Reduction in AR and Denials With Presenter:
Claudia Birkenshaw Garabelli, MSA Director, The Revenue Cycle The Rybar Group Conference Line: (646) 307-1705 Access Code: 472-258-522#
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Agenda • Overview of issues facing healthcare providers – national perspective • Identify three common roadblocks that cause denials and increased AR • Review critical components that ensure AR reduction and revenue cycle integrity • Learn about redesigning workflow and processes that improve AR performance
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Polling Question-1 What type of provider/organization are you? a) b) c) d) e)
Acute Care Hospital (IPPS-DRGs and OPPS-APCs) Critical Access Hospital (CAH) Physician(s) Provider Hospice, Nursing Home, Ambulance, Home Health Vendor, consultant, payer, other
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Revenue Cycle and Managing AR Today’s National Landscape • • • • •
Healthcare reform – Health Insurance Marketplace opening Oct., 2013 IPPS 2014 Final Rule OPPS 2014 Proposed Rule Physician Payments 2014 Proposed Rule Pay for Performance, Value-Based Purchasing, Quality Measures – HAC, POA, E H R, Health EDI, Core Metrics, Meaningful Use
• Moving from “fee for service” to bundling of payments and other new payment models • Standards/transactions – Rapid change continues– CAQH/CORE • Hospitals: Type of Bill 012x & CMS 1455-R and 1455-NR • Hospitals: Three-Day and/or One-Day Window Issues • ICD-10 – both Diagnosis and inpatient procedures • New 1500 Claim Form Conference Line: (646) 307-1705 | Access Code: 472-258-522 |
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Example of results from Medicare’s Hospital Compare: On the left of the page, select the hospitals you wish to view and compare
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CMS-Tons and Tons of Data • Consumers, Patients, Employers can view data:
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Examples of Quality Information from CMS’ Hospital Compare Site
Data from Hospital You Selected
U.S. National Rate
Hospital Acquired Condition (HAC) & Present On Admission (POA) Indicator
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Financial Penalties for Excessive Readmissions within 30 Days
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Transparency-Charges + Payments-IP
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Transparency-Charges + Payments-OP
CPT codes in APC # 0015 include: 11057, 11100, 11303, 11308, 11312, 11313, 15789, 15792, 16020, 16025, 17111, 17250, 17260, 17261, 17262, 17263, 17264, 17270, 17271, 17272, 17280, 36469, 36470, 36471, 45520, 46916, 54050, 96567, 96570, 96571, 96920, 96921, 96922, 97597, 97598, 97606 Conference Line: (646) 307-1705 | Access Code: 472-258-522 |
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Polling Question-2 Has your organization implemented one or more significant computer system(s)? a) b) c) d) e)
Yes, within the past six months Yes, we are doing that now We are talking about it No, we have not recently nor do we plan to Unsure
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Reducing AR and Reducing Denials
Hard-Wire Front End Processes
POS Collection
Revenue Cycle
Denial Management Tracking, Root-Cause Analysis
Clinicians, Charge Master, Enter Charges Timely, Health Information Management (HIM), Coding, Discharged Not Final Billed (DNFB) Regulations, Systems Updated, Education
Billing Systems Synchronized; AR < 90 days
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Core Steps – Revenue Cycle • © BridgeFront 2013. All rights reserved.
© BridgeFront 2013. All rights reserved.
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Step 4 – Communicate
Step 5Track, Measure, Report
Step 2 – List areas of concern Step 3 – Select Goal
Step 1 – Attending this session
© Copyright 2013 RGI
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Reducing AR and Denials • Registration/demographic error-Wrong Insurance, et al • Missing referral/authorization • Lack of medical necessity – Physician offices/practices – Hospital Outpatient – Hospital Inpatient
• • • •
Incorrect place of service Charge Master incomplete Claim not paid or underpaid and improper follow up System implementation issue and/or poor processes Conference Line: (646) 307-1705 | Access Code: 472-258-522 |
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Example of Establishing Denial Mgt Team
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Example, Continued Reducing AR Denial Mgt Team
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EDI Standards Clarification 837 – Claims – refers to the UB-04 and the 1500 (HCFA) claim forms 837I – Institutional 837P - Professional 835 – Payment - Remittance Advice (RA) 270 & 271 – Eligibility Inquiry & Response 276 & 277CA – Claim Status Inquiry & Response 278 – Prior authorization/referral 997 – Functional Acknowledgement-used to confirm file received 999 – Implementation Acknowledgement-used to confirm file received – used as of 3/2012 Conference Line: (646) 307-1705 | Access Code: 472-258-522 |
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Claim Adjustment Reason Codes (CARC) from Washington Publishing Company – Over 200 Codes Examples of Claim Adjustment Reason Codes 1 2 3
4 5 6 7 8 9 10
Narrative Description Deductible amount Coinsurance amount Copayment amount Procedure code inconsistent with modifier used or a required modifier is missing (see loop 2110 Service Payment Information REF) Procedure code/bill type inconsistent with Place of Service. (See loop 2110 Service Payment Information REF) Procedure code/bill type inconsistent with patient’s age. (See loop 2110 Service Payment Information REF Procedure code/bill type inconsistent with patient’s gender. (See loop 2110 Service Payment Information REF Procedure code inconsistent with provider type/taxonomy. (See loop 2110 Service Payment Information REF Diagnosis inconsistent with patient’s age. Diagnosis inconsistent with patient’s gender.
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Claim Adjustment Group Codes (CAGC) from Washington Publishing Company - 835 Group Narrative Description Code CO
Contractual obligation
CR
Corrections and reversals; NOTE: this value is not to be used with 5010 transactions and higher
OA
Other adjustment
PI
Payer initiated reductions
PR
Patient responsibility
CAGC are combined with CARC; examples: • PR1 – Patient Responsibility – This is the deductible amount and is the Patient’s Responsibility • CO60- Contractual Obligation - Charges for outpatient services are not covered when performed within a period of time prior to or after inpatient services
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Example: Tracking 835 Denials/Rejections Adj Grp Adjustment Code Reason Code OA 50 CO 22 CO 31 CO 27 OA 197 OA 200 OA 28 CO 31 CO 140 CO 110 CO 197 CO 198 CO 199 CO 22 CO 200 CO 50 CO 198
Total Charge $ 2,048.44 $ 973.00 $ 3,077.42 $ 2,357.45 $ 1,313.40 $ 8,878.16 $ 2,480.00 $ 13,699.63 $ 6,017.03 $ 1,074.30 $ 8,462.16 $ 17,997.39 $ 5,386.00 $ 521.00 $ 289.00 $ 7,354.00 $ 822.00
Date of Service 6/2/2013 6/7/2013 6/20/2013 6/21/2013 7/1/2013 7/2/2013 7/5/2013 7/7/2013 7/10/2013 7/10/2013 7/13/2013 7/15/2013 7/15/2013 7/28/2013 7/28/2013 7/28/2013 7/28/2013
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What Do All These Adjustment Codes Mean? Adj Reason Code 22 27 29 31 50 109 110 140 165 197 198 199 200
Narrative Description May be covered by another payer DOS after coverage terminated Filing Limit Patient cannot be identified as our insured Non-covered services; not deemed a 'medical necessity' by the payer Not covered by this payer; send to correct payer Billing date precedes DOS Patient/Insured health identification number and name do not match Referral absent or exceeded. Precertification/authorization/notification absent. Precertification/authorization exceeded. Revenue code and Procedure code do not match. Expenses incurred during lapse in coverage
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More Issues - Combination Codes Used Differently by Payers • CO133 – Medicaid payer Contractual Obligation – Claim is pended • CO16 – Medicaid Managed Care payer Contractual Obligation – Claim lacks information needed for adjudication • CO96 – Medicaid Managed Care payer Contractual Obligation – Non-covered charges
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More Terminology & Changes that Impact AR • CAQH (Council for Affordable Quality Healthcare) – A nonprofit alliance of health plans and trade associations whose mission is to support industry collaboration on initiatives that simplify healthcare administration for health plans and providers • CORE – Committee on Operating Rules for Information Exchange • New Standards January 2014 – New Tracer Segment – New Combination Codes
• For more information: see CAQH-CORE Conference Line: (646) 307-1705 | Access Code: 472-258-522 |
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Post Implementation Posting ANSI Codes–Issue Log Example Date
Reported By Problem/Issue Reported
Assigned To
Status
Completed
04.02.13 04.02.13
Pam T Shawn A
System doesn't always refresh when entering a new claim #. Occurred with Payer xxx, Acct# 9292 + others Control - L list errored stating too full
To Lynn
Opened Ticket XXXX opened ticket
04.03.13 04.02.13
04.02.13
Tammy Z
Unable to enter Admit Dates Acct#123. Other times, it works.
David
Called the help desk previously. Per Mgr Cindy, it was previously fixed appears broken again
04.10.13
04.03.13 04.03.13
Sharon B Mike L
BC Edits for amounts don't match. Occurs when payer rejects an entire procedure (ie PR49). Acct #456. Medicaid error reports are truncating the check number
Lydia John
Lydia is working; believe this is a vendor issue (xxx). Need mtg with vendor. Lydia scheduling. Opened Ticket
04.04.13
04.04.13
Jeff N
Payer xxx CO-45 and PR-3 claims incorrectly suspending. See xxx.
Brandy
Jeff sending screen prints of recent examples by 4.5.13 to xxx 04.10.13
04.04.13 04.04.13
Herb B Keith P
835 file posting errors. 2nd claims only posted and posted as Medicare. xx 835 not showing late fees or interest payments
David John
Opened ticket. Had worked properly during testing Opened ticket. Had worked properly during testing
04.04.13
Pam T
Image of vouchers stopped working again, see #123 dated 04.01.13
04.04.13
Pam T
Error Reports not accurate when compared to paper remits. See xxx dated 04.01.13-the error rpt lists "offsets" not on paper voucher
John
John working directly with xxx
Tammy Z
CO-59 and CO-B10 amounts are transferring to patients. See acct# 678, Blue Cross voucher of 4.2.13
Brandy
Brandy testing the fix in Test System.
04.04.13
Jeff N
System unable to post both reversal payment and new payment on same day with automated posting
Opened Ticket
04.05.13
Tammy Z
Payer xxx-when 100% disallow, the Master Benefit Pkg doubles, creates an incorrect credit. See Acct# 777, vouchere dated 4.2.13
Brandy working with payer for joint resolution.
04.05.13
Tammy Z
When biller does a Claim Correct and if there had been a previous payment, the history is lost. See Acct #8888, Payer AAA. DOS 2/28/13
Opened Ticket
04.04.13
Addt'l Notes
Opened ticket. Had previous problems during testing
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Common Roadblocks • Lack of dedicated resources and lack of hours to analyze and redesign systems, interfaces, and processes • Lack of education • Ignorance of new/changing regulations/statues/rules • Misunderstanding and miscommunication of the issues – Misunderstanding of data; incorrect interpretation – Examine & attack root causes • Lack of staff support and lack of trust within the organization • Lack of communication • Not establishing goals • Issues with accountability • Systems not maximized and not synchronized Conference Line: (646) 307-1705 | Access Code: 472-258-522 |
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Celebrate Success
Innovative Strategies. Exceptional Results.
To Reduce AR and Denials – Start Measuring, Tracking, Reporting Track Measure, Communicate
Start Collecting Data – When Issue Found, Redesign Process Develop Team – To Learn & Understand
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Workflow and Revenue Cycle Processes that Improve AR Performance • What issues are critical to you? • Which processes need to have workflows designed to identify fail points? • Where are written procedures needed? • Where is leadership’s attention? • Which processes should be revamped and redesigned with a focus on high, quick turn-around
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Recommendations • Collaborate + build cohesive team efforts with patient and revenue in mind •
Staff Buy In - educate and explain why the need for the re-design • Team building – group participation, build trust by being open and transparent
• Keep lines of communication open – ensure to keep all department managers informed across the enterprise from Front Registration, Ancillary, Clinical, HIM, Administration, and Billing/Back PFS Teams • To drive best practices, may have to remove barriers and silo situations which may include staff • Ensure you are able to escalate appropriate issues in a meaningful manner • Establish and communicate goals • Data will drive buy-in •
Accountability - monitor, measure, track and report progress to all across the enterprise
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Reducing AR & Reducing Denials Measure – Track – Report Communicate Net Days AR
POS Cash Collectio ns
Aged AR – 90 days and older
Discharged Not Final Billed (DNFB)
Final Bad Debt Billed, Write Not Sent Offs (FBNS)
27.22 – 39.02
41.4% 13.6%
6.8% to 22.9%
4.08 to .08 to .77 0.6% to 6.03 days days 2.1%
Point of Service (POS) Collections -- Calculation: POS Payments divided by Total Patient Cash Collected
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Polling Question-3 We are confident that we are doing a very good job keeping abreast of new and changing regulations: a) b) c) d) e)
5 – Extremely confident 4 – Fairly confident 3 – Middle 2 – Not very confident 1 – Not confident at all Conference Line: (646) 307-1705 | Access Code: 472-258-522 |
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The Rybar Group • Hospital Revenue Cycle Services and Physician Services – – – – – – – – – – – – –
Patient Access Scheduling, Pre-Registration, Registration Insurance Verification Point of Service (POS) Processes Medical Necessity, Medicare Secondary Payer (MSP) Advanced Beneficiary Notice (ABN) Financial Clearance Education along any aspect of the revenue cycle-management, line staff Interim Management, AR Analysis, Metrics Billing, EDI Transactions Cash Posting Collections, Bad Debt Coding Audits, Charge Master Reviews
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The Rybar Group – About Us • Healthcare financial management and reimbursement related services are the sole focus of The Rybar Group. Our creative and practical strategies, backed by over 150 years of collective expertise, has strengthened the financial positions of hospitals, physicians and other providers we've assisted nationwide for over 24 years. • Provide best practices, innovative and results-oriented services. • Team of highly experienced strategists familiar with compliant and efficient business operations • Client-centered approach with familiarity navigating complex third-party regulations
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The Rybar Group – Our Services Include • • • • • • • • • • • •
ICD-10 Data Integrity , Coding Audits, Compliance Reimbursement Optimization and Strategy Development Cost Report Reimbursement Strategy Services Critical Access Hospital (CAH) Revenue Cycle Services and Optimization Rural Health Services Blue Cross Revenue Strategies Medicaid Payment Strategies Disproportionate Share Hospital (DSH) Provider Reimbursement Analytics Strategic Pricing Volume Decrease Payment Appeals Conference Line: (646) 307-1705 | Access Code: 472-258-522 |
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Questions?
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Thank You for Attending! If questions, please contact Claudia Birkenshaw Garabelli, MSA
[email protected] 810.853.6165
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Appendix • List of Hospital Acquired Conditions (HAC) affected by the Present on Admission (POA) indicator on the UB-04 Claim Form
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Condition
ICD-9-CM Codes: CC* & MCC*
Foreign Object Retained after Surgery
998.4 (CC)
Foreign Object Retained after Surgery
998.7 (CC)
Air Embolism
999.1 (MCC)
Blood Incompatibility
999.60 (CC)
Blood Incompatibility
999.61 (CC)
Blood Incompatibility
999.62 (CC)
Blood Incompatibility
999.63 (CC)
Blood Incompatibility
999.69 (CC)
Pressure Ulcer Stages III & IV
707.23 (MCC)
Pressure Ulcer Stages III & IV
707.24 (MCC)
Falls and trauma:
Codes within these ranges on the CC/MCC list: 800 - 829 830 - 839 850 - 854 925 - 929 940 - 949 991 - 994
• • • • • •
Fracture Dislocation Intracranial Injury Crushing Injury Burn Other Injuries
Conditions Affected by HAC and POA Indicators
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Condition
ICD-9-CM Codes: CC Additional Notes: & MCC
Catheter-Associated Urinary Tract Infection (UTI) 996.64 (CC)
Also excludes the following from acting as a CC/MCC: 112.2 (CC) 590.10 (CC) 590.11 (MCC) 590.2 (MCC) 590.3 (CC) 590.80 (CC) 590.81 (CC) 595.0 (CC) 597.0 (CC) 599.0 (CC)
Vascular Catheter-Associated Infections
999.31 (CC)
Vascular Catheter-Associated Infections
999.32 (CC)
Vascular Catheter-Associated Infections
999.33 (CC) 250.10-250.13 (MCC) 250.20-250.23 (MCC) 251.0 (CC) 249.10-249.11 (MCC) 249.20-249-21 (MCC)
Manifestations of Poor Glycemic Control • Diabetic Ketoacidosis • Nonketotic Hyperosmolar Como • Hypoglycemic Coma • Secondary Diabetes with Ketoacidosis • Secondary Diabetes with Hyperosmolarity
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Condition
ICD-9-CM Codes: CC & MCC
Surgical Site Infection , Mediastinitis, following Coronary Artery Bypass Graft (CABG)
Surgical Site Infection, following Certain Orthopedic Procedures: • Spine • Neck • Shoulder • Elbow Surgical Site Infection, following Bariatric Surgery for Obesity: • Laparoscopic Gastric Bypass • Gastroenterostomy • Laparoscopic Gastric Restrictive Surgery Surgical Site Infection, following Cardiac Implantable Electronic Device (CIED)
Notes:
519.2 (MCC) And one of the following procedure codes: 36.10-36-19 996.67 (CC) 998.59 (CC) And one of the following procedure codes: 81.01-81-08, 81.23-81.24 81.31.38, 81.83, or 81.85 Principal Diagnosis 278.01 539.01 (CC) 539.81 (CC) 996. 61 (CC) 998.59 (CC) And one of the following procedure codes: 00.50, 00.51, 00.52, 00.53, 00.54, 3780, 3781, 37.82, 37.83, 37.85, 37.86, 37.87, 37.94, 37.96, 37.98, 37.74, 37.75,37.76, 37.76, 37.77, 37.79, 37.89
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Condition
ICD-9-CM Codes: CC & MCC
Deep Vein Thrombosis and Pulmonary Embolism following certain Orthopedic Procedures: • •
Total Knee Replacement Hip Replacement
Latrogenic Pneumothorax with Venous Catherization
Add’tl Notes:
415.11 (MCC) 415.13(MCC) 415.19(MCC) 453.40-453.42.(CC) Add one of the following procedure codes: 00.85-00.87,81-51.81-52 or 81.54 512.1 (CC) And the following procedure code 38.93
CC – Complications and co-morbidities MCC – Major complications and co-morbidities
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