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Premium member Presentation Transcript CHAPTER 1 : CHAPTER 1 REIMBURSEMENT, HIPAA, AND COMPLIANCE Third-Party Reimbursement Issues : Third-Party Reimbursement Issues Each coding system plays critical role in reimbursement Your job is to optimize payment Your Responsibility : Your Responsibility Ensure accurate coding data Obtain correct reimbursement for services rendered Upcoding (maximizing) is never appropriate Population Changing : Population Changing Elderly fastest growing patient segment By 2030, there will be one person 65 and older for each person 19 and under Medicare primarily for elderly Medicare—Getting Bigger All the Time! : Medicare—Getting Bigger All the Time! In 2016, Medicare will grow to $862 billion Health care will continue to expand to meet enormous future demands Job security for coders! Basic Structure Medicare : Basic Structure Medicare Medicare program established in 1965 2 parts: A and B Part A: Hospital insurance Part B: Supplemental—nonhospital Example: Physicians’ services and medical equipment Part C: Medicare Advantage, health care options (Added later and formerly termed Medicare + Choice) Part D: Prescription drugs Those Covered : Those Covered Originally established for those 65 and over Later disabled and renal failure added Persons covered “beneficiaries” Officiating Office : Officiating Office Department of Health and Human Services (DHHS) Delegated to Centers for Medicare and Medicaid Services (CMS) CMS runs Medicare and Medicaid CMS delegates daily operation to Medicare Administrative Contractors (MACs) MACs usually insurance companies Funding for Medicare : Funding for Medicare Social security taxes Equal match from government CMS sends money to MACs MACs handle paperwork and pay claims Medicare Covers (Part B) : Medicare Covers (Part B) Beneficiary pays 20% of cost of service + annual deductible Medicare pays 80% covered services Non-participating QIO Providers : Non-participating QIO Providers Payment sent to patient Non-QIOs receive 5% less than participating QIOs Slower claims processing Participating QIO Providers : Participating QIO Providers Signed agreement with MACs Agree to accept what MACs pay as payment in full Accept Assignment Block 27 on CMS-1500 (Cont’d…) Slide 13: (…Cont’d) Block 27 on CMS-1500, Accept Assignment Courtesy U.S. Department of Health and Human Services, Centers for Medicare and Medicaid Services. Why Be a Participating Provider? : Why Be a Participating Provider? MACs usually do not pay charges provider submits Significant decrease Participating providers receive 5% more than non-participating (Cont’d…) More Good Reasons to Participate: : More Good Reasons to Participate: (…Cont’d) Check sent directly from MACs to participating provider Faster claims processing Provider names listed in a directory Sent to all beneficiaries Faster Part A, Hospital : Part A, Hospital Hospitals submit charges on UB04 ICD-9-CM codes basis for payment MS-DRG (Medicare Severity Diagnosis Related Groups) More on this topic in Chapter 26 (Cont’d…) Part A, Covered In-Hospital Expenses : Part A, Covered In-Hospital Expenses (…Cont’d) Semiprivate room Meals and special diets in hospital All medically necessary services (Cont’d…) Part A, Non-Covered In-Hospital Expenses : Part A, Non-Covered In-Hospital Expenses (…Cont’d) Personal convenience items Example: Slippers, TV Non-medically necessary (Cont’d…) Part A, Other Covered Expenses : Part A, Other Covered Expenses (…Cont’d) Rehabilitation Skilled-nursing Some personal convenience items for long-term illness or disabilities Home health visits Hospice care Not automatically covered Must meet certain criteria Part B, Supplemental : Part B, Supplemental Part B pays services and supplies not covered under Part A Not automatic Beneficiaries purchase Pay monthly premiums (Cont’d…) Type of Items Covered by Part B : Type of Items Covered by Part B (…Cont’d) Physicians’ services Outpatient hospital services Home health care Medically necessary supplies and equipment Coding for Medicare Part B Services : Coding for Medicare Part B Services Three coding systems used to report Part B CPT HCPCS ICD-9-CM (Vol. 1 & 2) Health Insurance Portability and Accountability Act : Health Insurance Portability and Accountability Act Established 1996 Administrative Simplification Largest change Includes: Electronic Transactions Privacy Security National Identifier Requirements Federal Register : Federal Register Government publishes changes in laws Coding supervisors keep current on changes (Cont’d…) Issues of Importance in Federal Register : Issues of Importance in Federal Register (…Cont’d) October contains hospital facility changes November and December contain outpatient facility changes and physician fee schedule Federal Register : Federal Register Figure: 1.3 From Federal Register, January 26, 2009, Rules and Regulations, Vol. 74, No. 15. Outpatient Resource–Based Relative Value Scale : Outpatient Resource–Based Relative Value Scale RBRVS Physician payment reform implemented in 1992 Paid physicians lowest of 1. Physician’s charge for service 2. Physician’s customary charge 3. Prevailing charge in locality National Fee Schedule : National Fee Schedule Replaced RBRVS Termed Medicare Fee Schedule (MFS) Payment 80% of MFS, after patient deductible Used for physicians and suppliers Relative Value Unit : Relative Value Unit Nationally, unit values assigned to each CPT code Local adjustments made: Work and skill required Overhead costs Malpractice costs (Cont’d…) Relative Value Unit : Relative Value Unit (…Cont’d) Often referred to as fee schedule Annually, CMS updates RVU based on national and local factors Geographic Practice Cost Index (GPCI) and Conversion Factor (CF) : Geographic Practice Cost Index (GPCI) and Conversion Factor (CF) GPCI: Geographic Practice Cost Index Scale of cost variance of charge locations Charge location may be entire state CF: Conversion Factor National dollar amount Paid on Medicare Fee Schedule basis Converts RVUs to dollars Updated yearly Medicare Fraud and Abuse : Medicare Fraud and Abuse Program established by Medicare To decrease fraud and abuse Fraud Intentional deception to benefit Example: Submitting for services not provided Beneficiary Signatures : Beneficiary Signatures Beneficiary signatures on file Service, charges submitted without need for patient signature Presents opportunity for fraud (Cont’d…) Fraud : Fraud (…Cont’d) Anyone who submits for Medicare services can be violator Physicians Hospitals Laboratories Billing services YOU Fraud Can Be : Fraud Can Be Billing for services not provided Misrepresenting diagnosis Kickbacks Unbundling services Falsifying medical necessity Routine waiver of copayment Office of the Inspector General (OIG) : Office of the Inspector General (OIG) Each year develops work plan Outlines monitoring Medicare program MACs monitor those areas identified in plan Complaints of Fraud or Abuse : Complaints of Fraud or Abuse Submitted orally or in writing to MACs Allegations made by anyone against anyone Allegations followed up by MACs Abuse : Abuse Generally involves Impropriety Lack of medical necessity for services reported Review takes place after claim submitted May go back and do historic review of claims Kickbacks : Kickbacks Bribe or rebate for referring patient for any service covered by Medicare Any personal gain = kickback A felony Fine or Jail or Both Protect Yourself : Protect Yourself Use your common sense Submit only truthful and accurate claims If you are unsure about charges Check with physician or supervisor Managed Health Care : Managed Health Care Network health care providers that offer health care services under one organization Group hospitals, physicians, or other providers (Cont’d…) Managed Care Organizations : Managed Care Organizations (…Cont’d) Responsible for health care services to an enrolled group or person Coordinates various health care services Negotiates with providers Preferred Provider Organization : Preferred Provider Organization Providers form network to offer health care services as group Enrollees who seek health care outside PPO pay more Health Maintenance Organization : Health Maintenance Organization Total package health care Out-of-pocket expenses minimal Assigned physician acts as gatekeeper to refer patient outside organization Drawbacks of Managed Care : Drawbacks of Managed Care Organization has incentive to keep patient within organization Services provided outside organization limited Patient must have approval to go outside organization if services to be covered ConclusionCHAPTER 1 : ConclusionCHAPTER 1 REIMBURSEMENT, HIPAA, AND COMPLIANCE You do not have the permission to view this presentation. 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Chapter_001 bwl323 Download Post to : URL : Related Presentations : Share Add to Flag Embed Email Send to Blogs and Networks Add to Channel Uploaded from authorPOINTLite Insert YouTube videos in PowerPont slides with aS Desktop Copy embed code: (To copy code, click on the text box) Embed: URL: Thumbnail: WordPress Embed Customize Embed The presentation is successfully added In Your Favorites. Views: 47 Category: Entertainment License: All Rights Reserved Like it (0) Dislike it (0) Added: July 28, 2011 This Presentation is Public Favorites: 0 Presentation Description No description available. Comments Posting comment... Premium member Presentation Transcript CHAPTER 1 : CHAPTER 1 REIMBURSEMENT, HIPAA, AND COMPLIANCE Third-Party Reimbursement Issues : Third-Party Reimbursement Issues Each coding system plays critical role in reimbursement Your job is to optimize payment Your Responsibility : Your Responsibility Ensure accurate coding data Obtain correct reimbursement for services rendered Upcoding (maximizing) is never appropriate Population Changing : Population Changing Elderly fastest growing patient segment By 2030, there will be one person 65 and older for each person 19 and under Medicare primarily for elderly Medicare—Getting Bigger All the Time! : Medicare—Getting Bigger All the Time! In 2016, Medicare will grow to $862 billion Health care will continue to expand to meet enormous future demands Job security for coders! Basic Structure Medicare : Basic Structure Medicare Medicare program established in 1965 2 parts: A and B Part A: Hospital insurance Part B: Supplemental—nonhospital Example: Physicians’ services and medical equipment Part C: Medicare Advantage, health care options (Added later and formerly termed Medicare + Choice) Part D: Prescription drugs Those Covered : Those Covered Originally established for those 65 and over Later disabled and renal failure added Persons covered “beneficiaries” Officiating Office : Officiating Office Department of Health and Human Services (DHHS) Delegated to Centers for Medicare and Medicaid Services (CMS) CMS runs Medicare and Medicaid CMS delegates daily operation to Medicare Administrative Contractors (MACs) MACs usually insurance companies Funding for Medicare : Funding for Medicare Social security taxes Equal match from government CMS sends money to MACs MACs handle paperwork and pay claims Medicare Covers (Part B) : Medicare Covers (Part B) Beneficiary pays 20% of cost of service + annual deductible Medicare pays 80% covered services Non-participating QIO Providers : Non-participating QIO Providers Payment sent to patient Non-QIOs receive 5% less than participating QIOs Slower claims processing Participating QIO Providers : Participating QIO Providers Signed agreement with MACs Agree to accept what MACs pay as payment in full Accept Assignment Block 27 on CMS-1500 (Cont’d…) Slide 13: (…Cont’d) Block 27 on CMS-1500, Accept Assignment Courtesy U.S. Department of Health and Human Services, Centers for Medicare and Medicaid Services. Why Be a Participating Provider? : Why Be a Participating Provider? MACs usually do not pay charges provider submits Significant decrease Participating providers receive 5% more than non-participating (Cont’d…) More Good Reasons to Participate: : More Good Reasons to Participate: (…Cont’d) Check sent directly from MACs to participating provider Faster claims processing Provider names listed in a directory Sent to all beneficiaries Faster Part A, Hospital : Part A, Hospital Hospitals submit charges on UB04 ICD-9-CM codes basis for payment MS-DRG (Medicare Severity Diagnosis Related Groups) More on this topic in Chapter 26 (Cont’d…) Part A, Covered In-Hospital Expenses : Part A, Covered In-Hospital Expenses (…Cont’d) Semiprivate room Meals and special diets in hospital All medically necessary services (Cont’d…) Part A, Non-Covered In-Hospital Expenses : Part A, Non-Covered In-Hospital Expenses (…Cont’d) Personal convenience items Example: Slippers, TV Non-medically necessary (Cont’d…) Part A, Other Covered Expenses : Part A, Other Covered Expenses (…Cont’d) Rehabilitation Skilled-nursing Some personal convenience items for long-term illness or disabilities Home health visits Hospice care Not automatically covered Must meet certain criteria Part B, Supplemental : Part B, Supplemental Part B pays services and supplies not covered under Part A Not automatic Beneficiaries purchase Pay monthly premiums (Cont’d…) Type of Items Covered by Part B : Type of Items Covered by Part B (…Cont’d) Physicians’ services Outpatient hospital services Home health care Medically necessary supplies and equipment Coding for Medicare Part B Services : Coding for Medicare Part B Services Three coding systems used to report Part B CPT HCPCS ICD-9-CM (Vol. 1 & 2) Health Insurance Portability and Accountability Act : Health Insurance Portability and Accountability Act Established 1996 Administrative Simplification Largest change Includes: Electronic Transactions Privacy Security National Identifier Requirements Federal Register : Federal Register Government publishes changes in laws Coding supervisors keep current on changes (Cont’d…) Issues of Importance in Federal Register : Issues of Importance in Federal Register (…Cont’d) October contains hospital facility changes November and December contain outpatient facility changes and physician fee schedule Federal Register : Federal Register Figure: 1.3 From Federal Register, January 26, 2009, Rules and Regulations, Vol. 74, No. 15. Outpatient Resource–Based Relative Value Scale : Outpatient Resource–Based Relative Value Scale RBRVS Physician payment reform implemented in 1992 Paid physicians lowest of 1. Physician’s charge for service 2. Physician’s customary charge 3. Prevailing charge in locality National Fee Schedule : National Fee Schedule Replaced RBRVS Termed Medicare Fee Schedule (MFS) Payment 80% of MFS, after patient deductible Used for physicians and suppliers Relative Value Unit : Relative Value Unit Nationally, unit values assigned to each CPT code Local adjustments made: Work and skill required Overhead costs Malpractice costs (Cont’d…) Relative Value Unit : Relative Value Unit (…Cont’d) Often referred to as fee schedule Annually, CMS updates RVU based on national and local factors Geographic Practice Cost Index (GPCI) and Conversion Factor (CF) : Geographic Practice Cost Index (GPCI) and Conversion Factor (CF) GPCI: Geographic Practice Cost Index Scale of cost variance of charge locations Charge location may be entire state CF: Conversion Factor National dollar amount Paid on Medicare Fee Schedule basis Converts RVUs to dollars Updated yearly Medicare Fraud and Abuse : Medicare Fraud and Abuse Program established by Medicare To decrease fraud and abuse Fraud Intentional deception to benefit Example: Submitting for services not provided Beneficiary Signatures : Beneficiary Signatures Beneficiary signatures on file Service, charges submitted without need for patient signature Presents opportunity for fraud (Cont’d…) Fraud : Fraud (…Cont’d) Anyone who submits for Medicare services can be violator Physicians Hospitals Laboratories Billing services YOU Fraud Can Be : Fraud Can Be Billing for services not provided Misrepresenting diagnosis Kickbacks Unbundling services Falsifying medical necessity Routine waiver of copayment Office of the Inspector General (OIG) : Office of the Inspector General (OIG) Each year develops work plan Outlines monitoring Medicare program MACs monitor those areas identified in plan Complaints of Fraud or Abuse : Complaints of Fraud or Abuse Submitted orally or in writing to MACs Allegations made by anyone against anyone Allegations followed up by MACs Abuse : Abuse Generally involves Impropriety Lack of medical necessity for services reported Review takes place after claim submitted May go back and do historic review of claims Kickbacks : Kickbacks Bribe or rebate for referring patient for any service covered by Medicare Any personal gain = kickback A felony Fine or Jail or Both Protect Yourself : Protect Yourself Use your common sense Submit only truthful and accurate claims If you are unsure about charges Check with physician or supervisor Managed Health Care : Managed Health Care Network health care providers that offer health care services under one organization Group hospitals, physicians, or other providers (Cont’d…) Managed Care Organizations : Managed Care Organizations (…Cont’d) Responsible for health care services to an enrolled group or person Coordinates various health care services Negotiates with providers Preferred Provider Organization : Preferred Provider Organization Providers form network to offer health care services as group Enrollees who seek health care outside PPO pay more Health Maintenance Organization : Health Maintenance Organization Total package health care Out-of-pocket expenses minimal Assigned physician acts as gatekeeper to refer patient outside organization Drawbacks of Managed Care : Drawbacks of Managed Care Organization has incentive to keep patient within organization Services provided outside organization limited Patient must have approval to go outside organization if services to be covered ConclusionCHAPTER 1 : ConclusionCHAPTER 1 REIMBURSEMENT, HIPAA, AND COMPLIANCE