Fundamentals of Reimbursement The Basics of Getting Paid! David M. Franklin, MSA, Advanced Care Consulting Services, Shelby Township, MI
Top 4 Things to Know for CE 1. Make sure your BADGE IS SCANNED each time you enter a session to record your attendance. 2. Carry your Evaluation Packet with you to EVERY session. 3. Pharmacists, Pharmacy Technicians and Nurses need to track their hours on the Statement of Continuing Education Form as they go (the 2-page triplicate form, so press firmly!). 4. FOR CE: At your last session, total the hours and sign both pages of your Statement of Continuing Education Form. Keep the PINK copy for your records and place the YELLOW and WHITE copies in your CE Envelope. Make sure an Evaluation Form is in your CE Envelope for each session you attended (extra forms are available at the registration desk if you forgot to pick one up). Write your name and unique ID number (six digit number at the bottom of your name badge) in the designated area on the outside of the envelope, seal it, and place it in the drop box located near the 4/9/2012 2 registration area.
David Franklin declares no conflicts of interest or financial interest in any service or product mentioned in this program. Clinical trials and off-label/investigational uses will not be discussed during this presentation. 4/9/2012 3
Today s Focus: Fundamentals! Intake Revenue qualification Documentation Coding and billing Per diem Drug Nursing Collections
The Basics: Health care is a business Four major sources of payment Non standardization: Reimbursement methodologies Coding structures Rules Reimbursement is not an act, it is a series of processes
Gathering of Information: Janitor syndrome Patient demographics Clinical data Insurance data Employer data Credit card information Miscellaneous data
The Art of Intake: Verify everything! Is this the right doctor? Primary care Nursing home Rounding physician All necessary orders: Lab Anaphylaxis kit Discharge
The Art of Intake: Diagnoses: Initial ER diagnosis Does it support the order? Secondary diagnoses Correct number of digits Therapy specific data Insurance specific data Hospital specific data
The Art of Intake: Other providers involved? Hospice involved? Other services involved? Categorize data requirements: Minimal data set Desired data set Holy cow data set
Payer Therapy Communication Authority Skill sets Critical Variables: People skills Communication Organization
Purpose: Ensure that: A source of revenue for all services is identified Customers have a clear understanding of their obligations All potential sources are considered Factors: Clinical + Insurance = Coverage Out-of-pocket can t be ignored
Basic Procedures: Responsibility / accountability Frequency requirements Medicare (monthly) Medicaid (monthly) Commercial (quarterly) Revenue qualification form Record of new verifications
Basic Procedures: Contacts: Payer verify benefits Patient discuss responsibilities Referral source communicate status of the referral Internal pharmacy, nursing, reimbursement, marketing, etc
Medicare: Obtain a scan of the card Verify status: Part B, D, Medicare Advantage Verify region Specific coverage requirements
Medicaid: Varies by state Call / web site Medicaid HMO? Other insurance? Spend down / deductible? Administrative protocols? Pending policy
Commercial Payers: Non-standardized requirements Contract driven Beware of network constraints Documentation requirements Administrative protocols
Private Pay: > 20% of the payer mix across health care Clear, concise, detailed explanation of obligations Copayment, deductibles, not covered Expectations Credit card information CODs Delivery holds
General Rules: Every modality has specific requirements Medical need must be substantiated via medical records The Medical Record is not a single entity...
The Medical Record: Physician office records Hospital records Nursing home records Home health records Any other health care record The provider must be able to produce upon request
Dispensing Order Requirements: Fairly minimal requirements May be written, faxed, or verbal Must include a description of the product or service Must include the name of the patient Must include the date of the order Would be difficult to fill an order without
Remuneration Order Requirements: What you need to bill and be paid Much more extensive Must be written, can be faxed Must be personally signed and dated by ordering physician Must include the beneficiary s full name
Remuneration Order Requirements: Must include a detailed description of the product or service Suppliers can write orders and send to physician Physician must review, sign, and date Provider must be able to produce original signed document on demand
Proof of Delivery: Direct delivery: Delivery slip signed and dated by beneficiary or representative Delivery or shipping service: Provider invoice and service tracking slip Delivery to a nursing facility: 3 elements: Receipt of the supplies by the facility Supplies identifiable to a specific patient Documentation of use by that patient
Medical Records: Anything needed to justify medical necessity...
Summary: 5.8 Supplier Documentation Before submitting a claim to the DME MAC the supplier must have on file a dispensing order, the detailed written order, the CMN (if applicable), the DIF (if applicable), information from the treating physician concerning the patient's diagnosis, and any information required for the use of specific modifiers or attestation statements as defined in certain DME MAC policies.
Electronic Records: 5.2.3 Detailed Written Orders Detailed written orders are required for all transactions involving DMEPOS. Detailed written orders may take the form of a photocopy, facsimile image, electronically maintained, or original "pen-and-ink" document.
Electronic Records: 5.3 CMNs and DIFs When reviewing claims where the medical record contains a copied, faxed or electronically maintained CMN or DIF (any CMN or DIF created, modified, and stored via electronic means such as commercially available software packages and servers), the DME MACs, DME PSCs, or ZPICs must accept the copied, faxed or electronic document as fulfilling the requirements for these documents.
Miscellaneous Documentation Issues: New order required if: There is a change in the provider Required by medical policy Item is replaced Change in the supplier Orders need to be maintained for 7 years AOB needed in order to be paid directly DIFs replaced CMNs for infusion pumps, enteral and parenteral nutrition in 2007
Coding Systems: The language of health care reimbursement Methods of classification - not payment Four major systems applicable to infusion HCPCS ICD 9 (10) CPT-4 NDC
Level II HCPCS: Owned and maintained by CMS HIPAA approved / nationally standardized Product driven Medicare driven 5 digit alpha - numeric format Begins with a letter that means something
HCPCS Lettering System: A = Transportation / chiropractic / medical and surgical supplies B = Enteral and parenteral nutrition D = Dental E = Durable medical equipment G = Temporary / professional services H = Rehab services
HCPCS Lettering System: J = Medications K = P & O / dressings L = P & O / devices M = Medical services P = Pathology and lab Q = Miscellaneous / temporary
HCPCS Lettering System: R = Radiology T = Surgical services V = Vision / speech / hearing
ICD - 9 System: International classification of diseases Converting to version 10 Maintained by the WHO Standardized internationally Used internationally to track morbidity and mortality rates Used locally to justify medical necessity Critical to a matching process
CPT - 4 System: Current procedural terminology Proprietary - Owned by the AMA Physician services Hospital outpatient services Service driven Updated annually Strictly a 5 digit format
NDC System: National drug codes Controlled by the FDA The absolute standard for describing drugs Identifies the medication / manufacturer / dosage 5-4 - 2 digit numerical format
Coding Examples: HCPCS: J3370 CPT-4: 99601 ICD-9: 250.9 NDC: 00245-1267-01
Infusion Based Per Diem Reimbursement: Three major components: Per diem Drug Nursing A bundled methodology Nationally standardized Per Diem definition on NHIA web site Does not affect Medicare coverage
Professional Pharmacy Services: Patient assessment Clinical monitoring Care plans Coordination of care Sterile procedures Compounding Pharmacokinetic dosing Med profile set up Drug utilization review Vascular access knowledge Patient education Drug interaction monitoring Lab result interpretation Recommendations for med changes Patient discharge
Operational Expenses: Human resources Office supplies Marketing Building expenses Utilities Cell phones / pagers Postage / shipping Education materials CE expenses Legal services Accounting expenses Licensing fees Infectious waste removal Medical records storage Community commitment Property taxes New product R&D Everything else
Equipment and Supplies: Durable, reusable infusion pumps Elastomeric / disposable pumps All other administration devices Short peripheral vascular access devices Needles / gauze / tubing / catheters / dressing kits All other necessary supplies
Therapy Distribution Expenses: 24 hour / 7 day availability of a team consisting of pharmacists, nurses, others Mileage Insurance Vehicle maintenance
Clinical Coordination Expenses: Development and monitoring of nursing care plans Coordination of benefits, care, and services with multiple professionals Patient assessment and education Case management services
Inventories and Accounts Receivable: Interest and opportunity cost from carrying large A/R balances Depreciation Equipment maintenance and repair
Quality Assurance Expenses: Outcomes assessment and analysis Staff development and competency evaluation and assessment CQI / PI programs All accreditation expenses Certification fees and expenses
Reimbursement and Administrative Expense: Insurance verification Prior authorization Billing functions Cash posting Collections Bad debt DIFs and medical necessity documentation Regulatory compliance programs Professional association fees Subscription fees
What s NOT included: Medications Field nursing visits PIC and midline insertion/supplies Surgically implanted CVA Blood products
Nursing Component: Historically competing codes: CPTs: 99601 99602 HCPCS: S9123 S9124 G0154
Drug Component: Product vs. Service Competing Codes: HCPCS NDC Competing reimbursement methodologies AWP ASP
Drug Pricing Terms: PHS (340B) AC ADAP AMP ASP
Drug Pricing Terms: AWP BP Covered Entity Dispensing Fee FCP FSS
Drug Pricing Terms: FUL Non-FAMP PDP URA VANCP WAC HMOGTIC
Common Problems: Not understanding per diem Lack of Medicare acceptance Request for unbundled billing Billing unit discrepancies Not recognizing all per diem codes Requiring itemized listing Require hard copy billing to avoid HIPAA requirements
Front End Operations: Clear and concise communication on the front end Expectations Credit card information
Before the Call Know: The nature of the debt - why it is valid Billing dates of 3rd party payers Reasons claims were rejected Dates customer was billed Date account will be turned over to an agency Any other relevant data
The Collections Call: Be sure you have the right person - debtor, guarantor, spouse only If you mention the debt to anyone else you forfeit your collection rights Be polite but firm State the facts slowly and respectfully Do not allow the debtor to control the conversation
The Collections Call: Thoroughly document the call: Who you spoke to Date and time What happened Give the customer a reason to pay Maintaining a good credit rating Achieving piece of mind Being honest / doing the right thing
The Collections Call: Remember your role in the health care delivery system Never, ever take it or make it personal It s a job - be professional
After the Call: Do not re-bill at this point If not paid in full by the cutoff point, turn it over to an agency Write it off to bad debt Refer calls regarding accounts turned over to agencies to the agency
Prohibited Activities: Calling between 9 pm and 8 am Using forms or instruments that simulate judicial proceedings Making inaccurate or untrue statements Not revealing the true purpose of your call Threats: Harm / Imprisonment / Seizure
Prohibited Activities: Communicating directly with the debtors if they are represented Bringing or threatening public notice Using obscene language Calling debtors at work if they have stated that the employer objects
Summary: Intake Revenue qualification Documentation Coding and billing Per diem Drug Nursing Collections
Learning Assessment Questions & Answers Please refer to the NHIA Annual Conference & Exposition 2012 On-Site Program for a brief post-test. Dfranklin@advcr.com 4/9/2012 70