1. correct charge correct amount correct payer 2
Post on 15-Dec-2015
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CLINICAL RESEARCH
BILLING GRID:
AN OVERVIEW OF THE 3 CS
DERITA BRAN, RN, CCRCMANAGER, CLINICAL TRIALS OPERATIONSTENNESSEE CLINICAL TRIALS NETWORK 1
THE 3 C’S
• Correct charge
• Correct amount
• Correct payer
2
OBJECTIVES
• Discuss the purpose of a Billing Grid
• Discuss the Billing Grid process as a means to obtain/communicate accurate billing
• Understand and complete the steps to filling out a Billing Grid 3
PAYMENTS
4
• Study Procedures can be paid by:
• Sponsors
• 3rd Party Payers:• Private Insurance• Medicare• Medicaid
• Study Procedures are not being reimbursed
SO WHAT’S THE BIG DEAL?
5
Improper billing can lead to false claims
Improper Billing
False ClaimsPenalties
IMPROPER BILLING
• Billing a participant/insurance company for research-only procedures
• Billing a participant/insurance company for services covered by the sponsor
• Billing for services promised free in the ICF
• Billing the study for services that should be billed to the sponsor
6
CONSEQUENCESConsequences of Incorrect Billing:
• Fines• Committing fraud• Loss of time correcting error• Failure to recover costs• Criminal penalties• Financial penalties• Loss of Community trust• Restriction on research
operations7
WHAT CAN WE DO?
8
RESPONSIBILITIES
• Requires due diligence by all
• Informing subjects of financial obligations and liability (ICF language very important)
• Complete billing grid (indicates where specific charges should be billed)
• Ensure services for study procedures are billed in accordance with the billing grid
9
PROBLEMS YOU MAY FACE • Complexity of the trial
• Procedures
• Reimbursement payment
• Procedures not associated with a CPT/ICD code
10
GOAL
11
Accurate Billing of procedures associated with clinical trials
AVOIDING BILLING ERRORS• Start the process during contract/budget
negotiation
• Make sure it is clear what the sponsor is paying for
• Differentiate between SOC and research procedures where SOC procedures are not being reimbursed by the sponsor
• Read and evaluate the protocol, ICF (draft is fine) and budget 12
AVOIDING BILLING ERRORS
CONT’D
13
• Requires communication between the following:
• PI • Coordinator• Study Team• Clinic/Department manager• Clinic/Facility front desk• Clinic/Facility billing department• Additional departments that may provide services
for research procedures• Coders• Subject
Requires oversight by study personnel and Billing department
BILLING GRID EXAMPLE
Refer to handouts
14
INSTRUCTIONSDocuments required for a
thorough analysis:
• Protocol• Schedule of events• Contract (may not see until fully executed)
• Budget• ICF• CRF
All of these documents have to contain consistent language in regards to the payment of protocol procedures 15
CREATING A BILLING GRID
Step 1:Complete the header information
Step 2:Using the protocol, schedule of
events, ICF, and CRF (if available) to complete the procedure and visit information
16
Step 3:
Detail each subject Visit
Step 4:
Fill in which procedures will be performed at each visit, indicating this with an X
Step 5:
Determine which of these procedures are paid for by the sponsor and mark with an R
17
Step 6:
Determine which of the remaining procedures are SOC and mark as B
Step 7:
If any procedures are uncompensated mark with a U
Step 8:
If any remaining procedures cannot be determined to fit into any of these categories, leave as X until assigned by the PI
18
Step 9:
Discuss the Billing Grid with the research team, especially the PI
(PI will have the final determination re: the category of billing for each procedure as indicated with his/her signature on the grid)
Step 10:
Distribute to “ALL”
19
BILLING GRID CYCLE
20
Billing Grid
Assure Accuracy
Communication
Track Billing
QUESTIONS
21
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