Patient Access: Leading the Way2012 Revenue Cycle Fall WorkshopWV Chapter, HFMA

Presented by:Sandra J Wolfskill, FHFMAPresidentWolfskill & Associates, Inc.swolfskill@cs.com

Agenda

•Registration Accuracy – Getting it right the first time!•Medicare Secondary Payer•Closing Thoughts

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• Survey question 1: how many hospitals have formal quality assurance programs in patient access?• Survey question 2: how many

hospitals have informal QA review activities performed by supervisors or leads? 3

Opening Exercises …

What Do You Value Most?

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Your Perspective As Evidenced By Staff’s Perspective – Staff will …

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• QA programs are designed to track and report accuracy rates in order to:• Reduce/eliminate denials• Ensure compliance with government

regulations• Identify patterns of poor work• Identify training needs• Demonstrate compliance with corporate

integrity agreements• Hold staff accountable for established

performance outcomes 5

Why Formal QA Programs Work

• Recent surveys suggest that majority of programs are manual and daily• Automated options include:• DaVincian• AHIQA• AccuReg• CPSI• Emdeon Denial Management• Compass and Epic•McKesson

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Automated vs. Manual Programs

•Moving beyond simple error tracking•Knowing consequences to

performance failures•Clearly documenting the

organization’s tolerance for error and rework

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Building Accountability

•Do you want to be on the airplane serviced by the mechanic whose performance standard was 99% right?

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If 99% is good enough …

• Set standards and expected outcomes• Establish disciplinary steps to support seriousness of

expectations• Embark on comprehensive training program to bring

all staff to expected level of expertise and set=up staff to succeed:• Identify what staff doesn’t know• Review registration errors identified in your QA

program• Using variety of resources, TRAIN staff• Webinars• Intranet• CHAA Certification resources from NAHAM• CRCR Certification resources from HFMA

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Implementing an Effective QA Program

• Start program•Report results on regular basis• Enforce consequences for failure to

perform to standards•Retool as issues change (dynamic

nature of program)

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Implementing an Effective QA Program

Trick or Treat?

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The “trick” with MSP is to get it right;The “treat” is that you get a passing report from the MSP Auditors!

• Patient’s insurance as registered is in conflict with the MSPQ answers• Incorrect payer/plan information recorded

during registration•Missing required information (addresses for

“other” payer)• Failure to record occurrence code and date

for codes 18 and 19• Information on MSPQ does not match how

the account was actually billed• Incorrect subscriber identification

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MSP: Common Errors

•MSP audits – did you go through an audit?•What were the lessons learned for

your hospital?•What changes have you implemented

as a result of the audit experience?

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MSP

• Source: Medicare Secondary Payer Manual available at :

http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Internet-Only-Manuals-IOMs-Items/CMS019017.html

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MSP – Test Your Knowledge

• Do you know the details?• List the only MPS provision included in the

1965 Medicare law:

• In 1980 the MSP provisions were redefined to include group health plans, worker’s compensation, liability or no-fault. What other payers are primary to Medicare and for which does Medicare pay secondary benefits?

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MSP

• List details of the Liability rule:

• List details of the ESRD rule:

• List details of the Disability rule

• List details of the Working Aged rule16

MSP

• True or false: The primary payer may decline to make a primary payment based on its contract which calls for Medicare to pay first.

• True or false: Employer group health insurance plans for retirees are primary to Medicare.

• True or false: The coordination period for beneficiaries covered under ESRD provisions begins three (3) months after the beneficiary begins Medicare eligibility.

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The Answer Is …

• True or false: If a group health plan denies payment for services because they are not covered b y the plan as a plan benefit for all covered individuals, Medicare plays as primary if the services are covered by Medicare.

• True or false: The claim for a 66 year old disabled Medicare beneficiary whose spouse is employed by an employer with 250 employees is an example of a disability MSP claim. 18

The Answer Is …

• True or false: If the failure to take proper and timely action results in a loss of work compensation benefits, Medicare benefits are not payable to the extend that payment could reasonably have been expected under Work Compensation.

• If a beneficiary receives a Work Compensation settlement that includes funds for future medical expenses, Medicare will pay for those future expenses. 19

The Answer Is …

• True or false: Medicare is not secondary to all types of no-fault insurance.

• True or false: Medicare will not make a secondary payment if the provider accepts the primary plan as full payment or full satisfaction of the patient’s responsibility.

• True or false: in the Medicare manuals, the term Work Comp (WC) includes Federal WC programs such as the US Department of Labor.

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The Answer Is …

• Case: A Medicare beneficiary with GHP coverage was a hospital inpatient for 20 days. The hospital's charges for Medicare covered services were $16,000. The inpatient deductible had not been met. The gross amount payable by Medicare for the stay in the absence of GHP coverage is $11,500. The GHP paid $14,000, a portion of which was credited to the entire inpatient deductible. How much will Medicare pay? 21

The Answer Is …

• True or false: With regard to WC insurance and no-fault insurance, prompt or promptly means payment within 90 days after receipt of the claim.• An individual who has not met any part of the

Part B $140 deductible incurred $140 in charges for which the GHP paid $70. The Medicare fee schedule amount was $140. • How much is credited to the Part B deductible?• How much will Medicare pay?• How much will the patient owe? 22

The Answer Is …

• True or false: A Medicare beneficiary may not reject employer coverage for self or spouse.

• True or false: If an individual becomes entitled to Medicare based on age or disability after being entitled based on ESRD, the coordination period automatically ends on the date of the disability or age eligibility.

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The Answer Is …

• Case: William Moneypenny, age 75, is a Medicare beneficiary with coverage under Part A and Part B. He retired from the Acme Tool Company in 2003 and received retirement health insurance coverage that is secondary to Medicare. His wife, Mary, age 64, has been employed continuously with the local police department since 1977 and since that time has received coverage for herself and her husband under the department's GHP. The priority of payment for John's medical expenses is as follows: • Primary payer is __________________• Then what happens? ____________________________________________________________________ 24

The Answer Is …

• For the same case as on the previous slide:If the retirement plan is permitted to pay after the GHP under

the private coordination of benefits, the order of payment will be as follows:

• Case: Chris Kringle, age 67, is a Medicare beneficiary with coverage under Part A and Part B. He has been employed continuously by XYZ Bolt Company since 2002 and has GHP coverage through his employer. His wife, Glenda, age 62, has been retired from the local police department since 2000 and received retirement health insurance coverage for herself and her husband that is secondary to Medicare. The order of payment for Chris' medical expenses is as follows: 25

The Answer is …

• Foundation for success is a strong QA program with known and enforced rewards and consequences• There is NO excuse for anything less than 100%

accurate compliance with MSP rules• The road to continued success is paved with the

motto: Train Train Train for Success!• Patient Access should always lead the way to the

highest level of quality and accuracy within the revenue cycle 26

Summary

Sandra J Wolfskill, FHFMAWolfskill & Associates, Inc.swolfskill@cs.com440-285-4094

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Contact Information