Rural Hospital Revenue Opportunities

1. PPS CAH Rural Hospital Revenue Opportunities 340B OBS Module 4 – Services and Strategies Facility ER Charge Capture

2. Charge Capture • Charge for all you can. • Medicare and Medicaid, as well as other payers, must review the bill to determine what services were rendered. • If it isn’t on the bill, how will the payer know it was performed!

3. Charge First, Bill Later • A hospital cannot get paid for any service or supply unless it is charged to the patient’s account. • Although there may be certain items that are considered not separately billable, this does not necessarily mean that the service or item should not be charged. • Charges generate revenue, while billed items generate collections.

4. Covered Services • There is a difference between a covered item or service and a separately billable item or service. • Medicare and Medicaid will pay for a covered service in several ways. • May receive separate payment for the line item or service, • May receive payment as part of per diem or percentage of charge reimbursement, or • May receive payment through the packaging of cost into payment for related service.

5. Specific Non-covered Items • There are certain charges that Medicare and/or Medicaid have deemed as non-covered by definition. For example • Self administered drugs • Non-emergency transports • Eyeglasses • Although such services should be charged and mapped to hospital revenue on the general ledger, these items should never be billed as covered to the Medicare program. • If certain conditions are met, however, the patient may be held responsible for paying these charges.

6. Separately Billable Services • Separately billable items are those items that can be billed in addition to a routine room charge, facility fee or procedure charge. • These items are NOT considered as part of the charge for the procedure (i.e. syringes, needles, equipment etc.) or part of the room cost (i.e. linens, meals etc.)

7. Separately Billable Supplies • In order to be considered as separately billable the following conditions must be met: • Directly identifiable to a specific patient • Furnished at the direction of a physician because of specific medical needs • Not reusable or representing a cost for preparation • Not routinely furnished to all patients within a setting • Not a reusable item • Meet a specific medical need • Charged to Medicare and non-Medicare patients similarly • Commonly charged as ancillary by providers within the State

8. Charge Everything • Services that are identified with a specific patient should always be charged either separately or as part of the charge of a related procedures. • Do not use estimates • Do not separately charge for items that are used in bulk (i.e. cotton balls, tape, etc.). The cost of these items should be packaged with the charge for the related procedure.

9. Packaged Items and APCs • PPS hospitals are paid under APCs for outpatient services. • The APC payment amount may not only include reimbursement for the procedure, but also for supplies and drugs used in the procedure. • Although drugs and supplies may be packaged for APC payment, the charges should continue to appear on the UB 92 claim form.

10. Non-Medicare Charge Capture • Just because Medicare will not pay, doesn’t mean other payers won’t. • Conscious sedation • Vaccines • New patient definition

11. Review for Lost Charges • 10 bills from each area • Surgery • ER • Observation • Hospital based clinics • IV infusion • Chemotherapy • Labor & Delivery • Treatment Room

12. Lost Charges • Are facility fee type charges billed when applicable? • If a drug was charged, how was it administered and billed? • How are charges captured? • Stickers • Order Entry • Upon Result

13. Lost Charges • Late charges • Are these billed to the patient? • If on a wrong account, is the charge billed to the right account?

14. Lost Charge Prevention • Are there ways to get charges on a bill without a nurse having to mark a ticket or intervene? • Nurses need to concentrate on documentation that will enable others to charge correctly. • Revenue capture department • OR and Recovery Time • Observation v. Inpatient v. Outpatient • Multiple procedures • Needle placements, interventional • Start and Stop Times – Timed Units

15. Constant Monitoring • Scheduled services or those departments which maintain (logs etc.) should be reconciled to daily charges by department. • Radiology • ER visits • Therapy services • Anesthesia charges in OR

16. CDM Review • Review the Charge Description Master annually. • Ensure appropriate revenue codes and CPT/HCPCS codes are assigned. • Ensure all charges are included separately in the CDM or are packaged with other charges.

17. Observation in CAH • Medicare pays 100% of costs for observation. • CMS clarified in its Medicare Claims Processing Manual (Section 30.1.1), that CAHs: • Are exempt from the 1 and 3 day payment window provisions • Do not bundle OP services provided prior to inpatient admission on the inpatient bill • OP services must be billed as OP, and on a separate bill (85x TOB) from IP services • Outpatient services rendered on the date of admission to an inpatient setting are still billed and paid separately as outpatient services in a CAH

18. Observation in CAH • Falls under Part B (outpatient) services – coinsurance applies • Requires written notice of non-coverage to beneficiary (ABN) prior to stay • OBS beds count as part of 25 maximum bed count

19. ER On Call / Standby • Critical access hospitals should review the costs of ER physician availability and on-call costs. • Review contracts • Review time studies • If CAH, evaluate the benefits of Method II billing • Claim bonus payments related to HPSA and PSA

20. ER Procedures • Look for surgical procedures • Anything that penetrates the skin should be separately billed • Injections • Infusions • Minor surgeries • Laceration repairs

21. Ancillary Facility Fees • Consider billing facility fees for outpatient services in which a specific procedure was not billed (i.e. Labor and Delivery, Treatment Room, etc.) • patients must be registered as an outpatient of the hospital • the encounter must take place in hospital owned space • a hospital employee must render a Medicare service, (i.e. chart medical complaint, vitals, assessment) • the medical record must be retained by your facility • documentation in the medical record should support all medical services provided