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BRIDGING THE GAP BETWEEN CONFUSION AND CLARITY IN HEALTHCARE
National Physician Advisor ConferenceNPAC2019
The Physician Advisor in the Revenue Cycle:First Touch to Final Payment
R. Phillip Baker, MDMedical Director Case Management and Physician AdvisorSelf Regional HealthcareGreenwood, SC
Day EgusquizaPresidentAR Systems, IncTwin Falls, ID
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• Pre-admission – both clinical (common) and financial (less common)• Estimates, insurance coverage/limits, pre-authorization, discharge planning,
home safety
• Registration – interviews the patient to update historical data base and sign pertinent paperwork• Consents/HIPAA, notice of payment responsibilities, correct payer information.
• Charge capture – each department has responsibility to input their own charges that can be done in multiple ways• Bar coding, auto thru ‘finalizing’ the order, order entry with data entry/selection.
Exception: Drug administration /outpt and ER E&M/facility can be done by a dedicated, trained charge capture analyst.
First Touch – The Beginning of the Revenue Cycle
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• Coding by HIM- soft coding/usually 0-69999 CPTs require reviewing the documentation to identify the correct CPT code. Should match the professional component. ICD -10 for all inpt and outpt services.
• Charge master/CDM – hard coding/usually 70000-99999 CPTs are loaded into the charge master. Charges are attached to each charge number that creates an itemized statement. The CPTs and charges move to a UB-04/facility that is sent to all payers. Payers pay according to the individual payer contracts. Patient portions are based on ‘allowed charges/payer specific’ for insurance. Non-insurance patients payment is billed charges or request for financial hardship = less due than full billed charges.
And more data elements within the Revenue Cycle
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• Claim’s Submission/Billing by PFS/BO – UB-04 is created during a ‘nightly run’ where all charges are gathered from all sources and 1 document is created. It has revenue codes = departments, CPT codes = clarify what was done, ICD -10 = support the reason for the procedure. If the pt is registered as Inpt/Bill type 111 – then it goes as inpt. The registration drives the bill type. (131/outpt)
• Edits – when submitting claims, many payer-specific ‘edits’ occur. This includes national coverage determination edits and local coverage determination edits. All result in the claim ‘rejecting’ when going thru the claim ‘scrubber’ – with action required to clear the account to be submitted. Edits use CPT and ICD-10 matches to determine ‘pass or fail.’
And more …
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• Out of network penalties- “Surprise Bills”. Few patients understand their out of network penalties. • Another deductible is due; pt owes full billed charges as no contract-
therefore, no reduction from billed charges.
• More difficult – Providers within the in-network hospital who are not contracted when the hospital IS contracted. • ER providers, rad docs/interprets, reference labs/send outs,
consultants/specialist. • What patient even knew or had the ability to say – “Hey, are you in my
network?” There are ways to address this –such as only billing the pt the amount they would owe if they were in-network, but it is not required nor universally done. Usually only by an irate patient. (Thus- new legislation-“Surprise bill ‘ limitation on out of pocket.)
And more …
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• Downgrades – DRG re-assigned. Should only be done after request for records. Closely monitored by the site when sending records.
• Disputes – Inpt was billed; records may be requested as an appeal or initial submission for inpt was disputed and the hospital sent the INPT anyway. Surprise – full denial. (Inpt = bill type 111; OBS/outpt = 131)
• Denials – 30 day readmission for ‘related’ services. Caution: Chronic conditions. There are up to 10 ICD-10 dx codes on the UB. Which one has to be a match to be related? And in which position – primary, secondary, etc? Huge concern.
• AND REMEMBER – many payers are not allowing P2P calls AFTER the claim has been processed. Then a formal appeal must occur.
And if the claim is not paid according to submission … 3 D’s
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• Mergers and Acquisitions: Many site-specific functions have now moved to a central, offsite location. Many facilities are rolled into 1 central Business Office.
• System offices: Coding, charge master, claim submission, rejections, explanation of benefits/EOBs from payers, contracting and denial software for tracking and trending. How does this information get moved forward to effect change? One of the downsides of ‘bigger’ – hard to find the ‘right person/people’ to effect change. Who reports to who? Dir of Revenue Cycle, Bus Office Mgr, Contracting, CFO, COO?
• 40+ years: No physician advisor to ask about the ‘clinical denials’, to help with words no one understands, or to help when trying to improve physician documentation according to the back end denials. UM operates and reports to nursing more than finance.
• SILOS ARE ALIVE AND WELL… and my turf needs protection…..
What has changed in our internal Revenue Cycles?
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1. Initial Bridge Design: Points where the Physician Advisor can impact revenue cycle
2. Location: Resources needed
3. Environmental Impact Studies: Potential gain for interventions
4. Viability of Bridge Project: Long-term return on investment
5. Real life impacts outlined
Objectives
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Denials Management Peer to Peer Discussions Appeals writing Physician education in denials prevention Relationships with Payer Community- friend or foe Probe Reviews, RAC, MAC, OIG, CERT, ZPIC, etc., if they audit I get
involved Service Line data reporting
Governmental Regulation Compliance Regulatory Changes in Payment for Observation Services, OPPS Two Midnight Rule Compliance Self Audits for overpayment 0-1 Midnight Stay Reviews
Case Management Status Reviews Condition Code 44 Encourage Physician Involvement in Discharge Planning Process Hospital Compliance with new discharge planning regulations Notice Act (Notice of Observation Treatment and Implication for
Care Eligibility) or how to MOON our patients Utilization Review Committee Compliance with Inpatient Only Procedures Surgery Precert Compliance Long Stay Accounts
CDI Team Physician Champion Encourage Physician Compliance with Query Process
Medical Staff Education on Documentation and Coding and how these affect quality and yes payment
Medical Staff Education on the Future of Healthcare Payment Models Value Based Purchasing
Clinically Integrated Care
Bundled Payments –BPCI Advance
HCC Coding
Peer Review Committee
Accountable Care Organization Manage Spend per Beneficiary
Post Acute Care Utilization
Funds Flow for shared savings
Manage downside risks
Building the Bridge – Structural Components
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• Physician Advisor – site supervisor
• Director of Patient Financial Services
• Director of Managed Care
• Corporate Compliance
• Director of Case Management
• Denial and Appeal Lead
• CDI Team Lead
• RAC/MA Coordinator
• PFS Follow Up Team
• Self Medical Group Director of Billing
• CFO – The Buck Stops Here – The rest flows downhill
Construction Crew – Ensure Wide Range of Strengths
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• Case Management involvement as soon as possible
• Payer Matrix with what information to each payer and how does the payer look at inpatient
• Status Reviews a frequent starting point for many Physician Advisors
• Long Stay Committee
• Centralized follow up with payers and escalation to Physician Advisor for follow up
• Process for IPO Cases and surgery precertification
Making Sure the Foundation is Strong
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• Peer to Peer as two-way education - $2,500,000 average return
• Building relationships with the payer Medical Directors – some help grease the wheels, yet others are the monkey wrench
• Avoiding delays in post-acute care approval – it’s not always the payer
• Provide feedback to the Medical Staff as to why they are getting those calls from the Case Managers and support to the Case managers in dealing with difficult medical staff
Physician Advisor as the Bedrock to Support the Structure
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• Regulatory Updates
• Short Stay Audits – Top 175 hospitals for short stays in the QIO Region
• TKA process
• TPE – self auditing to get ready for known audits –• Spinal Fusion 0% denials with state average 28%• Total Joint only lost one case after providing education to the practice
about necessary documentation (1/30 cases passed audit prior to beginning the TPE)
Understanding Construction Risks
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• Contracted versus non-contracted: what impact does it have
• Post discharge discussion where only observation is approved
• Denials management - $4,000,000-5,000,000 overturns per year with an overall hard denial write offs of 0.5% of revenue (3-6% revenue at risk in “soft denials”)
• Service Line Education
• Compliance with “Two Midnights" built into our hospitalist’s bonus structure
• Discharge Delays for SNF precertification
• Coding and Clinical Validation Audits – SEP 3, AKI, UHDDS, AHA Coding Clinic
• New Device or Procedures in Service Lines – TAVR, LYNX
Construction Regulations and Change Orders
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• BPCI Advance - initially took on 13 bundles• Evaluate the data• CC, MCC capture rate, and HCC coding• Post Acute Care utilization• Readmission• Opt Out period with no penalty
• ACO increasing risk models – 1+ Model with downside risk• Year 3 MSSP $16,380,000 savings• Ranked 21st total savings (162/472 ACO’s generated savings), 6th in quality
• HCC Coding Education for providers
Bridge Maintenance or Upgrades
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• Know the crew both inside your facility and from the payer side
• Understand the regulations for contracted versus non-contracted
• Track the data and know your vulnerabilities
• Educate the C-Suite and the Medical Staff
• Physician Advisors are a key component of any facility’s revenue cycle
• It takes a community to stay current with all the developments:• ACPA Website• RAC Relief Google group• Fellow Physician Advisors or ACPA Board Members
Summary
www.acpadvisors.org
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Office Phone 864-725-5589
Cell Phone 867-993-6863
Contact Information
Thanks for Joining Us in this Educational Journey…
Day Egusquiza, President
AR Systems, Inc
PO Box 2521
Twin Falls, Idaho [email protected]
208 423 9036 http://arsystemsdayegusquiza.com
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