Archive for: Patient access
Optimize patient flow to protect against RACs
Waits, delays, and cancellations are so common in healthcare that patients and providers have come to expect waiting as part of the care process. But poor patient flow can have seriously adverse effects on patient outcomes and your facility’s bottom line—and can even increase your susceptibility to RAC audits.
According to Kelly Cooke, MSN, RN, the director of clinical resource management, social work, and documentation improvement at the Hospital of the University of Pennsylvania, part of maintaining optimal patient flow is placing patients in appropriate level of care and creating a system that guards against readmissions.
“If you can initially place your patients in the appropriate level of care, this will enable your facility to have a very successful RAC audit,” says Cooke. In addition to up-front processes, she recommends creating strategies to prevent unnecessary readmission.
Editor's note: This article is an excerpt from HCPro’s newest resource for hospital case managers—www.CaseManagementMentor.com—a free online blog dedicated to connecting hospital case managers to industry pacesetters, peers, and best practices. Visit the blog to read the complete article.
Q&A: Submitting ABNs
Q. Do we include a copy of the Advance Beneficiary Notice (ABN) with the claim form?
A. No, do not submit a copy of the ABN unless requested to do so by the carrier.
Source: Centers for Medicare & Medicaid Services
Tell us about your readmissions cases and win a free book!
We would like to find out about your experiences with transition of care challenges for a research study HCPro is undertaking. We’re interested in understanding the challenges your organization faces with patients who have transitioned between multiple healthcare settings (e.g., from home health care to the hospital to a nursing home, or from a hospital to a skilled nursing facility and then back to a hospital.)
If you are interested in providing information about an actual case, please e-mail Julie McGinley at jmcginley@hcpro.com.
Of the respondents, 10 will be selected to receive a complimentary book up to $149 value from our online store! www.hcmarketplace.com/listings-M1_CAS.html.
Patient Access sample tool published
We’ve recently added a new free sample checklist for you to use when performing daily and monthly quality assurance checks on your patient access staff members. Checkc it out under the "Tools and Forms" section of the Web site.
Hints for when Medicare is the secondary payer
Editor’s note: Dunn Memorial Hospital in Bedford, IN, uses these hints to help its patient access staff members successfully complete the Medicare Secondary Payer Questionnaire.
Medicare is the secondary payor when:
- The patient is 65 or older and the patient or the patient’s spouse is still employed and has insurance through that employer
- The patient is under 65 and the patient or patient’s spouse is employed by an employer with 100 or more employees and has insurance through that employer
- The claim is workers’ compensation
- The claim is a Black Lung claim
- The claim is a result of an accident and liability insurance is available
- The claim is for ESRD and the patient is still in the 30-month coordination of benefits period
Additional MSP tips:
- When Medicare is the secondary payor, the primary payor is first in the sequence of payors
- Medicare is second in the sequence of payors when Medicare is the secondary payor
- MSPs are to be completed on each registration to ensure proper billing
Tip: Handle Advance Beneficiary Notices of Noncoverage
By Jackie Birmingham, RN, BSN, MS, CMAC.
A Medicare beneficiary (or authorized representative) who has been given an Advance Beneficiary Notice of Noncoverage (ABN) may elect to receive the item or service anyway. In this case, the beneficiary should indicate that he or she is willing to be personally and fully responsible for payment by marking options 1 or 2 in box G on the ABN form. This new version of the ABN is used before services are rendered (as the name implies) and it may be given by outpatient department staff.
Here are some more tips regarding filling out the ABN:
- Option 1 indicates the beneficiary or representative will pay for the service out of pocket, but the hospital will also bill Medicare to see whether Medicare will pay for the item or service. If Medicare does not pay, the patient has the opportunity to appeal, but there is no guarantee Medicare will pay for the item or service.
- Option 2 indicates the individual accepts full financial responsibility for the item or service. Medicare will not be billed, and the beneficiary cannot appeal. This option requires that the patient be informed of the cost of the service prior to receiving the service.
- When a beneficiary decides to decline an item or service, he or she should indicate this by marking option 3 in box G on the ABN form. Counseling the patient on this decision and documenting the discussion is important. The service has been ordered based on the patient’s physician’s advice, and if the patient declines the item or service, it is important to be sure that he or she is fully informed of the consequences of the decision.
- The beneficiary cannot refuse to sign the ABN and still demand the item or service.
- If a beneficiary refuses to sign a properly executed ABN, the notifier should consider not furnishing the item or service, unless the consequences (health and safety of the patient, or civil liability in case of harm) are such that this is not an option.
- Additionally, the notifier may annotate the ABN, and have the annotation witnessed, indicating the circumstances and persons involved.
Prepare for approaching ABN deadline
By Judith Kares, JD, CPC, regulatory specialist for HCPro, Inc.
Medicare has been going through a number of transitions recently. One of these transitions relates to the appropriate form of notice when certain providers, including hospitals and physicians, believe that the outpatient services ordered by the patient’s physician fall under the limitation on liability provisions of the Social Security Act. Under these provisions, the provider must provide advance written notice to the beneficiary (or his or her representative) prior to the performance of the services in order to be able to bill the beneficiary for those services if Medicare denies coverage.
Limitation on liability is likely to arise in the outpatient setting when the services ordered fail to meet Medicare coverage criteria for one of the following reasons:
- They fail to meet Medicare’s medical necessity guidelines;
- They are screening services that are provided more frequently than Medicare provides a benefit for; or
- They are custodial services.
In order to successfully shift financial liability to the patient, the provider must provide a prescribed form of notice prior to the performance of the services. Medicare is currently phasing out the prior prescribed forms (ABN-G and ABN-L), which continue to be effective through February 28, 2009. On and after March 1, 2009, however, providers must use the revised ABN form (CMS-R-131) in order for the advance notice to be effective when limitation on liability applies to outpatient services.
The revised form initially became effective for services provided on and after March 3, 2008, which gave providers a year to transition to the revised form. There are a number of technical requirements set out in the Medicare Claims Processing Manual, Chapter 30, that must be met if the ABN is to be effective. Most of the requirements that apply to the revised form are very similar to those that applied to the prior forms.
In September, 2008, Medicare issued Medicare Claims Processing Manual Transmittal 1587, which contained specific, updated instructions on completion and use of the revised ABN. The most significant change is the requirement that “Notifiers must make a good faith effort to insert a reasonable estimate for all of the items or services listed . . .” on the ABN. Nevertheless, Medicare permits a great deal of flexibility in meeting this standard. For example, so long as the estimate is within $100 or 25% of the actual costs, whichever is greater, the notifier will be considered compliant.
With just a month left during the ABN transition period, it is essential that providers assure that they are prepared to be fully compliant with the new requirements, including a good faith cost estimate, as set out in the updated sections in Chapter 30 of the Medicare Claims Processing Manual.
Consider ED bedside registration
York (ME) Hospital finds bedside registration in the emergency department one of the most effective tools to ensure an accurate and compliant patient claim.
Pat Finnemore, CHAA, who works on the patient access team at the 11-bed ED facility, says bedside registration in the ED:
- Increases efficiency of workload for registrars
- Opens strong lines of communication between clinical and access teams
- Provides convenience for patients who do not want to be shuffled from place to place.
“We have not found this process to be more difficult at all,” Finnemore says. “We have an excellent working relationship with the clinical staff. Patients also like not being shuffled around. They can get in and get comfortable.”
