the benefits of revenue cycle and compliance collaboration

The Benefits of Revenue Cycle and Compliance Collaboration

Kathy Ruggieri and Mary Devine from BESLER Consulting Presentation at the NJ HFMA 39th Annual Institute

NJ HFMA 39th Annual Institute 1

Today’s Focus• Highlight the importance of the working relationship between hospital

Revenue Cycle and Compliance teams • Provide participants concrete steps they can take to improve collaboration

between Revenue Cycle and Compliance groups that can have a tangible impact on day-to-day operations

• Discuss how to marry compliance and revenue cycle with data analytics• Identify data mining that can assist in identifying and resolving issues prior

to provider submission, reducing days in AR and improving cash in the door • Provide methods to reduce your risk of being non-compliant

NJ HFMA 39th Annual Institute2

Today’s Agenda• Who is Watching• OIG Work Plan

• Focus and Plan• Data Mining• How to handle

• Compliance and Revenue Cycle• Data Mining• Data Analysis

• RAC and ZPIC• Summary and Take- Aways


After attending this session you will be able to:• Identify issues under the microscope• Add edits in the mainframe system, to prevent claims halting in the billing scrubber• Create billing edits in the scrubber to assist with lack of mainframe capabilities• Use data analysis to implement corrective action• Provide feedback and education to appropriate departments that resolve key issues• Deliver benefits to your organization including:

Decreasing denials/appealsDecreasing days in ARDecreasing RTPsSpeeding and increasing cash flow Utilize the complimentary partnership can become seamless by utilizing the data

analysis obtained from 835 and 837 data sets, Return to Provider (RTP), CERTs, Readmissions, ZPICs, HACs, RACs and Transfer DRGs



Comprehensive Error Rate Testing (CERT)

Medicare Fraud Strike Force

State OIGs

Healthcare Fraud and Prevention Team (HEAT)

Recovery Audit Contractors (RAC)

Medicaid Fraud Control Units

Zone Program Integrity Contractors (ZPIC)

Medicaid Integrity Contractors

Medicare Administrative Contractors (MAC)

State AG Office

Who has you under a Magnifying Glass?

CMS

CMSOIG

OIG - DHHS• Office of the Inspector General for the Department of Health and

Human Services • Consists of Four Offices collaborating to “Protect the integrity of

DHHA programs, operations and the health/welfare of the people they serve”

• OCIG: Office of Counsel to the Inspector General• OEI: Office of Evaluations and Inspections• OI: Office of Investigations• OAS: Office of Audit Services


OIG #1 Goal• To Fight Fraud, Waste and Abuse (FWA)

• Understanding FWA• Knowingly and Willing

• Strategic Instrument – Data• Databases developed from all claims• Compare/Contrast data sets to identify trends and exceptions


Analytics Supporting the OIG Goal• Develop Annual Work Plans• Investigative trending analysis for any/all potential fraud, waste and

abuse• Accuracy investigations with provider overlap• Other customized investigations as reported or identified


OIG Common Analytic Approaches• Time Sequencing

• Identify billing patterns• Utilize timing and order of events

• Clustering• Identify groupings to organize in buckets• Investigate anomalies

• Association Rules• Identify events, services and conditions that are billed together• Investigate billings that don’t make sense


OIG Work Plan Hot Topics


• Sleep Disorder Clinics – High Utilization of Sleep Testing Procedures

• Diagnostic Radiology – Medical Necessity of High Cost Tests• Hospital Use of Outpatient & Inpatient Stays under

Medicare’s 2 midnight rule• Physicians Place of Service Coding Errors

• Facility vs non-facility based services

OIG Focus - 2 Midnight Rule• OIG will determine the impact of new inpatient admission• Criteria on hospital billing, Medicare payments, and beneficiary

payments• Hospital billing• Medicare payments• Beneficiary

• Hospital variance on inpatient data; Inpatient vs. Outpatient• 2 midnight rule analysis


OIG Work Plan Best Practices


• Be familiar with the entire work plan• Compliance Program Effectiveness• Seven elements of an effective compliance program• Program maturity• Perception of effectiveness among board, management, staff• Metrics• Compliance Risk Assessments• Substantive areas of concern• Understand your risk position (audits/monitors)• Understand vulnerabilities• Process complexity• History of failure• Monitor your control environment

OIG Work Plan Best Practices


• The OIG Work Plan is just a starting point – search for other federal reports

• Keep in touch with specialty societies that follow regulatory changes

• Search the Contractor website and newsletters for updates and changes in your contractor policy

Compliance and Revenue Cycle• Collaborate

• Shared Time and resources• Complimentary professional expertise

Access to in depth industry knowledge Networking Resources/Publication

• Access to information• Synergized goals and results expectations


How We Collaborate - 837 & 835 Data Sets• Two data sets (at a minimum)

⁻ Billed claims: ANSI ASC 837 (x)⁻ Paid claims: ANSI ASC 835 (x)

• Data is a starting point, not an end point in most cases• Data needs to be converted and managed to become useful to the

end user. The information will help identify risks to develop corrective actions.

• Variations between payer and provider data


837/835 Data Sets• Start with the end in mind:

₋ What do I want my end result to be₋ Database structure and maintenance (all data)₋ Updating with new data

• Storage/repository• Users

₋ Interfacing₋ Reporting

• Build or Buy?


Data Sets: 837/835 – Additional Uses• Clinical Documentation Improvement (CDI)• Revenue Integrity• ICD-10 implementation• Strategic planning• Legal Defense• Quality of care


Data Analysis

835 and 837 data

sets

Return to Provider

(RTPs)

Comprehensive Error Rate

Testing (CERT)

ReadmissionsZone Integrity

Contractors (ZPIC)

Hospital Acquired

Conditions (HAC)

Recovery Audit

Contractors (RAC)

Transfer DRGS

Analyzing and

identifying issues


Communication to Impacting areas

The Data analysis restarts and is a continuous process.

Rejection code to Focus On – 7272 OIG is focusing on Transfer DRG Overpayments

• 7272 Rejection reflects post-acute care after discharge• Claim will require a change in discharge status• Internal process to make this change• Tracking by Compliance / HIM of volume / trends


Return to Provider (RTP)• A claim submitted with missing or incorrect information for certain

specified items• Considered to be un-processable and is to be “returned” to the provider • Returning a claim as un-processable does not mean that every claim is

physically returned to the provider • “Return as un-processable” or “return to provider” refers to the many

processes utilized to notify the provider or supplier of service that their claim cannot be processed, and that it must be corrected or resubmitted.

For more details on these sections, you may view Chapter 1, Sections 70.2.3.1 and 80.3.2, of the Medicare Claims Processing Manual, Pub. 100-04, at http://www.cms.gov/Regulations-andGuidance/Guidance/Manuals/downloads/clm104c01.pdf on the CMS website.


Return to Provider – Two Types• Incomplete/ invalid information detected at front-end of claims

processing (In FISS)• Claim returned to the provider identifying the error(s) • Explanation on how to correct the errors prior to resubmission

• Incomplete or invalid information detected at the front-end of the claims processing system may be suspended

• Provider receives an additional information request (ADR)• Requested corrections and/or medical documentation must be submitted within

a 45-day period.• After the requested information is received, the claim is processed. Otherwise,

the suspended portion is returned and the supplier or provider of service is notified by means of the remittance advice.


Correction of Invalid Claims – “T Status”• Claims are corrected daily by the Business Office

• Focus is on Claim correction = REVENUE

• Routine billing corrections vs. Other corrections• Policies and procedures around RTP correction• Collaboration with Compliance


Deeper Dive into RTP• Download of RTP

• Work with EDI Vendors / Internal IT

• Sort by Status Code / Reason Code• Monitor RTP Trends Regularly


RTP Download ExampleADMIT FROM TO CHARGES TOB REASON SCODE LOCATION CC

09/19/2014 09/19/2014 09/24/2014 $ 59,294.32 117 30729 T B9997 E009/20/2014 09/19/2014 09/21/2014 $ 82,105.15 117 39011 T B9997 09,E009/16/2014 09/16/2014 09/17/2014 $ 17,144.56 117 30949 T B9997 6409/16/2014 09/16/2014 09/17/2014 $ 4,795.94 117 39012 T B9997 C5,E009/12/2014 09/12/2014 09/15/2014 $ 55,685.62 117 39011 T B9997 39,E009/10/2014 09/10/2014 09/12/2014 $ 17,453.72 117 37239 T B9997 C5,D109/06/2014 09/06/2014 09/09/2014 $ 17,280.37 117 39011 T B9997 E009/05/2014 09/05/2014 09/07/2014 $ 31,271.45 117 34931 T B9997 09,E008/27/2014 08/27/2014 08/29/2014 $ 305,611.00 117 31319 T B9997 C5,E008/26/2014 08/26/2014 08/29/2014 $ 19,407.67 117 39011 T B9997 09,42,D908/23/2014 08/23/2014 08/25/2014 $ 15,698.29 117 39011 T B9997 E008/16/2014 08/16/2014 08/17/2014 $ 7,412.75 117 30949 T B999708/12/2014 08/12/2014 08/15/2014 $ 5,256.67 117 39011 T B9997 09,E008/14/2014 08/12/2014 08/15/2014 $ 19,857.02 117 39011 T B9997 09,E008/12/2014 08/12/2014 08/15/2014 $ 16,438.20 117 37541 T B9997 C5,D908/05/2014 08/02/2014 08/07/2014 $ 33,813.78 117 30729 T B9997 09,E007/09/2014 07/09/2014 07/11/2014 $ 18,278.01 117 37547 T B9997 09,29,A5,C5,D4

07/04/2014 07/04/2014 07/06/2014 $ 12,098.40 117 31943 T B9997 D707/04/2014 07/04/2014 07/07/2014 $ 12,675.35 117 30924 T B9997 09,C5,E007/03/2014 07/03/2014 07/06/2014 $ 19,495.90 117 39011 T B9997 15,E006/28/2014 06/28/2014 06/30/2014 $ 22,148.17 117 34931 T B9997 09,E006/27/2014 06/27/2014 06/29/2014 $ 10,777.71 117 30950 T B9997 D9,E006/25/2014 06/25/2014 06/27/2014 $ 27,632.75 117 34931 T B9997 E0


Top RTP reason codesReason Code

Description

39011 The claim in question is untimely

3226 Revenue code on the claim should have units reported

38119 A skilled nursing facility claim or a non-prospective payment system inpatient claim has been submitted; however, the statement covers from date is greater that the admission date and there is no claim pending with a through date one day less than this claim from date

38038 An outpatient claim billed for the same date of service for the same provider number

15202 For an inpatient or skilled nursing facility claims, the number of covered days on page 1 of the claim must equal the number of accommodation units on page 2 of the claim

19301 When billing revenue code (s) 036x, 045x, or 076x on a bill type 11x and/or 13x filed with a principle procedure, an operating physician National Provider Identifier (NPI), physician last name, and first initial are required.

38204 Partial hospitalization claim for bill type 133 or 853 with condition code 41 and 'from' date on or after 01/01/13. There is no partial hospitalization claim (132, 133, 137, 852, 853, or 857) in history for the same beneficiary and provider with a line item date within 7 days prior to the from date for the incoming claim

12206 The sum of covered and non-covered days does not equal the days calculated between the statement covers ''From' and 'Through' date.

31816 Effective for claim with 'from' dates of service equal to or greater than 07/01/13, with type of bill equal to 12X, 13X ,22X, 23X, 34X ,74X ,75X, or 85X with a therapy evaluation/reevaluation code 92506, 92597, 92607, 92608, 92610, 92611, 92612, 92614, 92616, 96105, 96125, 97001, 97002, 97003, 97004, without a current G-code/functional severity modifier or appropriate paired functional goal status G-code/functional severity modifier and paired functional discharge status G-code/functional severity modifier.

W7072 Service not billable to the Fiscal Intermediary or A/MAC.

How We Collaborate – RTP and ADR• RTP and ADRs discussed between Revenue Cycle, HIM and

Compliance• Track and monitor requests• Determine root cause of request• Lends itself to Process Improvement and Improved Compliance


Recovery Auditors (formerly Recovery Audits Contractors) RAs• Review claims on post-payment basis to identify improper payments,

three (3) years from date claim paid• Two Midnight Rule is on hold until October 1st 2015.• TDRG Underpayment Reviews – method is not compliant


Quality Programs• Hospital Readmissions Reduction Program (HRRP)• Hospital Acquired Conditions (HACs)• Hospital Value-Based Purchasing Program (HVBP)


Zone Program Integrity Contractors (ZPIC)• Identifies cases of suspected fraud, investigate, and take action to

ensure any inappropriate Medicare payments are recouped


How We Collaborate – Clinical Issues• Utilization Review, HIM and Revenue Cycle must communicate with

Compliance• Avoid billing claims that are not medically necessary• Utilize data mining to track trends• Analyze• Evaluate• Implement


You have all of this data, now what?• Standardize data, track volume and financial Impact and compare

regularly to identify trends. • Once the trends are identified, determine the root cause and create a

process to correct the actions going forward. • Work closely with the department(s) causing the error and when

needed, utilize programs and systems to help flag these type of claims before the initial billing is processed.

• Get Compliance Involved! This will avoid denials and increase cash collection and days in AR.

• Written policies will help enforce the newly designed process.


In Review• Collaborate on expertise, resources and continually expand your

sphere of influence - Collaboration builds a better mouse trap

• With this knowledge, better monitor your billing (837) and payments (835)

- Internal analytics before someone from the outside does- Identify risk areas

• Identified risks should direct our corrective actions• Always Monitor Resolutions


Clean Claim Rate and Compliance• One important metric of quality is a high “clean” claim rate, which reflects both compliance and accurate

payment.

• Healthcare providers should focus on the following best practices to ensure clean claims and accurately received payment for all covered services performed:

• Setting up a continuous, proactive payment rules research and discovery plan. Make sure your facility understands CMS and your payers’ rules.

• Analyzing and reviewing denials and underpayment to determine the internal and external root causes of unsuccessful claims. Develop reports to trend and monitor denials and identify areas of vulnerability.

• Fostering a culture of education between clinical, HIM and finance staff to ensure common goals, accountability and understanding of the revenue cycle while developing corrective action plans to resolve underlining issues.

• Developing a well-documented claim-correction process• Trending issues by payer to identify critical issues• Collecting accurate documentation on all payer-related issues to support effective contract negotiations• Creating a teamwork approach for Clinical, Patient Accounting, HIM and Contracting to understand the revenue cycle for

your facility• Creating a culture of accountability for departments, teams and individuals• Tracking preventable denials back to the source for a permanent fix


Questions


Contact Information:• Kathy Ruggieri

• Senior Director, Revenue Cycle Services at BESLER Consulting • Email: [email protected]• Phone Number: 877-4BESLER

• Mary Devine • Senior Manager, Revenue Cycle Services at BESLER Consulting • Email: [email protected]• Phone Number: 877-4BESLER


mailto:[email protected]

mailto:[email protected]