Data Quality: Uniform Business Office & The Revenue Cycle DHA Uniform Business Office Program Manager January 2015.

Outline Uniform Business Office (UBO) Organization UBO Cost Recovery Programs MHS Billing Systems MTF Revenue Cycle Data Quality and How it Affects Each Phase of the Revenue Cycle UBO Success Factors Resources 2

Uniform Business Office (UBO) Organization 3 Business Support Directorate/CFO Budget Execution Division DHA UBO Program Manager Service and NCR MD UBO Program Managers ASD (Health Affairs) Director, DHA Intermediate Commands MTF UBO Army, Navy, Air Force Surgeons General Army, Navy, Air Force Chief of Staff MEDCOM BUMED AFMS Command – Control - Execution Policy & Guidance Secretary of the Army, Navy, Air Force UBO Advisory Working Group Service IM/IT, legal reps & subject matter experts (SME) Medical Coding Program Office Defense Health Clinical Systems (DHCS) Defense Health Services Systems (DHSS) MEPRS Financial and Performance Reporting System Improvement Work Group Medical Coding Program Office (MCPO) National Capital Region Medical Directorate (NCR MD)

UBO Cost Recovery Programs Third Party Collections Program (TPCP) Medical Services Account (MSA) Medical Affirmative Claims (MAC) 4

Who Gets Billed Under Which Cost Recovery Program? Third Party Collections Program – Bill insurers for care provided to eligible DoD beneficiaries (excludes Active Duty) with other health insurance (excluding Medicare & TRICARE) Medical Services Account – Includes billing for care provided to eligible patients from Veterans Affairs/Coast Guard /NOAA/ PHS/Civilian Emergencies/Foreign Military & their Family Members Medical Affirmative Claims – Bill for care provided to eligible DoD beneficiaries injured by third parties 5

Collections by UBO Cost Recovery Program Third Party Collections Program (TPCP) – $135.3M (FY 2014) Medical Services Account (MSA) – $289.8M (FY 2014) Medical Affirmative Claims (MAC) – $12.9M (FY 2014) ALL funds collected are retained by your MTF – TPC funds are in addition to the MTFs O&M budget 6

*NOTE: Collected amount includes dollars for healthcare services provided in previous FYs and may exceed current FY billings. On average, from FY10-FY13, 52% of total MHS uncollected dollars can be attributed to acceptable third party payer denials (co-pay, deductibles, out of network, non-covered benefits). Data Source: MTF DD Form 2570 submissions to the DHA UBO Metrics Report A/O 1 Nov 2014 ServiceFY10 FY11 FY12 FY13 FY14 BilledCollected BilledCollected BilledCollected BilledCollected BilledCollected Outpatient Army $ 88.0 $ 58.0 $ 91.9 $ 51.5 $ 79.0 $ 42.2 $ 69.8 $ 39.2 $ 60.1 $ 32.5 Navy $ 40.2 $ 27.7 $ 36.7 $ 21.2 $ 35.0 $ 18.0 $ 31.7 $ 16.0 $ 31.3 $ 14.0 Air Force $ $ 79.7 $ $ 70.9 $ $ 58.5 $ $ 51.3 $ $ 44.4 NCR MD $ 13.4 $ 9.2 $ 16.3 $ 9.0 $ 25.8 $ 12.0 $ 23.6 $ 12.0 $ 23.9 $ 10.8 Total $ $ $ $ $ $ $ $ $ $ Inpatient Army $ 53.7 $ 26.3 $ 55.1 $ 22.5 $ 44.6 $ 22.7 $ 41.3 $ 21.0 $ 35.2 $ 16.8 Navy $ 12.5 $ 4.6 $ 11.8 $ 4.7 $ 12.4 $ 4.5 $ 10.9 $ 4.4 $ 14.3 $ 3.8 Air Force $ 26.6 $ 10.1 $ 17.3 $ 7.9 $ 16.2 $ 5.4 $ 16.0 $ 4.5 $ 15.9 $ 4.0 NCR MD $ 6.7 $ 4.5 $ 6.8 $ 2.9 $ 14.0 $ 4.8 $ 8.9 $ 6.2 $ 16.4 $ 9.0 Total $ 99.5 $ 45.5 $ 91.0 $ 38.0 $ 87.2 $ 37.4 $ 77.1 $ 36.1 $ 81.8 $ 33.6 Third Party Collections Program (TPCP) Inpatient and Outpatient Amounts Billed and Collected ($M) FY14 Q4 7

Current MHS Billing Systems Third Party Outpatient Collection System – Government developed system for billing outpatient TPCP (includes outpatient visits, lab/rad/pharmacy prescriptions) CHCS Medical Services Account (MSA) Module – Government developed module used for billing TPCP inpatient claims (both institutional & professional charges) & MSA Relationship to other systems – Provider Specialty Codes and other Provider Data – Collection of other health insurance (OHI) information in CHCS – Centralized OHI Repository on DEERS – Coding Compliance Editor (CCE) 8

MSA Claims TPCP Inpatient Claims Financial Personnel Workload Legend Database Subsystem Data Documents CHCS DEERS TPOCS TPCP OP Claims MAC Claims EAS IV MDRM-2 ADM WAM PDTS CCE AHLTA Existing MHS Systems Billing/Collections 9

Data Quality Characteristics Accurate Complete Concise Cost-effective Relevant / Timely / Up-To-Date Presentation Consistent 10

MTF Revenue Cycle Results are increased resourcing with reliable outcomes in the form of usable data CHCS (Files & Tables) Patient Access Payer Education Appeals Payment Posting Denial Management Account Follow-up Claims Submissions Coding Encounter Document Patient Registration Ins Verify & Auth Data Quality Management CCE TPOCS Electronic Billing Data Quality Management Controls are the driving force and conduit for ensuring effective and efficient operations. Visual review for validating and streamlining major clinical business and resource management processes Improved patient access, records documentation and coding accuracy 11

Patient Registration 12 CHCS (Files & Tables) Patient Access Payer Education Appeals Payment Posting Denial Management Account Follow-up Claims Submissions Coding Encounter Document Patient Registration Ins Verify & Auth Data Quality Management CCE TPOCS Electronic Billing PATCAT Entry Collection & Validation of OHI DQMC Assessable Unit

Importance of Accurate PATCAT Entry Patient Category (PAT) determines the reimbursable rate (if any) for healthcare – Over 300 PATCATs to select from Challenge of Patients with Multiple PATCATs – Spouse of AD Member who is a Reservist and employed as a Federal Employee Who is responsible for training/accuracy? 13

Training for Selecting the Correct PATCAT PATCAT course now available via the DHA UBO website 14

Other Health Insurance (OHI) Information Use DD Form 2569 to capture OHI information about your patients – All Non-Active Duty Patients required to complete it every 12 months or if data changes – OHI needs to be entered into CHCS PII screen or it “doesn’t exist” for billing purposes – Direct correlation between presence of a current DD Form 2569 in patient record and rate of TPC billing – Reported monthly in Commander’s DQ Statement 15

CHCS (Files & Tables) Patient Access Payer Education Appeals Payment Posting Denial Management Account Follow-up Claims Submissions Coding Encounter Document Patient Registration Ins Verify & Auth Data Quality Management CCE TPOCS Electronic Billing Medical Record Availability Documentation Encounter Documentation / Coding 16

CHCS Provider Specialty Codes (PSC) Set of codes unique to CHCS Current business rules preclude TPOCS from receiving ADM encounters with blank PSCs or PSCs > 900 – (exception of 901 – Physician Assistant) – 702 (Clinical Psychologist) versus 954 (Psychology) Site visit to large medical center found 20% of PSCs fields were blank – Billable ADM encounter never reach TPOCS 17

Correcting the CHCS Provider Specialty Codes (PSC) Get your site’s most current CHCS Provider Profile and review the PSC fields for accuracy – No blank fields – Billable providers have PSC under 900 (plus 901 – Physician Assistant) Determine whose responsible for maintaining the PSC fields and TRAIN THEM!!! Periodically review the PSC fields to make sure the problem really has been permanently fixed 18

Type 1 National Provider Identifier (NPI) Every Provider who can bill for healthcare services is required to have a Type 1 NPI 23 May 07 was the deadline for MHS providers to obtain their own unique Type 1 NPIs Are all of your providers’ TYPE 1 NPIs in CHCS? – No NPI = No payment from Insurance Companies 19

CHCS (Files & Tables) Patient Access Payer Education Appeals Payment Posting Denial Management Account Follow-up Claims Submissions Coding Encounter Document Patient Registration Ins Verify & Auth Data Quality Management CCE TPOCS Electronic Billing Insurance Verification Claim Form Data & Line Item Billing Account Follow-Up Payment Posting Denial Management Type 1 National Provider Identifier (NPI) 20

Thank You Questions?