Information Integrity in the Revenue Cycle!

Order Entry, All Subsystems and The Charge Description Master

Presented by:Jessy Huebner, MAT, CHFPPresidentMedCompliance Services, Inc. 201

1

Our Philosophy: We are a firm believer in information integrity. Therefore we perform on or off site a full review of the hospitals Order Entry, Subsystems and CDM for accuracy and compliance while performing education and problem solving with all department heads and key staff during and after the interview process. We further believe “On Going Education and Daily Reconciliation” is key to the hospitals financial success. Educate and validate that the hospital personnel are completely knowledgeable in their documentation and charge capture and to insure the integrity of hospital compliance and billing. As we call it “Hand Holding” and at a reasonable price.

2011

Introductions and

BackgroundJessy Huebner, MAT, CHFP

Conceived and developed:

“The Healthcare Financial and RAC

Editor”

“The Information Integrity Editor”

“The Healthcare Department Modeler”

First to merge CDM applications into one

system.

Over 30 years of onsite healthcare validation

reviews.

Author and speaker for HFMA and MedLearn

with over 3,000 hours logged at the podium.

The Revenue CycleRevenueIntegrity

Claims Adjudicatio

nManageme

ntPatientAccess

• Claims Preparation

• Claims Submission

• Third Party Follow up

• Self Pay Follow up

• Rejection Processing

• Payment Posting

• Payment Validation

• Medical Case Management

• Denial and Appeal Management

• Revenue Cycle KPI’s

• Contracts

• Physician Credentialing

• EMR data from Clinical Care documentation & transcription

• Health Information Management

• Coding

• Charge Capture

• Charge Entry

• Billing System(s)

• Scheduling

• Medical Necessity Determination/ Orders

• Pre-Registration

• Registration and Demographic/ Insurance Validation

• Insurance Verification

• Pre-Certification

• Financial Counseling

• POS Collections

• CHARGE MASTER

Revenue Issues Facing Hospitals Today

-Confusion due to new rules-RAC Audits are increasing -The risk of fraud is escalating-Staffs need more education to document & charge accurately-Order Entry, all Subsystems and CDM are not synchronized-Incorrect CPT/HCPC and Diagnosis coding is taking place -Modifiers are not being correctly applied or missing-An understanding of the Medicare Rules and Regulations is lacking, especially how the Correct Coding Initiative (CCI) Editor & Medically Unlikely Editor (MUE) works-Difficult to stay current with CMS Addendum A & B-Improper packaging and bundling is an issue-Reporting needs simplification that can be easily customized-Internal controls and daily reconciliation, that will withstand scrutiny, are often missing

Did you know?

A good CPT code can be linked to a good procedure and still be wrong.

Coding must not create a fraudulent situation. Compliance is required throughout the process, necessitating a complete understanding of all aspects, from the front end to bill drop.

A clean and accurate CDM, not one that creates problems and causes lost revenue, is essential

A clean claim is the keyClean code + a clean CDM + a clean bill drop = more cash

Our Solution includes:

Clean up and synchronization of Order Entry through all Subsystems to the Charge Master

Reimbursement problem solving:On-the-job training, technical support, and on going maintenance

“The Healthcare Financial and RAC Editor”

The Healthcare Financial and RAC Editor

Merges Data from:- CDM- Revenue & Usage - Order Entry- All Sub-systems

Audits and Evaluates the Data for Issues in the following major areas:- Descriptions- Revenue Codes- CPT/HCPC Codes- Modifiers- Pricing- RAC Issues

There is 113 Columns of Data In The Healthcare Financial & RAC Editor

The main areas are:Hospital Two Years of Usage (IP & OP)Hospital CDM Item, Order Entry & Subsystem NumbersHospital CDM Description and AMA/CMS DescriptionsHospital Revenue Code plus 3M & Ingenix Revenue CodesHospital CPT/HCPC Code and AMA & CMS CPT/HCPC CodesHospital Modifier and AMA & CMS ModifiersAll Reference Tables, Issues & FilesHospital Charge and AMA & CMS APC & Fee SchedulesRAC Issues by Region

A few of the columns of data are:AMA CPT Codes, CMS HCPC Codes, AMA & CMS Long, Medium and Short Descriptions, 3M & Ingenix Revenue Code tables, CMS CCI & MUE Edits, CMS Addendums A & B (SIC, APC, Payment and Co-Insurance Amounts), CMS Fee Schedules (Lab, Pro Fee, Ambulance, DME), Medicaid Fee Schedules, Pharmacy Crosswalk Tables, RVU Tables, AMA Appendix Rules, AHA Type of Service Table, MedLearn Interventional Radiology File, CMS Part B Drug Schedule and all RAC issues by Region

“The Information Integrity Editor”

“The Information Integrity Editor”

Merges files and reviews:Order Entry,All subsystems, The Charge Description

Master

Regardless of the type of system in place at the hospital into one Excel Worksheet

MedCompliance

Financial Revenue Usage

Charge Description Master

Physicians Services

Order Entry

Radiology Pharmacy

Pulmonary

Cardiology

Lab(Cerner)

Central Supply(Lawson)

The Healthcare Information Integrity Editor

One Platform -- Bridging Information

Data IntegrityOptimizing Reimbursement Compliance Clean Accurate Billing

“The Healthcare Department Modeler”

Modeling We take a unique, more intimate approach than others, who still employ hard-coded logic that works off good code vs. bad code methodologies. Modeling enables overlay of each department’s CDM, to its respective model, thereby revealing services not found in the department’s CDM….increased revenue!

Built on nationals standards; enhanced through our work in hospitals.

Modeling is run for several reasons:-to perform impact analyses before departments or services are added.-to build Ad Hoc Reports to research “what ifs”.to compare and assess, by department, to identify missing services for increased revenue.

Models are consistently well received due to their level of detail and revenue has ALWAYS been identified, regardless of departmental size.

Example1 of Modeling

1While characterized as an example, this is actual data from a client assignment.

MedCompliance Demo of Editor

(Todays demo is of a 170 Bed Hospital in Dallas, Texas)

Output of the Initial ReviewMedCompliance Services Inc.

"Healthcare Financial Editor" Summary Report of Findings

''Healthcare Financial Editor'' Copyright ProtectedHospital Name : Medical Center - Dallas, TxReport Compiled at: October 7th 2011Prepared by: Jessy Huebner, CHFP, MAT

jessy@medcompliance.com

Number of Lines in Charge Master: 8661

Number Of Lines in CDM with Possible Alerts 20353

Number Of Lines in CDM with Alerts 5540 63.96% CRITICAL INDICATOR - EVALUATE

Total of All Issues: 8793 101.52% CRITICAL INDICATOR - EVALUATE

Number Of Lines in CDM With No Usage in Year 1 2356 27.20% CRITICAL INDICATOR - EVALUATE

Number Of Lines in CDM With No Usage in Year 2 2569 29.66% CRITICAL INDICATOR - EVALUATE

Number Of Lines in CDM With No Usage in Year 1 & 2 1589 18.35% CRITICAL INDICATOR - EVALUATE

Total of Revenue Code Issues: 15 0.17% CRITICAL INDICATOR - EVALUATE

Total CPT/HCPC Code Issues: 498 5.66% CRITICAL INDICATOR - EVALUATE

Total Description Issues: 18 0.20%Total Modifier Issues: 790 8.98% CRITICAL INDICATOR - EVALUATE

Total Status Indicator Code (SIC) Issues 2728 31.02% CRITICAL INDICATOR - EVALUATE

Total Hospital Price Issues: 4685 53.28% CRITICAL INDICATOR - EVALUATE

Total Special Issues: 59 0.67% CRITICAL INDICATOR - EVALUATE

Revenue Code IssuesRevenue Code Incorrect - Evaluate 13 86.67% CRITICAL INDICATOR - EVALUATE

Revenue Code Missing - Evaluate 0 0.00%Revenue Code is for Professional Fee - Evaluate 0 0.00%Revenue Code is for Patient Convenience Item - Evaluate 0 0.00%Revenue Code is '999' for Statistics Only - Evaluate 2 13.33%

CPT/HCPC Code IssuesCPT/HCPC Code Invalid - Evaluate 0 0.00%CPT/HCPC Code Missing - Evaluate 380 76.31% CRITICAL INDICATOR - EVALUATE

CPT/HCPC Code is SIC - D (Per AMA & CMS Code Deleted) - Evaluate 6 1.20% CRITICAL INDICATOR - EVALUATE

Revenue Code is for Implant That Has Missing CPT/HCPC - Evaluate 111 22.29% CRITICAL INDICATOR - EVALUATE

Revenue Code is for Drug That Has Missing CPT/HCPC - Evaluate 1 0.20%Description Issues

Description Missing - Evaluate 0 0.00%Description Issue - Evaluate 18 100.00%

Modifier IssuesModifier Invalid - Evaluate 174 22.03% CRITICAL INDICATOR - EVALUATE

Modifier Missing - Evaluate 616 77.97% CRITICAL INDICATOR - EVALUATE

Status Indicator Code (SIC) Issues-Not Covered by OPPSCPT Code is SIC - B (Codes Not Recognized by OPPS) - Evaluate 13 0.48% CRITICAL INDICATOR - EVALUATE

CPT Code is SIC - C (Inpatient only) - Evaluate 23 0.84% CRITICAL INDICATOR - EVALUATE

CPT Code is SIC - E (Not Covered - Get ABN) - Evaluate 12 0.44% CRITICAL INDICATOR - EVALUATE

CPT Code is SIC - N (Bundled/Packaged) - Evaluate 2680 98.24% CRITICAL INDICATOR - EVALUATE

CPT Code is SIC - M (Codes Not Billable to FI) - Evaluate 0 0.00%

CPT Code is SIC - Y (Non-Implantable Durable Medical Equipment - Not Paid Under OPPS) - Evaluate 0 0.00%

Hospital Price IssuesHospital Price is less than CMS Fee Amt - Evaluate 0 0.00%Hospital Price is less than HOPPS APC Rate - Evaluate 31 0.66% CRITICAL INDICATOR - EVALUATE

Hospital Price is ZERO - Evaluate 102 2.18% CRITICAL INDICATOR - EVALUATE

CPT/HCPC Code Same with Different Prices - Evaluate 3245 69.26% CRITICAL INDICATOR - EVALUATE

Hospital Price Gtr than OPPS Benchmark - Evaluate 1307 27.90% CRITICAL INDICATOR - EVALUATE

Special IssuesDepartment # Missing - Evaluate 0 0.00%DME Item Found - Evaluate 30 50.85% CRITICAL INDICATOR - EVALUATE

F & A Alert Found - Evaluate 0 0.00% CRITICAL INDICATOR - EVALUATE

RAC Alert Issue Found - Evaluate 29 49.15% CRITICAL INDICATOR - EVALUATE

Typical Example of Recommended Changes

Note : This is a 350 bed hospital in New Jersey that we audited January 2011 that had been audited by a National CPA firm in August 2010. The client was not happy with the August results.

Resulting Financial Impact

Note : This is a 350 bed hospital in New Jersey that we audited January 2011 that had been audited by a National CPA firm in August 2010. The client was not happy with the August results.

What Makes MedCompliance Different in the IndustryPhilosophy: We are a firm believer in information integrity.

Technology: Utilizes Excel and the clients information to merge and audit their order entry, subsystems and CDM information into one Excel spreadsheet…..a Soft Coded Logic approach not the Hard Coded Logic approach as utilized by others in the industry Merging of Data: Ability to merge data from all client sources into one Excel spreadsheet Modeling: Able to take hospital departmental models that contain AMA, CMS and AHA data and overlapping that information with the hospital data to show missing services the hospital can add for increased revenue

Reports: Standard plus Customer designed at no additional charge

Printing: Easy to print using Excel format

Multiple Facilities: Able to overlap and merge multiple facility hospitals and multi-tier physician groups CDM into one Excel spreadsheet which will show discrepancies and consistencies in coding, compliance, pricing and other features that may effect the Order Entry System, Subsystems and the CDM accuracy

Web-based & Support: Yes, we are Web Based with 24 hour phone and email support under our monthly maintenance contract

CDM electronically sent via Black Box to hard coded logic editor at

providers location

Providers location runs CDM through editor and sends results back to

hospital. Note: results are not

reviewed by the provider.

Hospital goes to "Black Box" to run reports and figure out

what needs to be corrected. Reports are not in Excel format

but in a format designed by provider.

Hospital gets limited assistance regarding issues found in editor reports

Hospital Hospital

CDM, Order Entry, Sub-system and Usage Reports sent to

MedCompliance Services

MedCompliance consultants run all files through MedCompliance

editors

MedCompliance consultants run all reports, assesses the data, provide

recommendations which require corrections and alerts for further clarification. Reports are in Excel format and sent back to hospital.

Together, Hospital staff and MedCompliance consultants review

all findings and corrections

Hospital

Competitor Systems

Benefits of Partnering with MedCompliance Services Inc.

-We provide cleanup of Order Entry, all Subsystems and the CDM-We use unique Modeling to reveal missing services, by department-We find missing revenue to drive immediate cash flow improvement-We reduce erroneous charging – thereby reducing your risk of fraud-We improve documentation/charging by hospital staff and physicians through on-the-job and formal training programs-We provide real-time updates

Partnering Benefits, Cont’d

-We use software applications, tools, education and personal on-site services to produce Clean Claims-Based on our reviews, you can reduce the risk of non-compliance and increase your confidence when you’re faced with outside audits-Unlike others, our reviews project expected Return on Investment (ROI). Our average ROI is 150:1 therefore we can guarantee our results-Our Reporting has the capability to deliver customer-specific information, to guide each staff member, in each department

Partnering Benefits, Cont’d

-Our Educational Services help turn around inefficient departments-Documentation and tools are used to help drive a deeper understanding of a customers billing factors-Ongoing maintenance assures that your CDM stays current, accurate and clean-We are accessible in person, by phone, or via email, within 24 hours

Thank You For Attending!

Jessy Huebner, MAT, CHFPMedCompliance Services Inc.800 West Ave - Suite 1001

Miami Beach, FL 33139&

129 Club House Road - Box 3520Breckenridge, CO 80424

jessy@medcompliance.com305-604-7931

Clinical Education & CDM Cleanup