FBCS Patch 39 Improper Payments Patch DSIF*3.2*39

1. FBCS Patch 39Improper Payments PatchDSIF*3.2*39

2. Patch 39 Overview • Prerequisite Installations • Background • Primary Purpose • Enhancements • Potential Duplicate Claims • Timely filing • Other Health Insurance • Management and Tracking or Remaining Number of Visits • Line Item Duplicate Justification • Payment Supervisor Queue • Additional Changes • Defect Changes • Supporting Documentation

3. Prerequisite Installations Patch 22 DSIF*3.2*22

4. Background • On November 20, 2009 Executive Order 13520, the Improper Payments and Errors Reduction Act (IPERA) was issued that requires the Federal Government to proactively identify and reduce improper payments. • In regards to Non-VA Care, this includes, but is not limited to the following categories: • Payments made to and/or on behalf of ineligible beneficiaries • Duplicate and/or incorrect payment amounts • Payments not in compliance with VHA policies and procedures

5. Patch 39 Purpose • To implement software changes to proactively identify and reduce improper payments focusing on payments made to and/or on behalf of ineligible beneficiaries, duplicate and/or incorrect payment amounts, payments not in compliance with VHA policies and procedures.

6. Patch 39 Overview Process modifications to key points in FBCS claim flow were introduced to help reduce the number of improper payments. These key points will change how users interact with eligible claims identified as: • Potential Duplicates Claims and Lines • Potential Timely Filing Violations • Potential Mill Bill claims with Other Health Insurance present • Claims exceeding a high-dollar threshold • Potentially exceeding number of visits available

7. Patch 39 Updated Modules • FBCS Distribution and Processing • FBCS Payment • FBCS Admin • FBCS Authorization

8. Patch 39 Updated Modules • Enhanced identification and management of duplicate claims/lines • Enhanced identification and management of violations of timely filing for Mill Bill and Unauthorized claims • Enhanced overpayment prevention mechanisms • Enhanced tracking and management of used and remaining visits per authorization. • Enhanced supervisory, pre-payment review of high-dollar claims

9. Potential Duplicate Claims Notable changes have been implemented when interacting with potential duplicates. • ALL potential duplicates must be reviewed • ALL potential duplicates must either be processed or issued a justification reason for further processing before closing dup window • Justification reasons will be displayed within the dup window and/or within Claim History

10. Potential duplicate message prompt will no longer appear in Distribution • In Processing, the user must review all potential duplicates and justify why the claim will be processed if not identified as a duplicate • All potential duplicates must be supplied with a justification reason or sent to RTP to exit the Potential Duplicate Screen • Justification reasons are hard-coded by business office • Justification reasons are reportable

12. Users must review all potential duplicates to determine if it should remain for further processing • Should the claim continue for further processing, a justification will be supplied • Otherwise, the claim should be RTP’d appropriately • Claims previously supplied with a justification reason and/or processed will display • If all potential duplicates contain a justification reason or are already processed, the user may close the screen

13. Duplicate Justification Reasons

14. Duplicate Claim Justification Reasons • Hard-coded and cannot be edited

15. Once confirmed, the justification reason cannot be edited • Claim history is updated with date, timestamp, reason, and user

16. TimelyFiling • FBCS will now identify MB and Unauthorized claims that were not timely filed and prompt the user with the capability to deny the claim or; • Supply a new effective date for timely filing.

17. Timely Filing Criteria A new prompt will display when a line item is checked to pay for claims that are not timely filed • Mill Bill: scanned/reopened date is 90 days after the last DOS on the claim • Unauthorized: scanned/reopened date is two years after the last DOS on the claim

19. A prompt will appear that allows the user to auto-deny the claim or select a new effective date for the claim to be filed

20. Selecting the deny button will auto-deny the claim and update the claim history with date, timestamp, user, and program-specific verbiage • Claim history date dependent of program type

21. Claim History/Letter Statement Updates FBCS will proceed to deny the claim for “Not Timely Filed - Unauthorized” or “Not Timely Filed - Mill Bill” per program type of claimwith appropriate accompanying verbiage supplied by NNPO:

22. The user can opt to not deny the date and select a new effective date. • For example, a resubmission of a timely filed claim that was originally sent with without medical documentation • The scanned date of the original claim could be supplied to indicate the claim is timely filed

23. Effective date must meet timely criteria dependent on program type • Effective date will be appended to the claim data tab and can be edited once initially supplied • Claim history updated to display timely filing effective date and user

24. Other Health Insurance FBCS will employ logic to identify Mill Bill claims considered for payment where the Veteran may have other health insurance. • FBCS will perform this review upon selection of a line item for payment in Processing • FBCS will review the selected Veteran’s Insurance information as collected from Distribution • FBCS will review all insurances on file and review effective dates of each • Should any insurance’s effective dates encompass any line’s date of service a prompt will appear informing the user • The user MUST either deny the claim OR supply a justification reason for further processing.

25. Mill Bill claims for patients with active insurance on file will receive a new prompt to deny the claim • All active insurances that encompass a DOS on the claim will appear as entered in the patient’s insurance file, regardless of type (Medicare A/B, supplemental insurances) • The prompt appears when line items are checked

26. Patient insurance has always been able to be retrieved in FBCS Authorization and D&P; however, now: • FBCS Processing will cross-check the claim DOS with active insurances in the patient insurance file & require the user to review the insurance data and make an active decision.

27. Confirming to deny the claim will append a date, timestamp, and denial statement to the claim history as denied because of “Other Health Insurance Present”

28. User can choose to not deny the claim and select an insurance justification reason • For example, Medicare A vs. B or other insurance types listed • Claim history is appended to state date, timestamp and the justification reason

29. Other Health Insurance Justification Reasons • Hard-coded and cannot be edited

30. Management & Tracking of Remaining Number of Visits FBCS has augmented the current functionality in Auth and Processing to assist in managing and tracking number of visits used. • Total Number of visits field is no longer mandatory • When an auth contains a number of visits greater than 1 FBCS will require user to supply a value to deduct • FBCS will require this value cannot exceed the number of remaining visits • FBCS will commit the value to deduct if users send the claim to Payment • FBCS will allow for the authorization’s total number of visits to be increased but not decreased below the number of visits used. • FBCS will display the total number of visits and visits remaining in D&P • Visits deducted per claim and total visits used and remaining per auth is reportable

32. If a claim is attached to an authorization that has more than 1 visit prescribed, the processing user must supply the number of visits to deduct • Visits to Deduct must be supplied before sending the claim to scoring/payment • The value entered in Processing can be zero, indicating the payment should not be counted/tracked as a visit

33. The difference between the “Total Number of Authorized Visits” and the “Visits Deducted” value will be tracked as the “Remaining Visits” value in the Authorization module. • Claims returned to Processing from Payment will restore the deducted number visits to the Total Remaining Visits count for the selected authorization. • Users will not be allowed to send a claim to Payment if the “Visits Deducted” is greater than the Remaining Visits value.

34. Claim history statement appends each time the number of visits to deduct is supplied with date, time, user and quantity.

35. Visits to Deduct will update on the authorization and can be accurately tracked

36. Special Considerations Before Install • In regards to tracking number of visits: • Management must determine which services are recurring and determine method for counting visits, for example: • Dialysis or PT often require multiple visits • Auth users must identify these services and supply correct amount of visits authorized • 10 visits/month for one year= 120 visits • Processing users must know how to identify how to appropriately identify the number of visits per claim • Conversely, Auth users must identify services that do not require multiple visits and supply 0 in the Number of Visits field, indicating that multiple visits will not be required to be tracked • Examples would be services such as post-op follow-ups that are preauthorized to be paid, regardless of follow-up visits need.

37. Management must identify services that require tracking visits that multiple bills will be paid for one visit. • For example, services such as radiation therapy will have a facility bill and a physician bill for one visit. • Since both bill types are attached to same authorization, a value must be supplied for number of visits to deduct. However, since multiple bills are paid for the same visit, the remaining number of visits could be inaccurately tracked if not identified. • Management must also determine how to appropriate count for visits authorized against an authorization created prior to the install of patch 39. • Since visits were not tracked prior to patch 39, when the first claim for an authorization (with more than one visit) created prior to the install, the user identify how many visits were previously paid and update the authorization accurately. - The auth can be updated to subtract the total amount and an explanation can be entered; or processing users can enter the visits of the current claim PLUS the previously paid visits.

38. Line Item Duplicate Justification • FBCS Payment • Similar to the justification reason in FBCS Processing, a user must choose a justification for a potentially duplicate line item not being removed from the work area • Per usual, when a line item is checked in the work area, FBCS cross-checks with the VistA fee database for potentially duplicate line items

39. If the user selects YES:FBCS will append a line item non-payment reason of “Duplicate Line” and remove the line from the Work Area; accompanying verbiage will read “Duplicate Line”. • Processing will continue to be updated with the previous payment information, however the line will become unchecked for the identified duplicate.

40. Per usual, the claim history will be updated with a date, timestamp and statement indicating the line item has already been paid.

41. IF the user selects NO: User must choose a justification reason from a standardized reason list

42. Claim history is updated with date, timestamp, justification reason, and user

43. Payment Supervisor Review Queue A supervisory review queue has been added to FBCS Payment to list claims identified as requiring a secondary review • Claims in which the amount to be paid meets or exceeds a hard-coded dollar threshold (currently at $25,000.00) • Claims that had previously violated FBCS’s timely filing check • A shared list between all users who hold the FBAA SUPERVISOR key and are assigned the supervisor review permission in FBCS Admin • Review Queue users decide whether a claim can return to Payment queue of clerk OR return to Processing queue of clerk. • Memo field accessible for input in queue • Clerks will be notified their claim is eligible for review and will move out of their queue. • Claim history will be updated with supervisor review decision.

44. Tab available to users with the FBAASUPERVISOR key and have “Sup Review” access granted in the Edit Users section in FBCS Admin

45. High Dollar Threshold Reviews • The notification will appear when a user attempts to add outpatient claims to a batchwhen the amount to pay meets or exceeds the amount to pay threshold. • For inpatient claims, the notification will appear when a user completes a payment for inpatient UB claims that were non-pricer exempt. • For pricer-exempt claims, the notification will appear when the claim is added to a batch.

46. Timely Filing Reviews • Prompt will inform the user if an outpatient claim should require supervisor review for timely filing violations upon adding the claim to the work area. • For inpatient claims, the prompt will appear upon loading the Inpatient/Mainstay tab

47. Supervisor Review Queue • New tab in FBCS Payment that holds a single list of claims to be reviewed • Claims will not be added to the batch and will be routed to the supervisor queue. • Supervisor will then review claim and line item data and either approve the claim or opt to return the claim to D&P • Displays claim level data elements and line level elements to assist in supervisory review

49. A memo field can supply a free text memo that will append to the claim level data and will appear in the memo field in D&P • Memo field for supervisor review queue is a maximum of 50 characters

50. If supervisor approves the claim, it will reappear in the user’s payment queue and can be re-added to the batch. • If the “Amount to Pay” value in the Payment module is modified, the claim will be re-evaluated to determine if the amount meets or exceeds the dollar threshold.