Archive for: Patient access
Be prepared for ABN changes
More than a year after several rounds of review on proposed revisions to existing Advance Beneficiary Notice (ABN) Forms ABN-G and ABN-L, CMS published revised Form CMS-R-131.
As with the prior ABNs, the revised ABN is designed for use by hospitals, physicians, and certain other furnishers of healthcare services (“healthcare providers”) to notify Medicare beneficiaries when outpatient services are expected to be denied, primarily in the following circumstances:
- The services fail to meet Medicare’s medical necessity guidelines
- The services are screening services that are provided more frequently than Medicare provides a benefit for
- The services are custodial in nature
As with the prior ABNs, the revised ABN is designed for use by hospitals, physicians, and certain other furnishers of healthcare services (“healthcare providers”) to notify Medicare beneficiaries when outpatient services are expected to be denied, primarily in the following circumstances:
BENCHMARK REPORT: Registration accuracy rates
Want to know how your peers do with their registration accuracy rates? Want to know if their numbers are better than they were 18 months ago?
That is why we prepared this eight-page benchmarking report. Your revenue cycle department is only as good as your patient access team. And it all begins with accuracy on the front end.
To read the report, please click here.
IDENTITY THEFT: Facilities must be prepared
Effective November 1, hospitals must have a plan in place to detect, mitigate, and prevent red flags that signal potential identity theft, according to the Identity Theft Red Flags and Address Discrepancies Under the Fair and Accurate Credit Transactions Act of 2003 (final rule).
There was confusion over whether the rule, which is primarily geared toward financial institutions and other lenders, also applied to healthcare providers. However, although the rule doesn’t specifically reference hospitals, it does imply that they may fit the legislation’s extremely broad definition of “creditor” because they permit a deferred payment of certain ongoing accounts.
Essentially, providers become “creditors” when they establish payment plan. Supplementary information published with the rule states the following: Creditors in the healthcare field may be at risk of medical identity theft (i.e., identity theft for the purpose of obtaining medical services) and, therefore, must identify red flags that reflect this risk.
Examples of red flags could include, but are not limited to, any of the following:
- A mismatch between an individual’s address according to his insurance policy and what appears on his driver’s license
- A photograph on a driver’s license or other ID that doesn’t match the individual presenting it
- An address provided that is a P.O. box or mail drop
- The telephone number provided is for a pager or answering service
To view the red flag rule, which was published in the November 9, 2007 Federal Register, visit this government Web site. For illustrative examples that hospitals can use when developing an identity theft prevention program, refer to Supplement A to Appendix J of the rule. Also refer to the World Privacy Forum Web site to view its latest report titled “Red Flag and Address Discrepancy Requirements: Suggestions for Health Care Providers,” released September 24.
Click here to view the report.
Quality Control: 8 tips for quality control auditing
The quality assurance team at Community Regional Medical Center in Fresno, CA used hard numbers to show the need for automated quality assurance software for its facility. Whether you use a similar approach or not, here are some helpful tips and reminders from healthcare consultant Steven Orvis as you think about your quality assurance program:
1. Eliminate subjectivity on front end. Software providers can create lists of customized services that physicians regularly provide. When a service is ordered, staff members enter a diagnosis code, and the software determines whether it meets medical necessity. It can also generate an Advanced Beneficiary Notice (ABN), as necessary. The advantage of having this as part of the front-end tools is that it is hard to train or expect staff to make medical necessity determinations, and this eliminates subjectivity.
2. Get it right before the visit. Software is available that will match members to their health plans and benefits, so that this can be done before the visit, and reduces or eliminates insurance verification errors.
3. Customize your own rules. Registration scrubber software automates much of the review process and lets users build edits and rules. The rules allow users to automatically check for required fields. The systems can also take this information and build worklists for the auditors.
4. Comply with HIPAA early. HIPAA provides an electronic standard for eligibility verification. The best practice is that eligibility verification occurs during the scheduling process, or pre-registration.
5. Beat the billing scrubber. Failure to review the accuracy of registration data before the billing scrubber review will delay the billing of the claim.
6. Do not disregard training. The best software system in the world cannot replace good, strong, face-to-face training. You need an adequately-trained team, including tools and processes for formal and consistent QA and training.
7. Create registration fields if choosing manual approach. A manual QA process involves an auditor, spreadsheets, copies of face sheets, insurance cards, and Explanation of Benefits (EOBs). The auditor should create a list of registration fields that affect a clean claim and review each field against the documents provided. You can review approximately 100-150 registrations per day. The auditor would then document the errors and identify the problem areas and training needs. This is labor-intensive and time-consuming.
8. Monitor performance. You need to track and monitor the overall adherence to and effectiveness of the QA process for at least six months. This will ensure that there is a working process, consistent reporting, and a reasonable accuracy target.
MORE RAC TIPS: What patient access managers should watch
Editor’s note: These tips are provided by Tanja M. Twist, director of patient financial services at Methodist Hospital in Arcadia, CA. Twist is the finance chair for the American Association of Healthcare Administrative Management (AAHAM) who has fought Congress on Capitol Hill for better transparency and answers to concerns with RACs on behalf of hospitals.
1. Review your ED admissions. Twist cautions that many admissions from the ER are made because the facility needs to free up ED beds, which can lead to medical necessity problems with the RAC. “Emergency rooms are busy all across the country,” Twist says. “A key component is to make sure you meet the medical necessity criteria for the ER admissions too. The nature of the emergency department beast is things get rushed, but you have to ensure there are protocols in place to watch the ER admissions, too.”
If you do not have a 24/7 ED case coordinator position that monitors admissions, ensure someone like your case manager or you, the patient access manager, comes in first thing in the morning to clean up the admissions, she says.
2. Review your one-day stays. “This is another piece the RACs are focusing on,” Twist says. “Should those patients be observations? I’ve seen admitting orders just say ‘admit.’ You have to make sure that physician orders have an ‘admit to acute or admit to observation’ designation. There could be some type of check box for the physician to clearly indicate his selection. From here, the concern is whether or not the acute admission meets criteria.”
MSP COMPLIANCE: Take-home hints on MSP
Editor’s note: Dunn Memorial Hospital in Bedford, IN, uses these hints to help its patient access staff members successfully complete the Medicare Secondary Payer Questionnaire.
Medicare is the secondary payor when:
- The patient is 65 or over and the patient or the patient’s spouse is still employed and has insurance through that employer.
- The patient is under 65 and the patient or patient’s spouse is employed by an employer with 100 or more employees and has insurance through that employer.
- The claim is workers comp.
- The claim is a Black Lung claim.
- The claim is a result of an accident and liability insurance is available.
- The claim is for ESRD and the patient is still in the 30-month coordination of benefits period.
- When Medicare is the secondary payor, the primary payor is #1 in the sequence of payors.
- Medicare is #2 in the sequence of payors when Medicare is the secondary payor.
- MSPs are to be completed on each registration to ensure proper billing.
News: Medicare announces 2009 deductibles, premiums
CMS announced last week that the 2009 monthly premium for Medicare Part B will stay at $96.40, the same as it was in 2008. It’s the first year since 2000 there was no increase in the standard premium from the previous year.
According to CMS, the standard Medicare Part B premium is set to cover one-fourth of the average cost of medical services incurred by beneficiaries over age 65. Even though medical expenses for the beneficiaries are expected to increase in 2009, the premium was not increased because the Supplementary Medical Insurance trust fund, from which the Part B expenditures are drawn, is expected to be at a higher than adequate level at the end of 2008.
In contrast, Part A beneficiaries will see a jump in costs. While 99% of them do not pay a monthly premium, the cost of the Part A deductible will rise $44 for 2009, from $1,024 to $1,068. The deductible covers up to 60 days of Medicare-covered inpatient hospital care within a benefit period. After 60 days in 2009, Part A beneficiaries must pay an additional $267 per day for days 61-90, and $534 per day for more than 90 days. These costs are up from the prices in 2008, which were $256 and $512, respectively.
Source: Centers for Medicare & Medicaid Services
Tip: Quality of Care
Quality of care continues to be a priority with both the state and federal government. Consider the following questions and concerns when examining your compliance program:
- Evaluate the procedure in place to monitor quality of care.
- Is an oversight board in place?
- Is the quality of care part of the provider’s plan?
- How are quality-of-care problems handled?
- Educate professional and nonprofessional staff on quality of care and the ethical responsibility each has in this area.
- Is quality of care in the mission statement?
- Are the goals and charitable duties of the facility in concert with quality of care?
- Immediately address problems or concerns regarding quality of care and errors.
- Is there a clear line of communication among staff, the compliance officer, and the board to address quality of care problems?
- Are inquiries and questions handled discretely and in confidence?
- Are inquiry results made available to the complainant and others in a timely manner?
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Conduct internal audits and evaluations to ensure quality of care in all areas of the facility.
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Make them part of compliance.
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Use quality of care to your advantage.
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Recognize and promote the organization’s effectiveness and efficiency to the government and, more importantly, to the public.
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Quality of care, correction of errors, and promotion of good healthcare systems will drive down the cost of malpractice insurance and give beneficiaries the services and care they need.
This tip was adapted from The Compliance Officer’s Handbook. For more information about the book or to order your copy, click here
ABNs: CMS releases new instructions
- Is an oversight board in place?
- Is the quality of care part of the provider’s plan?
- How are quality-of-care problems handled?
- Is quality of care in the mission statement?
- Are the goals and charitable duties of the facility in concert with quality of care?
- Is there a clear line of communication among staff, the compliance officer, and the board to address quality of care problems?
- Are inquiries and questions handled discretely and in confidence?
- Are inquiry results made available to the complainant and others in a timely manner?
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Make them part of compliance.
-
Recognize and promote the organization’s effectiveness and efficiency to the government and, more importantly, to the public.
-
Quality of care, correction of errors, and promotion of good healthcare systems will drive down the cost of malpractice insurance and give beneficiaries the services and care they need.
CMS posted new instructions for the revised Advance Beneficiary Notice of Noncoverage (ABN) form.
Last month, CMS had pushed back the mandatory date for using the new form from September 1, 2008 to March 1, 2009. Providers may still use the revised ABN for all situations in which Medicare payment is expected to be denied.
The revised ABN, CMS says, replaces the existing ABN-G (Form CMS-R-131G), ABN-L (Form CMS-R-131L), and NEMB (Form CMS-20007). Beginning March 1, 2009, the ABN-G and ABN-L will no longer be valid.
TIP: Develop a customer service script
Editor’s note: The following is an excerpt from the HCPro, Inc.’s book, The Patient Access Director’s Handbook, co-authored by Sandra J. Wolfskill, FHFMA, and Marilyn H. Lipka, MBA. The full story will appear in the October issue of Patient Access Advisor.
Scripting involves identifying common situations, activities, and questions posed to patient access and teaching staff and how to answer appropriately to project the caring, professional image of a staff member working hard to exceed the customer’s expectations.
The most difficult part of implementing scripted responses is to develop the appropriate responses and train the staff. Thereafter, all managers and supervisors must be held responsible for monitoring staff compliance with the use of the expected responses and statements.
If management fails to hold staff accountable for following the scripts, then the entire scripting exercise is a waste of time and money. Hold your staff accountable for following the scripts so the scripting exercise proves to be time and money well spent rather than wasted.
