Title: How to Bill the Coast Guard Session: M-3-1530–1720

1. Title: How to Bill the Coast Guard Session: M-3-1530–1720

2. Objectives Understand the Memorandum of Understanding (MOU) Create a process to ensure each MTF is receiving maximum collections Understand this is a billing process USCG are eligible beneficiaries not FUNDED by the Department of Defense. Funding is provided by the Department of Home Land Security

3. Authority The Coast Guard was authorized to enter into a Memorandum of Understanding between the Department of Defense (Health Affairs) and the U.S. Coast Guard in pursuant to 14 USC, section 141 and 14 USC, section 93(a)(17)(20) Title 10 USC 1074(a)(b), 1076, 1079, 1086 and 1097 provides the CG Active Duty, Family Members of CG, Retired CG, their families and survivors the entitlement of all benefits and services of the MHS in the DoD facilities as the DoD Active Duty, Retirees, and family members and survivors

4. Financial • Title 10 USC 1085 states that when medical facilities of one Executive Department provide health care to beneficiaries of another Executive Department, care will be reimbursed at rates reflecting the average cost of providing care. Rates are published as Memorandum for Under Secretary of Defense (Comptroller) by Department of Defense, Health Affairs • Inpatient is Interagency Rate (IAR) • Outpatient/Ambulance/Dental are Interagency/Other Federal Agency Sponsored Rate (IOR) • Billing submission to U.S. Coast Guard presented by the U.S. Coast Guard Representative • Thursday, March 17, 2010, 0900–0950 (R-3-0900)

5. MOU Highlights • A beneficiary’s other health insurance will be billed at Third Party Collection Rates. Any unpaid balances will be paid by the USCG up to established IAR or IOR • Federal Medical Care Recovery Act (FMCRA) under Title 10 USC 1095 • Bill U.S. Coast Guard for care • Send FMCRA claims to U.S. Coast Guard to pursue

6. References • Memorandum of Understanding Between the Department of Defense and the U.S. Coast Guard • UBO Website: www.tricare.mil/ocfo/mcfs/ubo/index.cjm • Dental Rates • Pharmacy Estimator • Updates posted on UBO Website • Point of Contact for Coast Guard: • <name and contact info Redacted> • www.comptroller.defense.gov/rates/index.html • ASA/IAR rates are updated by Fiscal Year (FY) • IOR rates are updated by Calendar Year (CY)

7. Coast Guard Billing • Three phases of Coast Guard Billing: • Inpatient = Charges based on DRG weight • Dental = Charges based on ADA codes & weights • Outpatient = Charges based on CMAC rates or average cost for care • Charges are computed based on published discounted percentages, for the specific dates of service

8. Inpatient Billing • Follow Coding guidelines when billing inpatient • If patient is admitted through Emergency Room (ER), all ER and ancillary charges are included in the admission. Delete/Exclude those charges when billing Outpatient • If the admission is less than 24 hours, verify the admission is valid with inpatient coding. Could be an observation. In that case, observation rates would be billed, including the ER and ancillary charges. Work with coding to ensure the correct billing is done • We do not bill for Medicare patients

9. DD7 Report The DD7 Report will only have the coded admissions. It can be carried over from the previous month.

10. DD7 Report This report will give you all of the information that is required.

11. DD7 Report • This will give you the total of ALL inpatient billing. • Delete MEDICARE patients from the total. • Patient categories of C28 USCG Newborn of Former Service member and C29 USCG Newborn of Sponsor’s Daughter are Full Reimbursement and we are not allowed to bill the U.S. Coast Guard for those admissions.

12. Additional Inpatient Reports • DD7 report may not reflect all the admissions for the month being billed. Other CHCS reports are available • Admission By Diagnosis Report: • Some MTFs use this report to gather ALL inpatient admissions. It is a very large report and it reflects ALL patient categories • Ad-Hoc reports: • INCP GS INPT BY DIV NOAA, CG, PHS • Bremerton uses this • There are other Ad-Hoc reports created by individual MTFs

13. Admission by Diagnosis Report Report is pulled up by specific dates. (Example: 01Dec10-31Dec10) You will be able to identify patients who have Other Health Insurance (OHI) from this report.

14. INCP GS INPT by DIV NOAA, CG, PHS This ad-hoc report reflects only the admissions for Patient Category of C, P, and B. It is pulled up by specific dates. **You will be able identify the OHI patients**

15. Inpatient Billing

16. Inpatient Billing

17. Inpatient Billing Balance bill the U.S. Coast Guard for patients who have other health insurance Example: Insurance is billed $14,778.04 (DRG 1.2641 x $11,690.56 FRR) Insurance paid $14,778.04 – $8,050.00 = $6728.04 balance U.S. Coast Guard rate billed $14,006.62 (DRG 1.2641 x $11,080.31 IAR) USCG is billed $5,956.62 ($14,006.62 – $8,050.00)

18. Inpatient Reporting Data Spreadsheet is done by the Navy MTFs. Use Service-specific guidelines when submitting. • All inpatient data is input into a spreadsheet • Information needed: • PatCat • Patient’s Name • FMP/SSN • Date of Birth • DMIS ID • Admission Date and Discharge Date • MEPRS Code • DRG • Case Weight • ASA Rate

19. Inpatient Spreadsheet Charges are in PATCAT order specified by the USCG. Add the additional billing from the OHI Patients.

20. Dental Billing • Dental Clinics are not required to use CHCS. All billing information for visits are collected manually • DD Form 7A (Superbills) received from Dental Clinics: • Name and SSN • Pay Grade • Duty Station • Diagnosis • Date of Service • ADA Code/Procedure Code • Recommend: DEERS verification for patients not in CHCS

21. Dental Billing There can be the several of the same ADA codes listed. Each tooth is a separate procedure and listed separately on the spreadsheet. Example: D1351 Sealant – per tooth

22. Dental Rates IOR Rate is used. Example D0120: 0.47 x $82 = $38.54 DoD Weight x IOR = Rate

23. Dental Spreadsheet When verification is done, information is gathered and input onto a spreadsheet. PATCAT order as specified by the USCG.

24. Outpatient Billing • Outpatient billing is a billing process. It’s not just a report to be pulled up, printed, finalized, and submitted. We are looking at 30 days of visits • Need to ensure we capture every billable encounter • $2.00 Pharmacy • Incorrect Quantity • Missing ADM encounters • OB Patients • Pathology Tests • OHI patients

25. DD7A Report Navy uses an Ad-Hoc report that pulls the information from the DD7A report in CHCS and puts it into a Excel Spreadsheet format.

26. DD7A Report In order to view every itemized billing, Print Preview

27. DD7A Report Print the Detailed Itemized Preview List. There are charges that might need to be appended, excluded, and added. Recommend: Report usually cuts off around the 26-27th of the month. Print the report around the 15th of the following month and work the report. Example: 27Nov10-27Dec10 report – print 15Jan11 to review and make necessary changes. The ad-hoc report the Navy uses does pull data over for the specific dates. Example: 01Dec-31DEC10

28. Outpatient Billing There could be visits that have not been completed though the coding process. When verification is done with the ad-hoc report and the DD7A report, you can capture all of the billable visits. Example: ER visits are pulled up and coded prior to spooling the DD7A report. This is one of the ad-hoc reports that identify ALL kept appointments for the patient categories C, P, and B. **OHI patients included**

29. DD7A Report There are 2 charges that need adjustment. RX #1 Dimaphen $2.00 charge = expired NDC RX #2 Deep Sea $2.02 charge = incorrect qty **Perfect World: Pharmacy would update their NDC files**

30. $2.00 RX Charges This is what your MTF can miss: $$$$

31. Incorrect Quantity EXAMPLE: Flonase Incorrect qty (1) = $3.49 Correct qty (16) = $25.84

32. Pharmacy Pricing Estimator Save this from the UBO Website. It is very easy to use.

33. Missing Visits Valid visits can come over without charges. Verify in CHCS if appointment was kept and adjust charges. **Sometimes, the 1st visit was cancelled and 2nd appointment booked and kept, but system only picked up the 1st visit. **

34. OB Patients Most OB patients have been coded with a CPT 0502F Subsequent Prenatal. OB is billed with a global CPT code. After delivery, gather all encounters (ADM) and let the coders code the pregnancy. CPT 59426 Antepartum care; 7 visits or more = $832.06

35. Anesthesia and CoPath Lab Test ** Verify if Anesthesia charges came over. ** Most common missed lab is called a copath lab. Usually done when there is a biopsy done. Verification is done within the patient laboratory inquiry.

36. CoPath Labs

37. CoPath Labs There are 3 tissues that can be billed.

38. Rates Menu Path: MSA> FIM (Inquire to File Entries) > CMAC Rate Professional Rate $36.10 x .941 = $33.97 (94.10%) Technical Rate $63.16 x .941 = $59.43 (94.10%)

39. Patients with Other Health Insurance • MOU allows MTFs to balance bill the USCG • Identify the OHI patients: • Can be done by developing or using existing ad-hoc reports in CHCS • It will reflect all kept appointments for all patient categories of C (USCG) for the month of billing • Tracking and Billing: • Spreadsheet can be used • Enter data into the DD7A report • Work with TPC personnel

40. OHI Spreadsheet • Why do we bill for the OHI patients? • HMOs (Normally only allow to bill for Emergency Room visits and Emergency Room admits) • Deductibles and Co-pays • Non-covered services • Over-the-counter drugs • Insurance billed $1783.35 – $1070.30 Paid = $713.05 balance • U.S. Coast Guard billed $1676.35 – $1070.30 = $606.05

41. Additional Billing Average of $9,705 per month of additional billing, which includes $2.00 RX, Incorrect Qty, OHI Patients, OB Patients, and Pathology.

42. Navy Labs In Navy MTFs, the unbundled labs will need to be bundled. The CPT codes of 82465, 83718, and 84478 need to be bundled to the CPT code of 80061 Lipid Panel.

43. Appending/Excluding Charges

44. Appending/Excluding Charges If you append the pharmacy charge, the pharmacy estimator will give you the charges that include the $2.00 dispensing fee. You will need to deduct the $2.00 from those charges. You can exclude the $2.00 charge and do a one-time charge.

45. Navy Spreadsheet The data from DD7A report is spooled into an ad-hoc report, then imported into a spreadsheet. Data is put in order as specified by the USCG. The spreadsheet is reviewed and adjustments are made.

46. Finalized the DD7A Report Additional billing to be added to report Exclude and/or append each additional billing in CHCS Adjustments are made in the spreadsheet for those using that format (Navy) Children who reach the age of 21 or 23 are not covered at this time Exclude all Medicare patients that have charges attached. If patient turns 65 on May 25, all of May charges would be excluded Exclude all occupational health visits for those retirees and family members who have dual status Not all Medicare patients are 65 – Disability patients and Renal Failure

47. Finalize the DD7A Report

48. Final DD7A Report The DD7A report is finalized by DMIS ID and patient category. Follow Service-specific guidelines for final submission to the USCG.

49. Navy Cover Sheet

50. Summary These are non-funded beneficiaries that are eligible to be seen at your MTF The MOU allows the MTF to bill for all services It is our responsibility to ensure all billable services are collected Billing process can beworked throughout the month Use the tools that are available This will ensure that your MTF is receiving the maximum revenue!