5 steps to success - hfmatxgc.org · a bit of history: mva philadelphia contributionship 1897 –...
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Complex Claims Billing for Texas Hospitals: 5 Steps to Success
09.18.2019
Who We Are
Jason Smartt, Esq., CRCRSr. Director, Complex Claims
(615) 846-9432
Rob PowersVice President, Client Services
(937) 267-6060
About EnableComp
The Complex Claims Experts Workers’ Compensation Motor Vehicle Accident Veterans Administration
Over 800 Hospitals Nationally
Technology-Driven Service Provider
Over $1 Billion Collected
A Bit of History: Work Comp
Began in Germany First Social Insurance Program All States Regulated by 1949 The Grand Bargain Protects Workers Protects Employers
3 million cases annually $92 Billion system
A Bit of History: MVA
Philadelphia Contributionship 1897 – Gilbert L. Loomis 1898 – Dr. Truman Martin 1925 – Connecticut Massachusetts Early 1930’s Early 1970’s
2010 - $99 Billion in Repairs 2016 – 6.3 million cases reported
Poll Question #1
What percentage of the time do insurance
companies pay hospitals the correct Fee Schedule
amount?
A. 15%B. 32%C. 55%D. 68%
Poll Question #1
B. 32%
Every State is Different
MVA PIP State
MVA PIP Add-on State
The Neglected Pay Class
Small piece of the pie
Drains resources
Ever-changing
Hospitals are “out-gunned”
Inpatient Payer Mix 2011
5 Basic Questions
“Where do I send the bill?”
“How do I get paid?”
“How should I send it?”
“How do I measure success?”
“Should I keep it in-house?”
Poll Question #2
What percentage of complex claims
are sent to the right place?
A. 15%B. 35%C. 55%D. 75%
Poll Question #2
B. 35%
1. Where do I send the bill?
Bill the right payer – the first time
65% of all bills go to the wrong place
Lengthy payment delays
“First in Time, First in Right”
Complete denials
Start with Registration
How did you get hurt?
Police Report and passengers?
Who is your employer or insurance carrier?
Should I pre-authorize?
Start with Registration
Don’t forget the key detail!
Pre-Auth Required for most non-ER hospital services
The correct MVA Claim number
2. How do I get paid?
At Fault Lien Law Admit Issue
CMS basedImplant option
DRGAPCOutlier
Per DiemStop Los
Implants
3. How should I send it?
Send the bill THE RIGHT WAY Include medical notes (AOB)
Lien filing
Send bills electronically
20% faster payment (WC)
Work Comp E-billing States 2017
4. How do I measure success?
60-90 Days to Payment in Full
30% AR over 90
5. Should I keep it in-house?
How many billers are handling our complex claims? Are they effective? Do they understand my expectations? Am I managing my Liens/LOPs? Do I have a good legal strategy? Am I meeting and exceeding my
revenue goals?
Does this really work?
The MISSION Act – Pilot Program?
On June 6, 2019, the MISSION Act became effective. Senators John McCain, Daniel Akaka, and Samuel Johnson drafted and sponsored the MISSION act, which is short for Maintaining Internal Systems and Strengthening Integrated Outside Networks as a consequence to the VA scandals involving Veteran care.
What changed on June 6, 2019?Established the Veterans Community Care Program, which has
different eligibility criteria for Veterans so they have an “easier” time of going out of network. This was meant to allow Veterans another remedy to receive treatment
that the VA could not provide in a timely manner or they lack the resources to provide.
Eligibility criteria significantly changed. Terminated the Veteran’s Choice Program, which exhausted the VA’s
resources in adjudicating.
The MISSION Act – Veteran Eligibility
How veteran eligibility changed under the MISSION Act: The Veteran, in order for the VA to furnish care, must meet at least one of more of the
conditions listed below; A. The covered veteran required hospital care, medical services, or extended care services and:
1. No VA facility offers the care, services, or extended services the veteran requires, OR2. The VA does not operate a medical facility in the State in which the veteran resides, OR3. The veteran was eligible to receive care under the VACA Act of 2014, OR 4. The veteran has contacted an authorized VA official to request the care required, but the
VA has determined that they cannot furnish it, OR 5. The veteran and their referring clinician determined it is in the best medical interest of
the veteran, to access care or services from an eligible entity based on the following factors:
a. Distance, Nature, Frequency, Timeliness, Improved Continuity of Care, Quality of Care, or if the Veteran faces an unusual burden:
i. Excessive driving distance, Whether care at the VA is reasonably accessible, Whether a medical condition of the veteran affects the ability to travel, Whether there is a compelling reason the veteran needs to receive care and services from a non-VA facility, The need for an attendant, and The VA facility would not furnish the type of care that meets the VA quality standards.
The MISSION Act – Claims Submission
Under MISSION, the claim submission process changed. Prior to MISSION
All claims, regardless of authorization, level of care, status, went to the VA for processing. The VA would review for Service Record (Stolen Valor), an authorization on
file, type of service (Planned / Emergency), admission type, (IP / OP), and score the claim.
If the claim’s total billed charges were over a threshold, the claim went to D.C. for confirmation.
Once approved, the VA would confirm the hospital could receive payment (taxes, fines, etc.) and then the Department of Treasury would remit payment.
If the claim was service related, the VA would purchase the care at 100% of Medicare. If the claim was not service related, the VA would purchase the care at the 75th percentile (69.5% to 70.5% reimbursement) of Medicare. Millennium Bill claims as authorized by the Millennium Act of 2001.
The MISSION Act – Claims Submission
Under MISSION, the claim submission process changed. How the MISSION changed Claim Submission
Claims are now divided by authorization. AUTHORIZED
If the hospital received authorization from Triwest, either a planned admission or an ER admission that was authorized within 72 hours, the Uniform Bill (UB) goes to Triwest.
The VA receives the medical records (along with a copy of the claim to accelerate processing) to confirm that services rendered match the authorization. If authorization matches, Triwest will process and pay the claim. If authorization does not match, Triwest will deny.
NOT AUTHORIZED All non authorized claims should be submitted with the UB and Medical
Records to the local VA that houses the Veteran.
VA Pain Points
When working a Veteran claim, here are some points to keep in mind. Authorization
If the patient presents for ER services, they must be authorized (exception to EMTALA). The timeline is 72 hours from admission and whether a bed is available.
Standard of Care Per statute, if the patient feels their life is in danger and a reasonable person
would conclude that services are needed, the VA will not deny the claim.
Denials The most common denials are other insurance (VA is payer of last resort), lacking
an authorization (did not meet criteria), patient not enrolled (Veteran did not enroll in 24 months), the responsibility of Triwest (PC3 claim), and coding (hybrid of Medicare).
Reimbursement Service related = 100% / Non Service related = 69.5% to 70.5%
5 Basic Questions
“Where do I send the bill?”
“How do I get paid?”
“How should I send it?”
“How do I measure success?”
“Should I keep it in-house?”
Questions?
Thank You!