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July 8, 2016
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Introductions◦ Kristina Donohue, CRCE-I, CRCS-I
◦ Steven F. Honeywell, MBA, CRCE-I / P
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The objective of the Billing portion of the AAHAM exam is to test your knowledge with regard to getting an appropriate claim to the payers and getting paid in a time manner.
When you are done studying for this section, you should have comprehensive knowledge of the different types of insurance plans, coordination of benefits along withchargingand payment methodologies
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Insurance Plans / Payers insurance payers
Assigning correct insurance filing order (coordination of benefits).
Impact of HIPAA on medical billing
Importance of maintaining the charge master
Various payment methodologies and formulas
Locum Tenens physician can bill
Billing for Durable Medical Equipment (DME)
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There are two generic categories of insurance payers – Governmental and Non-Governmental payers.
There are many subsets within these two generic categories with all sorts of variations regarding a patient/subcriber’s participation enrollment.
Some of these variations take into consideration: - Patient’s age
- Patient’s financial status
- Type of plan (fee for service, capitated, managed care etc.)
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Medicare (aka Title XVIII)
Medicaid
Veterans Affair’s (VA)
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Also known as Title XVIII
Established in 1966
Requirements Age 65+ Permanently Disabled End Stage Renal Disease
Four Levels of Coverage Part A – Hospital Insurance Part B – Medical Insurance Part C – Medicare Advantage Part D – Medicare Prescription Drug Plan
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Other Important Medicare phases you should be familiar with:
◦ Funded via the Federal Government
◦ Medicare Administrative Contractor (MAC)
◦ Medicare Participating Physician Program
Becoming a Par Provider / Accepting Assignment
◦ Medigap coverage
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Also known as Title IX
Established in 1965
Assure medical coverage for the medically vulnerable and financially indigent population
Shared Funding w/ Federal & State Gov’t
Patients can be dually Eligible for Medicare/Medicaid
Medicaid is the payer of last resort
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Commercial
Self-Insurance
Health Savings Accounts
Worker’s Compensation
Liability
Tricare
Children’s Health Insurance Program ( CHIPS)
Self- Pay
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Commercial◦ Covered Individuals◦ Payer Examples◦ Cost-control Mechanisms
Self-Insurance
◦ Definition◦ Advantages & Disadvantages◦ Stop-Loss Coverage◦ Employee Retirement Income Security Act (ERISA) (1974)
Health Savings Accounts◦ Definition◦ Disposition of Unused Funds
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Workers’ Compensation
◦ Coverage for individuals injured in the course of performing his or her job duties
◦ Information Gathering
Liability◦ Property◦ Casualty◦ Auto◦ Med-pay/No-fault◦ Liability
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TRICARE (previously known as Champus)
◦ Active-duty service, spouses & dependents
◦ Retirees (unless Medicare eligible)
◦ Member eligible on the first day of active orders, others are eligible after the member is active duty for 30 days
◦ Defense Enrollment Eligibility Reporting System (DEERS)
◦ Non-availability Form
◦ Claims are sent to the region based on the member’s home address
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Children’s Health Insurance Program (CHIP)
◦ Also known as Title XXI
◦ Previously called State Children’s Health Insurance Program (SCHIP)
◦ Established in 1997
◦ Uninsured children & pregnant women with income too high to qualify for state Medicaid programs
◦ Programs are designed by the state (within federal guidelines)
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Self-Pay
◦ True Self-pay is defined as patients without insurance
◦ Numerous Reasons for being self-pay
Unemployed Self-employed No plan offered by employer or plan is too expensive -ACA By choice
◦ Self-Pay related Discounts
◦ Charity Care
◦ Self-Pay Balance Due after insurance
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Describe types of insurance and insurance payers
Determine proper coordination of benefits
Describe the impact HIPAA has had on billing
Explain the purpose and importance of chargemaster updates
Describe payment methodologies and methods to determine the value of services
Describe circumstances under which a Locum Tenens physician can bill
Define and give examples Durable Medical Equipment (DME)
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Coordination of Benefits (COB) is the determination of which insurance is the appropriate primary payer vs. secondary payer etc.
Medicare is the most common payer that involves Primary vs. Secondary coverage consideration.
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Laws governing the determination of coverage.
Consolidated Omnibus Budget Reconciliation Act (COBRA) of 1980
Omnibus Budget Reconciliation Act (OBRA) of 1987
Tax Equity and Fiscal Responsibility Act (TEFRA) of 1982
Deficit Reduction Act (DEFRA) of 1984
Balanced Budget Act (BBA) of 1997
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Medicare – Primary vs. Secondary
◦ Situations where Medicare would be considered as secondary payer: Workers’ Compensation
TPL or No-Fault
VA
End Stage Renal Disease (ESRD)
Clinical Research Trial
Active employment coverage if employee is over 65 and employer has >20 employees
Active employment if employee is disabled and employer has >100 employees
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Other Determining Factors◦ GHP (Group Health Plan Insurance)
◦ Medicaid is payer of last resort (except when Indian Health Services is involved)
◦ TRICARE is payer of last resort unless a supplemental plan is purchased
◦ Liability/Property/Casualty/Auto
◦ Two Commercial Payers Birthday Rule
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Describe types of insurance and insurance payers
Determine proper coordination of benefits
Describe the impact HIPAA has had on billing
Explain the purpose and importance of chargemaster updates
Describe payment methodologies and methods to determine the value of services
Describe circumstances under which a Locum Tenens physician can bill
Define and give examples Durable Medical Equipment (DME)
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General Considerations
◦ Patient Rights
◦ Fraud & Abuse protection
◦ Date Storage & Recovery
◦ Administrative Simplification
Role of ANSI in establishing standard transactions for EDI
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Health Insurance Portability & Accountability Act
HIPAA took effect on April 14, 2003.
A law designed to provide privacy standards to protect patients' health information provided to health plans, doctors, hospitals and other health care providers.
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Developed by the Department of Health & Human Services, these new standards provide patients with access to their medical records and more control over how their personal health information is used and disclosed.
Provides guidelines for standard transaction sets for electronic communication of information.
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Standard Transactions
Code Transaction
270 Healthcare Eligibility Inquiry
271 Healthcare Eligibility Response
275 Attachment
276 Healthcare Claim Status Inquiry
277 Healthcare Claim Status Response
278 Referral Certification and Authorization
354 Claim Status Response
820 Health Plan Premium Payments
834 Enrollment and Disenrollment in a Health Plan
835 Healthcare Payment and Remittance Advice
837D Dental Claim
837I Institutional Claim
837P Professional Claim
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Mandated Transaction Code SetsCode Set Acronym Use
International Classification of Disease
ICD (ICD-9, for the ninth revision*)
Diagnoses and inpatient procedures
Current ProceduralTerminology
CPT (CPT-4, for the fourth revision)
Outpatient procedures
Healthcare Common Procedure Coding System
HCPCS Outpatient procedures
National Provider Identification
NPI
Provider identification, as dictated by CMS’s Administrative Simplification Identifier Standards
Taxonomy CodeType and specialty of a provider
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ICD-9-CM (Clinical Modification)◦ Recently replaced by ICD-10
◦ Designed to provide for universal, consistent and accurate coding of medical diagnoses and procedures
◦ The ICD manual is organized into 3 sections:
◦
Tabular List
Alphabetic List
Procedures
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ICD-10 provides for the following information in order to allow for accurate coding
Diagnostic Statement
Alphabetic Index
Notes Related to Main Terminology
Modifiers
Subterms
Cross-Reference
Confirm in Tabular List
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CPT/HCPCS - Designed to provide for universal, consistent and accurate coding of medical services and procedures.
Coding is broken down into 3 sections:
Level 1: CPT Codes (Common Procedural Terminology)
Level 2: Alpha-Numeric Codes
**Level 3: State-Specific Codes not Allowed under HIPAA**
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◦ CPT provides very specific guidelines governing the coding for Medical Evaluation and Management types of services as well as other medical services and procedures
◦ Physician Medical services (Evaluation and Management Services – E&M ) require the consideration of the following seven items when determining how to code for a service. History Examination Medical Decision-Making Counseling Coordination of Care Nature of Presenting Problem Time Spent
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◦ While E & M services take into consideration numerous factors, the procedures and other services noted in CPT-4 are very specifically detailed and described.
◦ Many CPT codes can be further clarified/altered by the use of Modifiers.
◦ Some notable Modifiers are as follows:
25 – Separately Identified E&M service on same day as procedure
26 – Professional Component Only
50 – Bilateral Procedure
53 – Discontinued Procedure
77 – Repeat Procedure
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Describe types of insurance and insurance payers
Determine proper coordination of benefits
Describe the impact HIPAA has had on billing
Explain the purpose and importance of chargemaster updates
Describe payment methodologies and methods to determine the value of services
Describe circumstances under which a Locum Tenens physician can bill
Define and give examples Durable Medical Equipment (DME)
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Definition◦ A listing of all charges that might be posted to a patient
account; also called the fee schedule, item master, and other similar names.
Timely & Accurate Maintenance◦ Needs to be kept up-to-date and accurate for claims to
be correct and compliant with Gov’t and Payer requirements
◦ Should also match the superbill information.
◦ Requires a good understanding of CPT coding and procedures. Often times managed by committee.
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Describe types of insurance and insurance payers
Determine proper coordination of benefits
Describe the impact HIPAA has had on billing
Explain the purpose and importance of chargemaster updates
Describe payment methodologies and methods to determine the value of services
Describe circumstances under which a Locum Tenens physician can bill
Define and give examples Durable Medical Equipment (DME)
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Healthcare is probably the most unique product / service in the country with regard to how it is paid for…
◦ DRG (Diagnostic Related Groups)◦ APC (Ambulatory Payment Classifications)◦ Per Diem◦ Capitation◦ Fee Schedule
Fee For Service % of charges
◦ Inpatient Rehabilitation Facility (IRF)
◦ PPS (Prospective Payment System) Skilled Nursing Home Health
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Diagnosis-Related Group (DRG)
◦ Elements
◦ DRG as a Total Payment
◦ Major Diagnostic Category (MDC)
◦ MS-DRGs (Medicare Severity)
◦ Discharge Status
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Ambulatory Payment Classification (APC)
◦ Outpatient analogy of DRGs
◦ Medicare OPPS
◦ Structure
◦ Use of CPT/HCPCS
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Fee schedule
◦ Outpatient Services
◦ Resource-Based Relative Value Scale (RBRVS)
◦ Usual, Customary, and Reasonable
◦ Third-Party Payers
◦ Data Accumulation
◦ Limited Ability for Negotiation
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Skilled Nursing Facility PPS
◦ Resource Utilization Group (RUG) system◦ Minimum Data Set (MDS) Assessment◦ Consolidated Billing
Home Health Care PPS
◦ Requirements for Medicare Coverage◦ OASIS Assessment◦ RAP Billing◦ Consolidated Billing
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Critical Access Hospital (CAH)◦ Definition
◦ Payment Rate
Swing Bed◦ Definition
◦ Payment Implications
Inpatient Rehabilitation Facility (IRF)◦ Definition
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Capitation◦ Definition◦ Disadvantages
Per Diem◦ Definition
Percent of Charges◦ Definition
Fee-for-Service◦ Definition
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Describe types of insurance and insurance payers
Determine proper coordination of benefits
Describe the impact HIPAA has had on billing
Explain the purpose and importance of chargemaster updates
Describe payment methodologies and methods to determine the value of services
Describe circumstances under which a Locum Tenens physician can bill
Define and give examples Durable Medical Equipment (DME)
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Locum tenens, or substitute, physicians usually assume professional practices in the absence of a regular physician for reasons such as illness, pregnancy, vacation, or continuing medical education.
Also Known as - Reciprocal Agreement or Temporary Substitute
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The substitute physicians generally have no practice of their own and move from area to area as needed.
Medicare rules require that a locum tenens cannot provide services for longer than 60 continuous days at a time for another physician (unless the other physician has been called or ordered to active duty as a member of a reserve component of the armed forces)
The regular physician generally pays the locum tenens a fixed per-diem amount, with the locum tenens having the status of an independent contractor rather than an employee.
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The regular physician may submit the claim using the Q6 modifier.
The regular physician must keep on file a record of each service provided by the locum tenens along with the locum tenens' National Provider Identifier.
Under reciprocal billing arrangements, a patient's regular physician may submit a claim and receive payment for the services arranged to be provided by a substitute physician on an occasional basis.
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The regular physician should identify the service as substitute physician services and bill with the Q5 modifier (service furnished by a substitute physician under a reciprocal billing arrangement).
For commercial payers, the requirements may vary, making it necessary to determine billing procedures on a payer-by-payer basis
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Describe types of insurance and insurance payers
Determine proper coordination of benefits
Describe the impact HIPAA has had on billing
Explain the purpose and importance of chargemaster updates
Describe payment methodologies and methods to determine the value of services
Describe circumstances under which a Locum Tenens physician can bill
Define and give examples Durable Medical Equipment (DME)
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Durable Medical Equipment (DME) is any equipment that provides therapeutic benefits to a patient in need due to certain medical conditions and/or illnesses. Durable Medical Equipment (DME) consists of items that are:
◦ Primarily & Customarily used to serve a medical purpose;
◦ Not useful to a person in the absence of illness, disability, or injury
◦ Ordered or Prescribed by a physician;
◦ Reusable, can stand repeated use & appropriate for
use in the home.[1]
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◦ Examples of DME
Crutches
Wheelchairs
Hospital Beds
Oxygen Concentrators
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DMEPOS◦ Short for durable medical equipment, prosthetics,
orthotics, and supplies.
DMERC◦ Regional carrier that processes claims for DMEPOS
Billing◦ Separation
◦ Required Items
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Describe common or required ‘forms’ used in billing
Explain the significance of billing timeframes
Describe key Medicare edits and types of denials
Describe the five levels in the Medicare appeals process
Describe the importance and process of comprehensive follow-up in the Billing department
Describe the Medicare Summary Notice and its uses
List considerations for selecting a billing system
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UB04◦ Standard paper form for facility billing
◦ Structured form locators
◦ Governed by the National Uniform Billing Committee (NUBC)
837I◦ Standard electronic claim for facility billing
◦ Structured data fields called loops
Defined lengths
Allowable elements
Condition, Occurrence, Value, Revenue Codes
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Superbill 1500◦ Standard paper form for physician and non-
physician practitioner billing◦ Structured form locators
837P◦ Standard electronic form for physician and non-
physician practitioner billing◦ Structure data fields
837D◦ Standard electronic form for dental billing
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Describe common or required ‘forms’ used in billing
Explain the significance of billing timeframes
Describe key Medicare edits and types of denials
Describe the five levels in the Medicare appeals process
Describe the importance and process of comprehensive follow-up in the Billing department
Describe the Medicare Summary Notice and its uses
List considerations for selecting a billing system
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Timely Filing
◦ Examples
◦ Consequences
Late Charges
◦ Definition
◦ Causes
◦ Handling
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1-Day & 3-Day Payment Window
◦ Previously called 72-hour rule
◦ Regulation Details
◦ Examples
◦ Attestation
◦ Ensuring Compliance
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Describe common or required ‘forms’ used in billing
Explain the significance of billing timeframes
Describe key Medicare edits and types of denials
Describe the five levels in the Medicare appeals process
Describe the importance and process of comprehensive follow-up in the Billing department
Describe the Medicare Summary Notice and its uses
List considerations for selecting a billing system
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Correct Coding Initiative (CCI) & Outpatient Code Editor (OCE) Edits
◦ Edit Applicability◦ End Results◦ Edit Details
Medically Unlikely Edit (MUE) Program◦ Purpose◦ Error Examples◦ Appeal Restrictions
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Present on Admission (POA) Indicators◦ Purpose
Hospital Acquired Conditions (HAC)
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Incomplete, Invalid, and ‘Un-Processable’ Medicare Claims◦ Detection◦ Handling
Denials◦ Types
RTP
Line-Item Rejection
Claim Rejection
Claim suspension
◦ Next Steps◦ Tracking Denial Information
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Describe common or required ‘forms’ used in billing
Explain the significance of billing timeframes
Describe key Medicare edits and types of denials
Describe the five levels in the Medicare appeals process
Describe the importance and process of comprehensive follow-up in the Billing department
Describe the Medicare Summary Notice and its uses
List considerations for selecting a billing system
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Redetermination
Reconsideration
Administrative Law Judge
Review by the Medicare Appeals Council
Judicial Review by the Federal District Court
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Describe common or required ‘forms’ used in billing
Explain the significance of billing timeframes
Describe key Medicare edits and types of denials
Describe the five levels in the Medicare appeals process
Describe the importance and process of comprehensive follow-up in the Billing department
Describe the Medicare Summary Notice and its uses
List considerations for selecting a billing system
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Importance◦ Cash Flow
◦ AR Days
◦ Turnaround Time
◦ Duplicate Claims
◦ Compliance
◦ Payer Issues
Recommended Process
Monitoring
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Describe common or required ‘forms’ used in billing
Explain the significance of billing timeframes
Describe key Medicare edits and types of denials
Describe the five levels in the Medicare appeals process
Describe the importance and process of comprehensive follow-up in the Billing department
Describe the Medicare Summary Notice and its uses
List considerations for selecting a billing system
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Medicare Summary Notice (MSN)
◦ Previously known as Medicare Explanation of Benefits or Remittance Advice
Medicare summary notice refers to a notice that contains information about health insurance claims. MSN is sent to the beneficiary upon filing a part A and part B claim by a doctor for the services offered under the original medicare plan.
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Describe common or required ‘forms’ used in billing
Explain the significance of billing timeframes
Describe key Medicare edits and types of denials
Describe the five levels in the Medicare appeals process
Describe the importance and process of comprehensive follow-up in the Billing department
Describe the Medicare Summary Notice and its uses
List considerations for selecting a billing system
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Determining Needs
Criteria
Considerations◦ Reporting
◦ Edits
◦ Access
◦ Billing
◦ Interface
◦ Support & Maintenance
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Calculate the amounts for which insurance and patient will be liable for a given scenario
Describe the importance of compliance in claim billing and resource/strategies for ensuring compliance
List the responsibilities of a Billing Supervisor
Describe the importance of strong hospital-physician relationships and typical needs of each party
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Importance of Manual Calculations
Terms◦ Noncovered Service or Charge
◦ Coverage Percentage (Reimbursement Rate)
◦ Deductible
◦ Coinsurance
◦ Out-of-pocket Maximum
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Calculate the patient portion for the following: Insurance Contract = 15% write-off Patient Deductible = $1000 unmet Plan Pays = 90% after deductible Charges = $6000
Calculation:6000 x 85% = 5100 5100 – 1000 = 41004100 x 10% = 410 410 + 1000 = 1410Patient Responsibility = $1410
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Calculate the amounts for which insurance and patient will be liable for a given scenario
Describe the importance of compliance in claim billing and resource/strategies for ensuring compliance
List the responsibilities of a Billing Supervisor
Describe the importance of strong hospital-physician relationships and typical needs of each party
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Critical Functions
Resources
General Requirements
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Calculate the amounts for which insurance and patient will be liable for a given scenario
Describe the importance of compliance in claim billing and resource/strategies for ensuring compliance
List the responsibilities of a Billing Supervisor
Describe the importance of strong hospital-physician relationships and typical needs of each party
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Compliance
Employee Management
Performance Measurements
Billing Edits
Billing Benchmarks
Payer Requirements
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Calculate the amounts for which insurance and patient will be liable for a given scenario
Describe the importance of compliance in claim billing and resource/strategies for ensuring compliance
List the responsibilities of a Billing Supervisor
Describe the importance of strong hospital-physician relationships and typical needs of each party
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Importance
Hospital’s Needs
Result
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Questions?
Thank you for attending! Please plan on joining us on August 14th for the Credit & Collections Session.
Keep Studying!
