Nursing Home and Hospice Billing Training Presented by Field Representatives Kinzie Baker & Liz Lovell-Poynor

Transcription

1 Nursing Home and Hospice Billing Training 2018 Presented by Field Representatives Kinzie Baker & Liz Lovell-Poynor

2 Wyoming Medicaid General Manual Chapter 1- General Information Chapter 2-Getting Help When You Need It Chapter 3-Provider Responsibilities Chapter 4-Utilization Review Chapter 5-Client Eligibility Chapter 6-Common Billing Information Chapter 7- Third Party Liability Chapter 8-Electronic Data Interchange (EDI) Chapter 9-Wyoming HIPPA Electronic Specifications Chapter 10-Important Information

3 Provider Notifications RA Banner RA Payment Summary * Bulletins

4 Provider Contact It is important for all providers, both treating and pay-to providers, to maintain current and accurate contact information. Why it is important to update provider contact information? o To receive up-to-date policy information o Receive updates when Medicaid needs a copy of your new license o Any other communication which needs to occur between Wyoming Medicaid and providers To update your provider contact information, please do the following: o , mail a request on office letterhead and include the following: NPI/Provider number & Name Provide contact information Update needed Physical, correspondence, or financial address, provider phone or fax number, or addresses on file Date this change needs to go into effect Pay-to Providers can also update their contact information by logging into the Provider Web Portal and going to Update Provider Demographics addresses on file can also be updated by speaking to a representative at Provider Relations by calling options 1, 5, and then 0.

5 Getting Help Quick Reference When to write for help Online resources Requesting a provider training visit

6 Provider Responsibilities Eligibility When can a client be billed? Issues most commonly heard in call center: Clients requested to troubleshoot claims or check PA status Client billed or sent to collection Billing and coding questions Recordkeeping

7 Notes

8 Common billing Information Service thresholds Under 21 Over 21 NDC Conversion Attachments See web portal tutorial Adjustments and Voids Sterilization, Hysterectomy and Abortion Consent Form Requesting Replacement RA s Timely filing Telehealth

9 Attachment Troubleshooting Paper-Attachment cover sheet TCN How to get the TCN ACN (Attachment Control Number) Electronic Attachments How to complete Common Attachment issues: Incomplete ACN does not match Legibility issues Information on form does match claim Rendering/treating provider listed as Pay-to No Attachment indicated on claim

10 Adjustments & Voids Paper Complete all required information Attach corrected clean claim and indicate on form Attachments Electronic How to complete 6-Adjustment 7-Replacement Common Issues: All lines not included on electronic adjustment No changes made to the claim Too many changes being made Not all corrections made Not attaching supporting documents

11 Notes

12 Third party Liability Third Party Payers Unreported coverage Provider not enrolled/no Opt out option How to indicate TPL on a claim Medicare/ No Opt out option

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14 Required Evaluations Prior to Admission Pre Admission Screening and Resident Review (PASRR) Level 1 Completed via web portal Cannot be corrected** Required for all clients regardless of payment source LT101 Valid for 90 days Can be corrected with state approval** Utilize portal to check for previously completed LT101 s Only required for Medicaid clients **Requests to delete a PASRR Level I can be sent to sara.rogers@wyo.gov & requests to correct a LT101 can be sent to sherry.mitchell1@wyo.gov

15 PASRR Level II WYhealth Medicaid will not reimburse a nursing facility for services provided to any individual with MI or MR who is admitted prior to completion of a PASRR Level II. Payment will commence upon the date of determination of appropriate placement. No retroactive payment will be made. If a PASRR Level II has been completed but is not reflected on the client file contact WYhealth

16 Attestation for Admission * What is an Attestation Form? When is an attestation form necessary? Common Attestation Form issues: Not completely filled out No signature Attest box not checked Client not in the system Client information incorrect

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18 Scenario 1 Dates of service: 4/1/18-4/30/18 Covered Days:30 Admit date:04/01/18 Units billed: 30 Lt101 Provider referral date:3/30/18 PASRR Date: 03/30/18 Patient status: 30-Still a patient Billed amount $5, Claim paid: $5,230.00

19 Scenario 2 Dates of service 04/01/18-04/30/18 Admit date 04/01/18 Covered days: 30 Units billed: 30 LT101 Provider Referral Date: 04/09/18 Date of PASRR: 4/13/18 Claim Denied 372,370 Patient Status:30-Still a patient Billed Amount: $5,230

20 Scenario 3 Dates of service: 4/1/18-4/30/18 Admit date: 4/1/18 Lt101 Provider Referral Date:3/30/18 Covered days: 27 Units billed: 30 Patient Status:30-Still a Patient PASRR level1 Date: 3/30/18 No PASRR Level 2 on file Claim denied 373,078 Billed amount $4,987.00

21 Notes

22 Scenario 4 Dates of service: 04/01/18-04/30/18 Admit date: 9/15/17 LT101 Provider Referral Date: 3/27/18 Covered Days:30 Units billed: 30 Patient status: 30-Still a patient Date of PASRR level 1: 9/13/17 Claim Denied 579 Billed amount $5,230.00

23 Patient Contribution Patient contribution determination Patient contribution changes Patient contribution not applied to claim Allocation discrepancies

24 Scenario 5 Dates of service: 4/1/18-4/30/18 Patient liability: $ Admit date: 11/8/17 Covered days: 29 Lt101 Provider referral date: 11/8/17 PASRR Level 1 date:11/8/17 Units billed: 30 Total amount billed:$5, Patient status:20-died Claim denied

25 Scenario 6 Dates of service: 02/02/18-02/28/17 Admit date: 2/2/18 Lt101 Provider referral date: 2/2/18 PASRR Level 1 date: 2/2/18 Covered days: 27 Total amount billed: $7, Patient status:30-still a patient Medicare payment: $6,592.00

26 Important Reminders Covered days Patient status Statement dates Units billed Leave days not covered

27 Notes

28 Hospice Services

29 Required Documentation Hospice Benefit Election Form Hospice Benefit Revocation Form

30 Hospice Services * Hospice Lock-in * Plan of care * PA Requirements * Services unrelated to the terminal illness

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32 Scenario 1 Line Rev Code Procedure code Dates of service Billed units Line /01/18-02/28/17 28 Claim Paid: $2,544.64

33 Scenario 2 Line Rev Code Procedure code Dates of service Billed units Line /01/18-04/15/18 15 Incorrectly billed due to # of days client has been in hospice Correctly billed for client in hospice care beyond 61 days Line Rev Code Procedure code Dates of service Billed units Line G /01/18-04/15/18 15

34 Notes

35 Scenario 3 Claim for hospice services: Line Rev Code Procedure code Dates of service Billed units Line /12/18-3/31/18 19 Claim for nursing home room & board: Line Rev Code Procedure code Dates of service Billed units Line /12/18-3/31/18 19

36 Wyoming Medicaid Website Welcome Page Manuals and Bulletins Fee schedule (NCCI) Contact Us Forms Provider Training Web Tutorials

37 Notes

38 Provider Portal Claim Submission Refer to: Attachments Refer to: Registering and adding users Refer to:

39 Continuity of Care Document CCD Viewer The CCD is a HITSP standard patient summary document that contains the following information from the THR Gateway: Problems Family & Social History Immunizations Vital Signs Test Results Medications Procedures Up 2 years claims history Alerts Allergies/Adverse Reactions And more To request THR CCD Viewer access, please send an containing: Clinic Name Address Phone Number Provider Names Provider Addresses Primary Contact To Andrea Bailey at: andrea.bailey@wyo.gov Visit the website at: d-viewer

40 What is the Program Integrity Unit? The Program Integrity (PI) unit is responsible, through a coordinated process of education, reviews, audits, and appropriate corrective action plans, for ensuring the integrity and accountability of all payments made for healthcare services on behalf of a recipient. Providers new to Medicaid should view the Wyoming Medicaid Program Integrity presentation. Learn more about PI or report suspected abuse, fraud, or waste by visiting:

41 Resources Provider Relations (Option 1,5,0) o o 9-5 MST Monday - Friday o Fax Number o EDI Services (Option 3) o o o o o 9-5 MST Monday Friday EDI Enrollment Form Trading Partner Agreement WINASAP Software & Technical Support for WINASAP Technical Support for Vendors, Billing Agents, and Clearinghouses o Provider Web Portal Registration Technical Support for Provider Web Portal & Password Resets

42 *Medical Policy (Option 1,1,4,3) o 9-5 MST Monday Friday o Prior Authorizations (PAs) Requests for: o Surgeries requiring PAs o Hospice Services: Limited to Clients Residing in a Nursing Home o Status of a Pending PA o How to Complete a PA Request o Authorizations of Medical Necessity for services prior to 11/1/17 o Denials for: o WATRS -Ambulance claims/ regarding trip report o Invoices * Third Party Liability (TPL) (option 2) o 9-5 MST Monday Friday o Client accident covered by liability or casualty insurance or legal liability is being pursued o Estate and Trust Recovery o Medicare Buy-In status o Reporting client TPL o New insurance coverage o Policy no longer active o Problems getting insurance information needed to bill o Questions or problems regarding third party coverage or payers o WHIPP program

43 Questions???