Transcript BC 835 to BST - HFMA - Great Lakes Chapter

BCBSM:
835 File to BST
Great Lakes HFMA
Reimbursement Update
September 26, 2014
Nancy Drury, CPA
Deborah Sieradzki, PhD
Lubaway, Masten & Company
• Blue Cross Cycle
• Blue Cross Payment Logs
• Interim Payment Review
• Monthly Contractual Model
and/or Balance Sheet Test (BST)
• Interim and Final Settlement
AGENDA
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• Blue Cross Substantial Part of
Hospital’s Business
• Due to administrative
complexities, it is challenging
to have a handle on the
process
• HUGE Negative Impacts
Why Do We Care?
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Blue Cross Cycle
File Cost
Report
Rebasing
IP and OP
Settlement
Rates
IP and OP
Vouchered
Rates
Vouchered
Claims
Monthly
Contractual
Model
Periodic
Balance
Sheet Test
BIP
Review
Initial
Settlement
Final
Settlement
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BLUE CROSS LOGS
Blue Cross Payment Logs
Maintaining accurate record of cleared claims
is ESSENTIAL for:
• Accurate settlement calculations for Financial
Statements
• Reasonableness of interim payments
• Accuracy of interim and final settlements
Easier said than done!!!!!
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Blue Cross Logs
• Logs are compilations of cleared charges
and other information summarized from
Electronic Remittance Advices (835).
• Data file “loops” so it’s impossible to
interpret volume of data without
converting data into readable format
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Sample 835 File
The 835 file contains payment, charge and statistical data
for each claim accepted. It contains rejection codes for
claims not paid. This data is posted to the hospital’s A/R.
Much of the data on the 835 is echoed back from
the 837 billing files submitted by the provider.
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Parse 835 File to Make Data Readable
• Once the 835 file has been parsed, save it in a human
readable file with titles.
• Detail is tied to Control Totals
• The data is then “Tweaked”
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Blue Cross 835 Files
Tricks ----- No Treats.
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LOGGING ISSUE #1:
KNOW WHAT’S IN YOUR BIP
• Receive MANY 835 files from Blue Cross
• Not all are included in BIP and settlement
calculation
• Includes both Professional and Hospital
• Includes BCBSM, FEP, MOS, NASCO, Medicare
Advantage, BCN, Blue Cross Complete,
Medicaid, Domestic Claims
• Knowing distribution schedule can help ID
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Logging Issue #2:
SIZE OF FILES
• Volume of 835 files are substantial – pick
and choose data elements to log
• Method of managing data – payer type,
software, claims cut-off date, etc.
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Logging Issue #3:
What you see is NOT what you get
What is clearing on the voucher as payment
may not be a good representation of your
settlement.
• DRG > Charge reimbursement
• Vouchered Rate ≠ Settlement Rate
• Differences can be substantial
• Need to determine how you will build into
model
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Vouchered Rates DO NOT EQUAL Settlement Rates
IP Settlement Rates
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+
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=
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+
=
Operating Cost per Case
Capital
GME
Bad Debt and Charity Care
Other
P4P
Inpatient Settlement Rate
Vouchering Differential
Trend Factor
Lesser Of Charge or DRG Adjustment
Vouchered Rate
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Vouchered Rates DO NOT EQUAL Settlement Rates
OP Settlement Rates
+
+
=
+
+
=
Fee Screen or Percent of Charges for Cost Based
OP Passthrough Factor
P4P
OP Fee Screen or Cost Based Settlement
Trend Factor
Adjustment to Passthrough Factor
OP Vouchered Fee Screen or Cost Settlement
Difference can be substantial!
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Logging Issue #4:
Know What Is Clearing
• Remove rejected claims and other excluded
from settlement (ie: domestic claims) if
applicable
• Understand zero pays
• Know your specific issues and decide how to
address – examples:
• Babies for Blue Care Network
• Claim Status 22
• No DRG Assignment
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Logging Issue #5:
Manual Adjustments Are Required
• 835 files are not always complete
• Blue Care Network files lack data essential to
get clearings in the proper buckets for
settlement – this needs to be input manually
• DRG # is included – weight is not. Need to
pull same period into logs from a separate
source document
• Take-backs are counted as a discharge
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Logging Issue #6:
So Many Codes!
• Properly categorizing patient data is essential
for properly calculating settlement
• Companion documents:
4010:
http://www.bcbsm.com/pdf/837_835_institutional_companion.pdf
5010:
http://www.bcbsm.com/content/dam/public/Providers/Documents
/835-companion-document.pdf
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Claim Status Codes
• Over 15 different status codes
• Examples:
• Claim Status #1 – Primary Claim
• Claim Status #2 – Secondary Claim
• Claim Status #4 – Denied
• Claim Status #22 – Reversal of Previous
Payment
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Type of Payment Indicator Code
• Determines what bucket the claims goes into
for settlement purposes
• 5 positions within the code that define the
claim
• Not every position is populated
• Currently know of 140+ combinations
• See companion guide for complete list
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Type of Payment Indicator Code
Position 1 – Voucher Codes
1=Inpatient Regular
3=Outpatient Regular
5=BC Complementary IP
6=BC Complementary OP
Position 2 – Accommodation Codes
0=BC-65 OP Complementary
1=Regular IP Hospital Admission
2=BC-65 IP Hospital Admission
3=Regular OP
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Type of Payment Indicator Code
Position 3 – Method of Reimbursement
B = Blue Care Network
C = PHA Controlled Cost
P = PPO Trust
R = PHA Per Diem
Position 4 – Provider Contract Indicator
Blank = PHA
B = Blue Care Network
T = Trust/PPO
Position 5 – Special Use Indicator
% = Percent of PHA
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Type of Payment Indicator Code
Example
Code: 11
Voucher Code = 1
Accommodation Code = 1
Method of Reimbursement = Blank
Provider Contract Indicator = Blank
Special Use Indicator = Blank
Patient = Inpatient Regular/RegIP Admission/PHA
Include in IP Traditional Settled
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Type of Payment Indicator Code
Example
Code 33 T
Voucher Code =3
Accommodation Code = 3
Method of Reimbursement = Blank
Provider Contract Indicator = T
Special Use Indicator = Blank
Patient = OP Regular/Regular OP/Trust Patient
Include in OP PPO Settled
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Type of Payment Indicator Code
Example
Code 60LT%
Voucher Code =6
Accommodation Code = 0
Method of Reimbursement = L
Provider Contract Indicator = T
Special Use Indicator = %
Patient = BC Complementary OP/BC-65/PHA Lower
of Cost or Charge/Trust_PPO/Percent of PHA
Include in Non-Settled
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INTERIM PAYMENTS (BIP)
• Receive a weekly estimated payment (BIP)
instead of payment that is specific to an 835
file
• Periodic BIP reviews are done to determine
reasonableness of weekly payments based
on cleared claims
• Logs are a key component to determining
whether BIP reviews are accurate
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BALANCE SHEET TEST
Balance Sheet Test
Know what is in your AR so you can
reserve appropriately
• Blues products not included in BIP are
reserved differently than those in BIP
• Calculate estimate on copays & deductibles if
still in primary payer code
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SETTLEMENT
Settlement
SETTLEMENT BALANCE =
EXPECTED PAYMENT less BIP
• Don’t operate in a vacuum!
• Make sure your contractual model / BST are
reasonable compared to BIP reviews and
other correspondence from Blues
• Remember to include claims after cut-off that
occur in the following year
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Settlement
• In a perfect world, 835 logs would tie exactly
to settlement detail – they won’t
• Some data elements used for settlement are
not evident in the 835 file – hard to get in
proper bucket
• Transfer cases not always identified with
discharge fraction
• Count on take-backs can cause an issue
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(248) 347-1416