Optimizing Revenue Cycle for Healthcare Providers

1. Focusing on the Revenue CycleLandon Tooke, CHC, CCEP, CPCO

2. Medicare is a “massive, complex health and safety program embodied in hundreds of pages of statutes and thousands of pages of often interrelated regulations.” – Supreme Court Medicare and Medicaid are “Convoluted and complex…a model of un-clarity.” - Connecticut District Court In terms of complexity, Medicare is “unrivaled anywhere in the world” and “its regulations outnumber even those of the labyrinthine Internal Revenue Code.” – Wall Street Journal “The medical billing system is so inefficient and complicated, people don’t even know how to make a dispute. They just throw up their hands.” - Martin Gaynor, Professor of Economics and Health Policy, Carnegie Mellon University Revenue Cycle

3. Goals: Collect every dollar earned. Receive payment as fast as possible. Comply with all laws, rules, and instructions. Topics: Revenue Cycle Steps…what is missing? Identify Risk Areas and how to manage them. Discuss Law Enforcement Revenue Cycle

4. 10 Step Revenue Cycle 1 2 3 4 5 Charge Entry Contracting Pre-Visit Check-in Encounter 6 7 8 9 10 Denial Management Analysis and Reporting Claim Submission Payment Follow-up

5. Revenue Cycle Elements • Setup • Software • Enrollment • Process Alignment • Controls • Technology • Software • Templates • Forms • Reports • Security • Providers • Committed • Productive • Quality-Focused • Team • Trained • Motivated • Educated • Analytics • Accurate • Meaningful

6. Revenue Cycle Development • Infrastructure • Technology • Software Setup • Charge Description Master • User Training • Provider Enrollment • Policies and Procedures • Process Design • Process Alignment • Provider Commitment • Processing • Scheduling • Pre-Visit Financial Clearance • Registration • Charge Capture • Coding • Claim Submission • Follow-up • Posting • Denial Management • Appeals • Collections • Analysis • Internal Controls • Benchmarking • Productivity Measures • Management Reporting • Accountability • Compliance

7. Infrastructure • Software • Automation • Electronic Remittance Advice • Electronic posting • Electronic Funds Transfer • Clearinghouse • Claim scrubbing • Data mining • Software integration • Security • HIPAA Security Rule - 45 C.F.R. §164 Sub. C • Risk Analysis • Required by law since 2003 • Must be ongoing

8. Infrastructure Policies and Procedures

9. Infrastructure Policies and Procedures • Standards and Controls • Policies • Processes • Procedures • Controls

10. Infrastructure Standards and Controls What is a policy? A policy is a rule, regulation, or a set of guidelines to which an organization and its workforce comply. Policies are meant to remain static and include responsibilities and consequences.

11. Infrastructure Standards and Controls What is a process? A process is a high-level set of actions, or set of procedures, which must happen to ensure compliance with a policy. A process defines who, when, and how often. Processes are the steps needed to ensure a policy is enforced. A process must align with a policy and outline an acceptable method to comply with the associated policy or policies.

12. Infrastructure Standards and Controls What is a procedure? A procedure is a detailed set of steps by which an individual performs a process. A procedure outlines who performs the steps, the order of steps, and how to address unknown variables. Procedures can be user-specific. Procedures may include tools or references such as computer screen shots or form templates. Policies have widespread application while processes and procedures are successively more specific in scope.

13. Infrastructure • Standards and Controls • Managing Policies, Processes, and Procedures • Policies are reviewed annually or biannually and change infrequently • Processes may change as the environment changes. • Procedures require continuous review and improvement at the conclusion of every cycle.

14. Infrastructure • Standards and Controls • What are Controls? • Controls are tools implemented to monitor and manage: • Performance • Productivity • Compliance • Happens at the procedural level.

15. Infrastructure • Standards and Controls • What are Controls? • Controls are vital in achieving organizational goals and meeting obligations of: • Corporate governance • Fiduciary duty • Due diligence • Controls reduce risk of: • Negligence • False Claims • Malpractice • Controls are tools which serve to ensure the quality and integrity of a process through offering evidence that procedures are followed.

16. Infrastructure • Standards and Controls • What are Controls? • Controls may include, but are not limited to: • Accounting standards • Financial statements • Operating metrics • Segregation of duties • Reconciliation • Approvals • Disbursement polices • Performance and productivity monitoring • Data integrity • Auditing • Information security

17. Infrastructure • Standards and Controls • Compliance • Do what your policies, processes, and procedures state, or change them. • Monitor, audit, and report on controls. • Use reports for accountability, performance improvement, and process improvement.

18. Infrastructure • User Training • Develop and Test User Software Capabilities • Proficiency • Self-Efficacy • OIG Recommends Annual Training • Coding requirements • Claim development and submission process • Outcome of signing a form for a physician without the physician’s authorization • Proper documentation of services rendered • Proper billing standards and procedures and submission of accurate bills for services or items rendered • Legal sanctions for submitting deliberately false or reckless billings • Advanced Compliance Training • Billing Risk Areas • Coding Risk Areas

19. Infrastructure • Provider Enrollment • 60-90 days for linkages • Up to 120 days for new enrollment • Found physicians working for a year with incomplete enrollment. • The practice of billing under another provider’s NPI number (or ghost) is illegal. • An unenrolled physician may provide services incident-to a billing physician’s services. 42 C.F.R. §410.26 (2016) • Supervising physician is liable for all services • Supervision rules apply • Some commercials may not allow it

20. Infrastructure • Process Design and Alignment • Align processes with software. • Avoid: • Shortcuts • Convenience • Laziness • “That’s the way we’ve always done it.” • Working outside your software creates: • Inefficiency • Inflated workloads • Overstaffing • Risk

21. Infrastructure • Provider Commitment • Registration and Administrative work are complex and cumbersome. • Providers must be committed to completing their job…which involves more than direct patient care. • Patient Safety and Quality issues: • Timely completion of records • Compliance with statutes, program rules, and program instructions • Creating billing complications causes distress for team members and patients

22. Scheduling, Pre-Visit Financial Clearance, Admission, and Registration • Inputs • Demographic Information • Insurance Information • Verify information without leading the patient. • Cost to rework a claim: $251 • Eligibility • Verify active coverage • Verify benefits • Obtain pre-authorizations if necessary • Coordinate benefits – Medicare Secondary Payer Program • 42 U.S.C. §1395y (2018) • Kane ex rel. U.S. v. Healthfirst, Inc. et al., $2.95 million • Negron ex rel. U.S. v. Progressive Cas. Ins. Co. et al., $2 million • 1 MGMA. (2014). Processing

23. Medical Record Documentation • Consents and Releases • Informed Consent for Treatment – protects a patient from making decisions about treatment without first being provided the necessary information • Assignment of Benefits – assign the right to payment to the facility; financial liability for non-covered services • Advance Directives – written statement regarding treatment Processing

24. Medical Record Documentation • Consents and Releases • Authorization for Release of Information: • the specific name or general designation of the program or person permitted to make the disclosure • the name or title of the individual or the name of the organization to which disclosure is to be made • the name of the patient • the purpose of the disclosure • how much and what kind of information is to be disclosed • the signature of the patient and, when required for a patient who is a minor, the signature of a person authorized to give consent under 42 C.F.R. §2.14; or, when required for a patient who is incompetent or deceased, the signature of a person authorized to sign under 42 C.F.R. §2.15 in lieu of the patient • the date on which the consent is signed • a statement that the consent is subject to revocation at any time except to the extent that the program or person which is to make the disclosure has already acted in reliance on it. Acting in reliance includes the provision of treatment services in reliance on a valid consent to disclose information to a third party payer • the date, event, or condition upon which the consent will expire if not revoked before. This date, event, or condition must serve the purpose for which it is given. More restrictive requirements are associated with special records which include HIV/AIDS, psychotherapy, and substance abuse disorder. • 42 C.F.R. §2.31 (2018) Processing

25. Scheduling, Pre-Visit Financial Clearance, Admission, and Registration • Consents and Releases • Advance Beneficiary Notices – modifiers used • Items or services that Medicare isn’t expected to pay for • An estimate of the costs for the items and services • The reasons why Medicare may not pay • “To transfer financial liability to the beneficiary, the provider must issue an advance written notice of noncoverage when an item or service is not reasonable and necessary under Medicare Program standards.” 1 • “An advance written notice of noncoverage should be issued far enough in advance of potentially noncovered items or services to allow sufficient time for the beneficiary to consider available options.” 1 • “The ABN must be reviewed with the beneficiary or his/her representative and any questions raised during that review must be answered before it is signed.” 2 • Centers for Medicare and Medicaid. (2018). Medicare Advance Written Notices of Noncoverage. Medicare Learning Network, ICN 006266 October 2018. • Centers for Medicare and Medicaid. (2018). Form Instructions, Advance Beneficiary Notice of Noncoverage (ABN), FFS ABN OMB Approval Number: 0938-0566. Processing

26. Charge Capture • Office and Outpatient Charges • Schedule all visit types • Missed Visit Report • Daily reconciliation • Inpatient Charges • Request electronic access to hospital registration and clinical systems • Verify charge capture with source documents: • Hospital discharge and transfer reports • Consultation requests • Operative reports • Discharge summaries • Clinical databases • Service logs Processing

27. Medical Documentation and Coding Key Performance Indicators Processing

28. Medical Documentation and Coding Key Performance Indicators Processing - Decision Health, 2016

29. Medical Documentation and Coding • Documentation Risks • Copy and paste • Copy forward or carried forward • Cloning • Automatic field population • Auto-authentication • Macros • Templates • These can lead to prepayment reviews, overpayments, payment suspensions, and liability under the False Claims Act. Processing

30. Medical Documentation and Coding • Questionable Findings… • Physician exams are nearly identical in every encounter. • What was actually performed? • Does the documentation support the services? • Multiple patients have the same findings. • Does the information in the record pertain to the patient? • Does the ROS match the H&P? • Does every patient have the same diagnosis? • Are diagnoses assigned based on what will get the claim paid? • Default documentation is used. • The records may not be individualized for the patient or the visit. • Did patients actually receive the service? • Do the records establish that the service was provided? Processing

31. Medical Documentation and Coding • Documentation Risks • “Cookbook Medicine” – taking the individualized thinking out of medicine because a provider is prompted by software. • “Note Bloat” – copying notes from prior encounters making it difficult to determine what was performed during a current encounter. • Cloning – each entry is worded exactly like or similar to previous entries or if entries are the same from patient to patient. Medicare considers this a “misrepresentation of medical necessity requirements for coverage.” • Macros – programmable code used to auto-populate based upon keystrokes. For example: Autocorrect. • Auto-authentication – a provider may click a button in an email or notice to automatically authenticate a record, a result, or a batch of multiple records. The metadata will show that the provider never entered the record to authenticate. Processing

32. Medical Documentation and Coding • Documentation Risks • Copy and Paste – this function is not a non-compliant practice, but it is also not recommended. Compliance is determined based upon whether the information supports the service. • Copy forward – moving previous information forward but manually updating episode-specific information such as vital signs. This is not a best practice, but is lower risk than copy and paste. The Office of Inspector General recommends against both practices. • If you are going to do either… • Never move information from Patient A to Patient B. • Always copy, paste, edit, then review for accuracy and authenticate. Processing

33. Medical Documentation and Coding • Templates • Advantages • Streamline documentation process • Improve legibility • Improve records search • Disadvantages • Limited ability to enter free text when necessary for accuracy or completeness • Checking boxes may not capture all information to support medical necessity • Canned documentation – Example: Drug dosages • Must be updated, particularly problematic with personal customization • Auto-wording can promote upcoding – Examples: creating the appearance of an examination of all systems when not actually performed; EMR may designate a body part as “unremarkable” instead of “unexamined” leading to incorrect billing • CMS does not approve or prohibit. CMS discourages templates with limited options and checkboxes in place of free text fields. Processing

34. Medical Documentation and Coding A Big Deal? Copy and Paste July 7, 2016 – MD2U (Home Health company) agreed to pay $21.5 million for allegations of upcoding and cloning enabled by improper EHR use. NPPs were able to cut, copy and paste medical notes from prior visits which grossly exaggerated the level of service provided – the Justice Department figured this out using data mining. The complexity of the records indicated that nurse practitioners were spending 5-15 minutes with patients; however, the software time-stamping function revealed that these records were open for as little as 34 seconds. Department of Justice. (2016). Louisville Based MD2U, a Regional Provider of Home-Based Care, and Its Principal Owners Admit to Violating the Federal False Claims Act and Being Liable for Millions. July 7, 2016. https://www.justice.gov/opa/pr/louisville-based-md2u-regional-provider-home-based-care-and-its-principal-owners-admit Processing

35. Medical Documentation and Coding A Big Deal? Copy and Paste/Carried forward “We analyzed 23,630 notes written by 460 clinicians. In a typical note, 18% of the text was manually entered; 46%, copied; and 36%, imported. Residents manually entered less (11.8% of the text) and copied more (51.4%) than did medical students (16.2% of the text manually entered and 49.0% copied) or direct care hospitalists (14.1% of the text manually entered and 47.9% copied).” “Of the 253 physicians who wrote inpatient notes electronically, 226 (90%) used CPF, and 177 (70%) used it almost always or most of the time when writing daily progress notes.” O’Donnell HC, Kaushal R, Barrón Y, et al. Physicians’ Attitudes towards Copy and Pasting in Electronic Note Writing. J Gen Intern Med. 2009 Jan; 24(1): 63–68. doi:10.1007/s11606-008-0843-2. Also available as of March 2015 at http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2607489/ Processing

36. Medical Documentation and Coding A Big Deal? Providers are going to use copy and paste. The challenge is not to eliminate it, but to manage it and the associated risk through quality audits. Processing

37. Medical Documentation and Coding A Big Deal? Templates U.S. v. William King, MD (2008) Practice developed an office template which resulted in 99215 on almost every visit. The template allowed the physician to check off elements of the visit which included templated text. The templated text included services that were not actually performed and resulted in the software coding engine upcoding each visit. The result was billing for services not provided. Patients testified that they did not receive those elements of the exam. The physician was convicted of 59 counts of health care fraud, 13 counts of mail fraud, and 10 counts of false statements. Processing

38. Medical Documentation and Coding A Big Deal? Auto-authentication Do not authenticate until after services are performed. - Program Integrity Manual CMS Pub. 100-08 PIM §3.3.2.4 All patient medical record entries must be legible, complete, dated, timed, and authenticated in written or electronic form by the person responsible for providing or evaluating the service provided. – 42 C.F.R. §482.24(c)(1) Processing

39. Medical Documentation and Coding A Big Deal? Auto-authentication “A system of auto-authentication in which a physician or other practitioner authenticates an entry that he or she cannot review, e.g., because it has not yet been transcribed, or the electronic entry cannot be displayed, is not consistent with these requirements. There must be a method of determining that the practitioner did, in fact, authenticate the entry after it was created. In addition, failure to disapprove an entry within a specific time period is not acceptable as authentication… if the electronically-generated document only prints the date and time that an event occurred (e.g., EKG printouts, lab results, etc.) and does not print the date and time that the practitioner actually reviewed the document, then the practitioner must either authenticate, date, and time this document itself or incorporate an acknowledgment that the document was reviewed into another document (such as the H&P, a progress note, etc.), which would then be authenticated, dated, and timed by the practitioner.” – A-0450 Rev. 47, Issued: 06-05-09, Effective/Implementation: 06-05-09 Processing

40. Medical Documentation and Coding • A Big Deal? • Metadata • Currently, the federal government is not routinely requesting metadata that will show: • Who was in the record? • What did they do? • How long were they in it? • As law enforcement learns how to best leverage this information, they will begin to subpoena it as part of e-discovery and will begin to use it as they did in MD2U. Processing

41. Billing • Risk Areas: • Billing for items or services not rendered or not provided as claimed, such as using a covered code or diagnosis when the practice knows the service is not covered. • Double-billing (when a provider bills for the same item or service more than once or another party billed the federal healthcare program for an item or service also billed by the provider) resulting in duplicate payment. For example, charging a Medicare patient a fee just to be a member of your practice, and then also charging Medicare the fee for the services rendered to that patient such as an office visit. Double billing can also be caused by automatically sending another claim when a service has not been paid by the insurance carrier. • Knowing misuse of provider identification numbers that result in improper billing, such as using another physician’s number because the performing physician does not have a number yet. Processing

42. Billing • Risk Areas: • Unbundling (billing for each component of the service instead of billing or using an all-inclusive code). For example, if dressings and instruments are included in a fee for a minor procedure, the provider may not also bill separately for the dressings and instruments. • Using coding modifiers improperly. • Clustering, or coding/charging, one or two “middle” levels of service exclusively under the philosophy that some will be higher, some lower, and the charges will average out over an extended period. (In reality, this overcharges some patients while undercharging others.) • Up-coding the level of service provided, such as purposely billing for a higher evaluation and management (E/M) code than actually provided. • Patient inducement – routine waiver of patient cost-sharing responsibilities. Arguments can be made against persistent failure to provide ABNs. Hardship waivers are permissible but must be documented. Processing

43. Collections • Applicable Laws: • Fair Debt Collection Practices Act – 15 U.S.C. §1692-1692o • Fair Credit Reporting Act – 15 U.S.C. §1681-1681u • If your RHC is a department of a tax-exempt hospital under 26 U.S.C. 501(c)3… • 26 U.S.C. §501(r)6 - An organization meets the requirement of this paragraph only if the organization does not engage in extraordinary collection actions before the organization has made reasonable efforts to determine whether the individual is eligible for assistance under the financial assistance policy. • Reasonable Efforts? 26 C.F.R. §1.501(r)-1 – Application Period begins on the date the care is provided and ends on the 240th day (8 months) after the date that the first post-discharge billing statement for the care is provided. Additionally, 26 C.F.R. §1.501(r)-6 requires 30-day Notification. Processing

44. False Claims Act • False Claim – what do investigators look for? • Must be a claim requesting federal money. Excludes private plans. - 31 U.S.C. §3729(b)(2) • A falsity must exist…actual or legal. • Legal falsity may include a violation of laws, rules, or instructions. • Certification – CMS Form 1500 • “The information…is true, accurate, and complete.” • “I have familiarized myself with all applicable laws, regulations, and program instructions.” • “I have provided or will provide sufficient information required to allow the government to make an informed eligibility and payment decision.” • “This claim complies with all applicable Medicare and/or Medicaid laws, regulations, and program instructions for payment.” • “The services on this form were medically necessary and personally performed by me or were furnished incident to my professional service by my employee under my direct supervision, except as otherwise permitted by Medicare.” • “I agree to keep such records as are necessary to disclose fully the extent of services provided to individuals.” Compliance Risk

45. False Claims Act • False Claims: • Implied Certification – an express certification is not required. A false statement may be implied where two conditions are satisfied: • A representation is made in connection with a claim. • There is a failure to disclose a violation of a material requirement that renders the claims representation misleading. • Example: UHS v. Escobar (2016) - services rendered by a provider without privileges or licensure • Materiality – a natural tendency to affect the government’s payment decision. Could it or would it? - 31 U.S.C. §3729(b)(4) • Causation – Direct submission of a claim or causing the submission of a claim Compliance Risk

46. False Claims Act • False Claims: • Knowledge – Acting with actual knowledge, reckless disregard, or deliberate ignorance. – 31 U.S.C. §3729(b)(1) • “OR” signifies that any will suffice • The company is liable for employees • DID you know? versus SHOULD you have known? Compliance Risk

47. False Claims Act • Reverse False Claims: • Definition: Concealment, avoidance, or reduction of an obligation to the federal government. • 31 U.S.C. §3729(a)(1)(G) - Knowingly making, using, or causing to be made or used a false record or statement material to an obligation to pay or transmit money or property to the government.“ Prohibits “knowingly concealing or knowingly and improperly avoiding or decreasing an obligation to pay or transmit money or property to the government.” • 60-Day Rule – established by the PPACA • Identification, notification, and repayment • 6 month investigation period • Incentive to not identify…but you SHOULD have known • PPACA 60-day rule is specific to Medicare and Medicaid, but used as guidance for other federal programs. Compliance Risk

48. False Claims Act • Do NOT allow your credits to age. Reconcile them in a timely manner. Compliance Risk

49. Laws that impact billing and coding: • Emergency Medical Treatment and Labor Act (EMTALA) • Health Insurance Portability and Accountability Act (HIPAA) • Patient Protection and Affordable Care Act (PPACA) • False Claims Act • Civil Monetary Penalties Act • Anti-Kickback Statute • Stark Law • Mail and Wire Fraud Statute • OIG Exclusions Provisions • CMS Conditions of Participation • Medicare Secondary Payer • Incident-To Statutes • Release of Information • HMO Act of 1973 Compliance Risk

50. Laws that impact billing and coding: • Fair Debt Collection Practices Act • Fair Credit Reporting Act • Federal Trade Commission Act • Gramm-Leach-Bliley Act • Telephone Consumer Protection Act Compliance Risk