CRCE Billing Coaching Session - s3.amazonaws.com · 08.07.2016 · 7/7/2016 2 Insurance Plans / Payers insurance payers Assigning correct insurance filing order (coordination of benefits)

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July 8, 2016

Introductions◦ Kristina Donohue, CRCE-I, CRCS-I

◦ Steven F. Honeywell, MBA, CRCE-I / P

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)

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.)

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

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

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

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

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

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)

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)

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.

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

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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General Considerations

◦ Patient Rights

◦ Fraud & Abuse protection

◦ Date Storage & Recovery

◦ Administrative Simplification

Role of ANSI in establishing standard transactions for EDI

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.

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

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

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

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**

◦ 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







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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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

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

Fee schedule

◦ Outpatient Services

◦ Resource-Based Relative Value Scale (RBRVS)

◦ Usual, Customary, and Reasonable

◦ Third-Party Payers

◦ Data Accumulation

◦ Limited Ability for Negotiation

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

Capitation◦ Definition◦ Disadvantages

Per Diem◦ Definition

Percent of Charges◦ Definition

Fee-for-Service◦ Definition







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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

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.

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







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]

https://en.wikipedia.org/wiki/Durable_medical_equipment#cite_note-1

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◦ Examples of DME

Crutches

Wheelchairs

Hospital Beds

Oxygen Concentrators

DMEPOS◦ Short for durable medical equipment, prosthetics,

orthotics, and supplies.

DMERC◦ Regional carrier that processes claims for DMEPOS

Billing◦ Separation

◦ Required Items

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

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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Timely Filing

◦ Examples

◦ Consequences

Late Charges

◦ Definition

◦ Causes

◦ Handling

1-Day & 3-Day Payment Window

◦ Previously called 72-hour rule

◦ Regulation Details

◦ Examples

◦ Attestation

◦ Ensuring Compliance







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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

Present on Admission (POA) Indicators◦ Purpose

Hospital Acquired Conditions (HAC)

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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Redetermination

Reconsideration

Administrative Law Judge

Review by the Medicare Appeals Council

Judicial Review by the Federal District Court







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Importance◦ Cash Flow

◦ AR Days

◦ Turnaround Time

◦ Duplicate Claims

◦ Compliance

◦ Payer Issues

Recommended Process

Monitoring







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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Determining Needs

Criteria

Considerations◦ Reporting

◦ Edits

◦ Access

◦ Billing

◦ Interface

◦ Support & Maintenance

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

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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Critical Functions

Resources

General Requirements





Compliance

Employee Management

Performance Measurements

Billing Edits

Billing Benchmarks

Payer Requirements

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Importance

Hospital’s Needs

Result

Questions?

Thank you for attending! Please plan on joining us on August 14th for the Credit & Collections Session.

Keep Studying!

Documents

CRCE Billing Coaching Session - s3.amazonaws.com · 08.07.2016 · 7/7/2016 2 Insurance Plans / Payers insurance payers Assigning correct insurance filing order (coordination of benefits)