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COMPLIANCE AND THE REVENUE CYCLE – What Does the Compliance Officer Need to Understand About the Risks?. PRESENTED BY: TAUNA SHELTON MHSM,MS,CHC REGIONAL DIRECTOR COMPLIANCE AND PRIVACY THR. REVENUE CYCLE PROCESS. Who is involved in the Revenue Cycle? Scheduling & Pre-Registration

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COMPLIANCE AND THE REVENUE CYCLE – What Does the Compliance Officer Need to Understand About the Risks?

PRESENTED BY: TAUNA SHELTON MHSM,MS,CHC

REGIONAL DIRECTOR COMPLIANCE AND PRIVACY

THR

revenue cycle process
REVENUE CYCLE PROCESS
  • Who is involved in the Revenue Cycle?
    • Scheduling & Pre-Registration
    • Registration Verification
    • Financial Counseling
    • Charge Capture
    • Documentation Coding
    • Bed Control
    • Billing
    • Payment Posting
    • Account Follow-Up
    • A/R Management
    • Contracting
    • Medical Records/ HIM
    • Case Management
    • Utilization Review
    • IT
    • Clinical Areas
each department provides opportunity for error and risk
EACH DEPARTMENT PROVIDES OPPORTUNITY FOR ERROR AND RISK
  • Scheduling & Pre-Registration: patient screening for demographic information, verification of orders, insurance, insurance approval for OP procedures – will ABN be needed for Medicare patient because diagnostic test does not meet medical necessity?
  • Registration Verification: verifying patient identity, insurance card (Is patient the person presented, or is this a fraudulent use of identification to obtain services by using someone else’s insurance card?) (Medicaid / Medicare), fraud perpetuated via follow up services? or case of identity theft by patient or even entity staff ?
error or risk cont
ERROR OR RISK (cont)
  • Financial Counseling: financial screening for self pays or charity care supported by organizational Charity Care Policy and state laws
  • Charge Capture: are the correct charges for services provided, including number of charges actually being placed onto the patient’s account (medications, procedures) including overcharging, undercharging, lost charges or charging for services not provided?
error and risk cont
ERROR AND RISK (cont)
  • Documentation Coding: Physician notes, Nurses notes, ancillary staff notes supporting the ordered services detailed enough to provide substantiation to an auditor ?
  • Bed Control: placement of patient in correct bed based upon order timed by physician, patient transfers?
  • Billing:billing the correct patient on the correct account, correct number of services?
  • CHARGEMASTER updates for each service, billing edits loaded, charge capture issues?
error and risk cont6
ERROR AND RISK (cont)
  • Payment Posting: payments posted on correct account, payments applied to correct account , credit balances on account worked?
  • Account Follow-Up: accounts worked with patient friendly guidelines and following state collection laws?
  • A/R Management: as accounts age are they being worked to resolve credit balances, bad debt and appropriate communications with payers?
error or risk cont7
ERROR OR RISK (cont)
  • Contracting: are payments being monitored by the CBO and the Contracting Department for proper payments based upon the written contract payment guidelines? are edits in place for both the entity and the payer?
  • Medical Records / HIM: coding by CCI guidelines, backlog in coding, increased query of physicians for confirmation of documentation, quality self department checks?
error and risk cont8
ERROR AND RISK (cont)
  • Case Management: are appropriate InterQual or M&R guidelines used for placement of patient into appropriate level of service based upon medical necessity and severity, observation or inpatient services required?
  • Risk Management: high profile cases being checked for billing and compliance issues, as well as, the current risk occurrence issue?
error or risk cont9
ERROR OR RISK (cont)
  • IT: system supporting all needs of clinical staff, billing staff, HIM staff – EHR being used, ability for tracking audit trails?
  • Clinical Areas: continuous communication on billing and charging changes, charge audits?
revenue cycle drill down
REVENUE CYCLE DRILL DOWN
  • FOCUS TODAY ON:
  • NEED FOR POLICIES
  • CHARGEMASTER
  • CENTRAL BUSINESS OFFICE and CREDIT BALANCES
  • CHANGES TO COME IMPACTING REVENUE AND OPERATIONS
system entity policies supporting the revenue cycle
SYSTEM / ENTITY POLICIES SUPPORTING THE REVENUE CYCLE
  • CHARGE CAPTURE POLICIES provide guidance for all staff involved in the revenue cycle who document charges, input charges, monitor charges or audit charges
  • CHARGEMASTER POLICIES provide guidance for all staff responsible for requesting new services, new charges or changes in existing charges with the addition of the appropriate CPT codes
policies cont
POLICIES (cont)
  • BILLING POLICIES: provide guidance to all staff associated with billing on how to handle discrepancies, credit balances, bad debt, A/R and billing cycle requirements
  • COMPLIANCE POLICIES: provide government based guidance to assist all system / entity staff with concerns of illegal activities, billing concerns, fraud issues or simple questions
compliance billing and operational laws
COMPLIANCE BILLING AND OPERATIONAL LAWS
  • MEDICARE REQUIREMENTS
  • MEDICAID REQUIREMENTS
  • FALSE CLAIMS ACT
  • STARK LAW
significant laws governing federal healthcare programs
SIGNIFICANT LAWS GOVERNING FEDERAL HEALTHCARE PROGRAMS
  • ANTIKICKBACK STATUTE: Authorizes criminal and civil penalties against anyone who knowingly and willfully solicits, receives, offers, or pays remuneration, in cash or in kind, to induce or in return for referrals for services payable under federal healthcare programs
significant laws cont
SIGNIFICANT LAWS (cont)
  • Civil Monetary Penalties Law: Holds a person or entity subject to penalties for submitting a false claim or a claim that should have been known to be false, allows a penalty of up to $10,000 for each service or item falsely or fraudulently claimed and an assessment of up to three times the amount claimed and potential exclusion from the federal healthcare program or programs
significant laws cont16
SIGNIFICANT LAWS (cont)
  • False Claims Act: Holds a person or entity liable for up to treble damages and up to $11,000 for each false claim it submits or causes to be submitted to a federal healthcare program, does not require a specific intent to defraud and includes a provision for Qui Tam or whistleblower suits, which allow individuals to file suit on behalf of the U.S. government
significant laws cont17
SIGNIFICANT LAWS (cont)
  • Health Insurance Portability and Accountability Act of 1996: Addresses use and disclosure of individuals’ health information (protected health information) by hospitals and other covered entities; includes standards for individuals’ privacy rights and how their health information is used.
significant laws cont18
SIGNIFICANT LAWS (cont)
  • Physician self-referral law (Stark Law): Prohibits hospitals from submitting to Medicare any claim for designated health service if the referral of the DHS is generated by a physician who has a prohibited financial relationship with the hospital. Hospitals and physicians who violate the Stark law are subject to civil monetary penalties and exclusion from federal healthcare programs
stark iii update
STARK III UPDATE
  • On September 5, 2007 CMS issued final regulation outlining the third phase of regulations prohibiting physician self-referral. This prohibits physicians from referring Medicare patients for certain items, services and tests provided by businesses in which they or their immediate family members have a financial interest. This regulation is the third part of the final regulations implementing the physician self-referral prohibition commonly referred to as the Stark law taking effect on December 4, 2007
stark iii cont
STARK III (cont)
  • Redefines arrangements between hospitals and individual members of group medical practices as “direct” rather than “indirect” compensation; eliminates the “safe harbor” methodology for calculating fair market value for hourly physician service; and create additional flexibility for rural hospitals in recruiting and retaining physicians. This rule makes no changes to the in-office ancillary services exemption, but cites this area as a possible target for future rulemaking.
patient financial services
PATIENT FINANCIAL SERVICES
  • BILLING LAWS
  • BILLING CYCLE
  • EDITS
  • BAD DEBT
  • CREDIT BALANCES
  • CHARITY CARE
  • WRITE OFFS
financial risks associated with credit balances
Financial Risks Associated with Credit Balances
  • FRAUD
  • WASTED MAN-HOURS AND PROCESSING COSTS
  • MIS-STATED PROFIT
  • LOST BILLING OPPORTUNITIES
  • MEDICARE PENALTIES
causes of credit balances
CAUSES OF CREDIT BALANCES
  • Mis-posted allowances – incorrect estimates of cash amounts due
  • Duplicate payments
  • Charge credits subsequent to billing
  • Full payments by both primary and secondary insurers
  • Up-front collections – incorrect estimates of patient liability
stats on hospital resolution
STATS ON HOSPITAL RESOLUTION
  • Most credit balances are not the result of overpayments
  • One third resolved result in a refund to patient or payer
  • One half are mis-posted allowances that need to be reversed on the PA system and don’t require refunds
  • Payer contracts can result in incorrect rates and terms loaded into the hospital system – these create understatements of a hospital’s profitability and AR
additional sources of errors
ADDITIONAL SOURCES OF ERRORS
  • Errors occur when a claim is paid twice by a payer
  • Problems created by manual errors, system errors or a combination of both
  • Results of better point-of-service collections – better up-front collections create higher volume for credit balances
  • Over-estimates of what is owed in a Managed Care environment
risks of credit balances
RISKS OF CREDIT BALANCES
  • Real risks posed by :
    • Medicare penalties
    • Wasted time
    • Lost payment opportunities
medicare penalties
MEDICARE PENALTIES
  • Suspension of Medicare payments caused by non-compliance with federal regulations concerning credit balances
  • Fines
  • Imprisonment
  • CMS requires hospitals report all Medicare credit balance overpayment accounts quarterly using form CMS-838, which must be signed and attested to by an officer of the hospital, specifically by the CFO or CEO.
medicare penalties cont
MEDICARE PENALTIES (cont.)
  • Documentation must be maintained that shows that each patient record with a credit balance was reviewed to determine if any credit balances are attributable to Medicare
  • Most hospitals do not have an effective means to ensure compliance which means several credit balance accounts can be present
  • Risky for the CFO because after signing the Medicare Credit Balance Report, he/she is attesting to the fact that all of the hospital’s credits have been reviewed
  • Credit balances are NOT a profit center!
lost billing opportunities
LOST BILLING OPPORTUNITIES
  • Once accounts are analyzed and adjusted, billing opportunities to generate additional cash receipts are often revealed
  • Amounts due from payers and patients have been hidden by the credit balances
  • Failure to analyze credit balances in a timely fashion can result in permanent lost cash
fraud
FRAUD
  • High volume of refund checks issued by large hospitals to patients, insurance companies and vendors make it impossible for controllers to scrutinize & verify each refund
  • Because refund checks pass through many hands, they can end up in the hands of the originator of the request
  • Credit balances and the refund processes are ripe for fraudulent activity – making hospitals exposed to financial losses and corporate embarrassment
  • Refund checks can be misappropriated because of weak internal controls and because the intended receiving parties are not aware that they are due a refund check
negative press
NEGATIVE PRESS
  • Unresolved credit balances can trigger management letter comments to a hospital’s board of directors noting items of concern
  • Credit balances understate an organization’s profit and the AR
common misconceptions
COMMON MISCONCEPTIONS
  • Setting high dollar thresholds for account management creates a time-bomb effect…leaving a growing number of smaller balance credits
  • Hospital is forced to allocate staff to resolve the smaller credit balance accounts creating work pressure in PA
  • Vendor credit balance auditors are paid by commercial insurers to recover overpayments but only 1/3 of the accounts are commercial, largest percentage of credit balance accounts are government and patients
required reporting of medicare overpayments cms 838 form
Required Reporting of Medicare Overpayments CMS 838 Form
  • Providers must submit Quarterly Reports detailing all Medicare overpayments
  • CFO must sign the report attesting to the completeness and accuracy of the data
  • Failure to comply may result in:
    • Financial penalties that include interest and fines/treble damages
    • Criminal penalties
    • Compliance is monitored as part of the cost report auditing process
compliance solutions
COMPLIANCE SOLUTIONS
  • To reduce risk and improve cash flow:
    • Processes established to ensure compliance with Medicare requirements for refunding credit balances and filing the CMS-838
    • Determine total dollar amount and volume of credit balances
    • Determine volume of new credit balances created on a weekly basis to determine risk
compliance solutions35
COMPLIANCE SOLUTIONS
  • Determine thresholds allowed for credit balance levels based on total dollar and total volume of accounts (2 days of a hospital’s revenue)
  • Review current processes
  • Automate manual processes
  • Monitor unresolved Medicare credits
  • Minimize fraud potential and issuance of refund checks by using payers’ processes and systems that allow reporting overpaid accounts – insist on voucher recoveries by the payer
compliance areas of concern
COMPLIANCE AREAS OF CONCERN
  • Registration: fraudulent use of identifications to obtain services / ID Theft by patients or even entity staff
  • Insurance verification: patient using another patient’s Medicare number
  • Charge Capture: overcharging / charging for services not provided, lost charges
  • Billing Errors: Duplicate billing
  • Observation or IP : Medicare and Medicaid correct status
  • Charity Care: evaluations for medical assistance eligibility
medicaid audits state medicaid fraud control units mfcu
MEDICAID AUDITS: STATE MEDICAID FRAUD CONTROL UNITS (MFCU)
  • For fiscal year 2006, from October 1, 2005 and ending September 30 2006, the MFCU received more than $1.1 billion in court ordered restitution, fines, civil settlements, and penalties. They also obtained 1,226 convictions in FY 2006.
  • MFCUs reported 676 instances in which civil actions were taken with successful outcomes.
  • Of 3,425 OIG exclusions from participation in Medicare and Medicaid programs, 731 exclusions were based on referrals made to OIG by the MFCUs.
  • SOURCE: State Medicaid Fraud Control Units Annual Report, Fiscal Year 2006
example in texas
EXAMPLE IN TEXAS
  • In Texas, a physical therapy clinic operator was sentenced to 51 months in prison and ordered to pay $1.32 million in restitution for conspiracy to commit wire fraud and health care fraud. She and her partner billed the Medicare and Medicaid programs for services not rendered and billed for physical therapy services as if they were performed or supervised by a licensed physician. The investigation revealed that the defendants hired unlicensed foreign medical graduates to perform the services of a licensed physician. The investigation involved OIG, the Texas MFCU, and the FBI.
  • SOURCE: OIG Semi-Annual Report for First Half of 2007
key compliance and revenue cycle metrics
KEY COMPLIANCE AND REVENUE CYCLE METRICS
  • PATIENT ACCESS QUALITY:
    • Physician authorization compliance:

96-98%

    • Inpatient admissions error ratio:

<1-2%

    • Outpatient registration error ratio:

<1-2%

    • % Pre-registered IP accounts: 40-50%
    • % Pre-registered OP accounts: 25-30%

HFMA Benchmarks

key compliance and revenue cycle metrics40
KEY COMPLIANCE AND REVENUE CYCLE METRICS
  • CASE MANAGEMENT QUALITY
    • Payer acceptance of clinical treatment plan based on authorization: 95-97% acceptance
    • Clinical denials overturn rate: 95%
    • HFMA Benchmarks
key compliance and revenue cycle metrics41
KEY COMPLIANCE AND REVENUE CYCLE METRICS
  • HEALTH INFORMATION MANAGEMENT QUALITY
    • DNFB (discharged not final billed) and HIM bill holds
      • Awaiting coding: <0.5 day in A/R
      • Awaiting dictation: <0.5 day in A/R
      • Charge capture quality: 98% compliance

HFMA Benchmarks

key compliance and revenue cycle metrics42
KEY COMPLIANCE AND REVENUE CYCLE METRICS
  • PFS/PATIENT ACCOUNTING QUALITY
    • Gross Days Receivable Outstanding:

< 52 days outstanding

    • % A/R over 90 days: 17-20%
    • % A/R over 120 days: 10-12%
    • % A/R over 1 year: < 2%
    • Credit Balance A/R: < 1 A/R day
    • Billing turnaround: 5 days from DOS or discharge

HFMA Benchmarks

key compliance and revenue cycle metrics43
KEY COMPLIANCE AND REVENUE CYCLE METRICS
  • ALL REVENUE CYCLE DEPARTMENTS NET REVENUE EXPOSURE
    • Denial overturn ratio: 95-98%
    • Underpayments overturn ratio: 95-98%
    • Bad debt expense as % of gross revenue: < 2.5%
    • Bad debt expense as % of net revenue: < 2-3%

HFMA Benchmarks

chargemaster updates
CHARGEMASTER UPDATES
  • The CHARGEMASTER is a computer file that contains all the charges that a hospital makes. It is the link between services provided and the generation of claims and billings.
  • Key elements to review in a hospital CHARGEMASTER are: invalid or inaccurate CPT/HCPCS codes, invalid or inaccurate revenue center codes, inadequately defined procedures and tests, appropriateness of bundled CPT/HCPCS codes, and validity of service.
chargemaster updates45
CHARGEMASTER UPDATES
  • Must have an on-going CHARGEMASTER review since the factors that go into the CHARGEMASTER are constantly changing, including the annual updates of CPT/HCPCS codes, changes in reimbursement guidelines and advances in technology.
  • SOURCE: HFMA Compliance Checklist for Hospitals, Revised June 2002
new cms changes impacting compliance and revenue
NEW CMS CHANGES IMPACTING COMPLIANCE AND REVENUE
  • PRESENT ON ADMISSION (POA)start date 10/1/2007 is defined as present at the time the order for inpatient admission occurs – conditions that develop during an outpatient encounter, including emergency department, observation, or outpatient surgery, are considered as present on admission. Purpose is to distinguish between pre-existing conditions and complications.
  • All claims involving inpatient admissions to general acute care hospitals or other facilities that are subject to a law or regulation mandating collections of present on admission information
  • POA indicator is assigned to principal and secondary diagnoses and the external cause of industry codes
  • Issues related to inconsistent, missing, conflicting or unclear documentation must still be resolved by the provider.
poa affects payments
POA AFFECTS PAYMENTS
  • Starting 10/1/2007, CMS reduces payments in some cases when the patient acquires an infection (or other condition) during a hospital stay.
  • Will not assign higher paying DRG to patients who have /suffer from the 8 conditions, unless they are documented as present on admission:
eight poa s not assigned to higher drgs
EIGHT POA’s NOT ASSIGNED TO HIGHER DRGs
  • Serious preventable event – object left in during surgery
  • Serious preventable event – air embolism
  • Serious preventable event – blood incompatibility
  • Catheter associated urinary tract infections
eight poa s cont
EIGHT POA’s (cont)
  • Pressure ulcers (decubitus ulcers)
  • Vascular catheter – associated infection
  • Surgical site infection – mediastinitis after coronary artery bypass graft (CABG)
  • Falls
poa cont
POA (cont)
  • MULTIDISCIPLINARY EFFORT
    • HIM department / Coding professionals
    • Finance
    • Physicians
    • Quality department
    • Risk Management
    • Compliance
    • Support from Administration
    • Vendor readiness
severity adjusted drgs
SEVERITY ADJUSTED DRGs
  • CMS finalized the inpatient prospective payment system (IPPS) rule which forces hospitals to understand Medicare’s new approach to reporting complications and comorbidities (CCs) and determining what combination of primary and secondary diagnoses gets the most favorable reimbursement while remaining compliant
ms drgs
MS-DRGs
  • The final rule has 745 “Medicare Severity DRGs” (MS-DRGs) that replace 538 existing DRGs.
  • Severity adjusted DRGs are better designed to capture the extent of the patient’s illness and complications.
  • There is a third category to describe the relative intensity of a patient’s illness.
ms drgs53
MS-DRGs
  • Before the final rule, there was simply the absence or presence of CCs. CMS has added a new category to describe the most severe secondary diagnoses: major CCs (MCCs)
  • The best reimbursement scenario will be unclear to a hospital in any given case when a patient presents with two or more diagnoses that meet the definition of “principal diagnosis”
ms drgs54
MS-DRGs
  • Hospital coders will be required to analyze sequencing to protect the hospital’s bottom line because the principal diagnosis dictates the DRG and when there are two or more diagnoses that meet criteria for principal, Medicare allows hospitals to bill whichever it chooses.
  • Hospitals must ensure both diagnoses were present on admission, drove the admission and were treated or evaluated.
ms drgs55
MS-DRGs
  • Compliance Officers should use case mix index (CMI) to monitor how well their hospitals are doing with documentation of changes.
  • If the CMI flies above or below what it is now, consider why.
  • Urban hospitals should expect CMI increases because they generally take care of sicker, more complex cases / that is what the severity adjusted DRG system is designed to recognize
ms drgs56
MS-DRGs
  • CMS states payments under the new DRG system are expected to rise in fiscal year 2008 by about 3.5% “when all provisions of the rule are taken into account, primarily as a result of the 3.3% market basket increase”…CMS
  • Independent of Medicare reimbursement changes, the final IPPS rule has built-in payment reductions to account for what CMS considers to be the way hospitals adapt coding and documentation to capture severity of illness and thus get paid more under MS-DRGs and because CMS views the hospitals to be seeing sicker patients
ms drgs57
MS-DRGs
  • CMS has stated “We do not believe there is anything inappropriate, unethical or otherwise wrong doing with hospitals taking full advantage of coding opportunities to maximize Medicare payment that is supported by documentation in the medical record”
future fy08 ipps final rule
FUTURE: FY08 IPPS FINAL RULE
  • The FY08 Inpatient PPS final rule includes a full market basket (MB) update:
    • Increase of 3.3% effective October 1, 2007, for Inpatient PPS hospitals providing quality data
    • MB 2.0% or 1.3% for those not submitting data
impact of the final rule s changes
Impact of the Final Rule’s Changes

The change in payment per case for hospitals in FY 2008 is estimated to average a 3.5% increase, estimated by modeling those changes shown in Table I – Impact Analysis of Changes for FY 2008.

updates to inpatient rates
Updates to Inpatient Rates
  • The CMS impact analysis of the final rule’s changes attempts to account for:
    • The effects of the reclassification of diagnoses and procedures and the proposed recalibration of the DRG relative weights required by Section 1886(d)(4)(C) of the Social Security Act
    • Effects of changes in wage index values
    • Effects of wage and recalibration budget neutrality factors
changes to inpatient pps drg weights
Changes to Inpatient PPS DRG Weights
  • The final rule continues the 2-year transition to weighting DRGs on the basis of cost.
    • For FY 2008: two thirds on cost; one third on charges
changes to drgs
Changes to DRGs
  • The adopted “Medicare severity” adjusted DRGs (MS-DRGs)
    • Are based on the current CMS DRGs
    • Increase the number of DRGs from 538 to 745
changes to drgs64
Changes to DRGs
  • MS-DRGs split some current DRGs based on
    • MCCs – major complications or comorbidities
    • CCs – complications or comorbidities
    • No CCs
changes to drgs65
Changes to DRGs
  • Factors in dividing DRGs:
    • Variance of charges of at least 3%
    • At least 5% of patients in the MS-DRG are falling within the CC or MCC subgroup
    • At least 500 cases are in the CC or MCC subgroup
    • There is at least a 20% difference in average charges between subgroups
    • There is at least $4,000 difference in average charges between subgroups
changes to drgs66
Changes to DRGs
  • Redistribute case mix
  • Have a negative impact on rural hospitals, but CMS expects an offset to some degree from weighting on cost
  • Necessitate (CMS says) an offset of 1.2% in FY08 and 1.8% in FYs 2009 and 2010, for case mix improvement attributable to coding and documentation
changes to drgs67
Changes to DRGs
  • MS-DRGs affect the Postacute Care Transfer Policy
    • 273 of 745 MS-DRGs will be subject to the post acute care policy
    • For qualifying stays, hospitals will be paid 50% of the total inpatient PPS payment plus the average per diem for the first day of the stay
    • Fifty percent of the per diem amount will be paid for each subsequent day of the stay, up to the full MS-DRG payment amount
    • Includes MS-DRGs that share a base MS-DRG
changes in the ltc drg classifications
Changes in the LTC‑DRG Classifications
  • The LTCH PPS updates to the LTC-DRGs (MS-LTC-DRGs) will be included with the IPPS and effective for discharges occurring on or after October 1, 2008 and through September 30, 2009
outliers
Outliers
  • The fixed loss cost outlier threshold for FY08 is $22,650 (down from the current $24,485)
new services and technologies add on payments cont
New Services and Technologies Add-On Payments (cont.)
  • Add-on payments will not continue in FY08 for the new services and technology recognized in FY07
recalled no cost partial credit devices
Recalled/No Cost/Partial Credit Devices
  • The FY08 final rule expands the 2007 outpatient PPS final rule to pay a hospital less when a device is provided at no cost
  • CMS will apply the policy when the hospital receives a credit equal to 50% or more of the cost of the device
  • Hospitals will identify replacement devices; CMS will reduce the DRG payment to reflect the hospital’s lower cost
hospital acquired conditions
Hospital Acquired Conditions
  • Section 501(c) of the DRA requires hospitals to begin reporting on October 1, 2007, at least two secondary diagnoses that are present on the admission (POA) of patients
  • Beginning October 1, 2008, the two selected conditions will not be assigned to a higher paying DRG unless they were present on admission
physician owned facilities
Physician-Owned Facilities
  • The rule includes provisions for more transparency by physician-owned facilities and their physician owners
future opps proposal for 2008
FUTURE OPPS PROPOSAL FOR 2008
  • Medicare’s 2008 OPPS rule updates the conversion factor by 3.3% but also forces entities to be more efficient by reducing the ability to bill for additional, individual services
2008 opps proposed cont
2008 OPPS Proposed (cont)
  • Other proposed provisions:
    • No separate payment for observation
    • Ten outpatient quality of care measures
    • ASC payment system revised
    • Discounted device payments when manufacturer gives entity partial credit
    • End to billing for consults
conclusions
CONCLUSIONS:
  • REDUCING COMPLIANCE RISK and REVENUE CYCLE RISK will be more challenging and require increased system / entity policy audits
  • INCREASING REVENUE will require more detailed documentation from all who are members of the REVENUE CYCLE and require more Access Services, Medical Management, CBO, Charge, Billing, Denial and process audits on a continuous basis
  • MANAGING COMPLIANCE RISK surrounding the REVENUE CYCLE will require a willing MULTI-DISCIPLINARY TEAM with system and process improvement thinking who are not fearful of making changes
research sources
RESEARCH SOURCES:
  • HFMA: www.hfma.org, Revenue Cycle file
  • TWCC: This Week in Corporate Compliance
  • STATE MEDICAID FRAUD CONTROL UNITS ANNUAL REPORT FY 2006
  • MEDICARE COMPLIANCE, VOL 16, NUMBER 32, SEPT. 10, 2007
  • APC PAYMENT INSIDER, VOL. 9, NO. 8, 8/07
  • THIS WEEK FROM SG2 9/3/2007

Also: School of Hard Knocks

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