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Information Integrity in the Revenue Cycle! Order Entry, All Subsystems and The Charge Description Master

Information Integrity in the Revenue Cycle! Order Entry, All Subsystems and The Charge Description Master. Presented by: Jessy Huebner, MAT, CHFP President MedCompliance Services, Inc. 2011.

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Information Integrity in the Revenue Cycle! Order Entry, All Subsystems and The Charge Description Master

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  1. Information Integrity in the Revenue Cycle!Order Entry, All Subsystems and The Charge Description Master Presented by: Jessy Huebner, MAT, CHFP President MedCompliance Services, Inc. 2011

  2. 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

  3. Introductions and BackgroundJessy Huebner, MAT, CHFPConceived 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.

  4. The Revenue Cycle Patient Access Revenue Integrity Claims Adjudication Management • Medical Case Management • Denial and Appeal Management • Revenue Cycle KPI’s • Contracts • Physician Credentialing • Scheduling • Medical Necessity Determination/ Orders • Pre-Registration • Registration and Demographic/ Insurance Validation • Insurance Verification • Pre-Certification • Financial Counseling • POS Collections • Claims Preparation • Claims Submission • Third Party Follow up • Self Pay Follow up • Rejection Processing • Payment Posting • Payment Validation • EMR data from Clinical Care documentation & transcription • Health Information Management • Coding • Charge Capture • Charge Entry • Billing System(s) • CHARGE • MASTER

  5. 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

  6. 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 essentialA clean claim is the keyClean code + a clean CDM + a clean bill drop = more cash

  7. Our Solution includes:Clean up and synchronization of Order Entry through all Subsystems to the Charge MasterReimbursement problem solving:On-the-job training, technical support, and on going maintenance

  8. “The Healthcare Financial and RAC Editor”

  9. The Healthcare Financial and RAC EditorMerges Data from:- CDM- Revenue & Usage - Order Entry- All Sub-systemsAudits and Evaluates the Data for Issues in the following major areas:- Descriptions- Revenue Codes- CPT/HCPC Codes- Modifiers- Pricing- RAC Issues

  10. There is 113 Columns of Data In The Healthcare Financial & RAC EditorThe 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

  11. “The Information Integrity Editor”

  12. “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

  13. The Healthcare Information Integrity Editor • One Platform -- Bridging Information • Data Integrity • Optimizing Reimbursement • Compliance • Clean Accurate Billing

  14. “The Healthcare Department Modeler”

  15. ModelingWe 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 detailand revenue has ALWAYS been identified, regardless of departmental size.

  16. Example1 of Modeling 1While characterized as an example, this is actual data from a client assignment.

  17. MedCompliance Demo of Editor (Todays demo is of a 170 Bed Hospital in Dallas, Texas)

  18. Output of the Initial Review

  19. Typical Example of Recommended ChangesNote : 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.

  20. Resulting Financial ImpactNote : 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.

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

  22. Competitor Systems Hospital Hospital Hospital CDM electronically sent via Black Box to hard coded logic editor at providers location CDM, Order Entry, Sub-system and Usage Reports sent to MedComplianceServices Providers location runs CDM through editor and sends results back to hospital. Note: results are not reviewed by the provider. MedComplianceconsultants run all files through MedCompliance editors MedComplianceconsultants 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. 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. Together, Hospital staff and MedComplianceconsultants review all findings and corrections Hospital gets limited assistance regarding issues found in editor reports

  23. 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

  24. 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

  25. 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

  26. Thank You For Attending! Jessy Huebner, MAT, CHFP MedCompliance Services Inc. 800 West Ave - Suite 1001 Miami Beach, FL 33139 & 129 Club House Road - Box 3520 Breckenridge, CO 80424 jessy@medcompliance.com 305-604-7931 Clinical Education & CDM Cleanup

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