Data Quality:Uniform Business Office & The Revenue Cycle

DHA Uniform Business Office Program Manager

January 2015

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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

Uniform Business Office (UBO) Organization

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Business Support Directorate/CFO

Budget Execution Division

DHA UBOProgram Manager

Service and NCR MD UBO Program Managers

ASD (Health Affairs)

Director, DHA

Intermediate Commands

MTF UBO

Army, Navy, Air ForceSurgeons General

Army, Navy, Air ForceChief of Staff

MEDCOMBUMEDAFMS

Com

mand – C

ontrol - 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 OfficeDefense 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)

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UBO Cost Recovery Programs

Third Party Collections Program (TPCP)

Medical ServicesAccount (MSA)

Medical AffirmativeClaims (MAC)

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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

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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

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*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

Service FY10   FY11   FY12   FY13   FY14

  Billed Collected Billed Collected Billed Collected Billed Collected Billed Collected

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 $ 159.9 $ 79.7 $ 145.0 $ 70.9 $ 135.9 $ 58.5 $ 124.0 $ 51.3 $ 110.3 $ 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 $ 301.5 $ 174.6 $ 289.9 $ 152.6 $ 275.7 $ 130.7 $ 249.1 $ 118.5 $ 225.6 $ 101.7

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

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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)

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MSA ClaimsTPCP Inpatient Claims

FinancialPersonnelWorkload

LegendDatabase

Subsystem

Data

Documents

CHCS

DEERS

TPOCS TPCP OP ClaimsMAC Claims

EAS IV

MDR M-2

ADM

WAM PDTS

CCE

AHLTA

Existing MHS Systems

Billing/Collections

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Data Quality Characteristics

• Accurate• Complete• Concise• Cost-effective• Relevant / Timely / Up-To-Date• Presentation• Consistent

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MTF Revenue Cycle

Results are increased resourcing with reliable outcomes in the form of usable data

CHCS(Files &Tables)

PatientAccess

PayerEducation

Appeals

Payment Posting

Denial Management

AccountFollow-up

Claims Submissions

Coding

EncounterDocument

PatientRegistrationIns Verify &

Auth

Data Quality Management

CCE TPOCS

ElectronicBilling

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

Patient Registration

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CHCS(Files &Tables)

PatientAccess

PayerEducation

Appeals

Payment Posting

Denial Management

AccountFollow-upClaims

Submissions

Coding

EncounterDocument

PatientRegistrationIns Verify &

Auth

Data Quality Management

CCE TPOCS

ElectronicBilling

•PATCAT Entry•Collection & Validation of OHI•DQMC Assessable Unit

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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?

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Training for Selecting the Correct PATCAT

• PATCAT course now available via the DHA UBO website

• http://www.tricare.mil/ocfo/mcfs/ubo/patcat.cfm

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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

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CHCS(Files &Tables)

PatientAccess

PayerEducation

Appeals

Payment Posting

Denial Management

AccountFollow-up

Claims Submissions

Coding

EncounterDocument

PatientRegistrationIns Verify &

Auth

Data Quality Management

CCE TPOCS

ElectronicBilling

•Medical Record Availability•Documentation

Encounter Documentation / Coding

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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

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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

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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

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CHCS(Files &Tables)

PatientAccess

PayerEducation

Appeals

Payment Posting

Denial Management

AccountFollow-up

Claims Submissions

Coding

EncounterDocument

PatientRegistrationIns Verify &

Auth

Data Quality Management

CCE TPOCS

ElectronicBilling

•Insurance Verification•Claim Form Data & Line Item Billing

•Account Follow-Up•Payment Posting•Denial Management

Type 1 National Provider Identifier (NPI)

Thank You

Questions?