mbaa master presentation v6

MBAAMEDICAL BILLING ADVOCATES OF AMERICA

DEDICATED TO TRUE & ACCURATE, FAIR & REASONABLE BILLING

A JH CAPITAL GROUP SUBSIDIARY 1

MBAA – An Overview

Snapshot:

• 20 years Patient Advocacy experience

• Market Pioneer

• Recognized market leader in “True, Accurate,

Fair and Reasonable”


Leadership

A JH CAPITAL GROUP SUBSIDIARY

Michael Mann President

Gayle Sutherland, RN, CPC-H Director of Hospital Compliance

Jeanne Woodward, BSN, RN, CPC Director of Physician Compliance

Teresa Brown, BA, RN, CPC-HDirector of Hospital Accounts

Pat PalmerFounder

Healthcare consultant,

lecturer, author, and

patient advocate with

over 20 years of

experience healthcare

billings and insurance

reimbursements.

Responsible for the

strategic growth,

dedicated to Business

Development and

client relationships.

A manager of medical revi

ew, fraud and appeals wit

h over 35 years experienc

e with Medicare Part A Fis

cal Intermediary.

Healthcare lecturer and

trainer for professional

organizations including:

AAPC, MGMA, MD

Liaison, HCCA, and

administrative contractors.

Extensive experience

instructing companies

on compliance

requirements of the

Federal Government

Regulations.

3

Financially Stable – Positioned to Grow


TAMPA, FLTwo Site Locations

200 call center seats total

LOS ANGELES, CAJH Capital Group

JACKSONVILLE, FL100 Seat Call Center

LAS VEGAS, NV100 Seat Call Center

ST.LOUIS, MOCREDIT CONTROL200 Seat Call Center

VOORHEES, NJ200 Seat Call Center

Non-Traditional Private

Equity Group

• Based in Calabasas, CA

• Certified Minority Owned

• Owns 20 Portfolio Companies

• Healthcare

• Specialty Finance

• Cyber Security

• Real Estate

• Government

• Over 1200 Employees

ROANOKE, VAMBAA

Terry Buske

• Sr. Vice President,

Business Development

4

Would you pay this bill?


What questions would you ask?

5

Restaurant

1 Columbus Circle

New York, NY 10019

102 Tetsuo

Tbl 10/1 Chk 7080 GST 2

Feb28’ 07 7:58 PM

2 Prix Fixe 800.00

20.0000 X

20% Serv. Chrg. 161.00

FOOD/BEVERAGE 800.00

Gratuity/Service 161.00

Tax 67.42

Total Due 1033.42

THANK YOU FOR DINING WITH US!!!

A 20% service charge has been applied to the

bill. Any distribution of a service charge rests in

the restaurant’s sole discretion

You want the detail


Summary Bill Itemized Bill

VS.

6

Restaurant Two

2 Anywhere Circle

New York, NY 10018

102 Tetsuo

Tbl 10/1 Chk 7080 GST 2

Feb28’ 07 7:58 PM

Seared Ahi Tuna 32.00

Calamari 16.00

Rugged Flatbread 11.00

Cookie Sundae 8.00

Lobster Bisque (2 @ 8.00) 16.00

Queen Prime Rib 54.00

Rochiolli Vineyards Glass 9.00

Allagash White (2 @ 7.00) 14.00

Root Beer (2 @ 2.75) 5.50

Subtotal 165.50

Tax 14.90

Total Due 180.40

Restaurant One

1 Columbus Circle

New York, NY 10019

102 Tetsuo

Tbl 10/1 Chk 7080 GST 2

Feb28’ 07 7:58 PM

2 Prix Fixe 800.00

20.0000 X

20% Serv. Chrg. 161.00

FOOD/BEVERAGE 800.00

Gratuity/Service 161.00

Tax 67.42

Total Due 1033.42

THANK YOU FOR DINING WITH US!!!

A 20% service charge has been applied to the bill.

Any distribution of a service charge rests in the

restaurant’s sole discretion

UB-04 vs. Itemized


UB-04 Summary Itemized Statement

• Room and Board

• Pharmacy

• Med-Surg Supplies

• IV Solutions

• Laboratory

• Operating Room

• Recovery Room

• Emergency Room

• Every single service, item and drug used in a medical procedure and hospital stay

Why would this be different with your medical bill?

VS.

7

We Overlay the Detail from the

Itemized Bill with the

Summary from the UB-04 to

ensure all changes are Compliant

8

MBAA’s Billing Compliance Analysis

Compare - Contrast

Based on industry standard coding guidelines

including but not limited to:

• Uniform Billing Act

• Social Security Act

• Code of Federal Regulations

• CMS Guidelines

• False Claims Act and the

• AMA Billing and Coding Guidelines


UB-04Itemized

Statement

9

Common Billing Overcharges

• Toothbrush - $1009.00

• Hysterectomy can only be billed once

• Items like oxygen are bundled into the room

charge but are sometimes billed again

separately and individually Estimated amount of Non-Compliant and/or

Overcharged, Uncaptured & Up-Coded

Health Claim Errors - 2013


What happens when no one is looking?

10

Kaiser Case Study

The Focus of MBAA Reviews:

• 500,000 members

• Non-Contract Hospital Claims

• Review balances > $50,000

• Finding Average 17% Error Rates

• $8 Million in Savings (12 Months)


Patricia Hodney-Gould, RN

Kaiser Foundation

Utilization Management

"A clean claim doesn't equate to a correct claim."

11

Kaiser Case Study

Snake Bite Example:

• $950,000 Claim

• Member Plan 80/20

• Hospital offered 2% discount

• Result: True and Accurate = $86,000


90% Savings

12

TPA

Process Payments

Confirm Charges

Apply Discounts

Automation

Workflow - Prior to Pay Best Practice – Self Insured Organization using TPA

Pay this Amount

Self Insured

Organization

>$25,000

UB-04

Itemized

Statement

EORDetailed Support for Denial of

Non-Compliant Charges


Getting Started

Sign Agreement

On-boarding Call

Primary POC

• Determine Project Leader

Claim Criteria

FTP Set Up

• Secure and customizable

Drop Claims

• Airdrop and upload

Step 1 – Set-up Step 2 - Onboarding Step 3 – Intake, Support


On-Going Intake, Support

FTP – Monitor

24/7

Coversheet

UB-04Itemized Bill

Questions Answered

(1 hour a Week)

Compliance Analysis

EOR (Explanation of

Review)


5 (five) day

turnaround

MBAA Value Proposition

MBAA Performance Standard - Identifying 10-20% Error Rates

Current Performance for Kaiser Foundation Northwest - 17%

For every $100M in Claims, MBAA will

return $10M - $20M to your bottom line

No Risk – if there is no savings, there is no cost

MBAA retains 25% percentage of the Savings


CompetitiveAdvantages


• How are we able to find so many errors so

efficiently?We have invested millions of dollars into cognitive computing technology with a

company who’s leadership was directly involved in the architecture and creation

of IBM’s Watson (The Super Computer that won JEOPARDY!).

• Our TPA already reviews our claims, what is

different with your services?TPA’s only receive the UB-04 (summary bill).

• My TPA states our contract does not allow this

type of audit.A Compliance Analysis is not a medical record audit – Under ERISA, it is a

fiduciary obligation.

• Will this affect our employees/members and any

provider discounts?No, we take all measures to assure there is no balance billing and no lost

discounts.

Priority / Payoff Matrix


High Payoff / Easy High Payoff / Difficult

Low Payoff / Easy Low Payoff /Difficult

Payoff

High

Low

Resource, Time Allocation Easy Difficult

• Questions?

• Stakeholders?

• Next Steps?

18

What can you expect from your TPA?1. They will say, “You are not allowed to audit your statements.”

2. They will say, “We cannot get the Itemized Statements.”

3. They will stall out abiding by the payers request.

4. They will say, “We have a team that spot checks the bills.”


Support DocumentationPrior to Pay Service Agreement

First TPA Notification Letter of Service

Second TPA Notification Letter of Service (if necessary)

ERISA Explanations

HIPAA Compliant FTP Drop Site

Drop Site Instructions

Detailed reports of non-compliant changes


mbaa master presentation v6

Documents

jh capital group subsidiary

service charge rests

center st

center voorhees

healthcare lecturer

tetsuo tbl

columbus circle new

center seats total los