1. Data Quality: UBO & TPOCS
Tom Sadauskas, TMA UBO Deputy PM
Jerry Robinson, RITPO

2. OUTLINE Uniform Business Office (UBO) MTF Revenue Cycle
Data Quality Characteristics
Data Quality and How it Affects Each Phase of the Revenue Cycle
UBO Success Factors
Third Party Outpatient Collection System (TPOCS)
Resources

3. UNIFORM BUSINESS OFFICE
Third Party Collections (TPC)
Medical Services
Account (MSA)
Medical Affirmative
Claims (MAC)

4. UBO Organization Chart
Dr. William Winkenwerder
ASD (Health Affairs)
Director, TMA
Secretary of the
Army, Navy, Air Force
Command – Control - Execution
Policy & Guidance
Army, Navy, Air Force
Chief of Staff
MG (sel) Elder Granger
Deputy Director, TMA
Army, Navy Air Force
Surgeons General
Mr. John Kokulis CFO, TMA
Mr. David Fisher
Director, Management Control & Financial Studies
Army MEDCOM
BUMED
AFMS
UBO Work Group Members:
*TMA UBO Program Manager *Voting members
*Army UBO Program Manager
*Navy UBO Program Manager
*Air Force UBO Program Manager
Service IM/IT, Legal reps and subject matter experts (SME)
TMA/IM Manage the Business rep
Clinical Information Technology Office (CITPO)
Resource Information Technology Office (RITPO)
Unified Biostatistical Utility (UBU)
MEPRS Management Improvement Group (MMIG)
TriService Information Management Program Office (TIMPO)
UBO Advisory
Work Group
Lt Col Jeanne Yoder
TMA UBO
Program Manager
Service UBO Program Managers
(Army, Navy, Air Force)
Intermediate Commands
HSO/MAJCOM
(Army, Navy, Air Force)
Service IM/IT, legal reps & subject matter experts (SME)
TMA/IM, Unified Biostatistical Utility (UBU),
Clinical Information Technology Program Office (CITPO),
Resources Information Technology Program Office (RITPO),
MEPRS Management Improvement Group (MMIG)
MTF UBO

5. Direct Care TPCP FY02 – FY05 - Billed & Collected ($ Millions)
Service
*FY02
Billed -- Collected
*FY03
*FY04
*FY05
Outpatient
Army
$ $27.4
$ $18.5
$ $21.9
$ $24.7
Navy
$ $15.2
$ $10.8
$ $14.6
$ $13.4
Air Force
$ $26.8
$ $18.3
$ $30.6
$ $26.1
Total
$ $69.4
$ $47.6
$ $67.1
$ $64.2
Inpatient
$ $25.7
$ $20.9
$ $22.5
$ $21.4
$ $13.8
$ $9.3
$ $10.0
$ $9.4
$ $15.5
$ $13.6
$ $14.3
$ $11.3
$ $55.0
$ $43.8
$ $46.8
$ $42.1
Billed value is the cumulative billed value for three quarters.
Collected value is the cumulative collected value for three quarters; however, included in that amount is collections for services billed from current and prior years.
*NOTE: Collected includes dollars for healthcare services provided in previous FYs and may exceed current FY billings. Different billing methodologies in place for outpatient billing. FY02 used an all-inclusive/flat rate based upon MEPRS clinic; FY03 involved a transition to Outpatient Itemized Billing (OIB).
Data source: MTF DD 2570 as reported to the TMA UBO Metrics Reporting System

6. Direct Care TPCP Draft 1st Qtr - Billed & Collected ($ Millions)
Service
*FY03
Billed -- Collected
*FY04
*FY05
*FY06
Outpatient
Army
$ $6.1
$ $4.8
$ $5.6
$ $6.4
Navy
$ $3.3
$ $3.2
$ $3.4
$ $3.4
Air Force
$ $4.4
$ $5.9
$ $3.7
$ $7.6
Total
$ $13.8
$ $13.9
$ $12.7
$ $17.4
Inpatient
$ $6.1
$ $4.7
$ $5.9
$ $4.4
$ $2.2
$ $1.9
$ $2.1
$ $2.0
$ $2.7
$ $3.7
$ $1.8
$ $2.8
$ $11.0
$ $10.3
$ $9.8
$ $9.2
Billed value is the cumulative billed value for three quarters.
Collected value is the cumulative collected value for three quarters; however, included in that amount is collections for services billed from current and prior years.
*NOTE: Collected includes dollars for healthcare services provided in previous FYs and may exceed current FY billings. FY03 numbers reflect a transition to Outpatient Itemized Billing (OIB) and away from the previous all-inclusive/flat rate based on MEPRS clinic.
Data source: MTF DD 2570 as reported to the TMA UBO Metrics Reporting System

7. DATA QUALITY CHARACTERISTICS
Accurate
Complete
Concise
Cost-effective
Relevant / Timely / Up-To-Date
Presentation
Consistent
The move to OIB has made data quality very important. The following are a list of data quality characteristics and we will talk about these characteristics as you are introduced to the MTF revenue cycle. We will show you where these characteristics come into play.
Data is the catalyst that initiates action and is the element around which applications and systems revolve, such as DEERS, CHCS/ADM, and TPOCS.
Accurate: correct and valid data
Complete: comprehensive; all information to make informed decision
Cost-Effective: does value gained equal or outweigh costs of providing the services
Relevant / Timely / Up-to-date: assist/hinder decision making, does data appear at appropriate time for decision making, does data reflect current knowledge
Presentation: presented so data is clearly understood
Consistent: standardized procedures
Collection of OHI
Consistent follow-up of denials
All of these characteristics must be present at EACH phase of the revenue cycle!

8. UBO SYSTEMS CHCS I DEERS TPOCS EAS IV MDR M-2 Legend PDTS ADM WAM
TPC Claims
MAC Claims
MSA Claims
Inpatient Claims
EAS IV
Financial
Personnel
Workload
MDR
M-2
ADM
Legend
Database
Subsystem
Data
Documents
WAM
PDTS
Real Time
Rx Billing
(future)
To support the MTF Revenue Cycle, there are various DOD systems in place to accommodate the business practices.
Data Quality starts with both CHCS and DEERS. This data is fed to TPOCS (Third Party Outpatient Collection System), which performs outpatient billing for the TPC program only. Any errors found in TPOCS that have to do with coding, etc. must be corrected in the source system (i.e., CHCS/ADM). Inpatient and MSA billing is done through CHCS.
CHCS also feeds EAS IV, MDR, and M-2. Data from these systems are used in developing some rates that are billed. The data is also used to look at practice patterns and efficiency.

9. MTF REVENUE CYCLE Information / Data Cash O&M Collections Cash Flow $$
INFRASTRUCTURE (MTF Commander and Other Leaders)
Patient
Registration
Provider Encounter Data
Patient
Registration
Coding
Billing
Accounting
INFORMATION SYSTEMS
Focus on the big picture. UBO and OIB fits into what we refer to as the MTF revenue cycle. The revenue cycle is made up of the administrative functions that contribute to the creation of billable events, submission of bills, collection, payment and posting. The revenue cycle is paramount for the success of OIB. We must minimize the “leaks”.
There now exists an interdependency among all MTF staff from the registration clerk (in the collection and confirmation of OHI) to the provider (for accurate documentation), to the coder and biller. All these people are interconnected to make the UBO Program successful.
The MTF Commander and other leaders must communicate to all involved parties in order to generate support for data quality.
Data quality is critical!!!!! Why? Every phase of the revenue cycle is highly dependent on the completeness and accuracy of the data collected. Starting from the beginning of the revenue cycle, every data point is passed along to the next person and ultimately affects reimbursement for the MTF. An error in one part can affect the whole cycle.
As you can see, all disciplines have responsibility and impact regarding data quality. We will be going more in detail about this in the next slides.
O&M Collections
Cash Flow $$

10. GAO REPORT FINDINGS
Results from a February 2004 GAO report identified breakdowns in each phase of the revenue cycle and the resulting adverse effects on collections
Breakdowns reduce DOD’s Third Party Collections $ $ $ $ $
Medical
documentation
Billing
Accounts
Receivable
Patient intake
Coding
Some billable care is not identified due to coding or systems problems
Staff issues
Failure to collect & maintain insurance
information
Missing medical records
Poor medical record documentation
Inadequate follow-up
Legal issues
Incomplete
Inaccurate
Process
Breakdowns
Source: GAO R

11. PATIENT REGISTRATION Information / Data Cash
PATCAT Entry
Collection &
Validation of OHI
DQMC Assessable
Unit
Information / Data
Cash
INFRASTRUCTURE (MTF Commander and Other Leaders)
Now that we know about the revenue cycle and data systems, let’s look at the impact of the revenue cycle and data quality on the stakeholders.
Patient data collection begins with the Registration Clerks.
PATCAT: accurate? The PATCAT is looked at by systems when making a decision about data. PATCAT reflects billable or non-billable events – e.g., if active duty, not billable, MSA PATCAT?
Collection & Validation of OHI: accurate, complete, up-to-date and timely? For any TPC billing to take place, the OHI must be entered into CHCS within a 3 day timeframe otherwise the data is not pushed to TPOCS for billing purposes. After that timeframe, billing must be done manually, and that is only if the biller knows there was an encounter and has all the information.
OHI: consistent – is the collection of OHI a standardized procedure? Is the entry consistent with the SIT table? E.g., BCBS vs Blues.
GAO Report R dated 20Feb04: The report indicated that, “the single biggest obstacle to increasing collections is inadequate identification of patients with third party insurance.” Millions of dollars are not collected each year because of the lack of effective systems and processes for obtaining and updating insurance information for patients who have OHI. This includes verifying the accuracy of the data.
For example, based on work performed by service auditors at five MTFs, they found that while MTF records identified 4.5% of the outpatients as having OHI, in fact about 9.8% of the outpatients had OHI, more than doubling the number of patients with insurance and projected to include an additional 96,000 patients.
Patient
Registration
Patient
Registration
Provider Encounter Data
Coding
Billing
Accounting
INFORMATION SYSTEMS

12. 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
Whose responsible for training/accuracy?
Form the UBO perspective, the three Services have POCs available for additional information/guidance (on UBO website).

13. Medical Affirmative Claims (MAC)
Are all patient injuries being identified for JAG review as possible MAC cases?
Active Duty Included
Is anyone training your intake personnel to identify potential MAC claims?
If no one is responsible then it’s not getting done
How much is your MTF losing in unidentified MAC cases?

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 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 Report

15. PROVIDER DATA Information / Data Cash
Medical Record
Availability
Documentation
Information / Data
Cash
INFRASTRUCTURE (MTF Commander and Other Leaders)
Encounters of Providers listed with a CHCS Provider Specialty Codes above 905 DO NOT come over to TPOCS. Example of Internal Medicine instead of Internist Cardiology instead of 014 – Cardiologist.
TPOCS is screwed Up!!! Had Psychology instead of Psychology Social Worker
Documentation: is this accurate, complete, concise, relevant, timely, consistent – coding depends on documentation, codes are put on a claim for billing.
Many providers use Superbills/Templates
POSITIVE: helps with coding, should be tailored to their specialty
NEGATIVE: may not contain all codes that are needed. Has to be updated annually to reflect current codes.
NEGATIVE: easy to get in a habit of simply checking the same E/M codes for care rendered in a specific specialty area.
FUTURE FEATURE: Provider GUI software, Superbills will be enhanced by a Coding Compliance Tool. One touch documenting.
GAO Report (20Feb04): One independent study conducted at 50 MTFs found that approximately 17% of the records reviewed did not contain documentation for the specified date of the outpatient visit and about 35-47% of the time, reviewers could not find documentation in the medical record for the diagnosis or procedure performed.
If there is no documentation, it didn’t happen!!!
Patient
Registration
Patient
Registration
Provider Encounter Data
Coding
Billing
Accounting
INFORMATION SYSTEMS

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 – Physicians Assistant)
702 (Clinical Psychologist) versus 954 (Psychology)
Site visit to large medical center found 20% of PSCs fields were blank
Billable ADM encounter never reaches TPOCS

17. Correcting the CHCS Provider Specialty Codes (PCS)
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 – Physicians 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. CODING Information / Data Cash
HCPCS/CPT-4
Modifiers, ICD-9-CM
Units of Service
Information / Data
Cash
INFRASTRUCTURE (MTF Commander and Other Leaders)
Ability to code based on specific care provided to patients using modifiers, units of service and multiple E/M codes.
Coding must match documentation. Presentation. Coders must work with both providers and billers to ensure what is sent out is an accurate picture of what occurred. As long as diagnostic and procedural coding serves as the basis for payment methodologies, ensuring accuracy of coded data is a shared responsibility between coders, billers, and providers. Correct documentation and coding provides a complete picture of the encounter for other health professionals to use in subsequent care.
Coders should thoroughly review the entire medical record as part of the coding process in order to assign the most appropriate codes.
Adhere to all official coding guidelines.
Cost-effective, relevant – complete and accurate diagnostic and procedural coded data is necessary for research, epidemiology, outcomes and statistical analysis, financial and strategic planning, reimbursement, evaluation of quality of care, and communication to support the patient’s treatment is more critical than before. M-2 and MDR data is used by the MHS to make decisions.
Patient
Registration
Patient
Registration
Provider Encounter Data
Coding
Billing
Accounting
INFORMATION SYSTEMS

19. BILLING Information / Data Cash
Insurance
Verification
Claim Form Data &
Line Item Billing
Information / Data
Cash
INFRASTRUCTURE (MTF Commander and Other Leaders)
Insurance Verification - Billers are the ones that send claims out the door to payers. They must choose the accurate payer to send the bill to process.
Claim form data – With OIB, line item billing and data elements on the claim form must be clean. The goal is clean, accurate claims.
Accurate – if medications and services are not provided but billed to patients and insurers, the time-consuming and costly process of error correction is initiated.
Complete - When medications and service are supplied but not billed, the problem often goes unnoticed and revenue goes uncollected.
Timely – the longer a claim is not sent, the harder it is to collect money.
Presentation – is the claim form clean? Are the data in the correct fields? Does additional supporting documentation need to be sent with the claim?
Improved data quality can prevent fraudulent insurance claims, which drive up the cost of insurance and healthcare for individuals and employers.
The insurance that is sent from CHCS to TPOCS must also be correct. The OHI must be entered into CHCS within 3 days in order for data to be pushed to TPOCS.
Patient
Registration
Patient
Registration
Provider Encounter Data
Coding
Billing
Accounting
INFORMATION SYSTEMS

20. ACCOUNTING Information / Data Cash
Account Follow-Up
Payment Posting
Denial Management
Information / Data
Cash
INFRASTRUCTURE (MTF Commander and Other Leaders)
EOBs: accuracy - In order to account for money coming in the door to the MTF, the accounting staff must accurately read and interpret EOBs.
Timely – is the revenue posted in a timely manner?
Denial management: Denial codes
Accuracy – is this the accurate and correct reason?
Consistent – is there consistent follow-up of denials?
Web-based Metrics Tool – the UBO has a web-based metrics tool in which MTFs report out the collections for each month and it is consolidated, validated and tracked at both the Service level and TMA level. The tool lets all levels of the UBO benchmark and trend their MTF, Region or Service by time periods or against other MTFs, Regions, or Services.
Timely – this must be done on the last day of the month. If this snapshot is not taken then, any postings done will be counted during that timeframe. This is because the DD 2570 is a snapshot in time and does not cut off on a certain date of service.
Remember the money collected is used for the business operations of the MTF. This money can be used to optimize services or staffing.
Patient
Registration
Patient
Registration
Provider Encounter Data
Coding
Billing
Accounting
INFORMATION SYSTEMS

21. UBO SUCCESS FACTORS What are the Focus Points? MTF Revenue Cycle
Team Effort (not the just the UBO’s challenge)
Staff Education & Training
Electronic Interfaces
Leadership Involvement
Stress the need to complete the OHI forms (DD2569s)
Brief them on UBO Performance (OHI Capture, Billings & Collections)
With every entry point in the MTF Revenue Cycle, it is important that all data be accurately recorded and tracked. Data must be entered correctly the first time.
Staff education - Most of the clinic personnel responsible for the data input were not trained to complete the fields properly. Nor are they aware of the impact of the data on their clinical and business operations. Our facilities found that if they could show how the data directly impacted collections, there was a dramatic improvement in the accuracy/quality of the data.
Some sites eliminated access to SIT/OHI entry to those who were not specifically trained to enter the data. The information is sent to the few personnel authorized to enter the data. Four facilities also improved their OHI identification by over 20%. This has led to a doubling of their collections in 3 of the facilities. The SIT is now standardized and updated quarterly.
Specifically train on coding and target providers on E&M coding. Alternatively, hire coders, hire someone to audit to provide a baseline, educate internally, educate externally, invite coding students to intern, contract centrally through your MAJCOM,, pay for coders at another MTF to provide training to your staff, etc.
Electronic Interfaces - Using the CHCS and ADM electronic interfaces, existing patient and insurance information can be imported into TPOCS, thereby reducing data entry time. However, with inaccurate data bases, the downloads drop large quantities of records. Instead of correcting the problem, most sites have opted to continue manual entry. However, manual entry is time-consuming and can also lead to mistakes.
Leadership involvement is important for ensuring business processes are followed, such as OHI collected. This directly affects collections.

22. TPOCS: BILLING SYSTEM What is TPOCS? Relationship to other systems
OHI in CHCS
Provider Specialty Codes
Future enhancements
Centralized OHI Repository on DEERS
Patient Accounting System (PAS)/ Charge Master Based Billing (CMBB) to replace TPOCS and CHCS MSA Module for TPC billing
Questions
MTFs have the authority to collect private health insurance benefits for health services provided to insured military dependents with other health insurance. TPOCS is the system designed to assist in fulfilling this requirement.
TPOCS is both a recipient of data from source systems such as CHCS and ADM as well as a data entry point.

23. TPOCS / CHCS / ADM CHCS TPOCS Provider GUI Master Files Demographics
(12)
(13)
M/Objects
Master Files
Demographics
Admissions
Outpt Appts/Visits
ADM 3.0+
LAB-RAD
MSA/DD7A Billing
CHCS
Provider GUI
TPOCS
Appt List
Outpt Coding
Level 1 Edits
Order Entry
ORE Dx Links
Results
SIT
OHI
PROVIDER
ADM
SADR
(9)
Templates
Claims Processing Interfaces:
10 – TPOCS UB-92/1500 to 3M Audit Expert Outpatient
11 – Error Report 3M Audit Expert Outpatient to TPOCS
Provider GUI Interfaces:
12 – CHCS to/from Legacy Gateway Server
13 – Legacy Gateway Server to/from Provider GUI
Local File Server
3M Audit
Expert Outpatient
(Omega)
10)
(11)
One of the problems we are trying to work on is the variation among MTFs as to which version of TPOCS and its various components sites are currently using.
In an effort to improve data quality, a workgroup was convened to review the CPT update process and the end result was the release of the CPT tables on time (which is before or by the January 1 effective date). Efforts were also made to synchronization the loading of the tables among the various systems that use CPT tables.
An issue for TPOCS upgrade was obtaining a CoN (Certificate of Networthiness) from the Air Force due to security issues. Delayed the delivery of all AF TPOCS servers and continues to have an impact on billing process for OIB.

24. RESOURCES UBO Web Page http://tricare.osd.mil/rm/ubo_home.cfm
RITPO Web Site
TPOCS Help Desk Web Site
CHCS Web Site
Form the UBO perspective, the three Services have POCs available for additional information/guidance (on UBO website).

25. QUESTIONS? Tom Sadauskas TMA UBO Deputy PM 703-681-3492 x4069
Form the UBO perspective, the three Services have POCs available for additional information/guidance (on UBO website).