Transcript The Dynamics of Implementing HIPAA in the AR –

Finding your lost revenue and keeping it
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 CAHs
have similar services = same as OPPS
hospitals
 CAHs have different claim submission rules
for outpt to inpt but documentation of
billable services are the same.
 CAHs are paid differently than the OPPS
hospital, but the rule for billable services are
the same.
 EXCEPTION: J codes/pharmacy are only
required for LCD/NCD drugs; G codes for
OBS. CAHS are paid by billed charges/outpt.
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 Does
the order match the service that
matches the billed item/UB- the 3 step!
(charge/chart audit)
 Hot
spots for audit:
Wastage – SDV vs MDV; SDV wastage must
be documented to bill. No ability to bill
wastage with MDV. (CMS pub 100-04 Chpt 17, section 40)
Nursing, pharmacy, RT, imaging, anesthesia = hot!
Original order changed after receipt.. Did
referring physician’s order change in the record?
Protocol – must be ordered pt specific
(OB, LAB, Imaging, RT, pharmacy, others?
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Lost
Charges/Revenue
Daily Charge Reconciliation
Cost of Late Charges
And
easy chart/charge audit
ideas to identify
documentation challenges and
charge alignment
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 Recovery
– house wide – up to 4-6 hrs
 Nursing services in ancillary areas
 Drug Administration – Observation
 OB –HBC scheduled visits, delivery
rates/levels, labor levels, unplanned
 Hospital based clinics – E&M visits
 Blood transfusion – house wide
 Scheduled procedures done in the ER
 OR – Implantables & invoice reconciliation
 OR – unscheduled, interrupted/7x modifer
 Ancillary – reduced/52 modifier
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 Department
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Benchmark UB04 audits:
Compare 10 UB-04/billing documents against the
itemized statement– Outpt areas 1st (Obs, ER, Surgery,
Hospital based clinics/IV therapy/Chemo)
Look for potential lost charges (ER: sutures but no
procedure)
Look for billing combinations that were missed:
250/pharmacy –how was it given? IV Infusion, injection
Look for non-billable items present: Medicare outpt self
administered medications/pt pays; routine supplies
Look for descriptions that won’t pass the ‘Mom’ test
Look for charges that are not uniform across the facility
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 Not
‘new revenue’ but lost revenue
 Question: “What services are we currently
not billing for or costs that we are not
covering?”
 Brainstorm with department heads, compile
a master list and start looking – primarily
outpatient but limited inpt.
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 Nursing
is not good at charge capture..so…
 Aggressively look for ways to move ownership
with nursing still responsible for charting,
not charging:
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Lab – Blood Transfusions/36430. Auto have Blood
products/P + 36430 bill together. (Safety net: billing edit
to reject any claims without both 390 and 391 present.)
Charge Capture Analyst – identifies charges, completes
charge ticket and logs all lost charges due to missing
documentation. Nursing’s partnership is to ensure the
start and stop times of each bag are present. CCA ‘s
partnership is charge capture. WORKS!
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 Daily
Dept-Specific Audits:
 Compare scheduled/resulted/completed
patients against charges generated. (2 day
lag)
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Manual schedules or automated
Registrations with no charges. Why?
Ensure each patient activity is accounted for.
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Focus on high stress/severity of illness
areas
Focus on labor intensive processes
Ask all depts to look for potential lost
revenue
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Code Blue – how is nursing assuring charges made it
to the bill? Drugs? Supplies? 92950/Cardiac Arrest?
Procedures done?
“Sticky” for supplies – nursing has them on their
clothing. Who do they belong to? How many go
down on the sheets?
Patient complaints – once research, corrected claim
–but is research done to determine who the charge
really does belong to?
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 Drug
adm – nursing floating outside the care
area. Who is completing the charge ticket?
 OB – look at the aspects of outpt : ER to OB;
scheduled visits; post inpt
discharge/lactation HBC visit, delivery rates
 Scheduled visits in the ER – bill as a HBC visit
 Drop in pts for after care as an outpt – bill as
a HBC visit (suture removal, follow up care)
 All Drug Adm and Blood –outpt housewide
 Physician orders, medically necessary
services, E&M leveling for all HBC visits,
incident to the physician
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 Rework
– to the
individual dept, to
PFS and the pt –as
they get corrected
bills/EOBs
 Reprocessing the
claim, lost
productivity
 Lost Revenue with
limited
accountability
 Decreased
patient
satisfaction
 Track and trend
repeat late
activity, dept
specific
Do dept
heads know
what a late
charge is?
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The Medicare Reimbursement Manual defines Routine Services in
2202.6 on page 22-7:
“Inpatient routine services in a hospital or skilled nursing facility
generally are those services included by the provider in a daily service charge—
sometimes referred to as the “room and board” charge. Routine services are
composed of two broad components: (1) general routine services, and (2) special
care units (SCU’s), including coronary care units (CCU’s) and intensive care units
(ICU’s). Included in routine services are the regular room, dietary and nursing
services, minor medical and surgical supplies, medical social services, psychiatric
social services, and the use of certain equipment and facilities for which a separate
charge is not customarily made.
“In recognition of the extraordinary care furnished to intensive care, coronary
care, and other special care hospital inpatients, the costs of routine services
furnished in these units are separately determined. If the unit does not meet the
definition of a special care unit (see § 2202.7), then the cost of such service cannot
be included in a separate cost center, but must be included in the general routine
service cost center. “ (See § 2203.1 for further discussion of routine services in an
SNF.)
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Top At Risk Issues for Pt
Status Audits
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2 MN rule is alive and well
AND we are looking ‘back to
the future’ with an enhanced
definition of ‘rare and
unusual.’
Still use the physician’s
documentation of ‘why an
inpt’ but if the provider
cannot estimate 2 MN
/Presumption –then declare an
inpt with rationale for
‘severity of the
condition/intensity of the
care’ that will require in
hospital care. HUGE AUDIT
RISK!
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QIO/level 2 appeal group will
perform all audits (more peer to
peer)
High volume of ‘rare and unusual’
flagged for audit = RAC
RAC lookback to 6 months from
date of service/30 days to
review=more changes but only
with new RACS
No change to SNF
No Short Stay DRG
Comments accepted thru 8-31
http://www.americanbar.org/publications/aba_health_esourc
e/2014-2015/july/wading.html (The HealthLaw Partners)
https://www.cms.gov/Newsroom/MediaReleaseDatabase/Factsheets/2015-Fact-sheets-items/2015-0701.html?DLPage=1&DLEntries=10&DLFilter=two%20midnight
&DLSort=0&DLSortDir=descending
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RAC 2013
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ALL PAYERS
 Admit to inpatient
 Diagnosis
 Reason for
Admit/Plan for
why an inpt for dx.
 All part of a predetermined order
set.(Ques in the
EMR or paper)
2015
 MEDICARE
ONLY
 “Clarify” that the LOS is an
estimated 2 MN/Presumption
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“Clarify’ that after the 1st
outpt MN, a 2nd ‘in hospital’
MN is required/Benchmark
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After 1-1-15, provider still
outlines why the 2 MN, what is
the plan that will take 2 MN. No
longer ‘certify’ but still needs to
clarify the order/signed prior to
discharge and rationale for the 2
MN. (Do certify 20 day
mark/outlier)
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Critical Access Hospital – must
still certify initial 96 hrs and
again, at the 96 hr mark.
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 Does
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the physician clearly state: Why an inpt?
What is the plan that will take 2 MN/Medicare? For nonMedicare – why can’t the pt be treated safely as an outpt.
(Same issues as Medicare-just no 2 MN declaration)
Medicare/only-If the pt needs a 2nd MN after 1 MN as an
outpt – what is occurring with the pt’s condition that will
‘push the pt’ to stay a 2nd MN? Convert to inpt and
include: Why?
 Mgd
Care Medicare/PartC/Medicare
Advantage – HIGH AT RISK. What criteria are they
using? Get it in the contract! NOT SUBJECT TO
TRADITIONAL Medicare rules
 Commercial
Mgd Care or Commercial- who
knows? Makes their own rules for disallowed charges.
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
USA July 27th reported
2 huge potential
purchases:
Anthem BX purchase of Cigna
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lack of inpt certifications:
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Long LOS in obs with no ‘rules’ for
conversion to inpt
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Each payer gets to define their own
coverage rules
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Following the 2 MN Medicare
Traditional rule AND clinical
guidelines. (EITHER Interqual or
Milliman.)
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Levels of appeal clearly included –
clarify why not following the 5 levels
within CMS’s process. Timelines for
each and who does what.
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Denials of coverage ‘after discharge’
as the pt ended up getting better
faster/not as sick as presented on 1st
contact/ other
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HAVE AN ATTORNEY READY !!
Aetna purchase of Humana
Making United the last of the 3
powerhouse companies.
WATCH: Denial for the catch phrase:
not medically necessary! MEANS?
Negotiating will be more difficult.
Ensure there is arbitration in all
contracts.
Define an inpt-with no ability to do
retro denials ‘after discharge.”
Timelines to certify inpt status.
2015
Hot issues with denials or
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
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2midnight presumption
“Under the 2 midnight
presumption, inpt hospital
claims with lengths of stay
greater than 2 midnights after
formal admission following the
order will be presumed
generally appropriate for Part
A payment and will not be the
focus of medical review efforts
absent evidence of systematic
gaming, abuse or delays in the
provision of care.
Pg
CLEARLY –At the point of
conversion – WHY AN INPT for
a 2nd MN?
2015
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Benchmark of 2 midnights
The new Medicare Inpt
“the decision to admit the
beneficiary should be based on
the cumulative time spent at
the hospital beginning with the
initial outpt service. In other
words, if the physician makes
the decision to admit after the
pt arrived at the hospital and
began receiving services, he or
she should consider the time
already spent receiving those
services in estimating the pt’s
total expected LOS.
Pg 50956
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
EX) Pt is an outpt and is receiving
observation services at 10pm on
12-1-13 and is still receiving obs
services at 1 min past midnight on
12-2-13 and continues as an outpt
until admission. Pt is admitted as
an inpt on 12-2-13 at 3 am under
the expectation the pt will require
medically necessary hospital
services for an additional
midnight. Pt is discharged on 12-3
at 8am. Total time in the hospital
meets the 2 MN
benchmark..regardless of
Interqual or Milliman criteria.

ER, Observation, outpt surgery =
all included in the 2 MN
Benchmark.
2015
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Ex) Pt is an outpt surgical
encounter at 6 pm on 12-21-13 is
still in the outpt encounter at 1
min past midnight on 12-22-13 and
continues as a outpt until
admission. Pt is admitted as an
inpt on 12-22 at 1am under the
expectation that the pt will
required medically necessary
hospital services for an additional
midnight. Pt is discharged on 1223-13 at 8am. Total time in the
hospital meets the 2 MN
benchmark..regardless of
Interqual or Milliman criteria.
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
After the 1st MN as an outpt – anywhere – or the
first MN in another facility and transferred in –
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“The decision to admit becomes easier as the
time approaches the 2nd MN, and the
beneficaries in necessary hospitalization should
NOT pass a 2nd MN prior to the admission order
being written.’ (IPPS Final rule, pg 50946)
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Never, ever, ever, ever have a 2nd medically
appropriate MN in outpt..convert, discharge or
free…
2015
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If the beneficiary has already
passed the 1 midnight as an
outpt, the physician should
consider the 2nd midnight
benchmark met if he or she
expects the beneficiary to
require an additional midnight
in the hospital. (MN must be
documented and done)
Note: presumption = 2
midnights AFTER obs. 1
midnight after 1 midnight OBS
= at risk for inpt audit but still
an inpt.
Pg 50946
2015
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..the judgment of the physician
and the physician’ s order for inpt
admission should be based on the
expectation of care surpassing the
2 midnights with BOTH the
expectation of time and the
underlying need for medical care
supported by complex medical
factors such as history and
comorbidities, the severity of
signs and symptoms , current
medical needs and the risk of an
adverse event. Pg 50944
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It never has and never will mean – “meeting clinical
guidelines” (Interqual or Milliman)
It has always meant – the physician’s documentation to
support inpt level of care in the admit order or admit
note.
SO –if UR says: Pt does not meet Criteria – this means:
Doctor cannot certify/attest to a medically appropriate 2
midnight stay – right?
11/1/2013 Section 3, E. Note: “It is not necessary for a
beneficiary to meet an inpatient "level of care" by
screening tool, in order for Part A payment to be
appropriate“
Hint: 1st test: Can attest/certify estimated LOS of 2
midnights? THEN check clinical guidelines to help clarify
any medical qualifiers… but the physician’s order with
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ROA – trumps criteria. RAC 2014
J5
5PC01
Documentation does not support services
medically reasonable/necessary
5PC02
Insufficient documentation
5PC12
Order missing
5PC13
Order unsigned
5PC15
Certification not present
5PC17
No documentation of 2-midnight expectation
J8
2015
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Denial Reason
% Denials JH
% Denials JL
Documentation did not support two
midnight expectation (did not support
physician certification of inpatient
order)
56%
53%
No Records Received
16%
17%
Documentation did not support
unforeseen circumstances
interrupting stay
4%
3%
No inpatient admission order
9%
15%
Admission order not validated/signed
11%
11%
Other
4%
1%
2015
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
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1st round:
 35% denial rate

REASONS:

2nd round:
 36% denial rate
REASONS:
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55% failed to document need
for 2 MN
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40% failed to document need
for 2 MN
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45% failed admission order
requirements
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60% failed admission order
requirements
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48% signed after discharge
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39% order missing from the record
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13 % order not signed
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35% order missing from record
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17% order not validated
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8% order not signed (as of 2-11-15)
MAC recommendations:
Providers document their
decision making process.
Paint a clear, concise
picture of the pt.
2015
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 Begin
with the 1st point of contact – ER,
direct or Surgery
 Why is the pt not safe to be discharged/ED?
 Why is the surgery an inpt if the CPT is not
on the inpt only list? (Medicare only)
 What provider laid out a plan for why 2 MN
for a direct admit to the floor? Did the
hospitalist see the pt immediately? Did UR
talk to the ordering provider?
 Who is validating status for transfers in? Who
is asking both the sending and the receiving
the 2 MN question? Count 1st in sending.
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Day Egusquiza, Pres



[email protected]
208-423-9036 Free Info Line
www.arsystemsdayegusquiza.com
“Finding HealthCare Solutions… together”
P.O. Box 2521
Twin Falls, ID 83303
(208) 423-9036
[email protected]
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At least quarterly, take a small sample and
compare orders, against documentation of
service, against actual billed service against the
UB.
 Ensure they all match –consider:
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Protocol vulnerabilities
LCD/NDC limitations
Physician orders present
Documentation to match the order
Severity of illness /doctor w/intensity of
services/nursing - inpt
Evaluate the impacts of the hybrid medical record
DEVELOP CORRECTIVE ACTION with compliance
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 For
charge capture to work, each
individual must understand their role in
the process.
 Explore observing each area, 24 hr shift
 Develop charge capture internal manual –
addressing manual process, order entry,
and other, more unique processes – pods,
HIM, etc.
 Develop feedback process for Deptspecific auditing
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 Using
the ongoing department-specific audits,
create tracking systems/T-N-T
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Accuracy of claims
Revenue identified
Lost charges lost no more!
New understanding of ownership
Change of culture
REPORT progress at Dept head meetings
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Diagramming the process flow for updating, changing, etc. the
CDM-including assessment the volume of items for activity
level.
Reviews all new or change items to the CDM with a focus on
standardizing like items, looking throughout the organization
for other areas providing similar services and educating on
same. (Focus on Routine supplies)
Providing yearly department head education on CDM issues.
Like-Item Pricing audits – as new items are added to specific
area.
FOCUS ON PATIENT FRIENDLY
and SIMPLIFY!
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