Improving Your Patient Revenue While
Ensuring Integrity and Compliance
Region II Annual Primary Health Care Conference
June 1 - June 3, 2010
Presented by:
Peter R. Epp, CPA, Healthcare Practice Leader,
Managing Director, RSM McGladrey
peter.epp@rsmi.com
Gil Bernhard, CPA, Managing Director,
RSM McGladrey
gil.bernhard@rsmi.com
RSM McGladrey Inc. is a member firm of RSM International – an affiliation of separate and independent legal entities.
Improving Your Patient Revenue While Ensuring
Integrity and Compliance
• Establishing a culture of Revenue Maximization and Integrity and
Compliance
• Setting the Health Center up for Success – operationally and
compliance
• Regular Reports and Monitoring
• Intervening When Necessary
2
Impact of Executive Management and Board
While the day to day processes of the revenue cycle are performed
by dedicated health center staff, executive management and the
Board play a large role in determining the success of the process
by:
– Establishing the proper culture of billing and collection: health centers that
have a clear mandate from the board through management to bill correctly
and maximize reimbursement as an organization priority do a better job of
billing and collection than those who do not. This mandate plays out in
management and staff goals
– Maintaining a balance of financial, operational and regulatory requirements
– Maintaining the overall financial health of the health center and its revenue
streams
– Developing and monitoring processes; intervening where appropriate
3
The Revenue Cycle
Patient Enters
Facility/greeted at
reception
Claims sent to
payor (noncapitation)
Remittance
Received with
Payment
Patient Registers
Patient Seen By
Provider
Provider
Completes
Encounter Form
Claim Report
Prepared
Encounter Form
Processed
Patient Released
at Front Desk
Billing Department
Reconciles and
Posts
Denials
Investigated and
Corrected
Resubmission of
Denied Claims
Month Ending
Journal Entries
Posted
4
Objectives when Reviewing Billing/Revenue Cycle
•
•
•
•
•
•
Strong internal control procedures/compliance with policies
Collection of proper billing information
Proper recording of revenue
Maintenance of subsidiary accounts receivable
Collection of information for management reporting
Satisfy Federal reporting requirements
5
Establishing Policies and Procedures
•
•
•
Set of expectations
Many health centers are strong in policies and weak in procedures
Steps for revising policies & procedures:
–
–
–
–
–
–
–
–
–
Board and management affirm commitment to process
Identify goals and implementation date
Develop internal committee
Develop appropriate policies and procedures
Board of Directors approves policies
Implement; distribute written policies and procedures
Reinforce that compliance with policies and procedures is central to health center mission
Reinforce through regular education and training
Monitor & take action against violators
6
Ensuring Compliance with Policies and
Procedures – Compliance Review
• Good Policies and Procedures without follow up are worthless
–
“Even the best laid plans of mice and men oft go awry.” – Robert Burns
• Review all Policies and Procedures
• Having a well-established compliance plan can reduce risk of fraud and abuse,
as well as potential penalties
•
Compliance plan also goes beyond Policies and Procedures by:
–
–
–
Defining appropriate behavior and helping improve employee behavior
Promoting self-evaluation, problem detection and resolution
Promoting open communication
7
Billing and Revenue Strategies
Billing and revenue strategies are intended to improve the billing and
collections process in the Health Center and encourage the effective
use of staff who perform these functions.
Common goals and objectives achieved through billing and revenue
strategies:
•
•
•
•
Increased patient revenue.
Improved collections rates.
Reduced medical coding errors.
Cost savings of doing it right the first time.
8
Typical Medical Billing for Primary Care Services
• Use Current Procedural Terminology (CPT) Codes and
Descriptions
– Charge-Master is tied to CPT Codes
• Use International Classification of Disease (ICD) Codes – 9th
version – Clinical Modification
– Referenced as ICD-9-CM codes
• Bill visit to insurance and patient is responsible for balance.
• Patient may have deductible and pays 100% until it is met.
9
Typical Medical Billing for Primary Care Services
Family Medical Practice
Statement
Date:
04/06/2009
123 Any Street
Date Due:
05/06/2009
Anytown, IA 88888
393-000-1250
STATEMENT OF ACCOUNT
Jesse James
234 One Way Street
Anytown, IA 88888
DATE
DESCRIPTION
CHARGES
CREDITS
Balance brought forward
04/01/09
99213 - Intermediate Office Visit - Dr. Jones
04/01/09
80048 - Basic Metabolic Panel
04/01/09
84132 - Potassium
04/01/09
Co-Pay
04/03/09
Filed Ins. - $205.00
ACCOUNT
BALANCE
$56.00
$75.00
$131.00
$125.00
$256.00
$20.00
$276.00
$15.00
($205.00)
$261.00
$56.00
10
Types of Health Center Reimbursement
• All-inclusive Rate
– Medicare (Cost-Based Reimbursement)
– Medicaid (Prospective Payment System)
• Fee-For-Service
– Commercial carriers
• Capitation
– Medicare
– Medicaid
– Commercial carriers
• Contract Revenue
• Patient Self-Pay Revenues
11
FQHC - Getting Started
• What is the difference between a FQHC and a Community Health Center?
• Must apply for FQHC status.
• FQHC Medicare Provider Billing numbers are by delivery site. Medicaid
may be different depending on your state.
• For FQHC Medicare, must complete and submit CMS-855A form in order
to enroll in the FQHC program. For FQHC Medicaid, your state may
require FQHC Medicare status before awarding FQHC Medicaid status.
Again, depends on your state.
• Approval timeline may be 2-4 months.
12
CMS 855A Form
•
Form requires completing information on health center’s identification (locations,
address, etc.), legal history (including adverse rulings), ownership interest (sheet per
board member with SSN), practice locations, etc.
•
Copies of all:
– Professional/business licenses
– CLIA licenses
– Pharmacy licenses
– Legal Action documents
– EDI Agreements
– Articles of Incorporation/Corporate charters
– IRS Documents
– Notice of Grant Award
•
Go to www.cms.hhs.gov/
– Click on Medicare; then CMS Forms
13
What are Billable FQHC Medicare Services?
•
Medicare FQHC Services, as defined in Regulation 405.2400 are:
– Physician Services and services/supplies incident to
– Nurse Practitioner and Physician Assistant services and services/supplies
incident to
– Clinical Psychologist and clinical social worker services and services/supplies
incident to
– Visiting nurse services
– Nurse-midwife services
– Diabetes Self-Management Training (DSMT)
– Medical Nutrition Therapy (MNT)
– Preventive primary services
14
DSMT & MNT Services
• Effective January 1, 2006
• Section 5114 of Deficit Reduction Act of 2005, FQHC definition of
face-to-face encounter is expanded to include encounters with
qualified practitioners of Outpatient Diabetes Self-Management
Training (DSMT) services and Medical Nutrition Therapy (MNT)
• Program requirements for provision of such services set forth in
Part 410, subpart H (DSMT) and Part 410, subpart G (MNT)
• IOM 100-02, Chapter 15, Sec 300 = Accreditation from American
Diabetes Assn. or Indian Health Service
• IOM 100-04, Chapter 18, Sec 120 = Billing requirements
15
FQHC Medicare Services (Billable and Covered).
Preventive Primary Care Services
• Services required under Section
330 of PHS Act
• Furnished by providers listed in
previous slide
• Medical social services
• Nutritional assessment and referral
• Preventive health education
• Children’s eye and ear
examinations
• Prenatal and post-partum care
•
•
•
•
•
•
•
•
•
Perinatal Services
Well Child care
Immunizations
Family planning services
Taking patient history
Blood pressure measurement
Weight
Physical Exam
ETC
16
Medicare Cost Principles
• Social Security Act
– §1861(aa)(4) Statutory Requirements
– §1833(a)(3) = Payment provisions
1832(a)(2)(D) =Managed Care provisions
– 1861(v)(1)(A) = FQHC Services & IOM 100-02,Chap 13
– Regulation 405.2400 (RHC/FQHC)
• General Methodology
– The reasonable cost of any services shall be the cost actually
incurred, excluding any cost found to be unnecessary in the efficient
delivery of needed health services
17
Medicare Payment Provisions
•
Pay FQHCs/RHCs 80% of All-Inclusive Rate
•
No Medicare $100 Annual Deductible for visits to FQHCs
•
100% Reimbursement for Pneumococal and Influenza Vaccines and Administration
•
Medicare Bad Debt Recovery
•
Sliding Fee Scale Applicability
•
62 ½ % Reimbursement for treatment of mental, psychoneurotic, and personality
disorders (phase in of increase over next 5 years)
•
Medicare Part B for non-covered services
18
Medicare FQHC Billing-Outpatient Mental Health
• Outpatient Mental Health Treatment Limitation
– (Rev. 1843, Issued: 10-30-09, Effective: 01-01-10, Implementation: 01-04-10)
• The limitation has been 62.5 percent since the inception of the Medicare
Part B program and it will remain effective at this percentage amount until
January 1, 2010. However, effective January 1, 2010, through January 1,
2014, the limitation will be phased out as follows:
– January 1, 2010 – December 31, 2011, the limitation percentage is 68.75%
– January 1, 2012 – December 31, 2012, the limitation percentage is 75%
– January 1, 2013 – December 31, 2013, the limitation percentage is 81.25%
– January 1, 2014 – onward, the limitation percentage is 100%
19
FQHC Medicare
Medicare Advantage Plans
•
The Medicare Prescription Drug, Improvement, and Modernization Act of 2003
renamed the Medicare+Choice plan and made other changes including regional
PPOs, special needs plans for dual eligibles, and others, and created private drug
plans effective 1/1/06. Rates paid to managed care companies were also
increased in many cases.
•
Overall HHS target is to increase Medicare enrollees in managed care to 30% by
2013 from 12% in 2003. 10,609,264 are enrolled as of January, 2009, which is
approximately 25%.
•
Also includes supplemental wrap-around payments to FQHCs who contract with
Medicare Advantage (MA) plans.
•
Includes HMOs, PPOs, and PFFS’. All are known as MA Plans.
•
Created also were Special Needs Plans (SNP) which restricts enrollment only to
dual eligibles , those residing in institutional settings, or those with multiple chronic
conditions.
20
FQHC Medicare
Medicare Advantage Plans
• Health centers with MA plan contracts will be paid based on the
contract. In addition, will qualify for a supplemental wrap-around
payment when it provides FQHC Services.
• With PFFS plans, health center is entitled to 80% of its reasonable
costs (up to the cap), plus 20% of its actual charges, less the
plan’s co-pay.
21
FQHC Medicare
Wrap-Around Provisions
• Three contractual requirements between Plans & CMS:
– Must be written contract between FQHC and MA Plan
– MA plan must pay FQHCs an amount similar to what it pays other nonFQHC providers
– FQHC must accept MA payment and wraparound as payment in full
• Covers FQHC services only
– Does not include certain Part B services such as lab and x-ray. Does not
include pharmacy costs under Part D.
– Part B services should be billed directly to the MA plan
22
FQHC Medicare
Wrap-Around Provisions
• System changes made to accept payment on 6/3/06 (bill type 73x
and revenue code 0519)
• For first 2 rate years, FQHC submits an estimate of MA payments
to fiscal intermediary
• FQHC will receive payment for each wraparound bill it submits to
fiscal intermediary
• NACHC Issue Brief # 86 dated June, 2006
23
FQHC Medicare
Wrap-Around
Proc
Code
Procedure Description
Estimated
Units
Plan
Rate
Weighted
Rate
99211
Est. Office Visit
38
$ 21.16
99212
Est. Office Visit
411
62.25
25,585
99213
Est. Office Visit
3,596
72.04
259,056
Totals
5,200
Per-Visit-Rate
$
804
$ 309,388
$ 59.50
24
FQHC Medicare
Wrap-Around
AGE
PMPM
Annualized
Capitation/100
1-12
$13.32
$15,984
299.38
53.39
13-18
$27.55
$33,060
620.38
53.29
19-36
34.35
$41,220
765.60
53.84
37+
$46.42
$55,704
990.64
56.23
Per-Visit Rate
Estimated
Visits/100
Per-Visit
Rate
$ 54.19
25
FQHC Medicare
Part D Pharmacy
•
Starting 1/1/06, prescription drug plans (PDPs) will be the primary mechanism
for Medicare enrollees to receive prescription drug benefits
•
Optional benefit; enrollees will need to sign up
•
Dual eligibles will receive coverage through Medicare Part D, not Medicaid
•
Health centers with pharmacies will need to contract with PDPs to receive
reimbursement for Medicare pharmacy patients
•
No statutory provisions preventing health centers with 340B programs from
participating in Part D
26
FQHC Medicaid Services
• FQHC/RHC Services, as defined in Section 1902(a)(10)(A)
and 1905(a)(2)(C) of the Social Security Act, and any other
ambulatory service in the State Medicaid plan provided by the
FQHC/RHC
• Examples:
–
–
–
–
–
Dental and pharmacy
Enabling Services, i.e., transportation, case mgmt., translation
EPSDT services
Certain inpatient services
Nursing home or home care services
27
Prospective Payment System for FQHCs
•
“Beginning
with fiscal year 2001 with respect to services
furnished on or after January 1, 2001….”
– New Section § 1902(aa)(1) of the Social Security Act
• “The new Medicaid PPS requirements are effective in all States
with respect to services furnished by FQHCs on or after January
1, 2001.”
– January 19, 2001 State Medicaid Director Letter (SMDL)
28
Prospective Payment System
•
•
•
•
Who are the FQHCs?
Initial PPS rate-setting methodology
–
Current FQHCs
–
New FQHCs
PPS rate-setting for the future
Medicaid managed care shortfall payments (“wraparound”)
29
OVERVIEW OF PPS
•
Payment calculated on a per visit basis.
•
States required to pay current FQHCs 100 percent of the average of their reasonable
costs of providing Medicaid-covered services during FY1999 and FY2000.
•
Adjusted to take into account any increase (or decrease) in the scope of services
furnished during FY2001 by the FQHC and inflated by the MEI (Medicare Economic
Index) for 2001.
MEI
1999
Costs
Medical
$ 50.00
Ancillaries
$ 10.00
Enabling
$ 15.00
Administration $ 15.00
Capital
$ 10.00
Total
$ 100.00
2000
Costs
$ 55.00
$ 10.00
$ 15.00
$ 15.00
$ 15.00
$ 110.00
$
$
$
$
$
$
Avg
52.50
10.00
15.00
15.00
12.50
105.00
PPS Reimbursement
2.1%
2.6%
3.0%
2005
$ 63.38
$ 12.07
$ 19.70
$ 18.11
$ 15.09
$ 128.35
2006
$ 65.03
$ 12.38
$ 20.21
$ 18.58
$ 15.48
$ 131.68
2007
$ 66.98
$ 12.75
$ 20.82
$ 19.14
$ 15.94
$ 135.63
2.9%
2008
$ 68.92
$ 13.12
$ 21.42
$ 19.70
$ 16.40
$ 139.56
30
OVERVIEW OF PPS
New FQHCs After 2001:
• PPS baseline rates will be calculated using one of the following
methodologies. This varies by state.
–
–
–
the rates established for the fiscal year for other centers or clinics
located in the same or adjacent area with a similar case load or
in the absence of such a center, in accordance with Medicare FQHC
regulations and methodology, or
based on other tests of reasonableness as the Secretary may specify
• The MEI will be applied to the new FQHC’s rate for each year
following the baseline year.
31
PPS CHANGE IN SCOPE OF SERVICES
“Change in Scope” per CMS Q & A Document:
• A change in scope shall occur if :
–
–
The center has added or has dropped any service that meets the
definition of FQHC/RHC services; and
The service is included as a covered Medicaid service under the
Medicaid state plan.
• A change in the “scope of services” is defined as a change in
the type, intensity, duration and/or amount of services.
• In making such an adjustment, state agencies must add-on the
cost of new services even if these services do not require a
face-to-face visit with a provider.
32
PPS CHANGE IN SCOPE OF SERVICES
Cost Per Visit Analysis:
1999
2000
Avg.
Trended
2008
Medical
50.00
55.00
52.50
57.75
60.00
Ancillaries
10.00
10.00
10.00
11.00
20.00
Enabling
15.00
15.00
15.00
16.50
15.00
Administration
15.00
15.00
15.00
16.50
15.00
Capital
10.00
15.00
12.50
13.75
25.00
TOTAL
$100.00
$110.00
$105.00
$115.50
$135.00
33
Alternative Payment Methodologies
• States may opt to pay FQHCs using a methodology other than PPS (“alternative
payment methodology”) only if the methodology selected meets the following
conditions:
1.
2.
3.
Must be agreed to by the State and each individual FQHC to which the state
wishes to apply the methodology
Must result in a payment to the center or clinic that is at least equal to the
amount to which it is entitled under PPS.
Must be described in the approved State plan.
• Many states have adopted alternative methodologies. Examples of such
methodologies include:
–
–
–
–
Continuing to use cost-based reimbursement or some version of it.
Allowing states to select as their base year costs the higher of 1999 or 2000
Reimbursing for full capital costs. How capital is defined also differs amongst
states.
Varying when during the calendar year the MEI goes into effect.
• For more information on a state-by-state basis, please review the NACHC report at
www.nachc.com/
34
PPS Wrap-Around
• States required to make supplemental payments to FQHCs that subcontract (directly
or indirectly) with managed care organizations (MCOs) – particularly important in
Section 1115 States where managed care is statewide.
• Supplemental payment is the difference between the payment received by the
FQHC for treating the MCO enrollee and the payment to which the FQHC is entitled
under the PPS.
• IMPORTANT - Incentive payments, e.g. risk pool payments are excluded from the
wraparound calculation.
• Also, whether payments for non-direct medical services such as case management
and administration will be figured into the wraparound calculation will also vary on a
state-by-state basis.
• FQHCs are entitled to be paid at least as much as any other provider for similar
services.
35
Commercial Insurance Payers
HMOs, PPOs, Indemnity Coverage
36
BASICS OF MANAGED CARE
Cultural Changes Required to Participate in Managed Care
TRADITIONAL FEE-FOR-SERVICE
PROVIDER OF SERVICE
VISITS
REVENUE
REVENUE MAXIMIZATION
MANAGED CARE
MANAGER OF CARE
VISITS
NO CHANGE IN REVENUE
COST MANAGEMENT
37
BASICS OF MANAGED CARE
Forms of Reimbursement Under Managed Care
• Fee-For-Service:
– Based on CPT Codes
– Earn More Revenue by Performing More Services
– Different Charges for Different Types of Services
38
BASICS OF MANAGED CARE
Forms of Reimbursement Under Managed Care
• Capitation:
– Revenue is based on a prepayment of a fixed periodic
amount per member per month (PMPM).
– The amount of revenue earned is based on the number of
members enrolled - not on the number of visits.
– To earn more, control utilization and provide fewer and/or
less costly services.
39
BASICS OF MANAGED CARE
Contracts with Both Capitation and Fee-For-Service Components
In these cases two separate sets of entries should be booked in the general
ledger:
• Capitation payments received for month’s capitation
• Gross charges for capitation services rendered during month
• Gross charges and associated contractual allowance for all specialty services (if
a co-payment is required, then an entry to self pay receivable and revenue is
required)
NOTE:
Under this type of contract, it is essential that centers track
the different types of services rendered to each patient.
40
Fee-For-Service
Fee-For-Service (FFS) Methodology:
• In a FFS environment, reimbursement is based on Current
Procedural Terminology (CPT) code.
–
–
–
•
Different Charges for Different Services
Reimbursement Based on CPT Code at Fees Established by Third
Parties
Amount of Revenue Earned Is Based on the Number and Type of
Billable Services Provided
Fee-for-service procedures include, but are not limited to,
laboratory, radiology, etc.
41
Maximizing FFS Revenue
To generate more revenue, a health center can:
• Provide more procedures
• Properly code encounter forms to ensure all services provided are
billed
• Utilize a comprehensive encounter form to ensure all billable
procedures are included
• Have a system of collections
42
Ensuring Proper Coding – High Level Overview
• Collect data on provider visits (E&M Codes)
– By individual Provider
– In the aggregate for the health center
• Prepare graphs to show frequency of codes used
–
Show increasing intensity of visit from left to right
• Overlay Health Center providers and aggregate data in national
averages
– Include payor-source specific graphs
43
How Can You Recognize Improper Coding?
UNDERCODER HEALTH CENTER
70%
60%
50%
40%
30%
20%
10%
0%
99211
99212
99213
99214
National Average*
99215
Undercoder
*Source: Ingenix, 2001
Established Patient Visits
E&M Codes
99211
99212
99213
99214
99215
National Average*
% of Total
2.7%
20.6%
63.5%
11.3%
2.0%
Undercoder Health Center
# Visits
% of Total
2,300
23.0%
3,500
35.0%
3,800
38.0%
400
4.0%
0.0%
How Can You Recognize Improper Coding?
When we add payer-based coding information, the differences
may become even clearer:
60%
Medicaid
50%
Medicare
40%
30%
Commercial
Insurance
20%
Self Pay
10%
0%
99211
99212
99213
99214
99215
National
Average
45
Tracking Productivity and Performance
based on Relative Value Units (RVUs)
• Each procedure code has an associated value – an RVU
• The RVU compares services against one another
– The more intense the service, the higher its RVU
• Three components to the RVU
– Work RVU which measures effort of the provider
– Practice Expense RVU which measures support staff and overhead costs associated
with providing the care
– Malpractice RVU which translates the cost of average malpractice coverage attributable
to the code
• Work RVU is the important component for provider productivity
46
Billing and Revenue Strategies –
Understanding Contracts
•
•
•
•
•
•
Eligibility/preauthorization
Claims timeliness
Complete information
Accurate information
On appropriate forms
In compliance with managed care contract/from provider manual
47
Compliance Programs
• A set of procedures and processes instituted by an organization to
regulate its internal processes and train staff to conform to and abide by
applicable local, state and federal regulations.
• Defined corporate standards and expectations
• Communicates uniform work procedures to assure the corporate
standards and expectations will be met
• Describes the methods for monitoring standards
• Identified to ‘go-to’ person(s) for staff when compliance issues arise
• Provides corrective action processes
Required in Healthcare Reform Bill
48
Benefits of a Compliance Program
• Establishes and promotes awareness of federal and state regulations
• Defines the standard of organizational values and expectations
• Creates the framework for meeting regulations by providing the
necessary parameters and protocols for staff to follow
• Can help to identify organizational vulnerabilities/weaknesses
• In the event that a violation occurs, an effective compliance program
can serve as a mitigating factor in determining penalties.
49
Seven Recommended Elements of a Compliance
Program
• From OIG Compliance Voluntary Program Guidelines for Individual
and Small Group Physician Practices
–
–
–
–
–
–
–
Designating a Compliance Officer or Contacts
Conducting Internal Monitoring and Auditing
Developing Written Standards and Procedures
Conducting Training and Education
Responding Appropriately to Detected Offenses
Developing Open Lines of Communication
Enforcing Disciplinary Standards
• New York has eight
–
Policy of non-intimidation and non-retaliation for good faith participation in the
compliance program
50
Basic Elements of the Finance Portion of Your
Compliance Program
•
•
Accounting policy and procedure manual (Including Patient Revenue and
Receivable recording and reporting)
Policies and procedures governing
–
Internal controls
–
Grants management
 Community Health Center program
 Other (Ryan White, state & local grants)
–
Tax filings and compliance
 New IRS Form 990
•
–
Cost report filings and compliance (Medicare and Medicaid)
–
Billing and coding compliance (Medicare and Medicaid)
Internal auditing and monitoring
51
Objectives
•
The essential components of a revenue integrity program and introduces you to
the tools to build one. Topics covered include:
– Defining your scope of care…delivering the right services in the right setting with the right providers
– Documenting services…collecting and recording data to support your claim for reimbursement…on
paper, or in the computer
– Coding accuracy…making sure that your providers properly code the diagnoses of your patients
and the care they deliver
– Checking system performance…checking regularly to make certain your automated systems are
not automating an error!
– Monitoring revenue integrity results…establishing an ongoing program for reviewing and monitoring
the critical elements of your claims process, from point of care through posting of payment.
•
The responsibility for revenue integrity rests with all center staff. This applies to
clinical staff who provide care, business office staff who bill for the care, and those
in positions of leadership or governance.
52
Revenue Integrity Defined
• Revenue Integrity is the state of
accurately coding or classifying
care provided based on:
– patient needs
– services provided
– payer requirements
• And collecting, recording, and
storing the data required to
support the claims.
53
The Heart of the Matrix
Operational Performance
Financial Performance
Revenue Integrity
Quality Improvement
Corporate Compliance
54
Environment Scan
• There is increasing pressure on all providers of care to ensure
revenue integrity due to:
– Limitations of Federal and State reimbursement, with current budget concerns
– Increasing scrutity by Federal and State agencies on proper claims
submissions
– Development of a “revenue recovery” mentality by Federal and State
governments (e.g. RAC audits, State Medicaid Audits, etc.)
• Half of health care reform is expected to be funded by reducing fraud,
waste, and abuse by providers
55
McGladrey Pyramid of Revenue Integrity
System
Performance
Monitoring
Feedback
Define Scope
of Care
Proper
Coding
Board
Acurate
Charting
Clinicans
Staff
56
Foundation of Revenue Integrity Program
System
Performance
Monitoring
Feedback
Define Scope
of Care
Proper
Coding
Board
Acurate
Charting
Clinicans
Staff
57
Foundation of Revenue
Integrity Program
The people of your organization
provide the foundation of your
revenue integrity program. It is
critical to have their engagement,
support, and involvement in the
building of the pyramid in
whatever areas relate to their
individual jobs. In order for you to
achieve high levels of
engagement, support, and
involvement, you must develop
and implement a planned
strategy for success. This
includes everyone from the
governing body, to providers and
clinicians, to administrative and
support staff.
Strategies for Success:
• Include in job descriptions the specific activities of
each person as it relates to revenue integrity
– Keep job descriptions general and refer to following
policies and procedures which are frequently updated
•
Provide formal training during on-boarding of new
people of their expected performance
– Explain that revenue integiry is an important component
of the organization’s corporate compliance program
•
Provide periodic reviews of mission critical
performance activities
– Review quarterly or annually the policies and procedures
which are most important or have been problemmatic
•
Provide feedback on individual and team
performance
– Stress that achieving revenue integrity is a combination
of individual and group performance
58
Role Differentiation for Revenue Integrity
Board
Clinicians
Staff
• Participates in training on Revenue
Integrity, Compliance, and Quality
Assurance
• Includes revenue integrity as a goal
of it’s charge to management in
developing and implementing a
compliance and quality assurance
program
• Receives periodic performance
reports on revenue integrity as part
of compliance or quality assurance
program
• Allocates resources and ensures
follow through for development of
systems and processes to correct
or improve revenue integrity issues
identified.
• Participates in training on proper
documentation of care provided, and
on coding accurately
• Maintains awareness of coverage
status of common visits, tests and
procedures by common payers.
• Documents care provided according
to center’s standards
• Documents coding to center’s
standards
• Dates and signs all documentation
accurately.
• Writes clearly and legibly.
• Electronically signs and locks all
electronic documentation properly
• Participate in problem solving focus
groups when issues are identified..
• Participates in training on
supporting revenue integrity by
properly preparing and filing
documentation, collecting and
verifying insurance coverage
information on residents, and
maintaining an awareness of
coverage status of common visits,
tests and procedures by common
payers.
• Implement all procedures and
processes in support of revenue
integrit
• Participate in problem solving
focus groups when issues are
identified.
59
Define the Scope of Care
System
Performance
Monitoring
Feedback
Define Scope
of Care
Proper
Coding
Board
Acurate
Charting
Clinicans
Staff
60
Define Your Scope of Care
While each segment of the
revenue integrity pyramid is
critical, the definition of the scope
of care is a primary step. This is
where you determine what
activities needed by your patients
and provided by your staff meet
the requirements of coverage by
your payers. It also includes a
definition of who the appropriate
providers of these services are. It
is important to remember that
these payer requirements will
vary between Medicare, your
individual state’s Medicaid
program, and commercial payer
requirements.
Strategies for Success:
• Outline the clinical services needed by your
patient population
– Consider the age groups you serve, health status of your
population, and preventive care requirements
•
Identify the place of services that are required
– Consider if you serve children who may need school
based programs, or elders who may need nursing home
or home based visits
•
Review Medicare, Medicaid, and Commercial
Payer requirements for services and place of
care
– For each service you plan to provide (e.g. primary care,
podiatry, maternal/child, substance abuse) find the
regulation or provider manual reference that shows
coverage requirements, designated provider, and place
of service limitations.
– File supporting documents for each service
61
Sample Documentation of Scope of Care
Discussion Purposes Only– Must be individualized for each FQHC based on state regs
Clinical
Service
Place of
Service
Appropriate
Provider
Covered by
Medicare
Covered by Medicaid
Covered by
Managed
Care
Applicable
Utilization
Limits
Annual
Physical
Center or
Home Care
MD, NP, PA
Yes
Yes (This is State
Specific and need to
check State regs)
Yes
Medical
Necessity
Psychology
Services
Center or
Home Care
PhD (Psych),
or LCSW
Yes
Yes (This is State
Specific and need to
check State regs)
Varies by
contract or
plan—list
separately
Medicaid limits
to two visits per
month.
For each “yes” in coverage columns, attach copy of regulation or coverage memo
62
Appropriate Provider
• For each service provided, know the appropriate provider for that
service
– E.g. Primary care by MD, DO, NP, or PA
– E.g. Mental Health services by PhD (Psychologist) or LCSW
• Also make sure each provider is appropriately credentialed
– License and education verification
– Employment contract or agreement
– Validation that they are not on either a federal or state banned provider list
63
Utilization Limits
• Medical necessity is required for Medicare clinical services
• Many Medicaid programs, as well as commercial and managed care
plans, may have utilization limits
– Coverage limits by type of service
• Lifetime
• Coverage year
• Month
64
Ensure Adequate Documentation of Care (Charting)
System
Performance
Monitoring
Feedback
Define Scope
of Care
Proper
Coding
Board
Acurate
Charting
Clinicans
Staff
65
Ensure Adequate
Documentation of Care
We have all heard the adage, “If
you didn’t write it, you didn’t do
it.” Ensuring adequate
documentation is more involved
than documenting clinical care.
Specific requirements for
payment may depend upon
documentation, and providers
need to know them. For
example, some visits may require
documentation of a face-to-face
encounter with a provider, even if
the majority of care is given by
staff. And if E&M coding is used
for determining the level of
reimbursement, then the required
charting is needed as well.
Strategies for Success:
• For each service provided, create documentation
guidelines for providers to follow
– Consider the required documentation to support the
medical necessity of the service, the level of coding, as
well as any requirements for quality of care incentives
under managed care contracts.
•
Validate that clinical forms or electronic health
record templates support the required
documentation
– Providing cues for required documentation can improve
compliance, but make sure that documentation is
individualized to patient and not templated
•
Reinforce policies and procedures for dating and
signing clinical documentation
– Include standards for when signing/locking must occur
– Also, include procedures for making changes or
additions to documentation at a later date
66
Sample Documentation Guidelines
Examples:
99213- Established patient -Office visit
2of the 3 key components are required
(EPF) history, (EPF)examination, (MDM) low complexity.
• History = brief HPI 1-3, problem pertinent ROS, PFSH is N/A
• Exam = limited exam of the effected body area or organ
system, 6 elements.
• MDM= 2 or more self limiting problems, one stable chronic
illness, or an acute uncomplicated injury. Over the counter
drugs…..
43
67
Ensure Proper Use of Billing Codes
System
Performance
Monitoring
Feedback
Define Scope
of Care
Acurate
Charting
Proper
Coding
Board
Clinicans
Staff
68
Ensure Proper Use of Billing
Codes
The services provided, the
provider of those services, and
the place of service are
represented in codes on the claim
for each encounter. If the proper
codes are not utilized, payment
may be provided for services for
which the center is not entitled.
For example, if a provider
encounter for follow-up of CHF is
performed in a hospital rather
than in the center, if the place of
service is coded for the center
and not the hospital, the center
may be paid for a non-covered
FQHC service.
Strategies for Success:
• For each service provided, create coding
guidelines for providers and staff to follow
– Define the appropriate CPT or payer specific codes
required to describe the service provided
– Define the appropriate place of service codes for each
setting in which care is provided
•
For each service encounter, provide a
mechanism (either on paper or in electronic
health record) for provider to assign code based
on care provided
– Each year, review codes for continued applicability and
for any changes in definition or requirments
•
Design a process where coding is checked
during the claims submission process
– This may be done by manual review of each or a sample
of claims, or by electronic billing edits / reports
69
Coding and FQHCs
•
FQHC providers are not required to submit a HCPC code on a claim however
operationally many FQHC providers need to include a charge amount and HCPC
to allow a claim to be created in their practice management systems (PMS). An
FQHC commonly includes the E&M code only for the Medicare threshold visit
(regardless of what other services were provided) and includes the total charge
amount associated to that visit to the E&M code line item/HCPC.
•
Type of Bill (TOB) is used on Institutional claims which is required for FQHC
providers seeking reimbursement from Medicare for threshold visits, similar to
place of service on a professional claim. Centers should ensure they are using the
appropriate TOB and revenue codes to ensure claims are not denied. For example
certain mental health visits with certain diagnosis codes need to be submitted with
a revenue code of 0900 whereas medical visits are submitted with a 0521.
70
Coding and Billing Reviews
Was claim
submitted within
allowable
Timeframe?
Claim #
Date of
Service
Date
Claim
Filed
Submitted
Place of
Service
Was care given
in a covered
place of service?
Audited
Place of
Service
Submitted
Billing
Code
Proper
Billing Code?
Audited
Billing
Code
Do providers
match?
Submitted
Provider
Audited
Provider
71
E&M Codes
• E&M codes may be required by certain state Medicaid programs, or
by commercial or managed care plans that centers may contract
with.
• Even though E&M coding does not affect Medicare Part A
reimbursment for FQHCs, it is a good idea to promote acurate E&M
coding for these patients as well.
– This helps to ensure provider coding acuracy for patients with payers where
coding does matter.
– The clinical documentation needed to support E&M coding helps to
demonstrate medical necessity of the visit
72
Evaluation and Management
Documentation Guidelines CPT
The descriptors for the levels of E/M services
recognize seven components which are used
in defining the levels of E/M services.
These components are:
• History
• Examination
• Medical Decision Making
• Counseling
• Coordination of care
• Nature of presenting problem; and
• Time
Documentation and Coding are driven by
the nature of the presenting problem.
•
Key Components of the note.
– Understanding the basics of
choosing the correct level of service
– History, Examination, and Medical
Decision Making
– Understand how Contributory
Factors effect your level of service
– Successful linking of CPT and ICD-9CM
73
Evaluation and Management
Documentation Guidelines ICD-9-CM
•
•
•
The importance of consistent,
complete documentation in the
medical record cannot be
overemphasized.
Without such documentation accurate
coding cannot be achieved.
The entire record should be reviewed
to determine the specific reason for
the encounter and the conditions
treated.
•
Selecting the correct ICD-9-CM code
– When to code for signs and
symptoms
– Choosing the primary diagnosis
– Coding to the highest level of
specificy
– Prepare for the immanent
mandated change to the ICD-10CM.
74
Ensure Proper System Performance
System
Performance
Monitoring
Feedback
Define Scope
of Care
Proper
Coding
Board
Acurate
Charting
Clinicans
Staff
75
Ensure Proper System
Performance
Electronic health systems have
tremendously improved the
efficiency and effectiveness of
claims submission and
reconciliation…but they also have
introduced a new area of concern
for breaches in revenue integrity.
The electronic system only
formats claims in the way it is set
up to do, and using data provided
to it in an appropriate manner. If
the definitions or edits that have
been programmed into the
system are incorrect, then the
error is perpetuated through the
automated process…and it may
not be noticed for awhile.
Strategies for Success:
• Validate that all definitions, edits, and templates
in your electronic health system are consistent
with your policies, procedures, and processes
– This strategy should be performed during initial set up,
and updated annually or after any process change
•
Test a sample of automated claims against a
manual claims submission process
– Again, perform this during initial system implementation,
after any modification to system, and at least quarterly
– Be sure to include a sample of all claim types
•
Review user performance with system to identify
issues
– Check that providers are electronically signing and
locking notes
– Check reports of timeliness of claims processing, and
whether edits are unnecessarily holding up submission
76
Other Systems Considerations
• Systems are set to appropriately select payer
– E.g. Medicare should always be primary payer for dual eligibles, no-fault
insurance is primary for auto accidents, etc.
• Co-payments and co-insurance amounts are billed for and tracked
• Claim denials are tracked and appealed
– Claim denial trends are analyzed and systemic issues identified for
performance improvement
77
Sample System Performance Management
Date
Software Upgrade,
or “switch” turned
on or off
Post system change
testing completed
Comparison of post
system change testing
to hand coded sample
of clinical
documentation
6/1/2010
Rates updated in system
6/3/2010
100% correlation
78
Ongoing Monitoring Activity
System
Performance
Monitoring
Feedback
Define Scope
of Care
Proper
Coding
Board
Acurate
Charting
Clinicans
Staff
79
On-Going Monitoring
Activity
The monitoring activities of both
your center’s corporate
compliance program, and
quality/process improvement
program should support the goals
of your revenue integrity strategy.
Since revenue integrity is
important to demonstrate
compliance with Federal and
State regulations and prevention
of fraud, waste and abuse, and it
is critical for the financial success
of your organization, all of these
programs inter-relate. Successful
revenue integrity strategies will
lead to success in compliance
and meeting financial goals.
Strategies for Success:
• Conduct an annual risk assessment for revenue
integity to identify monitoring focus areas, based
on:
– High volume services
– Low volume, but complex services
– Services that are the focus of government or payer
audits
– Services for which claim submissions have been
problemmatic in the past
•
Design and implement a monitoring program for
the high risk areas identified
– Develop review tools and define frequency of
implementation
– Analyze results of these reviews and identify root causes
and develop corrective action plans
– Track corrective action plan implementation and check
for improvement
80
Provide Continuous Feedback
System
Performance
Monitoring
Feedback
Define Scope
of Care
Proper
Coding
Board
Acurate
Charting
Clinicans
Staff
81
Provide Continuous
Feedback
Remember that the foundation of
your revenue integrity program is
made up of your board, your
providers, and your staff. It is
critical that all three of these
groups get feedback from your
monitoring activity. If the
information on program
performance is collected, but not
shared, then any opportunity for
process and outcome
improvement is lost. The
feedback loop is two-way, and
ideas and suggestions from the
board, providers, and staff should
go back to the revenue integrity
team as well.
Strategies for Success:
• Communicate findings of revenue integrity
monitoring activity to board, providers, and staff
– Include these reports in regular board, provider, or staff
meetings
– Don’t report raw data– first conduct root cause analysis
and develop recommendations for improvement
– Be sensitive to compliance or legal issues when
reporting results– use data summaries and only
characterize problems as performance issues and not as
compliance or legal issues
•
Provide on-going education to providers and staff
– As requirements, policies, and procedures change, it is
critical to update written procedures and guidelines to
reflect them
– All changes should be communicated to providers and
staff
– A record of training should be maintained
82
Monitoring Verses Auditing
• Monitoring is a process of gathering data during the revenue cycle
process to ensure that procedures are being followed
– Example of monitoring in a paper based environment might be checking that
there is a encounter sheet signed by a provider for each claim being submitted
– Example of monitoring in an electronic enviroment might be an electronic email
notification if a claim lacks an electonically signed and locked clinical note
• Auditing is a retrospective process where a sample of claims is
selected and tested to see if the expected outcome matches the
actual performance
– Example of auditing is a review of 300 claims submitted against a checklist of
requirements, such as signed note, documentation of medical necessity, etc.
83
PDSA Performance Improvement Cycle
Plan
Do
Act
Study
84
Plan for Performance Monitoring
• Develop an annual plan for quality assurance audits of revenue
integrity, with a calendar of audits to be done throughout the year
– Plan should be based on high volume claim submissions, high risk, things that
have been problemmatic in the past, etc.)
• Feed findings of audits into PDSA cycle to facilitate process
improvements
• When strategies for improvement are identified, plan and implement
ongoing monitoring activities to make sure the gained improvements
are sustained.
85
Benchmark Monitoring
• Key benchmarks of revenue integrity performance should be
established and monitored by management and the governing body
• Examples include:
–
–
–
–
Net collection ratio
Rate of claim denials by payer class
Days from service to claim by payer class
Days receivable by payer class
• If data shows performance decline, closer review is indicated
86
McGladrey Pyramid of Revenue Integrity
System
Performance
Monitoring
Feedback
Define Scope
of Care
Proper
Coding
Board
Acurate
Charting
Clinicans
Staff
87
Self Assessment of Your Organization’s Revenue Integrity
Standard
Yes
Maybe
No
For each service or activity which we submit claims for, we have copies
of regulations or billing guidance showing that it is appropriate for an
FQHC to bill for in our state and settings.
We have written clinical documentation guidelines to ensure our
providers understand how to show medical necessity and to suppor
appropriate coding based on patient services provided.
We regularly review the coding of services, provider, and location of
service for accuracy and appropriateness.
After initial implementation and each software change, and at least once
annually, we review the billing generated by our electronic system for
accuracy and appropriateness.
We maintain a system for concurrent monitoring and retrospective
auditing of revenue cycle processes and accuracy and appropriateness
of claims submitted.
The results of our monitoring and auditing activities are appropriately
shared with board, providers, and staff.
88
Questions???
89