2 min read

Avoiding Unintentional Medicare and Medicaid Fraud

By Proclaim Partners on Wed, Jun 13, 2012 @ 08:00 AM

business_man_sad_face-resized-600Ignorance 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?

Topics: Medicare fraud Medicaid fraud automated revenue cycle management system revenue cycle management web portal to manage claims reducing DSO
2 min read

Getting Paid for Part A Therapy Services

By Prime Care Tech Marketing on Tue, Nov 15, 2011 @ 06:19 PM

Billing Medicare Part A for Ancillary Therapy Services - a change in what units represent

Focusing on Medicare’s coverage and payment for ancillary therapy services,Proper Therapy Unit Codes Transmittal 2239 (CMS Manual, Pub 100-04 Medicare Claims Processing, issued June 14, 2011, Billing SNF PPS Services, 30.4 - Coding PPS Bills for Ancillary Services) states, effective August 1, 2011, “For therapy services, that is revenue codes 042x, 043x, and 044x, units represent the number of calendar days of therapy provided.  For example, if the beneficiary received physical therapy, occupational therapy and speech-language pathology on May 1, that would be considered one calendar day and would be billed as one unit.” (Italics added.)

In other words, for each day a Medicare patient receives a therapy service, providers must record that as one unit. In the past, the number of units reported on a claim reflected the number of treatments provided. That is no longer the case. The new policy stipulates that units of therapy should tie to the number of days the patient received therapy services, NOT the number of treatments. For codes 042x, 043x, and 044x, providers are to record the total number of days a resident received therapy treatments as one unit for each day. Providers can look at this as an “on/off switch,” “yes or no” answer. Did the resident receive PT today? If, “yes,” then record 1 unit. If a resident had 16 days of physical therapy treatments, for example, the 042x revenue code should indicate 16 units. The aggregate of the total units/days of therapy services received would be recorded on the claim. 

The transmittal further stipulates that “SNFs are required to report the actual charge for each line item, in Total Charges.” The total should reflect the charges for actual treatments received as determined by your facility’s/company’s charge master and recorded in the Total Charges field.

Questions

If you are using a clinical software application for documenting therapy services, does it automatically convert days of service to units to be recorded in aggregate on the claim while recording the charges based on the quantity of treatments?

What changes were necessary for you to comply with this regulatory change?

With the hiring of Ms. Becky Bos and Ms. Kimberly Kelly, PCT offers enhanced Revenue Management Consulting Services to long term care providers. Cuts in Medicare and Medicaid services have forced providers to effectively maximize and capture the revenue they are able generate. Becky and Kimberly have extensive experience and expertise in working with large multi-facility corporations and small regional providers to identify and collect the cash owed. This is the first in a series of articles in which Becky and Kimberly share their collective wisdom regarding sound billing and collection practices providers can employ.

Topics: Part A Therapy Services therapy units transmittal 2239 042x 043x 044x therapy codes Medicare Part A revenue cycle management
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