Author Archive for Dom Nicastro

NEWS: Patients don’t understand Medicare coverage gap

Revenue cycle managers must continue to prepare their staff members to help confused patients with the Medicare Part D coverage gap.

More than 60% of patients who took a Medco Health Solutions survey do not fully understand the gap that forces patients to pay the entire cost of their prescription drugs, the Associated Press reports. And nearly 30% do not understand it at all, the survey says.

To read the full story in the Associated Press, click here.

RAC UPDATE: CMS RAC Open Door forum

During the November 12 RAC Open Door Forum for Part A providers, CMS announced its intent to do the following with the permanent RAC program:

• Minimize hassles for providers. This includes limiting the volume of medical records RACs may request, and allowing RACs to look back three years instead of four. In addition, CMS is requiring RACs accept imaged records on CD/DVD.
• Maximize transparency. Among other steps, CMS has made it mandatory for RACS to have a Web site showing status of every claim by 2010, as well as send out detailed letters to providers reviewing results. The Web sites will also post types of audits as well as vulnerabilities.
• Maximize accuracy. CMS has required RACs to have medical directors and certified coders (i.e., coders with CCF, CCA, CCSP, CPC, CPC-H, or CRNC credentials).

In addition, during the call, CMS recommended providers take certain steps to prepare for the permanent RAC program. Suggested steps include the following:

• Review and understand all documents from the RAC demonstration
• Review all findings by permanent RACs once the program begins
• Review all current OIG reports at www.oig.hhs.gov/reports.asp
• Review the information on the CMS Comprehensive Error Rate Testing (CERT) Web site at www.cms.hhs.gov/cert
• Put in place an internal audit program

CMS also confirmed that the only two types of claims that are not open for review by RACs are HMO Medicare (Part C) and prescription drug (Part D) claims.

Be prepared for ABN changes

More than a year after several rounds of review on proposed revisions to existing Advance Beneficiary Notice (ABN) Forms ABN-G and ABN-L, CMS published revised Form CMS-R-131.

As with the prior ABNs, the revised ABN is designed for use by hospitals, physicians, and certain other furnishers of healthcare services (“healthcare providers”) to notify Medicare beneficiaries when outpatient services are expected to be denied, primarily in the following circumstances:

• The services fail to meet Medicare’s medical necessity guidelines
• The services are screening services that are provided more frequently than Medicare provides a benefit for
• The services are custodial in nature

In order to be effective, such notice must occur prior to the performance of these services. This protects beneficiaries from unexpected financial liability. The provisions in Medicare law that require such protections are referred to as the “limitation on liability” provisions. Noncoverage most commonly arises with respect to diagnostic services (lab tests, imaging services, etc.). In such cases, the diagnostic information on the physician order does not support the medical necessity of the services ordered.

2008 SUCCESS: One patient access manager’s highlights

Editor's note: We asked patient access managers to share with us their success stories from 2008.

Catherine Pallozzi, patient access director, Albany (NY) Medical Center

Most of our year has been spent on internal institutional changes, such as staff realignment and training as well as our implementation of clinical systems. The following are some achievements by our team:

Implemented HDX - integrated eligibility system. We worked with our IT partners to ensure that the set up design was what would make us most successful. Our Quality and Development Unit assisted in the significant amount of training. Most importantly, we devised a very controlled manner in which to identify and resolve issues.

Developed a staff-driven Quality Improvement Team (QIT). Staff leads and managers meet once a month to review quality standards of the department. A problem area -- insurance, registration field -- is identified as the “training of the month.” The team creates the training document, and the QIT members are responsible for training all staff. In addition, the QIT is responsible for a monthly puzzle pertaining to Joint Commission, the hospital strategic plan, and department goals and objectives.

For more of Pallozzi's success, see next week's Patient Access Weekly Advisor.

2008 SUCCESS: One patient access manager’s highlights

Editor’s note: Last week, Florence Davis, director of Patient Access at Children’s Healthcare of Atlanta, a 489-bed pediatric health system, shared some of her successes from 2008. With more than 15 years experience in clinical and healthcare administration, Davis is a leader in developing long- and short-term strategies for seamless patient flow and front-end denial management.

Here are some more success stories from Davis:

• Registration system. We have been very busy with our new registration and scheduling system implementation. The go-live is not until next year, but we have been working with all areas to agree on a "schegistration" process. This is the process where at the time of scheduling, we will also be completing the registration of all appointments.This is a big win in terms of improving patient wait times and therefore improving customer service.
• Centralized admission. We have partnered with the clinical operations to launch a “transfer center.” This new center located off-site from the hospitals is where all admissions are called in and accepted /rejected by the physicians or nurses. As part of this team, patient access obtains the required registration information at time of admission acceptance by the nurses or physicians and performs eligibility and pre-certification of the admission prior to the patient showing up in our facility. We went live with this third quarter of 2008 and hope to see some positive impact in our reimbursement for admissions and transfers.

In 2009, we are looking forward to a successful implementation of EPIC our new scheduling, registration and billing system. Looking forward to a new image for Patient Access through deliberate "re-branding.”

NEWS: Changes for Medicare drug program

Older patients may pay more for drugs and co-payments under their Medicare drug-plan premiums next year, the Wall Street Journal reports.

To read the full story in the Wall Street Journal, click here.

NEWS: CMS delays RAC permanent program

CMS yesterday announced it has delayed the Medicare Recovery Audit Contractor (RAC) permanent program and put a moratorium on all RAC-relayed informational sessions across the country. CMS has yet to release further details but told the American Hospital Association the action was necessary due to “a RAC protest and a stay of performance.”

However, the California Hospital Association (CHA), in a memorandum obtained by HCPro., Inc, says that PRG Schultz (PRG), a contractor that submitted a bid for work in the permanent program but wasn’t selected as one of the four permanent contractors, was considering a challenge to the contract award process.

Despite the delay in the process, Joseph Zebrowitz, MD, executive vice president of Executive Health Resources in Newtown Square, PA, warns facilities not to change anything in terms of preparing for a RAC visit. The permanent program will not change, he says.

“Basically, this is infighting amongst CMS potential contractors who are upset that they were not awarded the RAC contract,” Zebrowitz says. “I think it is important that this delay is not because of any question of whether the RACs are fair, or good, or legal. The RAC program is unchanged, and there is nothing out there to say that anything is going to be different. [CMS] just can not start when the contractors are in doubt. Once they resolve these complaints, they will start up.”

Zebrowitz guessed the delay would take 30 to 60 days.

To sign up for HCPro, Inc.'s free e-newsletter, The RAC Report, click here.

Observation vs. inpatient admission

Check out this form from the TMF Health Quality Institute outlining the thought process for determining whether observation or inpatient admission is appropriate.

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Training Tool: Scripting for the ABN

It is never too early to look at your scripting policy for the Advanced Beneficiary Notice. CMS is making the revised ABN mandatory by March 1, 2009. The following is a script used by Jennie Jones, supervisor of access management at South Haven (CT) Community Hospital.

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Patient Access Advisor November 2008

Take a look at the November 2008 issue of the Patient Access Advisor newsletter, which features articles on:

• Get RAC ready
• The big picture for your Recovery Audit Contractor team
• Facts on Medicare’s Recovery Audit Contractor program
• 100% MSP compliance
• Enhance your revenue cycle performance through effective communication
• Map out copayment collection process
• Scripting for the ABN

Download this document