Health Care Collector - Kluwer Law International

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PAGE4 1. Physicians don’t sign attestations on Medicare accounts or provide the documentation necessary for coding; and 2. Coding is not completed in a timely fashion. This is usually the major reason for delays since coding can sometimes be done with the information in the record prior to discharge. “In addition, there is usually a suspense period for late charges, from two to five days depending on facilities. But this is often included as part of the delay,” Chrapla explains. How to Prevent Delays Hospitals can prevent or at least combat the problem of revenue being held up in the Medical Records department, according to Chrapla. He recommends the following ideas to avoid late charges and Medical Record delays. Late Charges To prevent late charges the facility should: 1. Establish policies indicating that late charges are not acceptable; all charges need to be posted within 24 hours of service; 2. Establish controls and monitor sources and reasons for late charges; 3. Develop corrective actions specific to each department to prevent late charges; and 4. Reverse late charges against the revenue of the department that is causing the revenue delay. Medical Record Delays To prevent Medical Record delays the facility should: 1. Establish policy (include medical staff in policy development) to make sure all coding is completed within a specific timeframe; 2. Track reasons and type of delays by physician; 3. Report to physicians and medical staff leadership about the physicians who are noncompliant with this policy; 4. Monitor coding delays by account type and coder backlogs; 5. Establish goals for daily coding performance; 6. Ensure staffing levels of coders are sufficient. If not, get more resources and outsource if needed; 7. Provide for flextime for coders and allow them to work remotely from home; 8. Determine when concurrent coding can be done on inpatients; 9. Ensure all outpatient procedures have codes prior to services being performed; and 10. Evaluate what level of chart completion is required to allow coding to be performed. Workflow needs to be designed with coding as a priority. ■ Reader’s Resource For more data and key indicators, see the HARA Report , published by Aspen Publishers, Inc. Call 800-234-1660, or see www.aspenpublishers.com. AUGUST 2010 ABNs Present Problems ... continued from page 1 requirements in radiology and lab procedures. Our highest success rate in obtaining ABNs is for lab services,” he says. “Better case management and documentation has been key.” Working Toward Change Hospitals try to make sure that prior to providing services, the service is covered as a medical necessity, says Deborah E. Shapiro, President and CEO of WFS Services, Inc., in Secaucus, New Jersey. “Sometimes, they are wrong. For example, the severity of the diagnosis does not match a procedure that is performed. When Medicare denies the claim due to medical necessity or as a non-covered service and the patient has signed an ABN, the patient can be billed,” she says. Sometimes, patients will elect to have a noncovered service and they will understand that they have to pay for it. “For example, some new types of wound care with artificial skin are not covered by Medicare,” Shapiro says. Source of Problems “Problems can arise when claims are submitted and providers should have known that the HEALTH CARE COLLECTOR
PAGE5 procedure was not covered. Procedures may not be properly investigated and screened prior to service in order to make sure that an ABN is signed,” says Stephen Chrapla, Director of Third Party Solutions for Revenue Cycle Partners, LLC, in Billings, Montana. “Claims should be also be checked prior to submission and, if the service is not covered by Medicare, the claim should not be submitted. The charge would have to be written off. If the claim is submitted, it could potentially be considered an abusive billing practice and subject to fines under Medicare Fraud and Abuse regulations,” Chrapla says. Shapiro concurs. “There is no ‘back end’ procedure for ABNs. If you have provided the service without the patient being informed or signing off on the charge, you may not bill. Anything other than that is called fraud,” she says. That is why getting the ABN signed during the registration process is so important. “What often creates a problem is not that the patients don’t sign, but that they sign and are not aware of having done so. During inpatient and outpatient registration, there are so many forms for people to sign; they may not really register having signed the ABN. Because ABNs are for Medicare patients, and the majority of Medicare patients are elderly, you may have a confusion factor anyway,” Shapiro says. The Appeal “If a patient has not signed an ABN or even if they have signed it but the hospital deems that the service should be covered, then they have to appeal Medicare’s decision to pay due to medical necessity,” Shapiro says. “Of course, the ABN cannot be signed after the fact when services have been rendered, but appeals can be made. Once the service is provided, the ABN is irrelevant in the appeal process,” she says. In the appeal process, the physicians are asked to provide additional diagnoses and information to get a service approved. “ABNs state that if the patient receives non-medically necessary and/or non-covered services, they are required to pay for the service. If they receive a service that Medicare deems not necessary, the provider might be able to end run the process by changing the diagnosis to something that Medicare will cover. This does not mean having the patient sign an ABN after the fact of service—it means changing the facts of service so that it would be covered,” Shapiro says. These appeals are very difficult and time consuming, Shapiro says. “The process requires coordination among the different departments, such as IT, registration, and patient accounts, so that future issues don’t arise. Because it is so difficult, some hospitals just write off the smaller amounts rather than take the time,” she says. ■ Biller’s Corner Why You Need to Understand Medicare Appeals, Part II Medicare Advantage Plans Judy I. Veazie, CPAM A Medicare Advantage plan is a health coverage choice for Medicare beneficiaries besides traditional Medicare. Medicare Advantage plans, sometimes called “Part C” or “MA plans” are offered by private companies approved by Medicare. Through a bidding process, these private payers must submit plans and assurances that they can meet the established standards and rules for processing claims under the Medicare system. Under these rules, the Centers for Medicare & Medicaid Services (CMS) intend to reassure the beneficiary and the provider that they can count on fair treatment by the MA plans. When a beneficiary joins an MA plan, the plan assures that it will provide all Part A (hospital HEALTH CARE COLLECTOR AUGUST 2010
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