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Medicare HAC/POA
October 1, 2008
The Medicare program will no longer pay for costs associated with designated preventable conditions acquired in a hospital. Hospital Acquired Conditions or better known as HACs, that are NOT present on the patient's admission will impact the MS-DRG grouping and payment. Cases with a specific preventable condition would not be assigned to a high payment MS-DRG unless they were present on admission. Present on admission or better known as POA is a data indicator which is clinically defined as, present at the time the physician orders for inpatient admission occurs. Other conditions that develop during an outpatient encounter, including emergency department, observation or outpatient surgery is considered present on admission. POA indicators are appended to each ICD-9-CM code reported for patient conditions and diagnoses documented in the medical record by physicians/provider.
Effective October 1, 2008 Medicare will no longer pay for the additional costs of certain preventable conditions acquired in the hospital.
Payable POA Codes
Y-present on admission
W-not possible to determine POA status based on data and clinical judgment
Non-payable POA Codes
N-not present on admit
CMS HAC 0539 here
Cost Report Data
Medicare has released a notice in MedLearn Matters that states many providers are failing to complete their Medicare cost report data.
View MM6132 detail
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Red Flag Alert
Under the FTC rule, hospitals, as creditors holding covered accounts must develop an identity theft prevention program that includes reasonable policies and procedures for detecting or mitigating identify theft. The program should enable the hospital to:
1. Identify relevant red flags(patterns, practices and specific activities) that signify possible identity theft and incorporate those red flags into its identity theft program.
2. Detect the red flag that has been incorporated in the program.
3. Respond appropriately to detected red flags to prevent and mitigate identity theft.
4. Ensure the program is updated periodically to reflect changes in risk.
Hospitals will need their governing boards or senior management to approve the initial written program.
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Healthcare Financial Newsletter
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Cirius Newsletter
October/2008
Issue: 5 |
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Financial metrics make the revenue cycle world go round, well at least in the business of healthcare finance. Economic times are turbulent in the healthcare market as well as the world market. Staying focused on the numbers-providing the highest quality financial information-is our pathway to stabilizing our business and financial success.
Revenue Cycle Metrics
Net/Gross A/R Days
A/R aged more than 90 days from discharge/date of service
Denials Percentage-Final denials(write offs)as a percentage of revenue
Cash as a percentage of net/gross revenue
Cost to Collect
Self Pay Balances
Credit Balances
FTE's
Total uncollectible accounts(bad debt and charity)as a percentage of gross revenue
Payer mix
Net to gross revenue ratio
Functional area-specific metrics-Example:Billing
FTE's
Claims 'scrubbed' per FTE per day
Percentage of claims billed within 2 days of 'bill drop'
Daily balancing of total claims submitted & acknowledged by payer
Claims rebilled as a percentage of total claims
Return to Provider(RTP) rate
Claim error rate
Payer specific performance metrics
Denials
Underpayments
Time from final bill to claim submission
Claim submission to acknowledgment
Claim acknowledgement to payment
Hospital centric performance metrics
It's all about the numbers and financial bottom line.
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| Revenue Cycle |
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UB04 REVISION CALENDAR
Effective Date Form Locator
10/1/08 FL 18-28:New Condition Code
for duplicate original bills and
claim appeals/reconsideration
W2-Duplicate of original bill
W3-Level I Appeal
W4-Level II Appeal
W5-Level III Appeal
1/1/09 FL 35-36:New Occurrence Span Code
80-Prior Same-SNF Stay Dates
for Payment Ban Purposes
1/1/09 FL 81:New Code-code qualifier for
attachment control number
1/1/09 FL 81:New Code Source for attachment
control number
NPI Update
Medicare states through systematic actions that they will implement on October 6, 2008 its objective of not accepting legacy provider numbers will be realized.
CMS RAC ATTACK October 6, 2008, CMS announced the names of the new national RACs.
Region A: Diversified Collection Services, Inc. of Livermore, California
Region B: CGI Technologies and solutions, Inc. of Fairfax, Virginia
Region C: Connolly Consulting Associates, Inc. of Wilton, Connecticut
Region D: HealthDataInsights, Inc. of Las Vegas, Nevada
Medicare CERT Program
Comprehensive Error Rate Testing-CMS calculates the Medicare Fee for service payments error rate and improper claim payments using a methodology the OIG approved. They randomly select claims for review of medical records and claim information comparing Medicare coverage, coding and billing rules.
Medicare Bad Debt Clarification
Until a providers reasonable collection efforts have been completed, including both in-house efforts and the use of a collection agency, unpaid deductible and coinsurance amounts cannot be recognized as a Medicare bad debt.
ICD-10-CM/PCS
CMS made a big splash this last month with the announcement of the plans to mandate the use of the ICD-10 CM/PCS code sets by 2011. The US is one of the last industrialized nations to adopt this code set as created by the World Health Organization(WHO). The main benefit will allow the clinical coding of a patient condition to become highly specific in the interpretation of his/her condition.
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| Managed Care |
Hospitals in nearly half of states won't bill for "never events"
A new analysis suggests that hospitals in almost half of U.S. states will no longer bill patients for serious medical errors, up sharply from the beginning of 2008. In February, an analysis by a news organization concluded that hospital associations in 11 states had asked members to waive payment for never events. Now, the number of states with such policies in place is 23, according to research by MSNBC.com. This trend, of course, has gained a great deal of momentum as hospitals and their trade groups have braced themselves for Medicare, and commercial health plans, to roll out no-pay rule for serious errors. Medicare will cease such payments as of October 1, 2008 while various commercial plans like CIGNA, Aetna and a number of Blue Cross Blue Shield affiliates have set their own policies and schedules.
The next wave may come from Medicaid agencies, which CMS has urged to enact their own non-payment policies. To date, Massachusetts, New York and Pennsylvania have done so, but no one knows yet how many more will follow.
Full article here
BCBS plans phasing out pay for errors, "never events"
Though they won't implement this change immediately, the Blue Cross and Blue Shield plans have decided that they won't pay for serious errors and "never events" like wrong surgical procedures and leaving foreign objects in the body after surgeries. Over the next several years, the nation's 39 Blue plans intends to begin changing coding systems to make such events easier to identify in claims, according to Kevin Shanklin, executive director of the Office of the President at Blue Cross and Blue Shield Association. At present, no Blue plans are currently refusing such payments.
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| Client Corner |
CMS launches website called Hospital Compare designed to provide consumers with better insight into quality of care
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REAL WORLD, in REAL TIME, with REAL RESULTS using Cirius Claims Management Software Solutions.
Manual Bill Touch Rate less than 15%
First Pass Pay Rate 98%
Billing Cost Reductions 50%
Cash Flow Improvement up to 20%
Denied Claim Rate all payers less than 2%
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