Likely, this is not new to you, but I think it’s worthwhile repeating – URGENTLY - and doing something about it, if you haven’t. Time is running out for those of you who are procrastinators. By April 2013, you will no longer be able to check on a resident’s Medicare eligibility through the Common Working File (CWF).  What does this mean? It means that if you haven’t already, you should start checking Medicare eligibility through the (bear with me here) Medicare Health Insurance Portability and Accountability Act (HIPAA) Eligibility Transaction System (HETS). (Ah, what’s in an acronym?) HETS replaces CWF inquiries. In a way, CMS has made life much easier for billers, because with HETS you can check a beneficiary’s eligibility in real time. (For more information about HETS and how to get into the system,contact us at 877-644-2312 or info@proclaimpartners.com.)

A little background, please. CMS has simplified the eligibility checking process so that through HETS you can submit your inquiry with a real-time 270 request and receive your 271 response, a Functional Acknowledgement (999), an Interchange Acknowledgement (TA1), or a proprietary error response over a secure connection. According to the guide, “The information included in the 271 response is not intended to provide a complete representation of all benefits, but rather to address the status of eligibility (active or inactive) and patient financial responsibility for Medicare Part A and Part B.” This change will likely require you to change your billing processes.

When you submit the 270 inquiry, essentially, you need only to include the following information:

• Health Insurance Claim Number (HICN)
• The Medicare beneficiary’s birth date
• The beneficiary’s complete first name
• The beneficiary’s complete last name

While the first name and birth date are optional, you will need to include at least one of them.

What information should you receive? The information includes the same you received from CWF which you need to file a claim, excepting psychiatric information.  Also it will give you additional information, such as the Part D plan number, address, and enrollment dates as well as the Medicare Advantage Organization name, address, website, and phone number. (Pretty nifty.)

Who can you talk to for help? If you have questions regarding eligibility/benefit data for Medicare Part A and Part B, you should contact your regional Medicare Administrative Contractor (MAC). For questions about Medicare Advantage (MA), Part D, eligibility/benefit and Medicare Secondary Payer (MSP) you should contact the appropriate plan(s) listed in the 271 response. You can also contact us at 877-644-2312 or info@proclaimpartners.com.

Some of the information HETS will send you will be in a format somewhat different from what you may be used to. Also, HETS will eventually be able to send Hospice information in the same format as the CWF. The HETS 270/271 Companion Guide gives you more insight into the eligibility information you will receive in the HETS 271 response. Click here for to view or download the guide.

If you are using a clearinghouse, such as ProClaim Partners, to access Medicare beneficiary eligibility information, they can also answer the questions you may have.

Question: If you are using HETS, how has this changed how you check a resident’s eligibility? Has this change helped you? If so, in what ways?

With all that we’ve been reading about alleged LTC Medicare fraud, overbilling, claiming more services than that which were actually provided, giving incorrect treatments, or up-coding Medicare claims, it’s hard for providers not to feel like a target. Therefore, on behalf of those who are trying to do their best in a world of changing rules, retro reviews, and the dramatic expansion of diagnostic codes, we cry, “Enough already!” We want to speak out for all providers who are doing their best and are NOT trying to rip the system. We believe that the majority of providers operate with integrity and with the intent to provide service consistent with each resident’s needs. Personally, I take exception to any outcry that providers are gaming the system before all the evidence is in place – makes good headlines, but poor policymaker/provider relationships and certainly LOUSY policy.

ProClaim Partners has the opportunity to work with LTC providers managing numerous facilities across the country. Because we work directly with their billing staff and AR managers, we believe that they are doing their best to meet the real needs of their residents and are striving to make sure that the bills are clean and accurately represent the care given.

Having said that, do errors occur? Certainly. Years ago as an adult Boy Scout leader, I, along with others, maintained that scouting would be great…if it weren’t for the boys. Well, providers are in the people business employing people – fallible people. Operating a people business without the messiness of working with people would be great, but unreasonable and illogical. Despite providers’ best efforts with triple checks and even with their clinical applications screening the claims, we’ve discovered extra digits in Medicare numbers, invalid ICD-9 codes, etc.

My advice? Tell your story with claims that accurately reflect the care given and which are properly screened and scrubbed by members of your team (triple check), your clinical application, and a third-party automated claims management solution like ProClaim Partners. And tell your PR department to get off its duff and shout from the rooftops every day the wonderful things your facility and company are doing for the residents you serve, particularly if you are providing services to higher acuity residents. Tell your story. NO, tell your residents’ stories. It’s great press and a great buffer to the possible regulatory scrutiny and bad press that you could encounter in the future.  

The headlines in the long term care media continue to highlight RACs audits, claims scrutiny, and claims denial. Further, at a time when sequestration threatens to reduce Medicare reimbursement by as much as 1.8%, revenue cycle management needs to have the constant attention of all providers every day. Of course, the first thing to do is to minimize the risk of denied claims as well as rejected claims.

Even if you are able to withstand an audit, assuming the clinical documentation supports the claims submitted, you still run the risk of poor cash flow management if your claims are rejected because of inadequate or outmoded claims preparation and “scrubbing” processes. Just as it’s important to “get it right the first time” by having the documentation to support your claims, you need to get it right when preparing the claims. In our free download position paper, Five Most Common Billing Errors, we offer insights into ways to avoid billing errors, improper diagnosis codes, invalid hospital stay dates, incorrect service dates, and etc. What we’re talking about in this post is taking your claims submission process to a higher level through claims automation. Claims automation can help by consolidating the claims submission and management process through one portal. This is the premise behind the ProClaim Partners clearinghouse. It’s a one-stop-shop for scrubbing, correcting, submitting, and monitoring claims as well as receiving payment notifications all in one place. You no longer have to trouble with multiple portals or applications.

Designed for long term care providers, the ideal enterprise-class portal will enable you to centrally monitor and manage all claims before and after they are submitted. From a central home page or dashboard, depending on the permissions/security levels you configure, you can review information and take action at a corporate, regional, or facility level. You can check for errors and clean them up before submitting the claims. The system’s scrubber, which constantly updates itself through its evolving database, can search for errors and omissions according to each payer’s rules. Within the portal you have the opportunity to make corrections in a number of ways according to your preferred workflow and internal policies. You can use the Search function to research claims and where they are in the submission-payment cycle.

You even have access to DDE and multiple MACs log-ins through this portal. While you can make corrections in the DDE, our clearinghouse lets you correct errors within the portal itself.

Other features allow you to stay on top of the revenue cycle for all payers. For example, your claims can be loaded into the system conveniently either via FTP or frequent data sweeps determined by you. Once the system receives the 835 payment notices, it sends emails to those you’ve designated to receive them.

To avoid unnecessary delays in payment, getting the claims submission process right the first time is critical for long term care providers. Visit us at our booth, #1418, during the AHCA/NCAL 63^rd Annual Convention and Expo or during the 2012 LeadingAge Annual Meeting and Exposition, Prime Care Technologies, booth #530, We can show how you can accelerate payments, increase collections, and reduce DSO. It’s the right thing to do.

Ignorance is no excuse. Over the last few months, like me, I’m sure you’ve seen headlines and read articles about the federal crackdown on Medicare and Medicaid fraud. Millions of dollars have been identified as fraudulently paid for services either not rendered or with limited justification. I acknowledge that there are unscrupulous practitioners and providers out there who should be identified, indicted, convicted, and sentenced to the fullest extent the law allows. However, while I don’t have the numbers, I wonder to what extent “fraud” was committed by those who unwittingly engage in poor billing practices, such as miscoding and/or absence of support documentation for procedures provided. Ignoring the old adage that if you didn’t document it, it didn’t happen, may put providers and practitioners at risk of investigation and indictment with all the attendant negative results, such as loss of reputation, decline in confidence, and possibly business failure.

If this falls within the reasonable realm of plausible possibility, I have to scratch my head and wonder why. Why place your business and your future at risk, when you don’t have to? Once again, IT can come to the rescue. Imagine the peace of mind you could have while reducing your DSO, assuming you are at risk not for lack of integrity, but credibility, if your organization had a billing and claims management system that would file clean claims each and every time.

Such an automated revenue cycle management system exists, specifically designed for long term care providers. Imagine a system comprised of a comprehensive and configurable user-friendly web portal to manage claims throughout the submission process, with functions for loading, reviewing, editing, and tracking claims online. With this portal, providers can fully leverage enterprise-level security and permissions with user-definable roles to satisfy their specific claims processing practices. As part of a complete health care transaction solution, providers can submit, monitor, edit claims, and review their claims on-line.

Key benefits of the ProClaim Partner’s application:

• Increased revenue stream and reduced DSO through quick claims turn-around and real-time claims management reporting viewable through a user-defined digital dashboard

• Smoother claims flow through direct connections with providers, trading partners, and value-added networks

• Eliminating avoidable payment delays by increasing successful first-pass rates, tracking claims, and automatically checking claim status

• Reduced transaction fees and paper handling costs by enabling direct connection with providers and payers

• Decreased operations costs through automated handling of routine questions and documentation requests associated with eligibility, claims status, and referrals

• Preserving investments in existing systems by offering an off-the-shelf claims management application that easily interfaces with existing adjudication, financial, and membership systems

   

• Reduced risk through its robust user audit functionality

Providers would be well rewarded for looking into it. In times like these and under this “gotcha” environment of fraud crackdown, doing billing right certainly has its virtues. But a system is only as good as the workflow that leads to the filing of claims – preadmissions screening and documentation; admissions documentation; clinical documentation; therapy services documentation; proper coding; charges compiled; and claims created, scrubbed, triple checked, filed, and monitored. All are critical components of the workflow and are at risk of vital data and information leakage.

In the next blog, we’ll discuss some of these workflow components which are considered industry best practices.

Question: What solid claims management practices have you observed or implemented?