rhc revenue cycle & improvement opportunities · 052x –professional services 0636 –drugs...
TRANSCRIPT
RHC REVENUE CYCLE & IMPROVEMENT OPPORTUNITIES January 16, 2020
RHC BILLING RULES
• Physician - Doctor of
medicine, osteopathy, dental,
podiatry, or optometry
• Nurse Practitioner
• Physician Assistant
• Certified Nurse Midwives
• Visiting nurse services to the
homebound
• Clinical Psychologist
• Clinical Social Worker
ELIGIBLE PROVIDERS
RHC VISIT
Defined as a face-to-face encounter between a patient and an eligible
provider during which a medically necessary service is rendered.
Revenue Codes to designate site of service on the UB-04:• 0521 Clinic visit at RHC
• 0522 Home Visit
• 0524 SNF (Swing bed) visit during a Part A covered stay
• 0525 SNF/NF visit not associated with Part A covered stay
• 0527 Visiting Nurse services (Home Health shortage designation)
• 0528 Visit at scene of an accident
• 0900 Mental Health Visit
Payment made on a “per visit basis” with these exceptions:• Medical & Mental visit on same day – two AIR
• Separate encounter on same day for unrelated visit – two AIR• Only time modifier 25 or 59 is appended
• Medical visit and IPPE (Welcome to Medicare) on same day – two AIR
HOURS OF OPERATION
RHC Hours of Operation regulations• State Operations Manual (SOM) – Appendix G
Provide services during posted operating hours• Requirement for midlevel available a minimum of 50%
• May be different times for different days of the week
• Can include administrative provider time
Patient’s are not to be
in treatment area
during times when provider
is not on the premises
6
ALL INCLUSIVE RATE (AIR)
Freestanding RHCs:
• 2020 payment limit per visit = $86.31
• Up 1.9% from 2018 = $84.70• Based on Medicare Economic Index (MEI)
Provider-based RHCs to hospitals in excess of 50 beds:
• Payment limit is the same as for Freestanding RHC_______________________________________________________
Provider-based RHCs to hospitals less than 50 beds do not
have a cost per visit limitation:
• AIR established based on Cost Reporting
• Each RHC will have a different rate
PATIENT RESPONSIBILITY DEDUCTIBLE/COINSURANCE
If no patient deductible:
• Medicare pays 80% of the AIR
• Patient pays 20% of charges reported on CG line
Deductible owed will be calculated up to 100% of charges:
• Example 1: Patient owes partial deductible:• Charge is $70, AIR is $100 and patient deductible due is $25
• Medicare pays 80% of $100 less $25 deductible ($75) = $60
• Patient coinsurance 20% of $70 less $25 deductible ($45) = $9 • Deductible $25 + Coinsurance $9 = Total patient amount due $34
• Medicare payment + Patient Payment = $94 (contractual gain $24)
• Example 2: Patient owes deductible:• Charge is $115, AIR is $95 and patient owes deductible
• Medicare applied total charge $115 to deductible
• Patient is responsible for $115 deductible (charge amount)
• Medicare reimbursement -$20 + Patient Payment $115 = $95 charge
SERVICES PAID ON FEE SCHEDULE
• 99490, 99487 & 99489 are all billed as G0511 (effective 1/1/2018)
• Initiating CCM code of G0506 not billable in RHC
• Paid at National Average blended rate of $66.77
Chronic Care Management:
• Paid at the National Average rate of $26.65
• Revenue Code 0780
• HCPCS Code Q3014
Telehealth Originating site only (can’t bill as
distant site provider):
Few services are reported on the UB-04 RHC claim, but
paid based on the Medicare Physician Fee Schedule.
VIRTUAL COMMUNICATION
SERVICESEffective January 1, 2019 RHCs can bill for communications-based technology and remote evaluation services:• Waived the RHC face-to-face requirements
Requirements:• Furnish at least 5 minutes of communications-
based technology or remote evaluation• Patient must have had a billable RHC visit
within last year• Medical discussion or remote evaluation
condition is not related to an RHC service:• Not provided within the previous 7 days• Does not lead to an RHC visit within the next
24 hours (or soonest available appointment)
Codes G0071 payment should be $13.70 (2019 rate) based on National Average blended rate for HCPCS codes: • G2012 (communication technology-based
services) $14.78• G2010 (remote evaluation services) $12.61
Covered under the RHC Program.
Traditional Medicare services are
NOT included on RHC claim:• Log to submit on the RHC Cost Report
• Date of service
• Patient name
• Patient Medicare Number
Medicare Advantage are
separately billed on a HCFA
1500 with
the administration code: • Serum CPT Code
• Administration Code
• G0008 = Flu vaccination
• G0009 = Pneumo vaccination
• Diagnosis Code Z23
INFLUENZA AND
PNEUMOCOCCAL INJECTIONS
COUNTING VISITSEssential to make sure actual visits are accurately
reported:• Includes RHC billable visits (one per day unless
unrelated)
• NH home visits (includes Swing Bed)
• Home Visits
Number of visits affects AIR calculation:• As compared to productivity standards for
physician and non-physician eligible providers
Develop process for capturing on
daily/weekly/monthly basis:• Don’t wait until time for Cost Report preparation
• Compare productivity standards to provider
productivity
• Scheduling system may or may not be viable
option for counting
• Revenue and usage cannot be used as a tool
• Exclude non-RHC visits (hospital services)
VISIT COUNT EXAMPLE
*Contracted physicians include regularly scheduled physician staff the facility contracts with for services. Locum Tenens
include only those physicians contracted or employed for the coverage of vacations, short term coverage due to lost
physicians, etc.
RHC
CLAIM
DATA
DATA
COLLECTION
• 50% of claim data originates with the
Registration Staff
• Patient demographic information
• Encounter specific information
• Insurance coverage• Primary vs. secondary or tertiary
• Insured
• Relationship to insured
• Group number
Remaining 50% is comprised of Coding,
Charge Entry and Billing required data.
PATIENT ACCESS RESPONSIBILITIES
• Identify patient
• Register based on services being provided
• Verify insurance eligibility• PCP referrals
• Determine pre-authorization status
• Complete required registration document
• Obtain/explain signature requirements• HIPAA notice
• Conditions of Admission/Consent for treatment
• Patient Rights and Responsibilities
• Medicare Secondary Payer Questionnaire
• Collect copay or minimum balance • Substantial increase in patient deductibles
• Scheduling
• Patient Portal education
PATIENT ACCESS TOOLS
• Verification of coverageo Phone callo Online payer portals o Vendor (billing system or clearinghouse)
• Price estimates
• Online credit card and receipt processing
• Insurance card scanner
• Payment options
• Scripting (essential for upfront collection success)
ANCILLARY CHARGES
Additional services provided on same date of service are included on claim:• Injections• Supplies• Medications• Venipuncture (performed in RHC)
Typical revenue code on RHC claim:025X – Drugs with no HCPCS code027X – Supplies0300 – Venipuncture052X – Professional Services0636 – Drugs with HCPCS code0771 – Vaccine Administration ( for Med Part B covered services)0780 – Telehealth (originating site only)0900 – Mental Health Services
18
LABORATORY & RADIOLOGY SERVICES
Are not covered as an RHC service and are separately billed.• Venipuncture remains on RHC UB-04
Freestanding RHC• Billed to Medicare Part B on the CMS-1500
reported with RHC NPI.
Provider-Based RHC• Billed under the Hospital NPI on the UB-04 along
with any other services provided on same date.
19
EKG
EKG can be billed global (93000) for non-Medicare
payors, but for Medicare must be split into:• Professional component (93010) billed along with RHC encounter if
eligible provider reads and prepares report
• Technical component (93005) billing:• Freestanding RHC submit to Medicare Part B on CMS-1500 with RHC NPI
• Provider-Based billed on Hospital UB-04
Same with TC/PC split billing for Holter Monitor• 93227 Professional component on RHC UB-04
• 93225 Technical component
MODIFIER USAGE
What the CG indicates to Medicare claims processor
• Attached to a professional service line = RC 052X and 0900
• If both medical and mental health services are provided on the same date of
service apply to both
• Line with total of all non-preventive service charges
• Line that pays the AIR
• Indicates the total charges on which deductible/coinsurance is applied
• Does not include preventive services for which coinsurance and deductible
amounts are waived
• If only preventive services are provided append CG
• Do not append CG modifier to IPPE, CCM or Virtual Communication Services
21
Payment is made on a “per visit
basis”.
Exception allowing for more
than one payment per visit:
• Medical & Mental visit on same day
• Unrelated separate encounter on
same day
• Medical visit and IPPE on same day
RHC BILLING/PAYMENT EXAMPLES
22
RHC BILLING EXAMPLE
Patient presents for a visit which includes an injection and
blood draw
Charges$125 = Level III Established Patient Office Visit
$ 25 = Venipuncture
$ 25 = Injection
$ 50 = Drug
$225 = TOTAL
One AIR is paid & patient responsibility $45 ($225 x .20)
23
Rev Code Description HCPCS/CPT Service Date Service units Total Charge 0.01 Charge
1 0300 Venipuncture 36415 010119 1 25.00 0.01
2 0521 Injection administration 96372 010119 1 25.00 0.01
3 0521 Level III Established Visit 99213CG 010119 1 225.00 225.00
4 0636 Rocephin 1 gm J0696 010119 4 50.00 0.01
TOTALS 325.00 225.03
RHC BILLING EXAMPLE CONT’D
Example of a separately billable service• Patient presents for initial visit as previous slide and later returns the
same date of service for medically necessary, separately identifiable visit
Second visit billed for Level IV Established Patient
Two AIR are paid• CG is appended first visit only (total of initial visit)• Second visit with 25 or 59 modifier (total of 2nd visit)• Patient responsibility 20% = $80 ($400 x .20)
24
Rev Code Description HCPCS/CPT Service Date Service units Total Charge 0.01 Charge
1 0300 Venipuncture 36415 010119 1 25.00 0.01
2 0521 Injection administration 96372 010119 1 25.00 0.01
3 0521 Level III Established Visit 99213CG 010119 1 225.00 225.00
4 0521 Level IV Established Visit 9921425 or 59 010119 1 175.00 175.00
5 0636 Rocephin 1 gm J0696 010119 4 50.00 0.01
TOTALS 500.00 400.03
RHC BILLING EXAMPLE CONT’D
Services provided on same date of serviceMedical Visit with Annual Wellness Visit (G0439)
One AIR is paid
• Office Visit plus Annual Wellness Visit (AWV)• Don’t roll AWV (preventive with deductible/coinsurance waived)
• Patient responsibility $45 ($225 x .20)
25
Rev Code Description HCPCS/CPT Service Date Service units Total Charge 0.01 Charge
1 0300 Venipuncture 36415 010119 1 25.00 0.01
2 0521 Injection administration 96372 010119 1 25.00 0.01
3 0521 Level III Established Visit 99213CG 010119 1 225.00 225.00
4 0521 Subsequent AWV G0439 010119 1 125.00 125.00
5 0636 Rocephin 1 gm J0696 010119 4 50.00 0.01
TOTALS 450.00 350.03
RHC BILLING EXAMPLE CONT’D
Services provided on same date of service• Medical visit • IPPE
Two AIR are paid• G0402 AIR paid at full 100% of AIR• CG line coinsurance $45 ($225 x .20) & Medicare pd 80% AIR
26
Rev Code Description HCPCS/CPT Service Date Service units Total Charge 0.01 Charge
1 0300 Venipuncture 36415 010119 1 25.00 0.01
2 0521 Injection administration 96372 010119 1 25.00 0.01
3 0521 Level III Established Visit 99213CG 010119 1 225.00 225.00
4 0521 IPPE G0402 010119 1 175.00 175.00
5 0636 Rocephin 1 gm J0696 010119 4 50.00 0.01
TOTALS 500.00 400.03
RHC BILLING EXAMPLE CONT’D
Services provided on same date of service• Medical visit • Joint Injection
One AIR is paid• CG line coinsurance $75 ($375 x .20) & Medicare pd 80% AIR
27
Rev Code Description HCPCS/CPT Service Date Service units Total Charge 0.01 Charge
0300 Venipuncture 36415 010119 1 25.00 0.01
0521 Joint Injection 20610 010119 1 175.00 0.01
0521 Level III Established Visit 99213CG 010119 1 375.00 375.00
0636 Kenalog J1885 010119 4 50.00 0.01
TOTALS 690.00 375.03
POLICIES AND
PROCEDURES
EXPECTED RESULTS IN THE ABSENCE OF P&P
• No standardization of
processes
• Variation in charge capture
• Non-compliance with billing
rules and regulations
• Inability to hold staff
accountable
• Billing stops when staff
member is out of the office
WHERE TO START?
• Determine which policies and
procedures are needed to address
issues.
• Shadow individuals to observe tasks.
• Instruct staff to document processes:• Have other staff follow the steps to fill
in gaps.
• Perform chart-to-payment reviews.
• Provide feedback for staff
education and training.
• How often are they reviewed and
updated?
MEDICARE BAD DEBT
Amount of beneficiary deductible and coinsurance which is unable to be collected at this time and there is no likelihood of collecting in the future.
Returned from outside collection agency as uncollectible.
Cannot include amounts meeting small balance write off criteria.
Dually enrolled beneficiaries –primary paid more than secondary allowed amount.
Report in the Cost Reporting year when deemed uncollectible.
Complete Exhibit 2 for Cost Report or provide report with required information.
ADJUSTMENTS
Contractual – only as reported on remittance advice.
Denied charges that can be appealed.
Administrative adjustments based on clinic policy:
• Small balance write-off• Untimely filing• Provider not enrolled• Medical necessity• Late Charge• Medicare Bad Debt (ability to run report)
Segregation of duties:• Biller completes log for review by
coworker• Manager approves• Posted by data entry clerk or payment
posting staff
LOG EXAMPLE
SECONDARY CLAIMS
Medicare is secondary payor:
• Follow billing rules as if Medicare is primary;
• Ability to generate UB-04 even though primary may have been sent on CMS-1500;
• Properly report primary payor payments and adjustments;
• Be prepared to split into UB-04 & CMS-1500 if non-billable services are reported;
• Administrative adjustment if only services reported on primary were non-billable (nurse only visit).
Other payor is secondary to
Medicare:
• Follow billing rules;
• Create CMS-1500 claim;
• Report primary payor payments and adjustments;
• Issues with Medicare primary apply deductible on RHC claims.
CODING
&
MODIFIER USAGE
35
MODIFIER USAGE – STANDARD CODING RULES
CMS guidance is for RHCs to report all services provided during the patient visit.
• Report CPT/HCPCS code for each service line• Append corresponding Revenue Code &
CPT/HCPCS
• Include covered diagnosis
25 Modifier Definition
• Significant, separately identifiable Evaluation and Management service by the same practitioner on the same day as a procedure or other service.
Append the modifier to the E/M provided on the same day as another professional service is provided.
• Absence could result in decreased reimbursement
36
RHC RULES FOR MODIFIER 25
Exception for RHC Medicare/Medicaid claims• 25 Modifier indicates the patient was seen, left the
RHC and returned at a later time the same day presenting with a completely unrelated diagnosis.
• Injury or accident
Append 25 modifier for all non-Medicare/Medicaid payors
Inconsistency in coding rules burdensome for practice
Billing misconceptions• E/M does not have to be unrelated to procedure• Separate diagnosis is not required
37
GLOBAL PERIODS
Surgical procedures furnished in RHC are not subject to the global billing rules
• Per Medicare Benefit Policy Manual, Chapter 13, Section 40.4
Surgical procedures furnished in other locations may be subject to global billing rules
• RHC must determine if services are included in a global billing period
Establish relationship with surgeons
• Coordination of care• Understanding of their billing process and codes• Procedure only modifier 54
38
ICD-10 CODE TO LEVEL OF SPECIFICITY
ICD-9 codes were not specific enough to reflect current terminology or practices
• ICD-10 provides worldwide comparable healthcare statistics
Focus on correlation of contributing factors and complicationsSpecificity• Acute Sinusitis → Acute recurrent ethmoidal sinusitis• Osteoarthritis Hip → Unilateral primary osteoarthritis right
hip
Complications • Type 2 DM → Type 2 DM with hypoglycemia with coma• Acute suppurative otitis media → Acute suppurative otitis
media with spontaneous rupture of ear drum, recurrent, bilateral
39
SEQUENCE OF CODES
First diagnosis is condition initiating the visit• May be multiple responsible for service, select primary• Acute conditions take priority over chronic or stable
Include coexisting conditions • Present at the time of visit• Affect care or treatment• Omit - Resolved or not affecting current treatment
Only code signs and symptoms in absence of definitive diagnosis• Example: When coding pneumonia don’t include cough
or fever
40
PREVENTIVE
SERVICES
COMMON PREVENTIVE SERVICES
Approved Preventive Health Services with Coinsurance and Deductible Waived
HCPCS/CPT Short Descriptor
G0402 IPPE - Initial preventive examG0438 AWV - Initial visitG0439 AWV - Subsequent visit
G0101 Ca screen; pelvic/breast examG0296 Visit to determine LDCT eligibilityG0442 Annual alcohol screen 15 minG0443 Brief alcohol misuse counselG0444 Depression screen annualG0447 Behavior counsel obesity 15 minQ0091 Obtaining screen pap smear99406 Tobacco-use counsel 3-10 min99407 Tobacco-use counsel >10
42
PREVENTIVE SERVICES CHART
https://www.cms.gov/Medicare/Prevention/PrevntionGenInfo/medicare
-preventive-services/MPS-QuickReferenceChart-1.html
43
INITIAL PREVENTIVE PHYSICAL EXAMINATION (IPPE)
Referred to as the “Welcome to Medicare” exam• One time benefit within first 12 months of Medicare Part B
eligibility
• Establish personalized prevention plan for beneficiary
• Billed with HCPCS code G0402
• Revenue code 052X (depending on location)
May include other preventive services such as• Screening EKG & Abdominal Aortic Aneurysm (AAA)
44
ANNUAL WELLNESS VISIT (AWV)
• 1 in 5 eligible Medicare beneficiaries have received
• Medicare is moving towards focus on value vs. volume of services to reduce costs• Establish Care Plans• Educate beneficiaries • Maintenance of or preventing chronic conditions
• Educate providers/patients this is not a routine exam
• Covered every 12 months – Beneficiary must have Part B• Billed with HCPCS codes G0438 & G0439• Revenue code 052X (depending on location)
45
WELL WOMAN EXAM
Not billable to Medicare under CPT codes 99381-99387
routine wellness codes billed to other payers
Bill out each component separately
• Q0091 – Screening pap test
• G0101 – Screening pelvic examination
• Both are covered every 24 months for low risk beneficiary
May include an office visit if other ailments are addressed
Billed in addition to the IPPE or AWV
46
ACCOUNTS
RECEIVABLE
FOLLOW-UP
STEPS TO FOLLOW
Conduct initial assessment to identify gaps in outstanding accounts.
Consistent report monitoring:
• Daily, weekly, monthly, quarterly, yearly
Compare findings from week-to-week or month-to-month.
Develop Action Plan as issues arise.
Run reports in limited quantity to finish review of all accounts:
• Focus on assigning accounts by alpha
• Date of service range
Summary aging sorted by:
• Financial Class
• Aged by buckets (unbilled, 0-30, >30, >60, etc.)
• Date of service when working timely filing
• Last billed date when working aged accounts with activity
• Without credit balances
Detail aging to focus on:
• Timely filing limits – accounts at risk
• Credit balances (state unclaimed property)
• Aged accounts with payment still in primary financial class
• Established high dollar amounts
• Unapplied payments
A/R ANALYSIS
SYSTEM ISSUES AFFECTING A/R
• Bill hold days
• Documentation not
signed off on in EHR
• Monitoring reports
• Incomplete/inaccurate
key patient data from
registration
• Have registrar correct
for education
• Late Charges
• Lack of account notes in
billing system for
follow-up
TOOLS
Payor specific portal to
check claim status and
make adjustments:• Medicare Direct Data Entry
(DDE)
• Payor portal sign-on with
passwords
Work queues:• Payor specific vs. alpha-split
• Denials
• Aged accounts
• Registration errors
• Coding edits
EDI EDITS• Incorrect claim information:
• Demographic
• Revenue code
• HCPCS code
• Diagnosis code
• Modifiers• Bilateral procedures
• Separately billable vs.
processes as incidental
• Medical Necessity.
• Frequency.
PATIENT FINANCIAL JOURNEY
• Lay the foundation on the front end:• Patient expectations• Options available• Share Deductible/coins information
• Educate staff so as to communicate same message each step of patient encounter.
• Follow-up with patient balance due in a timely manner.
• Establish policies and procedures and follow them for self-pay balances.
• Look for opportunity to automate processes and reporting capabilities.
• Publish point of contact on all website and correspondence.
STATEMENTS
• Manual vs. automated process
• Weekly vs. monthly
Frequency of statements
• At time of service
• Within “XX” days from first statement
Prompt pay discounts – post adjustment at time of payment
Negotiating tool for large balances remaining due
Underinsured vs. Uninsured
• Guarantor
• Patient
• Contract requirements (Medicaid copay amounts)
Minimum balance
• 90% of all denials are preventable.
• About 2/3 of these are recoverable.
• Carriers that no longer allow an adjusted
claim (be aware of contracts).
• Resolution and effort involved to overturn
denials.
• Financial impact of denials on the
organization’s bottom line.
DENIAL MANAGEMENT
CREDIT BALANCES
Posting errors
Corrected/ adjusted claims
Posted to incorrect encounter
Primary payor
disputes
Coordination of benefits
Duplicate payment
Liability claim
Overpayment Patient
paymentsTransfer balance
Up-front collections
PAYOR CONTRACTS
Payors are tightening their reimbursement by passing on
changes to the providers:
• Tougher negotiations
• Complex contract terms
• Increasing denial rates
• Underpaying providers based on contracts
Contribute to major drains on margins:
• Average facility loses 5% of annual revenue
• Preventable revenue loss that could be avoided
Does staff know what’s in your contracts?
Monitor payments to assure they align
with payor contracts.
Contact payor when underpayment is
identified:
• Ability to have claim reprocessed vs.
appealed
Claim corrections and resubmission:
• Online options
Identify denied line items and action
required:
• Noncovered vs. denied
UNDERPAYMENTS
BILLABLE
VS
NONBILLABLE
CHARGE CAPTURE• Missed charges results in missed
revenue opportunity:• Revenue and usage report review
• Charge capture process:• Documentation generated charges
vs. manual entry • Paper charge tickets• System interface issues
• Charge reconciliation – All charges match patient record:• Professional services • Supplies• Drugs• Vaccines• Injections• Venipuncture
SPECIFIC PAYOR REQUIREMENTS
• Maintain charges which are billable to non-Medicare/Medicaid payors.
• Nurse only visits.
• Medicare RHC visit and Hospital admission on same date of service:• Bill RHC visit to Medicare Part A on the UB-04• Along with admit to hospital to Medicare Part B on CMS-1500
• Medicare global billing rules differ from other payors:• OB claim per visit for ante and postpartum and then delivery only for
hospital services• Surgery services provided in hospital are not subject to global billing rules so
follow-up RHC visits are billable if 54 modifier is used
• Separate payors – Patient presents with sinusitis & W/C knee injury:• As long as two separate visit notes are documented both a Medicare and a
W/C claim is submitted
NON-COVERED RHC ANCILLARY CHARGES
• Need to be separately billed to Medicare Part B for reimbursement
• Venipuncture is RHC service (36415)
Lab/Radiology and the technical component of the
EKG are not allowable charges in the RHC:
• Billed on the CMS-1500 with the RHC NPIFree Standing RHC:
• Billed by the hospital on the UB-04 with the Hospital NPIProvider Based RHC:
• Is not billed globally under 93000
• Technical component 93005 billed to Medicare Part B
• Professional component 93010 billed by RHC if provider interprets and documents report on same day as face-to-face visit
EKG billing:
NON RHC PROFESSIONAL SERVICES
• Professional services provided outside the walls of the RHC designated space:• Hospital IP/OP (ER and Observation)
• Services billed to Medicare Part B on CMS-1500
• Provider visits with patient’s family (patient not present).
• MIPS Low-Volume Threshold exemptions:• Medicare Part B claims are less than $90,000 allowed charges
based on the Physician Fee Schedule (PFS)• Services provided to 200 or fewer Part B-enrolled individuals• Provide 200 or fewer covered professional services to Part B-
enrolled individuals
• MIPS Determination Period:• October 1, 2018 – September 30, 2019
DSMT and MNT:• Can be billed when
incident to face-to-face
Nurse only visits:• Injections
• Dressing Changes
• Blood pressure/Blood
sugar monitoring
COVERED MEDICARE PART B, BUT NOT RHC
MEDICARE PART B
COVERED
IMMUNIZATIONSTetanus when provided on same day as face-to-face visit required as a result of accident or injury (not for immunization).
Hepatitis B for patients identified as being at risk.
All others are covered under Medicare Part D and are nonbillable on the RHC claim:• Can obtain from pharmacy where they file
for medication coverage• Administration is not billable fee when not
paying for drug• Pharmacy can bill and administer• If patient receives in RHC they are
financially responsible• Provide billing information for them to
submit to Pharm D• Explore options such as TransactRx
BENCHMARKING
BEST
PRACTICE
CHARGEMASTER MAINTENANCE
Yearly Review
Regulatory updates
HCPCS and ICD-10 coding changes
Revenue Reliability
Updates to billing system
Payor Changes
Pricing Contract constraints
Compare to highest paying fee schedule
Medicare pays lesser of MPFS or charge
Compliance Overarching governance and oversight of the Revenue Cycle functions
CHARGE CAPTURE RESPONSIBILITY
Eligible Provider
Documentation to support the
services provided
Nursing Staff
Document and charge for supplies & injectables
Coding
CPT and ICD-10 Code assigned
per patient record
Record supports all charges on
claim
Results of ordered tests
Billing
Monitor payor specific charge
denials
BILLING ISSUES
• Missed charges resulting in
missed revenue
• Payment denials or delay
• Increased work for the back-end• Rework of claims
• Charge reconciliation
• Increase in accounts receivable
• Poor customer satisfaction
ratings due to inaccurate bills
• Increased potential for Medicare
scrutiny• Requests for information
• Penalties for inaccurate billing
• Contract negotiation impact
CLAIM TRANSMISSION
VERIFICATION• Internal billing software edits.
• Clearinghouse edits.
• Transmission reports - Compare to
system generated claim counts:• 837 – Claims transmitted
• 999 – Acknowledge receipt of claim
file
• 277 – Acceptance file (rejected claims)
• Work rejected claims within 24
hours:• Skews billing reports when system shows
claim was dropped but insurance
company didn’t accept
• No remittance advice denial will be
provided
REVENUE CYCLE BENCHMARKS
Days in A/R: < 30 Days
Aged Insurance Pending A/R
as a % of Total Ins Pending A/R
Report by discharge date
<20% over 90 days
<5% over 180 days(Break out by financial class and further into any carriers
with timely filing limits < 1 year. Remove credit balances)
Discharged Not Final Billed-DNFB < 2 days of average daily revenue
Credit Balances < 1 day of daily revenue
Denial Write-Offs < 1% of monthly net revenue
Point of Service Collections > 3% of monthly net revenue
Registration Error Rate < 5% of daily registered patients
Mail Return < 5% of mailed items
Claim Hold Days 2 business days
REVENUE CYCLE STRATEGIC PLAN
• Optimize revenue growth without relying entirely on new volumes.
• Reduce revenue erosiono Shift the organizational thought process to performance which centers on
collection of the services provided. o Software & clearinghouse edits don’t make up for
• Missed charges• Undocumented services (start/stop times for infusion or observation)• Documentation that doesn’t support medical necessary
• New Serviceso Notification of coding and billing staffo Medical necessity rules o Documentation requirements
• Focus on assisting with obstacles the revenue cycle is facing vs. blame.
WHO ARE THE PLAYERS?
• Shift Ownership to the stakeholders. o Ancillary departments
o Providers
o Management
• Look to three key areas for overall organizational success.o Physicians
o Provide documentation training to explain the revenue impact of inaccurate documentation.
o Address and work together on their pain points with the revenue cycle process.
o Target ways for staff/tools to maximize their performance.
o Patientso Faced with higher financial obligations for healthcare services than in the past.
o Educate them on their coverage/out of pocket obtained at time of insurance verification.
o Be prepared to offer options for meeting financial responsibility.
o Payerso Insurance Matrix
BREAKDOWN SILOS
• Revenue Cycle cannot continue to operate in a silo.o Whose job is it?
o Seek buy in from all departments within the organization.
o Send the same message to your patients and communities in
every area of the organization.
o Dedicate IT staff.
• Focus on letting the public and staff know that your organization
WANTS to be the best.
Management ProvidersAncillary
Staff
Registration
Coding
Billing
Collections
REDUCE WRITE-OFFS
• Providers • Pre-authorizations • Provider not enrolled• Referrals• Documentation deficiencies• Medical necessity denials - ABN
• Coding• Incidental service denials due to lack of modifiers• Assure proper coding of combined accounts for same DOS
• Claims processing• Timely filing limits• Appeal processes• Account follow-up
This presentation is presented with the understanding that the information contained does not constitute legal, accounting or other professional advice.
It is not intended to be responsive to any individual situation or concerns, as the contents of this presentation are intended for general information
purposes only. Viewers are urged not to act upon the information contained in this presentation without first consulting competent legal, accounting or
other professional advice regarding implications of a particular factual situation. Questions and additional information can be submitted to your Eide
Bailly representative, or to the presenter of this session.
QUESTIONS?
