Streamlined Capturing and Billing for Pre-Transplant Services

1. Capturing and Billing Pre-Transplant Services for Cost Reporting, Increased Revenue, and Donor Financial SafeguardsTFCA Annual Workshop forFinancial CoordinatorsSeptember 27th, 2017 Debbie Mast Manager-Finance and Data Stanford Health Care

2. In the Beginning: • Kidney initial evaluation services were billed to the Organ Acquisition Cost Center (OACC) • Significant reimbursement opportunities of $1,016,352. • The Kidney Transplant Program needed to increase revenue, capture all services, maintain donor billing compliance, capture other organs for OACC servicesThe potential for donors to be erroneously billed was astronomical

3. As a program we wanted to implement both bundling and Phoenix at the • same time: • Bundled episode - A record that collects billing information for a set of • services. Use bundled episodes to track the different phases of a transplant • and pull clinical information into your billing workflows • Work Queues (WQ) created to capture all active patients for “bundling” • and reviewing charges. • Rules were created to confirm all active recipient and donors are • captured in the WQ’s. • Charges are reviewed and moved within the charge router WQ based • on an active episode. • Recipient cases must be bundled before moving charges

4. The transplant manager, CC’s, PFS billers, and IT team met weekly to review work make any adjustments needed in the rules to capture only the active pre-transplant patients

5. Charges are reviewed by line item, not by service or date. • Each charge can be individually identified as to whether it is or is not transplant-related and whether it belongs under OACC.

6. Reports were created to track: • Medicare OACC charges • Transplant-Related commercial payer charges • Full charges for cost reporting • Charge Coordinator workload • Charges reviewed daily

7. Where are we Now? • Review all line item charges for our recipients and donors • Accurately capture all services for the cost report • Significant decrease in erroneous billing • Increased revenue to the kidney transplant program

8. You can review hospital and Professional services in one WorkQueue HB and PB are separate for us as an institution so we are not looking at type of charge, we are looking at all Episodes Of Care (EOC) services (Active patients) utilizing bundled episode properties and anything with a missing bundled episode

9. Auto-linking: in departments where we expect the charges to be related to the transplant • Not all charges within a department would be considered transplant related • Increases the number of WQ’s to be reviewed

10. BEAWARE • “Chg Handler” - A charge handler is an automatic activity. Rules are • built and macros used to support these activities. Post charge handler • implemented so team is last to review • “Process” – An automatic system change • The standard episodes functionality whereby certain visits or • other services are auto-linked. These are critical to program • clinical management and documentation BUT are they causing • charges to be “processed” without going through the router for • review –added build to capture both linked and non-linked • charges

11. Recipient Rules: look at the bundled episode instead* of phase Status *needed to re-add the phase status Without the Phase, all phases of the episode were showing. Built into the Router Profile

12. Missing Bundled Episode Rules Be sure when you update your rules in the router, you check the bundled episode rules

13. Donor Rules Updated Rules - 7/2017

14. Create Standard Work

15. Changing Bundled Episodes: Closed, Discontinued, or Void? Activeis the only way things will still be available to link up. While you’re still planning to link charges to it, you need to be in an Active state.Closedshould be used when it’s done and generally followed the parameters of the episode. (Transplant)Discontinuedshould be used when the episode was started for good reasons, but you’re no longer going forward with it for whatever reason and it didn’t complete (for example, patient died, patient was determined not to be eligible, patient moved and is no longer under our care, transplant was discontinued for lack of financial clearance, etc.).Voidedshould be used when you created bundle in error.For an active Episode, when a patient is transplanted, Charge Coordinator (CC) role in the process ends as the billing team takes over. *Review with manager if scenarios arise.

16. Outcome • Successfully capture charges and bill appropriately to commercial payers while still capturing all costs for cost reporting (Commercial and Medicare). • We can now capture services through the review process of ALL services rendered to our patient population. • Implementation of this project to all organ programs has enabled us to gather correct information and produce a comprehensive cost report. • Donors are no longer receiving bills and both patient and employee satisfaction has risen.

17. Router Review

18. Cost Report • No need for secondary review as charges being reviewed in the Router WQ and moved to appropriate area • Capture of ALL Recipient and Donor charges – review of ALL services by line item TRANSACTION_ID TRANSACTION_HAR TRANSACTION_HAR_NAME PATIENT_HAR PATIENT_HAR_NAME EPISODE_ID CURRENT_STATUS HLA_INDICATOR INP_OP PAT_NAME TRANSPLANT_DATE ADM_DATE DISCH_DATE PAT_MRN_ID PAT_ENC_CSN_ID RCP_DNR RECIPIENT_NAME RECIPIENT_MRN RECIPIENT_REL ORGAN1 ORGAN2 ORGAN3 QUANTITY TX_AMOUNT GL_DEBIT_NUM GL_COST_CENTER_DEBIT GL_CREDIT_NUM GL_COST_CENTER_CREDIT GL_ACCT_NUM GL_COST_CENTER_ID GL_COST_CENTER_DESC GL_COST_CENTER_NUM DEPARTMENT DEPARTMENT_NAME TX_POST_DATE SERVICE_DATE REVENUE_CODE_NUM REVENUE_CODE_DESC CPT_CODE DRUG_PHARM HCPCS_NUM PROC_CODE PROC_NAME TRANSACTION_GUARANTOR_ID TRANSACTION_GUARANTOR RESEARCH_ID RESEARCH_NAME PATIENT_GUARANTOR_ID PATIENT_GUARANTOR TRANSACTION_PLAN PLAN1_NUM PLAN1_DESC PLAN2_NUM PLAN2_DESC RPT_GRP_THIRTEEN_NUM RPT_GRP_THIRTEEN_DESC TX_TYPE EPISODE_PLAN PLAN_TYPE SYS_USER

19. Lookback/Offset • The lookback for FY changes to Medicare is easily handled by reviewing the cost report for services billed and monthly transplant report of recipient coverage at time of transplant • FY16 Revenue increase from billing commercial payers – Kidney • FY16 commercial charges captured and billed: $ 5,360,437 • FY16 increase in net revenue due to billing: $ 1,521,754 Revenue

20. Questions?