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The Audit You Want A charge capture audit will likely uncover “lost” reimbursement. When Elizabeth Schaub-DeBlock, MPA, worked for a billing management company, she regularly reviewed imaging facilities’ coding tendencies. What she found should scare you. “I never did a 30-record audit where the hospital left less than $17,000 in CMS [Centers for Medicare & Medicaid Services] reimbursement on the table,” Schaub-DeBlock said in her presentation at the American Healthcare Radiology Administrators annual meeting last month in Orlando, Fla. Never. Not one time. Her advice: Do a charge capture audit every other month. With radiology reimbursement being squeezed—and little evidence the situation is going to change anytime soon—imaging departments and facilities can’t afford to leave dollars on the table. Schaub-DeBlock, a consultant with CBIZ/Medical Management Professionals, Inc., advised administrators to start that process by gathering the radiologist reports, UB-92 claim forms, and the detailed bills from 20 to 50 patients across all the modalities their facilities provide. Select records that are three to four months old. Begin your analysis by looking at the referring doctor’s prescription. Confirm that it was ordered and provided properly (eg, CT with or without contrast) and includes appropriate medical necessity codes. Schaub-DeBlock noted this part is not usually a large source of errors. Then check the UB-92 form and make sure the appropriate CPT codes for the ordered procedures made it onto the form. Check the coding documentation by looking at the radiologist’s report, she said. For example, if the referrer ordered a chest CT without contrast but for some reason an abdominal scan was necessary and subsequently performed, that second charge may not have been added to the bill. Because the radiologist’s report is the record of what was done for the patient, a billing analysis needs to confirm the order and report match and that everything a physician must do to support a CPT code is documented in the report. If a physician does something but doesn’t document it in the report, the hospital won’t be paid for providing the service. The final step on the front end of a charge audit is comparing the detail bill to what has been generated by the HIM department. Make sure the proper information from the order and the report made it onto the bill. The question to answer for the audit, she said, is whether you can drop the bill without fixing it. “If you don’t do a process like this, there is no way you will know that what you’re doing will end up generating charges,” Schaub-DeBlock said. “Some department will have 0% error rates. Some have error rates up to 50%.” Schaub-DeBlock also noted that the CMS is beginning an effort to make sure a physician’s professional fee coding matches the hospital’s technical component coding for Medicare services. Comparing the professional and technical components of the same procedure make good communication between the physician and the facility even more important. Schaub-DeBlock suggested asking your radiologists’ billing office to provide a sampling of ten 1500 physician claim forms to compare with your UB-92s to see if each side is coding the same thing. “Part of the success of any radiology department is how bought in the physicians are to the processes,” Schaub-DeBlock said. Denials and EOBs During her presentation, Schaub-DeBlock took an informal poll about denial reports among the attendees. She asked them whether they received any feedback from their financial department about claim denials. Between two thirds and three quarters responded that they do not get such feedback. “It’s probably one of the more important things for you guys [administrators] because you are gathering the information,” Schaub-DeBlock said. “The radiologists are the ones who are providing the documentation to dispute or follow up on denials.” Comparing the explanation of benefits (EOBs) to the report and detail bill can provide valuable information about denials. A cluster of specific denials points out problems repeatedly occurring on the front end that can be fixed to further reduce denials. “If you can get some report of what is being denied and why it’s being denied, ultimately finance will see why it is a good thing that you are getting this report,” she added. In addition to auditing denials, a facility should also audit paid claims to make sure they were paid correctly. Knowing what should be paid and matching the amounts to the payments accompanying EOBs can help close potential revenue leaks. It All Starts Up Front “I have long been a proponent that the intake clerks, registration people, or whatever term is used in your institution, are one of the most important, least paid, and in some cases, least trained [employees],” Schaub-DeBlock said. “I would have to fight harder to get raises for my reception staff than anyone else. And when the stuff isn’t right at the beginning—the data isn’t correct—you’re never going to get paid properly.” In addition to gathering accurate data, your registration staff has the increasingly important task of handling the ever-growing precertification process for imaging exams. Schaub-DeBlock advised preparing a master list of every insurer’s precertification requirements. Make sure your schedulers have a list of every insurer’s precertification requirements so they can refer to it when patients call seeking appointments. Your staff needs to know that it cannot make an appointment unless the patients’ percertification requirements are fulfilled. Besides getting the information right, your registration staff may also be able to streamline some of the bureaucracy. Schaub-DeBlock knew of one imaging center that had an online registration Web page allowing patients to fill out registration forms before arriving—except that once patients arrived at the imaging center, they were asked to provide the same information again. Many practices routinely copy every patient’s insurance card and driver’s license on every visit. She pointed out that a timesaving alternative can be pulling out the copies on file and asking the patient to confirm that the information on file has not changed since the previous visit. Another worthwhile management tool is spending four to six hours sitting and watching registration and looking for inefficiencies and redundancies that can be eliminated. ABNs and Other Ideas “The patient needs to be give an advance beneficiary notice that you will be billing them for it because Medicare does not pay for that service,” she said. “You can bill secondary insurance, if patients have that, but it’s a loss without an ABN.” Managing Managed Care “The managed care department needs to know that you are doing something new that is very expensive and that it needs to be carved out or treated a little differently than the rest of the procedures,” Schaub-DeBlock said. Understanding what’s included in the contract or carved out falls to the provider, she cautioned, because payers are unlikely to call it to your attention that you may not be getting enough reimbursement from them. She pointed out an example from a few years ago when one insurer was identifying the 36200 CPT codes for angioplasty as surgical codes and reimbursing them at the $250 per diem rate for surgical procedures, regardless of what was actually being done. “It took the hospital months to find out that they weren’t getting paid the way they should be paid, especially in your high-cost, high-volume procedures,” Schaub-DeBlock said. “You need to understand what your managed care contract says and how you are getting paid. “When you look at your revenue and usage reports, do you know what is part of that one big number? Do you know whether you should have had $20,000 more revenue that month? It could be more than $100,000 in many cases,” Schaub-DeBlock added. Update That CDM Given Schaub-DeBlock’s audit experience of always finding at least $17,000 in “lost” reimbursement, she firmly believes education for everyone involved in the process is a good investment. And while coding and billing are rarely the most exciting topic, she suggested stressing their importance in human terms. “One thing I used to [tell technologists] is for every $50,000 or $60,000 I lose [in the coding and billing process], I’d explain to them that is one of you,” Schaub-DeBlock said. “That is someone the hospital had to lay off and/or couldn’t hire because we didn’t have the money because we just ignored it. I think it helps sometimes when we just put it into real people terms.” — A Radiology Today staff report
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