follow-up by email with additional questions Focus of the training is on beginning to intermediate skills Advanced training and TA are available

What is third party reimbursement (TPR)? Patient 1st Party Provider 2nd Party Insurer Medicaid Medicare 3rd Party services $ TPR is receiving payment from a source other than the patient for services provided to patients by a provider. This other source is the “third party”

Constructing an Effective TPR Strategy

HRSA Grant Funding Versus TPR The CARE Act is considered by the HIV/AIDS Bureau to be the payer of last resort This requirement is subject to audit CARE Act grantees have been audited Grantees and subgrantees should not rely on grant funds as their sole source of revenue HRSA grant funds are finite because they are capped in annual appropriations TPR is driven by patient service and volume Funds from TPR should be used in addition to HRSA grant funds

The Role of a Grantee’s Sponsoring Organization Communicate the availability and value of TPR Grantees and subgrantees (i.e., contractors) should agree upon billing and collections responsibilities and procedures Grantees should request periodic accounting of collected TPR payments, as appropriate These payments should be reported as grant income Grant income should be retained by direct service provider grantees or contractors Grantees should develop and implement clear, adequately documented processes for CARE Act invoices for Title I and Title II

Documenting CARE Act and Other Funded Services

Health and Case Management Record Basics The record is the core element of a visit or other unit of service It is a systematically organized record of a patient’s total care Everyone who records progress of care in the record should follow the same note writing format Policies and procedures dictate its organization and use Creates a verifiable record of services provided for third party payers and other interested parties (QI, accreditation, etc.)

Health and Case Management Record Basics The record is the primary instrument for planning care Forms the basis to bill and pay for care Documentation in the record can be reviewed by third party payers Records are legal documents that assist in protecting the interests of the patient, facility, and providers They are considered to be more reliable than an individual’s memory about events They can be used in court or for other legal matters They can protect you in a law suit

Record Documentation Documentation provides the who, what, when, where, why, and how of patient care Regardless of the complexity of documentation, records must be comprehensive enough to meet regulatory, licensing, accreditation, legal, research, and patient care needs and purposes Record notes must be comprehensive enough to support evaluation and management code assignment

Record Contents Date and time of service Place of service Chief complaint/presenting problem Objective findings List of tests/labs that are ordered and lab results Diagnoses Therapies administered and medications provided or prescribed Preventive services provided Disposition and patient instructions Provider’s name and title Length of the visit (e.g., minutes required to document time-specific procedures)

Minimum Records Processes Develop and implement a process addressing the use of standard forms including Responsible parties for form development and revision Form approval process Definition of timeframe for periodic review and revisions of forms Consistent use of forms across sites

CMS/AMA General Principles of Record Documentation An individual record is established for each person receiving care The patient’s name should appear on every page with their unique identifier (patient record number) The record should be complete and legible Documentation of each encounter should include Reason for the encounter Relevant history and physical examination findings Prior diagnostic test results Assessment, clinical impression, or diagnosis Care plan Date and legible identity of the observer

CMS/AMA General Principles of Record Documentation If not documented, the rationale for ordering diagnostic and other ancillary services should be easily inferred Past and present diagnoses should be accessible to the treating and/or consulting physician Appropriate health risk factors should be identified The patient’s progress, response to, and changes in treatment and diagnosis should be documented The CPT and ICD-9-CM codes reported on the health insurance claim form or billing statement should be supported by the documentation in the medical record If it’s not legible, it’s not there If it’s not there, it wasn’t done

Universal Record Standards All clinical information pertaining to a patient is kept in the record and must be readily available any time the facility is open Multiple sites Filing systems Records elsewhere – radiology, counseling, etc. Standards apply across all settings and are compiled from JCAHO, NCQA, AAAHC, Medicare, and Medicaid

Universal Record Standards Information should be recorded by the provider at the time of care At least on the same day The longer the delay, the lower the quality of the entry All staff should use the same set of approved abbreviations and symbols All entries must be dated, timed, chronological, legible, and signed in non-erasable blue or black ink by the provider with his/her credentials noted after their name No blank spaces in between entries Corrections can only be made with a new entry-cross out and initial

Reimbursement and Records Physicians and mid-level providers can make entries in the record and may generate charges during a patient visit All payers have specific guidelines about how to submit claims for non-physician charges Some payers may credential non-physicians to allow charges to be submitted under their own provider number Others only allow billing under a physician Whatever the rules, be sure that your health record documentation backs up the billing

Reimbursement and Records Charges can be generated based on office visits, consultations, procedures, diagnostic tests, X-rays, injections, vaccinations, and/or supplies Supporting documentation (including who provided the service) has to be located in the progress notes, laboratory reports, X-ray reports, or diagnostic service reports If services are provided in multiple sites (e.g., exam room and lab), charges have to be collected and organized for billing purposes A data collection form is the best way to do this

Why set-up record policies and procedures? Maintaining record policies and procedures is essential to protect your program and patients Licensing and accrediting bodies, as well as governmental entities, require them Your policies and procedures dictate how health information will be maintained and protected Your policies set the basis for your legal record

Minimum Record Policy Elements Confidentiality policies and procedures Chart organization: sections, forms, and their order in the chart Including specifications of what constitutes a complete record Record maintenance, storage, retrieval: access to and archiving, backing up, security, and destruction Patient compliance: informed consent and authorization to release information Health record documentation practices: who, how and when; entry authentication; correcting the record Sanctions or progressive discipline policy for staff who do not make proper entries into records

Set Your Record Audit Policy Internal record audits should be performed as part of your program’s QA procedures Internal review allows problems to be identified and corrected before someone else does it for you Record internal audit policies should address Audit content Auditors Audit timeframes, breadth, and scope Levels of review Audit types Qualitative or quantitative deficiency analysis Detailed audit process

Records Policy Implementation When policies are developed, be sure Input on the content has been received from all levels of staff, as appropriate Staff are trained on the content and retrained annually Maintain training session attendance records All new employees should be oriented upon hire All staff training should be documented Staff should have easy access to relevant policies Computer access is ideal

Step-by-Step Billing Process

Determine Eligibility Billing Process Schedule Appointment Generate & Sign Bill Register/ Determine Eligibility Submit Bill Contact Payer No Verify/Auth Payment? No Pend/Denial? Yes Yes Provide Care Deposit Correct Coding Post Payment Re-submit Bill Patient if applicable Charge Entry

Components of Bill Generation Schedule appointment Collect as much patient information as possible On-site registration Collect and verify outstanding patient demographic and insurance information Conduct financial screening, as necessary Create or have patient health record available Generate encounter form Provider encounter form Provider completes encounter form and health record, both of which go to coding

Components of Bill Generation Coding a claim Coder verifies record notes, assigns appropriate codes, completes encounter form, and forwards it to billing department Generating a bill Billing department books appropriate service charge and produces bill based on completed encounter form Submitting a claim Bills are aggregated to form a claim, claim is attached to transmittal sheet identifying included bills, and both are submitted to third party payer

Common Billing Forms The CMS1500 is the standard form used to bill all third party payers for professional services It must be completed accurately Timely collection of third party reimbursement depends on this form The CMS1450 (UB-92) is the billing form used for hospital-based outpatient care

CMS1500 – Top of Form

CMS1500 – Bottom of Form

Code Sets Coding transforms descriptions of diseases, injuries, conditions, and procedures from words to alphanumerical designations The purpose of coding is to utilize code sets (ICD-9-CM, CDT, CPT, DSM, HCPCS, DSM) to classify patient encounters The actual code set used is determined by Healthcare setting Regulatory agency Reimbursement system Approved HIPAA transaction code sets ICD-9-CM, HCPCS and CPT are the primary coding systems that are used to determine reimbursement in the United States and selected under HIPAA

International Classification of Diseases (ICD) ICD-9-CM has two volumes of diagnosis codes and one volume of procedure codes Resources for ICD Coding Clinic is a newsletter containing coding advice It is published quarterly and helps you keep up to date with ICD-9-CM Coding Clinic is agreed upon by a wide variety of parties and is considered authoritative Call 1-800-261-6246 to subscribe

Sample ICD-9-CM Codes

Current Procedural Terminology (CPT) Owned by the AMA and designed to facilitate communications between physicians, mid-level practitioners, and third party payers Codes represent procedures and services performed by clinicians and some codes for other staff Contains evaluation and management (E/M) codes To help with CPT coding, the AMA publishes a monthly newsletter called CPT Assistant Call 1-800-621-8335 for subscription, or go to http://www.ama-assn.org/catalog CMS, Medicare carriers, and fiscal intermediaries publish transmittals and bulletins about CPT coding to guide you in their use

Sample CPT Codes

Healthcare Current Procedural Coding System (HCPCS) HCPCS Level II Codes represent supplies, materials, injectable medications, DME, and services Used mostly for ambulatory care and is a three level system Level I is the CPT code Level II codes are developed and maintained by CMS and updated quarterly They are used primarily for reporting purposes in ambulatory care claims processing Level III codes are for new procedures, devices, and services not in Levels I and II Defined by fiscal intermediaries and vary by location or payer HCPCS – useful information at www.cms.gov

Sample HCPCS Codes

Other HIPAA Standard Code Sets Code on Dental Procedures and Nomenclature, Second Edition (CDT-2) Developed and maintained by the American Dental Association to record dental procedures Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM IV) Developed and maintained by the American Psychiatric Association to code diagnoses made by mental health and substance abuse treatment providers National Drug Codes (NDCs) Developed and maintained by the Food and Drug Administration to report prescription drugs in pharmacy transactions and some claims by health claim professionals

Coding Process The process of who does the coding may vary among settings However, the function of assigning codes does not change Providers and coders take clinical information (e.g., diagnostic terms, procedure descriptions) and assign a code to each one according to official rules Coders would take this clinical information from the provider’s portion of the health record The provider is responsible to record proper information Coding professionals do not make assumptions or use personal preferences Coding guidelines absolutely prohibit this

Coding Tips Documentation must substantiate the bill The note should back up the code chosen, and vice versa, or you can lose reimbursement Coding is a joint effort between the clinician and coder to achieve complete and accurate documentation, code assignment, and diagnostic and procedural coding ICD codes labeled “not elsewhere classified (NEC)” or “not otherwise specified (NOS)” should be used only when the documentation in the record does not provide adequate information to assign a more specific code

More Coding Tips Code to the highest level of specificity when applying codes (i.e., use the 4th or 5th digit if they exist) Do not code diagnoses documented as “probable,” “suspected,” or “rule out” as if the diagnosis is established Guidelines for these were developed for inpatient reporting and do not apply to outpatients You have to code the symptoms, signs, abnormal test results, or other reason for visit if no diagnosis is established at that time When no definite condition or problem is documented at the conclusion of a patient care visit, the coder should select the documented chief complaint or symptom

Evaluation and Management (E/M) Coding All physicians, regardless of specialty, may use any E/M service code History, examination, and medical decision-making are the key elements when determining a level of service There are different codes for new and established patients E/M codes encompass wide variations in skill, effort, time, responsibility, and medical knowledge required for diagnosis and treatment Includes private/clinic “office” visits or hospital-based outpatient visits and other types of services provided by physicians and mid-level providers

Coding and Reimbursement Coding errors can result in delayed, incorrect, or no payment With the added scrutiny of the Office of Inspector General and others, it is increasingly more important to minimize errors that can result from incomplete documentation or inappropriate use of codes Patient records have to include documentation for medical care, diagnostic tests, procedures and all other services submitted for payment

Coding Audit Triggers On Medicare’s Current Hit List Excessive use of higher-level E/M codes—too much use of 99215 Billing for consultations on established patients for minor diagnoses that do not support this level of service Billing for excessive repetition of lab tests when results are typically normal for that patient Upcoding and overutilization billing for office visits, especially when services were not medically necessary

TPR Collections: Step-by-Step

Determine Eligibility Billing Process Schedule Appointment Generate & Sign Bill Submit Bill Contact Payer Register/ Determine Eligibility No Payment? Pend/Denial? Verify/Auth No Yes Yes Provide Care Deposit Correct Coding Post Payment Re-submit Charge Entry Bill Patient if applicable

Collecting Third Party Payments Remittance Advice (RA) Third party payer forwards a RA to billing provider RA is usually accompanied by an Explanation of Benefits (EOB) form and a check for paid bills Deposit payment – deposit payment immediately upon receipt Post payment – payments made on outstanding amounts should be posted to patient accounts

Collecting Third Party Payments Bill secondary payer As appropriate, bill secondary payer (s) for remaining patient balances (or coordination of benefits) Bill patient After payment from a secondary payer is received, bill patient accordingly Analyze pended and denied bills Analyze RAs and EOBs to identify and resolve correctable billing errors Resubmit corrected bills

Remittance Advice (RA) The RA, or remittance statement (RS), is a written notice from a third party payer Itemizes submitted bills Identifies the payment amount for each submitted bill Gives the payment status of each bill (paid, pending, or denied) For each bill, the RA also shows Provider’s name and number Date of service Patient name and insurance ID number Service description, coding and billed charge Amount paid or payable for billed service (s) Patient deductibles or co-pays Payment status

Remittance Advice (RA)

Explanation of Benefits (EOB) Provider and patient identification Dates of service, procedures, and charges submitted Disallowed charges and explanation (usually codes) Allowed charges and explanation (usually codes) Deductible (if applicable) and year to date total Co-pay, if any Amount payable by the payer Identifies incorrect billing information that can be perfected and resubmitted Highlights ineffective operating procedures for collecting patient and service data used in billing so they can be modified, as needed Identifies the need for staff training on data collection and billing

Explanation of Benefits (EOB)

Bill Tracking and Adjustment Activities Essential bill tracking and adjustment functions Provider productivity Analysis of coding Frequency of illnesses Frequency of chronic versus acute illness Analysis of cost of care Account aging Cost center income and expense Profit and loss (yes, even in not-for-profits) Status of reimbursement transmittals/claims Bill tracking and adjustment activities are essential to maintain adequate cash flow Adding computerized tools can help with tracking and management, thereby improving cash flow

Overview of the Claims Payment Process Reject Claim Patient ID Match? Calculate Allowed Charges No Yes Procedure(s) Covered? Reject Claim No Calculate Deductible (if applicable) Yes Procedure(s) Match Diagnosis? Reject Claim No Calculate Copay (if applicable) Yes Duplicate Claim? Reject Claim Yes Create EOB No Yes Other Payer Responsible? Reject Claim Send EOB and payment No

Overview of the Claims Payment Process Payer scans the claim for a match with their database Claim procedure codes are checked Procedure codes are compared to claim diagnosis codes to confirm medical necessity Claim checked against previous claims Claim is checked to determine if another payer has responsibility to pay Allowed charges are calculated Deductible, if any, is calculated Co-pay, if any, is calculated EOB form is created EOB and payment is sent to provider

Rejected Bills Payable bills can be rejected due to correctible errors It is important to track rejected bills to Identify improvements in billing and collection processes Highlight correctable program operations and billing problems Assess performance of billing staff Get additional revenue Some bills are rejected because they are un-payable Other bills are rejected because the claim was completed incorrectly or contained incorrect data Electronic bill submission, either internally or through an outside firm, can reduce rejections and expedite payment

Common Reasons for Rejected Bills The patient not on file The bill is for non-covered services The procedure not medically necessary Out-of-network provider (rejected or reduced payment) A required preauthorization was not secured The patient’s coverage was terminated prior to date of service Other payer responsible

Automation

To Computerize or Not HIPAA requires electronic claims submission Billing and collections effectively require on-going management It is advisable, although not necessary, for a very small operation to computerize the data you need to collect General benchmark < 10,000 visits annually = manual system > 10,000 visits annually = computerized system Billing software vary in cost and training requirements Look before you leap

Building Your TPR Team: Tips in Reviewing Your Staff Responsibilities

Staff Responsibilities: Registration Clerk Constructs patient health records before visits Has records available when patients arrive Ensures patients arrive at your program and “sign in” Registers arrival time Ascertains if insurance status or address have changed Ensures patient demographic data is correct Handles appointment reminders by calling patients or preparing reminder cards Clerk may Record the patient’s chief complaint Complete forms in the health record with demographic data Explain co-payment or deductible to patient and collect the cash or charge to credit card Transcribe codes to face sheet or a super-bill based on the patient’s chief complaint (if trained by your coder)

Staff Responsibilities: Coding Staff Encounter forms typically allow providers to check off item(s) on the forms that list many visit/procedure options and diagnoses, with the corresponding codes The medical visit level and diagnoses and procedures are taken from the encounter form, coded, and entered into a billing system Coders should ensure corresponding notes are in the record If coding notes, obtain health records, encounter form(s), or charge slip(s) and determine codes Enter codes into billing system if they assigned the code, otherwise this is a biller’s function If coding staff are not entering information directly in a computer program, a manual log sheet can be used Verify accuracy of date and place of service If billing software is available to execute claims, coders and then billers initiate the billing process Physical layout is important for coders to be able to be most effective, they need to concentrate

Staff Responsibilities: Billing Staff Charges or fees are then applied by the biller and CMS1500 claim forms are generated Verifies that all services provided were coded Matches encounter slips to appointment register Enters charges for services and generates bills Completes claim transmission and submits claim in a timely manner In small organizations the biller and coder can be one person

Staff Responsibilities: Accounts Receivable (AR) Staff Posts, or records, the payments received from the payer Reviews Remittance Advice for Inaccurate information Adjustments Pended bills Denials Examines the EOBs to identify reasons for payment delays Communicates each reason to the provider, coder, or biller, as appropriate If payment is banked by electronic fund transfer, this reduces days in AR AR staff should know the date these deposits should be made and ensures the transactions occur Claims should all be paid within specific time limits AR staff should track or project payment dates and analyze this information to identify slow payers Provide input into fee schedule changes

Staff Responsibilities: Finance Staff Oversees all financial transactions, including billing, coding and collections Posts cash to the accounting system Produces cash flow reports, including aged AR, days in AR, and dollars in AR Regularly reports performance to CEO and board of directors Periodically audits coding and billing practices and ensures staff compliance with appropriate internal controls

Reimbursement Infrastructure

Constructing a Billing Department Well-trained intake/registration, coding, billing and collections staff, as well as adherent providers, are essential for success It is important to remember billing begins with the first contact by the patient This is their point of entry into service Consider billing process and functionality when making staffing decisions

Constructing a Billing Department For those of you who do not currently bill To decide on a plan to go forward Analyze who currently handles Scheduling Intake and registration Eligibility verification Creation of records These staff members can work collaboratively to create an effective billing department which integrates front desk, coding, billing, and claims submission functions

Re-engineering a Billing Department For those of you who currently bill It is a good time to get the entire front and back office together and go over all of your functions Ensure everyone is on board with the philosophy that you need to be paid for what you do, and their connection to the payment cycle Review everyone’s functions while together to ensure that everyone understands the jobs that others do Be sure everyone understands they are an essential piece of an important process Cross-train everyone, plan for vacancies and vacation

Constructing a Billing Department Before you meet with all staff, review financial and demographic data that are currently collected to identify information gaps in your data If currently billing Pick one important issue/problem, and teach people how to flowchart the current process Then, together, develop one ideal process For those not currently billing Develop flowcharts documenting optimal patient flow processes and supporting administrative functions Design a physical office layout around the optimal Create tracking tools to ensure same problems do not recur

Billing and Collections Processes Implementation For agencies newly billing Now you are ready to conduct a simulation of the entire billing process from patient registration to payment posting and refine, as necessary For agencies currently billing Be sure to pilot your solutions first, and then implement them on a full scale Work out the bugs If your program does not have a provider number (s) and/or claims transmission authorizations, apply for these now Test transmission capability before submitting the first “real” claim

Qualified Coding Staff Coding professionals are trained and often certified Beginning coders’ skills and credentials are adequate for primary care or freestanding outpatient settings Two organizations award coding credentials American Health Information Management Association (AHIMA) American Academy of Professional Coders (AAPC) Both have national credentialing exams

Three types of information are essential to estimate your return How do we estimate our financial return from TPR billing and collections? Three types of information are essential to estimate your return Patient base Services offered Service volume

What is your patient base? Identify prevalent insurers for your patient population Learn their payment rates, what services each plan covers and under what circumstances Evaluate your patient population to identify uninsured clients versus individuals eligible for Medicaid, other public programs, and commercial insurers

What billable services does your HIV program offer? Insurers vary in covered services, authorized providers, and payment rates Adjust your operations accordingly Hire Nurse Practitioners (NP) rather than RNs because NPs are billable Case management may be a covered service Charge for services that were previously provided at no charge

What is your service volume? A shift in perspective may be required Fee-for-service reimbursement and all inclusive rates are driven by the number of encounters or services provided Managed care capitated payments are driven by the number of patients enrolled with the provider

Alternative Billing Arrangements: Partnering Alternatives exist if the costs of developing internal billing infrastructure are prohibitive Collaboration with complementary organizations Buying into a common computer system, with a firewall to protect your organization’s autonomy and information Share staff to access greater expertise than you might afford on your own Leveraging technical and financial resources

Alternative Billing Arrangements: Outsourcing Do we build or buy our own billing systems? Companies exist that can handle all of the registration, billing, and collection processes by providing experienced on-site staff Billing services can Speed up payments through efficient processes, helping to improve cash flow Reduce rejected claims by catching billing errors during front-end editing Stay current with any changes in payer billing requirements Produce reports tracking billing performance

Staffing and Patient Flow Consider patient flow and your space needs and construct your design layout accordingly Maximizing patient flow is the key Processes to consider include Constructing charts Scheduling patients Verifying their insurance Collecting copays Handling walk-ins Telephone calls Making referrals Level of staff training on your software Understand what your processes are, if they deter or enhance patient flow, and aim for “no waits/no delays” Map the entire process so that you can be sure that staff can carry a task to completion

Staffing and Patient Flow Cross-trained staff should know when to jump in and help and be trained in troubleshooting To start your process mapping, gather some information Number of incoming and outgoing calls per day Number of visits per day/total and totals by type How many individual people call in by type -patients/ referrals/ pharmacies, etc. How many walk-ins per day - patients and others (sales people) Number of other interruptions, e.g., audits, deliveries Frequency of diagnoses (severity of illness) Service volumes, e.g., number of blood draws per day Number of new versus established patients seen per day Vacancy rates/absentee rates for all staff Number of charts constructed per day

Billing and Collection Processes Implementation Train all of your staff, including providers All policies and procedures relating to coding, billing, health and other record management and accounting Federal/state and local regulations and new regulations, as they evolve Corporate compliance HIPAA requirements, general fraud and abuse issues Documentation Confidentiality and security Coding requirements, such as E/M code rules and prohibitions on up-coding/double billing Third party payer expectation

Implementation: Staff Education All staff need education Concentrate on provider and front office staff concurrently Keep providers coming by making training topical and relevant to what they do on a daily basis Keep training limited to 30 minutes per session Provide follow-up to training by documenting results of what was learned ALWAYS follow policies and procedures as written If you do not, then revise the policies Motivate staff to come to training Reinforce the consequences of inadequate documentation

Other TPR Modules on Website Visit www.positiveoutcomes.net for additional training modules Automation of Records and Billing Functions In-depth Coding and Documentation Practices In-depth Billing and Collections Management Corporate Compliance Credentialing HIPAA