robert shesser m.d. mph george washington university patient care services reimbursement: 2011
TRANSCRIPT
Patient care services reimbursement
Revenue cycleDiagnosis codingProcedure codingCredentialingComplianceProductivity MonitoringReports
Revenue cycle I
Chart acquisitionCoding Data entry
Charge lag- interval between treatment and billingBilling
Primary and secondaryCharge posting, clean up, reportingAccounts receivable
everything that has been billed, but not collected Unit is “days” (total receivables/average charges/day)
Revenue cycle II
Benchmarking performance No data on charge lag Coding, Billing should cost 8% of collections GW MFA data
Charge lag EMR system: 5 days Charge lag paper charting: 8 days Chart acquisition, coding, data entry, charge correction,
registration updates $4.13/chart 3.6% collections
ICD (International Classification of Diseases) 1853-first International Statistical Congress-classification of
mortality 1893 - International List of Causes of Death- adopted by US 1898 1948 WHO took ILCD and developed ICD- included morbidity
coding application in US by National Center for Health Statistics
• branch of CDC developed ICD 9-CM (clinical modification) (1976)
official system of assigning codes to diagnoses and procedures associated with hospital utilization in the United States
National Center for Health Statistics pathologically based 5 digits E codes, V codes
Diagnosis Coding
ICD 10-CM (1989) Major change from ICD-9 6882 total codes in ICD-9, 12,420 total codes in ICD-10
Chapters (icd-10); Sections (icd-9) Letter followed by 4 numbers Codes reserved for provisional assignment of new diseases Country-specific clinical modifications- make certain
comparisons difficult ICD-10 CM in US; implementation date 10/1/13
Includes procedure codes
Diagnosis Coding
ICD-11 Process started in 2002 Attempting to decrease country-specific variations Web-based, function in an EHR environment Won’t be presented until 2014
SNOMED-CT (Systematized Nomenclature of Medicine Clinical Terms) Core of the electronic health record 311,000 active concepts with unique meanings formal logic-based definitions organized into hierarchies
Hierarchies have multiple levels of granularity International Health Terminology Standards Organization
(www.ithso.org)
Diagnosis Coding
Common Procedural Terminology (4th edition) developed and owned by AMA (1966)
Updated three times per year Three categories of codes
Category I-describe procedure or service 5 digits; series of 2 digit modifiers
used by all 3rd party payers to describe physician work
about 8000 codes E&M codes versus procedure code
Category II- supplemental tracking codes for performance measure reporting
Category III- tracking codes for new and emerging technologies
On AMA website Medicare fee schedules Complete RVU breakdown References describing commentaries on codes
Physician Billing
System to measure and compare physician work developed at Harvard University (Hsiao); 1989
commissioned by HCFA first employed by Medicare as payment basis in 1992
Medicare keys payment levels to RVU’s formula includes regional adjuster
three components physician work (52% of total value on average)
time technical skill risk
practice expense (44% on average) professional liability (4% on average)
Resource Based Relative Value Scale
Phase I vignettes of 25 services per specialty developed definition of time
pre-service, intra-service, post-service definition of intensity
physical effort/skill mental effort/judgment stress from iatrogenic risk
physician estimates national surveys small group processes
services in different specialties cross-linked by multiple regression
Development of RBRVS
Complex process of updating Social Security Act mandates review every 5 years AMA/Specialty society update committee
Relative Value Update Committee (RUC) receive input from specialty societies send recommendations to CMS CMS does final review and makes decisions
Resource Based Relative Value Scale
Process to verify physicians’ licensure, training and experience Licensure
State medical license Federal and state DEA numbers
Experience Residency training Board certification Hospital medical staff membership
Medicare Individual NPI number
Assigned directly by CMS Started by Medicare will replace all provider numbers for all payers
Group NPI number- provider group number
Physician Credentialing
Hospitals governed by JCACO processes (http://www.jcaho.org/)
Third party payers Medicare (http://www.cms.hhs.gov/)
Carriers (http://www.trailblazerhealth.com/) Medicaid (http://dchealth.dc.gov/information/maa_outline.shtm) Managed Care
NCQA (http://www.ncqa.org) Medical Groups
delegated credentialing
Physician Credentialing
Rigorous processes policies practitioners can review material and correct if inaccurate
Peer-review multidisciplinary committee Initial application
primary source verification license, training, education, board certification, work hx, liability hx
5 years of work history; gaps> 6 month need clarification National Practitioner Data Bank
Practitioner must attest to health status, history of loss, limitations of privileges
Elements of physician credentialing
Site visits managed care plans expected to visit physician offices
Recredentialing every 36 months primary source
licensure, board certification, NPDB
Ongoing monitoring between cycles
quality, complaints, sanctions
Elements of physician credentialing
Managed by HRSA (health resources and services administration of HHS)
National Practitioner Data Bank Created by act of Congress- 1986 alert system to “facilitate a comprehensive review of health care practitioners'
professional credentials” Includes:
adverse licensure actions by the States clinical privileges actions by Hospitals professional society membership actions paid medical malpractice judgments and settlements exclusions from participation in Medicare/Medicaid programs; r Adverse registration actions taken by the U.S. Drug Enforcement
Administration (DEA). Allied health practitioners added in 2010
Data Banks
Data Banks II
Healthcare Integrity and Protection Data Bank
Mandated in HIPPA (Health Insurance Portability Act-1996)
civil judgments against health care providers, suppliers, or practitioners related to the delivery of a health care item or service,
Federal or State criminal convictions against health care providers, suppliers, or practitioners related to the delivery of a health care item or service,
actions by Federal or State agencies responsible for the licensing and certification of health care providers, suppliers, or practitioners,
exclusions of health care providers, suppliers, or practitioners from participation in Federal or State health care programs,
any other adjudicated actions against health care providers, suppliers, or practitioners
System Performance Monitoring
Cash versus accrual Net Revenue = Gross Charges minus Contractual Allowances
Allowance- a contractually agreed upon discount Bad Debt- unpaid balance
Timely filing deadline Specified in most contracts Medicare is most forgiving (12 months) Many commercial plans are 90 or 120 days DC Medicaid is 180 days
Performance Monitoring
Useful Metrics Physicians
Patients per physician-hour worked RVU’s per physician-hour worked RVU’s per patient
Practice level Accounts with charges by year and by month Collected Dollars per closed case Collected dollars per billed RVU Total cash collected from the prior month