Transplant Billing Practices, Solutions, Resolutions

1. Transplant Billing Practices, Solutions, Resolutions Lisa McDermott, Transplant Operations Analyst Methodist University Hospital Transplant Institute Memphis, TN

2. Introduction • I am Lisa McDermott, TOA from Methodist University Hospital Transplant Institute (MUHTI) in Memphis, TN. • In medical field for past 13years. • In transplant for the past 7years, 3 of which were spent as a TFC. • Helped implement the TOA role approximately 5years ago.

3. Introduction • A leader in the field for more than 30 years. • Began in 1968 at William F. Bowld Hospital. • First kidney transplant April 1970, making it the 6th in the US to do so. • In 1982, introduced as the 3rd liver transplant program in the country.

4. Introduction • 1989 began combined kidney pancreas and pancreas alone transplants. • To date over 2,100 kidney transplants performed, over 1,000 livers, 121 pancreata and 268 SPK.

5. Introduction • 2008 MUHTI performed 216 transplants • 120 liver transplants performed in 2008 making it one of the ten largest liver transplant centers in the United States. • Our department helped to collect approx. $15million in 2008.

6. Topics of Discussion • Responsibilities of a Transplant Operations Analyst (TOA) • Global Billing & Contracts-What is it and how it works! • Utilize Your Resources-Make your computer system work for you! • Common Billing Issues • Questions & Answers

7. TOA Responsibilities • We handle most of the billing for the transplant program. • Act as the #1 hub of communication for reimbursement information. • Allows patients and providers to only make 1 phone call. • Financial process should be the least of your patients worries.

8. TOA Responsibilities • Manage and analyze all areas associated with the transplant institute to ensure maximum reimbursement. • Anything financially related to the transplant program or our patients is directed to our department for resolution. • Main point of contact for affiliated providers, patients, etc.

9. Flow ofCommunication Utilization Review Managed Care TFC Financial Coordinators Patient Accounting Transplant Operations Analyst Finance Patient Customer Service OPO’s Payors TA’s Medical Records Transplant Offices Recipients & Donors

10. TOA Responsibilities • Contract negotiations (Managed Care, Medicaid, and SCA). • TFC identifies out of network coverage, forwards to TOA for single patient negotiation. • Manage transplant consultant pool. • Funds set aside from global payments to aid in unexpected cost or additional global charges. • Track and analyze information for the Medicare Cost report.

11. Global Billing • Most commercial insurance companies and Medicaid programs carve out transplant benefits. • Transplant is a very costly and unique line of care. • The TFC role in global billing is just as important, if not the most important role in global billing

12. Global Billing • TFC documentation lays the foundation for the patients entire transplant case. • Most Transplant contracts are very date driven. • Guided by the beginning and end date of each phase of transplant.

13. Global Billing • Most transplant contracts are divided up into phases of the transplant. • Know reimbursement for each phase. • Documentation of the beginning and end date of each phase is crucial. • Phase I Evaluation • Phase II Pre Transplant Care • Phase III Transplant Event • Phase IV Follow Up/Post Transplant Care

14. Global Billing • Familiarize yourself with your transplant contracts. • Know the inclusions and exclusions of the contract to relay to your patient. • If out of network, has a single case agreement (SCA) been established? • Most contracts cover hospital and professional services.

15. Global Billing • Very manual process. • Rely heavily on TFC documentation of the transplant network. • Professional & hospital claims are bundle billed for each transplant phase. • Attached a detailed cover sheet quoting expected reimbursement.

16. Global Billing • Send high $$ claims signature required/overnight. • Global payment received by transplant facility and payments are dispersed.

18. Utilize Your Resources • Make your billing/registration system work for you. • Flag MRN’s as being transplant. • This will benefit your entire transplant program. • Singles out transplant patients from all other patients in the hospital system. • Offers communication with other departments, providers, team members, etc.

19. Utilize Your Resources • Attach identifier to each visit/registration. • Monitor each visit for billing purposes and cost reporting purposes. • Input transplant/donation dates. • TFC insurance notes/billing instructions. • Creation of Transplant Insurance Plans • Simplifies billing process. • Keeps billing in house.

20. Utilize Your Resources • Establish Transplant Guarantor’s • Keeps donors from getting a bill from hospital and affiliated providers. • Can be reported off of to monitor donor billing/insurance information.

21. Utilize Your Resources • Create custom reports for transplant. • Monitor patients accounts for insurance/billing purposes. • Simplifies process for cost reporting. • Can be used as leverage for contract negotiations.

22. Utilize Your Resources • Reports • Transplant Flag-Insurance & Medical Service Review • Cadaver Donor Review • Donor Guarantor Review • Kidney Transplant-No Medicare Review • AR reports to monitor billing and receivables.

23. Utilize Your Resources • Develop a Transplant Financial Score Card. • Tool used to rate or grade transplant reimbursement. • Use reimbursement history (AR days, payments, charges, etc.) to monitor progress. • Set collection goals for transplant. • Review monthly, quarterly, and yearly.

24. Utilize Your Resources • Get access to payor websites. • This allows you to view patients case management information. • Verify case effective dates and end dates for accuracy. • Check claim status.

25. Utilize Your Resources • Get UNET access. • Gives you access to listing dates, dialysis dates, date of transplant, etc. • Allows you to run reports of listed patients.

26. Utilize Your Resources • Share your access. • Share access with affiliated providers and other departments. • Initiates open communication. • Cuts down on questions/phone calls. • Allows them access to authorization info and pertinent insurance/billing information. • Email notifications/communications with your transplant team.

27. Utilize Your Resources • Make a “Wish List” of what capabilities you want your system to do for you. • Set up meeting with your information systems department.

28. Issue Global VS Not-Global Transplant VS Not-Transplant Carve Out VS Regular Medical Benefits Solution Patient identifiers, good documentation, know your phases. Good communication with providers. Be confident. Know your contracts & expected reimbursement Common Billing Issues

29. Live donor evaluation. Council each donor on the coverage. Give the donor a letter containing the billing direction. If off site, contact the provider. Common Billing Issues

30. Issue Live donor claim denials. Solution Attach a cover letter identifying the donor and recipient. Follow up phone calls. Be persistent. Involve the case manager. Common Billing Issues

31. Issue Non-Transplant Related Services (broken arm, etc.) Including services that are excluded in your global contract. Solution Attach cover letter quoting expected reimbursement. Bill to medical insurance, not the transplant network. Follow up phone calls. Monitor carefully. Common Billing Issues

32. Issue Not getting your full global case rate. Not getting paid per your contract agreement. Solution Misinterpretation of a contract can cost millions. Know expected reimbursement. Know your total global charges. Ask for a copy of the patients transplant case tracker. Common Billing Issues

33. Issue Underpayments Solutions Check your DRG Be familiar with your coding for transplants. Appeal, Appeal, Appeal. First name basis with someone for each contract. Common Billing Issues

34. Issues IVIG and plasma pharesis. Solutions Be proactive. Letter of intent for fiscal intermediary Covered by Medicare for certain indications. Must have documentation and accurate diagnosis to support the test. Work with HIM dept. to develop process and guidelines for billing. Common Billing Issues

35. Issue BMT billing Solutions Clear definition of key dates (mobilization, transplant, infusion, etc.) Know your contracts and reimbursement for each phase. Be confident. Common Billing Issues

36. Conclusion • Know your contracts. • Inform your patient of their benefits. (Medicare coordination, global periods, out of network coverage, donor coverage, etc.) • Documentation is vital. If you didn’t document it, then it “didn’t” happen. • Track AR and reimbursement. • If you do not like your contract, renegotiate.

37. Questions & Answers • Thank you for your time! • Have a safe trip home!

38. Contact Information Lisa McDermott,TOA Methodist University Hospital Transplant Institute 1265 Union Avenue, 604 Crews Memphis, TN 38104 901-516-9048 Office 901-516-2250 Fax