navigating the river of cash - leadingage new york care billing_hagen.pdf · 5 medicaid managed...
TRANSCRIPT
1
How to Safely Navigate the River of Cash
LeadingAge NY Financial Managers ConferenceAugust 2016
• Know your river
• Maneuver around obstacles
Strainers – enrollment and authorizations
Sweepers – audits and insurance verification
Eddies – payor requirements and collections
Hydraulics – appeals and denial management
Sandbars – NAMI collection and self pay
• Thorough trip planning
Navigation Considerations
Page 2
2
Page 3
Know your river…looks can be deceiving
• Since 2010 national enrollment increased by 30%
• July 2016: 1.28 million NY enrollees (38% penetration)
15 counties with < 25% penetration
o Clinton, Dutchess, Essex, Franklin, Nassau, Orange, Otsego, Putnam, Rockland, St. Lawrence, Suffolk, Sullivan, Tompkins, Ulster and Westchester
11 counties with > 50% penetration
o Bronx, Erie, Genesee, Livingston, Monroe, Niagara, Ontario, Orleans, Wayne, Wyoming and Yates
Medicare Advantage
Page 4
https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/MCRAdvPartDEnrolData/MA-State-County-Penetration-Items/MA-State-County-Penetration-2016-07.html?DLPage=1&DLEntries=10&DLSort=1&DLSortDir=descending
3
Page 5
New York Medicare Advantage (July 2016)https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-
Reports/MCRAdvPartDEnrolData/Monthly-MA-Enrollment-by-State-County-Contract-Items/MA-Enrollment-by-SCC-2016-07.html?DLPage=1&DLEntries=10&DLSort=1&DLSortDir=descending
# of Counties # of Contracts and Plans
16 100 - 109
29 110 - 124
17 125 - 149
7 150 - 199
3 200+
• I-SNP = Institutional Special Needs Plan
Restricts enrollment to Medicare Advantage eligibles who for 90+ days have had or are expected to need SNF/NF, ICF/MR or inpatient psychiatric facility services
Provides extra care coordination and preventive services benefits in addition to regular Medicare Advantage plan benefits
o January 2016 UHC blocked by NYS Attorney General from requiring some SNFs in its commercial-plan provider network to join the I-SNP network
Medicare Advantage I-SNP
Page 6
4
Page 7
New York I-SNP (July 2016)
# of Plans # of Reported Enrollees
27 234,029
https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/MCRAdvPartDEnrolData/Special-Needs-Plan-SNP-Data-Items/SNP-Comprehensive-
Report-2016-07.html?DLPage=1&DLEntries=10&DLSort=1&DLSortDir=descending
• Affinity, Agewell NY, Alphacare, Amida, Atlantis, Catholic Special Needs, Centerlight, Centers Plan, Cuatro, Elderplan, Elderserve, Empire Health Choice, Fallon Health Weinberg, Group Health Inc, Guildnet, HIP, Healthfirst, Humana, IHA, Liberty Health, MetroPlus, Quality, Senior Whole Health, NYS Catholic Health Plan, UHC, VNS Choice and Wellcare
Medicaid Managed Care• MLTC – Managed Long Term Care Plan
Long term care and home care services
Medicare/Medicare Advantage stays in place
Mandatory for dual eligibles
• MA – Medicaid Advantage
Includes Medicare services but Medicaid coverage without LTC
• MMCP – Medicaid Managed Care Plan (mainstream)
Managed care version of Medicaid and covers LTC
Mandatory for most Medicaid recipients – dual eligibles are excluded
Page 8
5
Medicaid Managed Care
• MAP – Medicaid Advantage Plus
Traditional insurance model for age 18+, intensive case management model
If required to enroll in MLTC may choose to enroll in a MAP
Must enroll in the plan’s Medicare product
Limited plans across the state
Page 9
Medicaid Managed Care• FIDA (Fully Integrated Dual Advantage)
Both Medicare and Medicaid services, including Part D Rx
Builds upon existing MLTC program
Bronx, Kings, Nassau, New York, Queens, Richmond, Suffolk and Westchester (delayed roll-out to Suffolk and Westchester)
Passive enrollment suspended December 2015
May 2016 enrollment dropped to 5,370
• FIDA-IDD (Intellectual and Developmental Disabilities)
Partnership with NYSDOH and OPWDD for dual-eligible enrollees
Demo slated to run through December 2020
Bronx, Kings, Nassau, New York, Queens, Richmond, Rockland, Suffolk and Westchester
Page 10
6
Medicaid Managed Care• HARP – Health and Recovery Plan
Specialized integrated product line for people with significant behavioral health needs
Eligible based on utilization or functional impairment
Must be insured only by Medicaid and eligible for Medicaid managed care
What HARP’s do:
o Manage Medicaid services for people who need them
o Manage and enhanced benefit package of Home and Community-Based Services (HCBS)
o Provide enhanced care management to help coordinate all physical health, behavioral health and non-Medicaid support needs
Page 11
Medicaid Managed Care• PACE (Programs of All-Inclusive Care of the Elderly)
Provides a comprehensive system of health care services for members age 55 and older who are otherwise eligible for nursing home admission
Both Medicare and Medicaid pay for PACE services (on a full-capitated basis)
PACE members are required to use PACE physicians and an interdisciplinary team develops care plans and provides on-going care management
PACE is responsible for directly providing or arranging all primary, inpatient hospital and long-term care services required by a PACE member
Page 12
7
Page 13
Insurance Fee for Service Managed Care Model
Have MEDICARE only
Regular Medicare• Original Medicare• Part D plan• Medigap (optional)
Medicare Advantage plan usually covers Part D• Voluntary but ~30% of Medicare
beneficiaries join • Pros: Cheaper than a Medigap
premium and controls other out-of-pocket costs
• Cons: Must be in-network and obtain plan approval
Have MEDICAID only
Regular Medicaid – only for people excluded or exempt from managed care (spend down, transitioning to Managed Care, etc.)
Medicaid Managed Care• Mandatory for non-dual eligibles• Covers primary, acute and long term
care HARP
Options if ONLY have Medicare OR Medicaid
Managed Care Options
Page 14
Insurance Fee for Service Managed Care Model
Medicaid & Medicare
(dual eligibles)
IF DON’T NEED LONG TERM CARE SERVICES
Medicare• Original Medicare• Part D plan• Medigap (optional)Medicaid
Medicaid Advantage – voluntary. Combines Medicare Advantage with Medicaid managed care plan in ONE. If in Medicaid Advantage can not join an MLTC.
IF NEED LONG TERM CARE SERVICES
Medicare• Original Medicare• Part D plan• Medigap (optional)Medicaid• Medicaid card – only
for primary, acute care
MLTC – Mandatory for most dual eligibles. Primary & acute care thru Medicare, with CHOICE of Original Medicare/Part D or Medicare Advantage plus Medicaid through MLTCMedicaid Advantage Plus (MAP) or PACE or FIDA or FIDA-IDD – voluntary option replaces all Medicare, Medicaid and MLTC coverage in ONE plan (full capitation)
Options for Dual EligiblesManaged Care Options
8
• Managed Care Enrollment
MLTC PACE – 9 Plans over 12 counties; 5,512 enrollees
MLTC Partial Cap – 32 Plans over all counties;157,088 enrollees
Medicaid Advantage (declining enrollment upstate)
o 7 Plans in 35 counties; 3,276 enrollees
o 7 Plans in NYC; 5,323 enrollees
Medicaid Advantage Plus (increasing enrollment)
o 4 Plans in 7 counties; 325 enrollees
o 7 Plans in NYC; 5,638 enrollees
http://www.health.ny.gov/health_care/managed_care/reports/enrollment/monthly/
Medicaid Managed Care – NY State July 2016
Page 15
• Managed Care Enrollment
Mainstream Medicaid Managed Care and NYSOH
o 19 plans; 4,436,994 enrollees
o HARP (increasing enrollment)
o 13 plans; 47,707 enrollees
http://www.health.ny.gov/health_care/managed_care/reports/enrollment/monthly/
Medicaid Managed Care – NY State April 2016
Page 16
9
Page 17
MLTC Partial Capitation Examples – July 2016
Elderplan
Dutchess – 20 Rockland – 67
Nassau – 246 Suffolk – 202
New York – 9,937 Sullivan – 5
Orange – 52 Ulster – 5
Putnam – 8 Westchester – 90
TOTAL 11,132
Page 18
MLTC Partial Capitation Examples – July 2016
Guildnet
Nassau – 1,884
New York – 11,994
Suffolk – 2,336
Westchester – 477
TOTAL – 16,691
United HealthCare
Albany – 44 New York – 1,640
Broome – 133 Oneida – 70
Erie – 68 Onondaga – 144
Monroe – 233 Rockland – 32
TOTAL 2,339
10
Page 19
MLTC Partial Capitation Examples – July 2016
VNA HomeCare Options
Albany – 129 Onondaga – 388
Chautauqua – 108 Oswego – 81
Erie - 119 St Lawrence – 98
Fulton – 106 Saratoga – 100
Jefferson – 83 Schenectady –144
Monroe – 301
34 counties (less than 80 each) – 827
TOTAL 2,484
WellCare
Albany – 47 Rockland – 198
Erie – 198 Suffolk – 41
Nassau – 77 Ulster – 110
New York – 5,480 Westchester –69
Orange – 203
TOTAL 6,423
Page 20
Medicaid Advantage Plus – July 2016
Fidelis ElderPlan Guildnet Health First
HealthPlus SeniorWhole Plus
VNS Choice
Plus
Albany(39)
Nassau (16)
Nassau (90)
Nassau (30)
NYC (2)
NYC (126)
NYC (109)
Montgomery (3)
Westchester (24)
Suffolk (91)
NYC (3,809)
Rensselaer (14)
NYC (1,059)
NYC (477)
Schenectady(18)
NYC (56)
11
Page 21
HARP – April 2016
Affinity CDPHP Excellus Health Plus HealthFirst
HIP IHA
144 277 808 4,720 16,070 3,248 234
MetroPlus MVP NY Catholic(Fidelis)
Today’s Option
UHC YourCare
8,424 467 10,048 189 2,844 234
• Transition of Nursing Home Populations and Benefits to Medicaid Managed Care January 2015
https://www.health.ny.gov/health_care/medicaid/redesign/docs/2015-01-22_nh_transition_rev.pdf
• Transition of Nursing Home Populations and Benefits to Medicaid Managed Care Frequently Asked Questions January 2015
https://www.health.ny.gov/health_care/medicaid/redesign/formatted_nh_faq_part_a.htm
• Office of Health Insurance Programs Transition of Nursing Home Benefit and Population into Managed Care February 2015 Implementation
https://www.health.ny.gov/health_care/medicaid/redesign/docs/nursing_home_transition_final_policy_paper.pdf
Helpful Resources
Page 22
12
• Transition of Nursing Home Populations and Benefits to Medicaid Managed Care Frequently Asked Questions March 2015
http://www.leadingageny.org/linkservid/D967539D-BE36-AC54-1D3B78EE97E6FFBF/showMeta/0/
• Transition of Nursing Home Populations and Benefits to Medicaid Managed Care Frequently Asked Questions Part 2 March 2015
http://www.leadingageny.org/linkservid/D970DB53-BEAA-CF4B-1617BFF7257C1CB7/showMeta/0/
• Transition of Nursing Home Populations and Benefits to Medicaid Managed Care Frequently Asked Questions March 2015 (Updated)
email [email protected]
Helpful Resources
Page 23
• Transition of Nursing Home Populations and Benefits to Medicaid Managed Care Frequently Asked Questions October 2015 (Consolidated)
https://www.fideliscare.org/Portals/0/DocumentLibrary/Providers/Resources/NH%20QAs%2010-15%20consolidated.pdf
• Transition of Nursing Home Populations and Benefits to Medicaid Managed Care Frequently Asked Questions Revised January 2016
http://www.health.ny.gov/health_care/medicaid/redesign/docs/2016-jan_rev_nh_transition_faqs.pdf
Helpful Resources
Page 24
13
• FIDA Resources: updates, notices, policy documents, outreach and education, FAQs, webinars
http://www.health.ny.gov/health_care/medicaid/redesign/mrt_101.htm
• FIDA Open Questions FAQ April 2016
http://www.leadingageny.org/?LinkServID=33305257-9D82-8CD6-0185A0626F0B1BEA
Helpful Resources
Page 25
• Medicare Advantage
Negotiated per diem rates or Medicare rate
• Commercial Plans
Negotiated rates
o “Pay lesser of daily rate or billed UCC rate”
• Medicaid Managed Care
Rate – 3 year current FFS (benchmark) rate or negotiated rate
Must be increased if it falls below current benchmark rate
If previously negotiated rate: pay benchmark during transition unless other arrangement is agreed to
Rates
Page 26
14
• Medicaid Managed Care
Are you working with MLTC’s to set future rates?
o What is your value?
o What value initiatives are they interested in?
Rates
Page 27
• Medicaid Managed Care
Bed hold methodology – unless otherwise negotiated, MCO required to follow current Federal/State Medicaid bed hold regulations (CFR 483.12 and 10YCRR 415.8 and 18NYCRR 505.9) – prior authorization may be required
Bed Hold Methodology
Page 28
Reimbursement Limitations
LOA temporary hospitalization / health care professional therapeutic
50% Not to exceed 14 days in any 12 month period
LOA non-hospitalization / health care professional therapeutic
95% Not to exceed 10 days in any 12 month period
Must have been resident for at least 30 days and unit to which recipient will return has a vacancy of no more than 5%
If plans not paying – contact Vallencia Lloyd (Mainstream) [email protected] OR
Mark Kissinger (MLTC) [email protected]
15
• Medicare Advantage and Commercial
Billing cycle – monthly
Payor specific payment cycle and remittance retrieval options
BCBS switch to InstaMed
• Medicaid Managed Care
Billing Cycle –at least every 2 weeks (bi-weekly) or twice a month
o Not generally mentioned in provider/billing manuals – don’t make assumptions
o Does billing department needs to change current process?
Payor specific payment cycle and remittance retrieval options
• Medicaid
Weekly payment cycle
Billing / Payment Cycle
Page 29
Page 30
Maneuver Around Obstacles
16
• Underwater obstacles you get pushed into by the current
Strainers
Page 31
• Medicare Advantage and Commercial plans
Enrollment changes not limited to open enrollment periods although many changes occur then
Families often not good at communicating changes
Facilities don’t routinely verify coverage
Strainers AKA Enrollment
Page 32
17
• New Eligible/Not in a Medicaid MCO
Coming from home to NH (long term): Apply for Medicaid following all current regulations, including physician recommendation, PASRR process, Patient Review Instrument (PRI), etc.
LDSS has 45 days to complete determination for long term Medicaid eligibility
Once approved and any penalty period has elapsed and NAMI amount is identified resident has 60 days to choose an MCO
NY Medicaid Choice will assist in education, plan selection and enrollment (in a plan with which the nursing home contracts)
Auto enrolled if not select
MLTC: No lock-in so enrollment may change
Strainers AKA Enrollment
Page 33
• Enrollment – Already Medicaid MCO Enrolled
MCO must authorize all long term placements and pay the NH while long term eligibility is being conducted by LDDS
NH and MCO assist with submitting documentation to LDDS (send MCO authorization with 3559)
Member has 90 days from date long term placement is determined to submit the application for coverage of long term custodial placement to the LDSS
LDSS will notify MCO, enrollee and NH
o If eligible – MCO keeps paying NH and NAMI is collected
o If ineligible – MCO recoup payment from NH and coordinate safe discharge into the community
Strainers AKA Enrollment
Page 34
18
Strainers AKA Enrollment• How do you track open enrollment changes?
• How will you track initial Medicaid managed care enrollments?
• How will you track enrollment changes?
“The provider must check eligibility and enrollment status at the time of service or weekly for NH services for billing purposes” FAQ March 2015
Develop policies and procedures and provide staff training
Failure to track may result in untimely billing to the correct payor
834 electronic enrollment files or will payor provide a roster?
Enhanced communication with families?
Page 35
• Medicare Advantage and Commercial
Authorization is generally required
o Revenue Code level or Level of Care
• Medicaid Managed Care
If enrolled in a plan, MCO must authorizeall long term care placements and will pay the nursing home while long term eligibility is being conducted by LDSS
Authorization is generally required
• Responsibility for initiating authorizationand timing is payor specific
Ultimately SNF bears the risk
Strainers AKA Admission Authorizations
Page 36
19
Strainers AKA Authorization Requirements• UAS-NY assessment completed by Medicaid MCO – required when
individual enrolls in a plan and every 6 months thereafter or when significant change in condition occurs – in person (per MLTC Policy 16.01: UAS-NY Assessment Requirements)
MCO required to compare the UAS-NY assessment needs with the MDS assessments conducted by NH and consider both when authorizing services, equipment and supplies
The care plan, MDS, UAS-NY, medical record and input from care management team will provide the MCO with the information needed for authorization of services
Although reassessment using UAS-NY is required at above schedule, MCOs may authorize for shorter time periods
o daily, several times each week, weekly and monthly
• Medicaid MCO may require authorization for bed holds
Page 37
• UAS-NY Considerations
MCO is using your data to make authorization decisions
o How well are you representing your data and your care?
Who is working with payer Case Manager?
o One or several employees?
o Is the presentation the same by all?
UAS-NY and MDS don’t cross-walk perfectly
o Are you documenting in a manner that supports both sets of requirements?
Strainers AKA Admission Authorizations
Page 38
20
Strainers AKA Authorization Requirements
Page 39
• All Managed Care
Always verify if an authorization is needed and for what services – admissions, routine services, supplies, equipment, etc.
o If you perform and bill for x-rays do you need an authorization?
Payors may require authorizations for some plans but not others
o Specific plan determines authorization requirements
Document contact person and telephone numbers for future authorization extensions and reassessments
Strainers AKA Authorization Requirements
Page 40
• All Managed Care
When is re-authorization required? What form? Portal or paper?
Can current staff handle the increase in work due to Medicaid Managed Care?
o Case management vs floor staff vs billing staff vs new position?
Coordination between billing and prior authorization staff
o When/how/does billing get the authorization number?
21
• Overhanging obstacles
Sweepers
Page 41
• OMIG 2016 – 2017 Work Plan
ALP Resident Care and Needs
Goods/Services Included in ALP Rate
Base Year Audits
Eligibility for Bed Holds
Capital Costs
MDS (7/1/14 – 6/30/15 rates)
Notice of Rate Changes (Rollovers)
Rate Appeals
Coordination of Benefits
Social ADC MLTC Eligibility
Home Health Services, Spend Downs, Medicare Maximization
• Compliance Program On-Site Review
Sweepers AKA Audits
Page 42
22
• Do you have revenue cycle policies and procedures?
Include: Admissions, Business Office, Billing, MDS, Therapy, Medical Records, Medical/Professional Services, Nursing, Materials Management
o Insurance Verification
o Prior Authorizations
o MDS Completion/Submission
o Therapy documentation/coding/charges
o Charge Entry
o Consolidated Billing
o Claims Submission
Sweeper AKA Audits
Page 43
o Payment Posting
o NAMI verification
o Resident Trust
o Bed Hold
o Diagnosis Codes
• When were policies and procedures last updated?
Software/vendor changes
System updates
Clearinghouse implemented
New positions that changed processes
Sweepers AKA Audits
Page 44
23
• Do you have a training program?
New hires and routine refresher training
o Regular cycle and as needed
Must be documented
o Staff sign off on skills sheet
o Meeting minutes
o Attendance sign-in
Sweepers AKA Audits
Page 45
• Do you conduct internal reviews?
Credit Balances – All payers
o Review and process at least monthly for a quick/easy review
o Quarterly Medicare Credit Balance Report
Denials for all payers
o Rotate focus on a new payor throughout the year
o Utilize electronic reports
Demand Bills requested by resident
o Hold self pay billing
Medicaid Managed Care
Sweepers AKA Audits
Page 46
24
• Medicare, Medicare Advantage Plan, Medicare Part D, Supplemental Plans, Medigap, Commercial Plans, Medicaid, Medicaid Managed Care, Medicaid Long Term Care, HARP +++
• Dual Eligible with original Medicare, Medicare Part D, Medigap and MLTC will have 5 insurance cards
• Medicaid Managed Care Internal Considerations
Provider must check eligibility at the time of service and before billing
o Currently may not be checking eligibility before billing Medicaid
o Is this going to be a new process?
o Will you do it for all payors?
o Who is going to do it?
o What resources will they use?
Sweepers AKA Insurance Verification
Page 47
• Medicare FISS/Connex
Check for each resident – not just Medicare Part A admissions
• Payor websites or phone calls to each insurance
• Clearinghouse insurance verification portal
• Batch eligibility verification (271 / 271 files)
Prior to billing submit 270 file for eligibility verification via clearinghouse
Possible: submit excel spreadsheet to clearinghouse if billing system can’t create a 270 file
• ePACES / Plan Rosters
Look at eligibility and Restriction/Exemption codes (institutional Medicaid, spend down)
Sweepers AKA Insurance Verification
Page 48
25
Page 49
• Avoid being swept into the river
Staff training
Identify type of coverage (MA, MLTC, Dual Advantage, MAP, etc.) AND plan
Document every call/contact in your billing system
Complete verification before admission and billing
Utilize technology to save time
Sweepers AKA Insurance Verification
Page 50
26
• Water rushes around an obstacle and forms a whirlpool
Eddy
Page 51
• Revenue Code / Level of Care
• Billing Rate
• Claim Format
• Timely Filing
• NOMNC
Eddy AKA Payor Requirements
Page 52
27
• Medicare Advantage and Commercial
Billing formats may vary
Code properly to get the revenue you are entitled to
Eddy AKA Revenue Code / Level of Care
Page 53
Revenue Code
Excellus Medicare Advantage and
Commercial
UHC EverCare MVP
191 Skilled Nursing Level I Level A – Continuing Care
199 Level Ia
192 Sub-acute Therapy Level II Level B – Low Rehab
193 Sub-acuteRehabilitation
Level III – Intensive Service Delivery
Level C – High Rehab
194 Level D – Medically Complex
• Medicaid Managed Care
Uniform billing codes addressed in budget
Law requires standard billing codes by January 1, 2016
Eddy AKA Revenue Code
Page 54
Description Fidelis Care at Home Revenue Code
Healthfirst Revenue Code
Bed Hold – Temporary Hospitalization
0185 0185
Bed Hold – Therapeutic LOA 0183 0183
Bed Hold – Other Therapeutic LOA 0189 N/A
Room and Board + Ancillary Services
0190, 0191, 0192, 0193 0100 (all inclusive custodial & respite)
Room and Board Only 0190, 0191, 0192, 0193 0100 (all inclusive custodial & respite)
28
• What rate should be on claim?
Medicare or Medicaid Rate
Negotiated Per Diem
UCC (Usual and Customary Charge)
• Watch out for “Pays lesser of daily rate or billed UCC rate”
Eddy AKA Rate
Page 55
• Every new format creates added work
Set up like another payor or plan?
Which revenue codes?
What rate?
Which modifiers?
Itemized or just R&B?
Excluded services?
Eddy AKA Claim Format
Page 56
29
• Medicaid Managed Care
Claim format may be similar to Medicaid format because rate code is required
Claim format may be similar to HMO because authorization number is required
• Look at each plan and determine if a new claim format needs to be built
Requires testing
• Maintain examples of clean claims for various bill types and service types for each payor and plan in your billing office
Eddy AKA Claim Format
Page 57
• Know timely filing requirements for each payor
Most payors have a 90 day timely filing requirement
Contract negotiations may extend this
• Bill at least monthly – no later than the 15th
• Bill as often as payor will allow
• Maximize billing and payment cycle
For Example: Medicaid Cycle
o Start date = Thursday, 7/7/16
o End date = Wednesday, 7/13/16
o Check date = Monday, 7/18/16 (2 business days after end date)
o Check release date = Wednesday, 8/3/16 (3 weeks after end date)
Eddy AKA Timely Filing
Page 58
30
• Does MLTC payer require a denial from Part A?
Results in significant slow down in revenue cycle
• Will payer accept a NOMNC in lieu of a Part A denial?
Develop internal process for issuance of NOMNC
Submit copy of NOMNC instead of Part A denial
Eddy AKA NOMNC
Page 59
• Keep all claims alive with follow up
Document every submission, mailing, phone call, etc.
No more than 30 - 45 days between follow up attempts
Verify receipt of claim – acceptance reports, fax confirmation, registered mail
Utilize billing system collections module
o If none – write follow up on calendar
Prioritize follow up by large dollar and nearing timely filing
Group calls to payor to save being on hold
Eddy AKA Collections
Page 60
31
• Water circulates on top of itself often at the base of a waterfall
Can be fatal!
Hydraulics
Page 61
• Per AMA 1.38% – 5.07% of claims are denied on 1st
submission
Aetna – 6.00% UHC – 4.30% Cigna – 3.80% Medicare – 2.30%
• Need to work electronic rejection/acceptance reports
Must review 999 and 277CA
o 999 confirms that a file was received. However, the 999 includes additional information about whether the received transaction had errors. Accepted (A), Rejected (R), Accepted with errors (E)
o 277CA acknowledges all accepted or rejected claims in the file
• Must work payor denials – review remittances
Hydraulics AKA Denials
Page 62
32
• Industry shift toward managed care requires SNF to focus on denial management
• Denial management is “old news” to physicians and hospitals
Long ago addressed in their billing systems and processes (payment posting and reporting)
• SNF billing systems and SNF process deficiencies
Many billing systems don’t capture payment codes
Many billing systems can’t generate denial management reports
Minimal use of clearinghouses and available denial-related reports
Many SNFs don’t post zero payments
Most SNFs do not have a robust denial management program
• Consider additional report writing add-on software or programming
Hydraulics AKA Denials
Page 63
• Cost to re-work a claim
Staff time $10.67
Supplies $ 1.50
Interest $ 1.75
Overhead $ 1.00
TOTAL $14.92
• Key Performance Indicators (KPIs):
% of denied claims <5%
% of EDI denied claims <1%
% of paid after 1st appeal >75%
Lag time to work denial < 5 days
Hydraulics AKA Denials
Page 64
33
Hydraulics AKA Retro-Denial Process
Page 65
Claim Billed and
Paid
Records Requested
Records Not
Support RUG –
Payment Retracted
Follow Appeal
Process
Win…
Lose…
OR
Give Up Trying
• Track by payor
• Track documentation deficiencies (make improvements going forward)
• Learn your weaknesses
Therapy minute discrepancy
ADL documentation
• Submit summary page with records that shows how/where RUG/level is supported
• Perform documentation audit and CDI project
Hydraulics AKA Appeals
Page 66
Payor and Plan Appeals/Disputes/Reconsiderations(on-line Provider Manuals)
Payor One Medical necessity appeal - Submit within 60 daysAdministrative denial reconsideration (timely filing, co-insurance, eligibility, lacking pre-auth, other errors on claim, underpayments) – Submit within 60 daysTimely filing – penalty of up to 25% may be imposed
Payor Two Timely filing, incidental procedures, bundling, unlisted procedure codes, non-covered, etc. – Submit within 6 years of the date of denial
Payor ThreeMCare and MCaid Advantage Plans
Disputes resulting from claim adjustments or denials:Standard reconsideration request – denial of payment or medical necessity –per contract
Payor ThreeMedicaid MLTC
Disputes resulting from claim adjustments or denials: Standard reconsideration request – denial of payment or medical necessity –per contractRequest for denial of payment due to claim coding – Submit within 90 daysRequest for denial of payment due to no authorization – Submit within 90 days
34
• Know each payors appeal process for each type of appeal
Filing time limits (60, 90, per contract)
Payment discount for timely filing appeal
Specific forms
• Review your process for each type of appeal
Who gathers the necessary documents?
Who submits?
Who monitors status?
Are outcomes shared with all?
o Are you learning from denied appeals?
Hydraulics AKA Appeals
Page 67
• Raised area of sand that is easy to get stuck on
Sandbars
Page 68
35
• Estimate at admission and attempt to collect
• Medicaid Managed Care
Initial implementation shifts responsibility to MCO and MCO may delegate it to NH or other entity
o Should be outlined/agreed to during contracting
o Make sure you have an internal process in place if agreement is different than your current norm
o Long term plan – State or designee will assume financial and operational responsibility to distribute NAMI and collect NAMI income
Sandbars AKA NAMI Collection
Page 69
• Two important questions
Who manages Social Security and other income?
Does NH manage a resident fund of PNA money?
• If NH is rep pay it will never be free from NAMI responsibility
• Develop a spreadsheet to track
Sandbars AKA NAMI Collection
Page 70
$1,000 income
NH rep payee = $600
Plan collects from resident = $400
NH keep $50 PNA
NH keep $550 of NAMI
Plan pay NH $400
$1,000 income
Resident = $1,000
Plan collects from resident = $950
Resident give NH $50 PNA (or keep)
Plan pay NH $950
36
• Pre-bill
Many NH not pre-bill on new admissions if monthly statements already gone out
• Need a dedicated collections representative or allocate time for biller to follow up
• Must make phone calls
• Extended work hours for collections representative
Evenings and Saturday
On-site near lobby
Be convenient
Sandbars AKA Self Pay
Page 71
Sandbars AKA Resident Fund and Direct Deposit Management• Resident Fund Management & Direct Deposit Management
Direct Deposit
Automated care cost payments and resident allowance retention
Direct debits from family member accounts at any bank to pay for care
Automatic return of direct deposits when a resident expires or transfers
o National Datacare Corporation
o Built into some EMR/Billing Systems
Page 72
37
Page 73
Thorough Trip Planning Review duties, resources and processes among financial and
clinical staff to enhance efficiencies, performance and outcomes
Assignment of Billing Staff• Small homes: one biller may not be enough
• Current silo structure may become ineffective
Medicaid Managed Care
o May be too much work for one person to handle
o Medicare Advantage/Commercial blurring into Medicaid Managed Care
Consider alpha-split or shift additional FTE to Medicaid managed care billing
Page 74
38
Billing Calendar• Make modifications to billing calendar for new billing cycles
Page 75
Estimated Per Transaction Opportunity
Page 76
TRANSACTION ESTIMTEDPROVIDER/FACILITY
COST
POTENTIAL SAVINGS
OPPORTUNITIES
CLAIM SUBMISSION (837 I /P)ManualElectronic
$2.58$0.54
$2.04
ELIGIBILITY and BENEFIT VERIFICATION (270/271)ManualElectronic
$3.55$0.16
$3.39
PRIOR AUTHORIZATION (278)ManualElectronic
$18.53$5.20
$13.33
CLAIM STATUS (276/277)Manual Electronic
$2.25$0.23
$2.02
39
Estimated Per Transaction Opportunity
Page 77
TRANSACTION ESTIMTEDPROVIDER/FACILITY
COST
POTENTIAL SAVINGS
OPPORTUNITIES
CLAIM PAYMENT (835)ManualElectronic
$1.83$0.30
$1.53
REMITTANCE ADVICE (835)ManualElectronic
$1.83$0.30
$1.53
Sources: CAQH, Milliman, Inc. (2013)
• Vendor that serves as a middleman between facility and payors
• Claims submission: Rather than sending paper claims or electronic claims to each payor as a separate transmission the clearinghouse is a centralized portal that receives your claims and forwards claims to the appropriate payors
$2.04 per transaction savings opportunity
• Many homes use multiple cheap/free which lack in reporting and high-level analysis capability
• Provides other valuable billing-related services: electronic remittance, eligibility verification, claim status, resident statement printing/mailing, payment portal
• If use ABILITY for Medicare now (IVANS NOW or EASE) – consider CHOICE All-payor Claims and COMPLETE (eligibility)
Others may be less expensive with equal or better service – don’t settle just because ABILITY is what your biller is used to
Clearinghouse
Page 78
40
• Electronic claims remittance advice and posting
If submitting electronically should be able to receive remittances electronically
If receive remittances electronically most billing systems can auto-post payments
Update file with payors to request electronic remits and request billing system auto-post training...don’t assume you know how to do it for each payor
o High-value opportunity to eliminate redundancies and errors
o $3.06 combined saving opportunity
May need a “reader” if billing system doesn’t supply one or request a pdf version of remit from payor
Maximize Billing System Functionality
Page 79
• Batch eligibility verification (271 / 271 files)
Prior to billing submit 270 file for eligibility verification via a clearinghouse
o May be able to submit an excel spreadsheet to a clearinghouse if billing system can’t create a 270 file
Fall back plan: utilize payor websites
Maximize Billing System Functionality
Page 80
41
• Common SNF Billing System / EHR Deficiencies
Insurance verification
Payment code posting
o If not posting sequestration reductions will it post VB payment reductions?
Need reader for remittances
Inadequate reporting and need for additional report writing software
o Crystal reports, analytics programs, SQL database programmer
Difficulty generating “clean” claims
Difficulty in programming contractual adjustments
Account notes and tickler system
Lack of sophistication to handle VB arrangements
o Bundled payments, hospital readmissions by diagnosis reports, length of stay by diagnosis reports
Expect More From Our Systems
Page 81
Communication – Internal • Inter-departmental – must understand key components of
plan and how they impact reimbursement and resident care/ coordination
• Contract, provider manuals, billing manuals available to all key players
• Develop summary page of each plan
Need to keep updated
Page 82
42
• Authorizations/notifications for transfers and other care services (routine, elective, urgent)
Clinical staff will have to coordinate with payor case manager for many more residents
Significant increase in time
• Coordination with vendors/suppliers
More time required to coordinate coverageand benefits
• Clinical Appeals
More time spent by clinical, HIM, others
• Documentation changes needed?
Clinical Implications – Medicaid Managed Care
Page 83
• Often a Nurse or Social Worker
• Certification through the Commission for Case Manager Certification (CCMC) or the American Nurses Credentialing Center (ANCC)
Function as intermediary between SNF, each resident and the payor – balancing the fine line between the discharge goals of the payor, the needs of the resident and working with facility staff to recognize how care delivery changes may be needed to satisfy the discharge requirements of particular payor
Monitor expiration, medical record submission dates and approvals of initial, ongoing and ancillary service authorizations
Communicate care plan/service changes with payor
Case Manager
Page 84
43
Page 85
Andrea Hagen, Director
Bonadio Receivable Solutions, LLC171 Sully’s TrailPittsford, NY 14534
Office (585) 662-2270 Cell (585) 967-3716
www.bonadio.com/brs