Managed Care Readiness Training Series: Revenue Cycle Management 4th Learning Community Remi;ance, Appeals, Collec?

Transcription

1 Managed Care Readiness Training Series: Revenue Cycle Management 4th Learning Community Remi;ance, Appeals, Collec?ons and Analysis

2 Remi;ance, Appeals, Collec?on and Analysis Presenter: Boris Vilgorin, MPA

3 Managed Care Technical Assistance Center (MCTAC) Overview What is MCTAC? MCTAC is a training, consulta?on, and educa?onal resource center that offers resources to all mental health and substance use disorder providers in New York State. MCTAC s Goal Provide training and intensive support on quality improvement strategies including business, organiza?onal and clinical prac?ces, to achieve the overall goal of preparing and assis@ng providers with the transi@on to Medicaid Managed Care. 3

4 Managed Care requirements For two years Medicaid Managed Care Plans will be required to contract with providers that serve five or more of their enrolled individuals. MCOs will be required to pay the Medicaid fee for service rate for all authorized procedures delivered to individuals enrolled in managed care plans and HARPs. HCBS rates are listed on the HCBS fee schdule 4

5 Revenue Cycle Defined All administra?ve and clinical func?ons that contribute to the capture, management, and collec?on of client service revenue. This describes the life cycle of a client account from crea?on to payment collec?on and resolu?on. The client account cycle is supported by a number of addi?onal ac?vi?es necessary to assure that all encounters are billable, meet regulatory requirements and revenue collec?on is maximized. 5

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7 Phases of the Revenue Cycle Prior to Service Pre- registra?on including eligibility verifica?on and authoriza?on Scheduling During Services New client registra?on Eligibility verifica?on Collec?on of fees Charge capture and coding Following Services Claims submission Payer follow- up RemiEance processing and Ongoing Analysis Process improvement 7

8 Remi;ance What is Remi;ance? Pos?ng and applying payments and adjustments to client accounts and pos?ng payments in aggregate amounts to the General Ledger 8

9 Remi;ance Pos?ng Payments should be posted in a?mely fashion Payments can be posted manually or electronically. Electronic Payment Pos?ng is referred to as Electronic Payment Advice (EPA) The Electronic Remi;ance Advice (ERA), or 835, is the electronic transac?on which provides claim payment informa?on in the HIPAA mandated format. These files are used by prac?ces, facili?es, and billing companies to autopost claim payments into their systems. You can receive your 835 files through your clearinghouse, direct connec?on, or download them from payers. (United HealthCare) 9

10 Remi;ance Pos?ng Con?nues Why chose EPA? Increase efficiency Reduce resources Reduce errors Reduce Time Are there clear guidelines on how fast payments need to be posted? What happens if payment is received and cannot be matched to a client and/or service? 10

11 Remi;ance Review Compare payments received to amounts billed and reconcile differences Who is responsible to review remi;ance? Who is responsible to reconcile differences? Is there an established process to manage under and over payments? Review adjustments made by the payer to individual claim. Record expected amount or payments in General Ledger Is there a clear and agreed upon process to record revenue in General Ledger? Is it based on expected amount or paid? 11

12 Appeals Appeals process involves both U?liza?on Management and Revenue Cycle Management staff. Appeal process usually involves adverse clinical decision. 1. What if your organiza?on cannot support the decision of the MCO? Conflict Resolu?on (both external and internal) Are there liability issues in not providing a service, even if the MCO denies payment? 2. The first step, for U?liza?on Managers faced with an adverse decision, is to request that a call take place between the MCO and the trea@ng provider. 3. If the respec?ve clinicians do not agree on a plan of ac?on, the next step is to formally submit an expedited appeal. Mandated?meframes guide this process for both the facility making the appeal as well as the MCO and must be adhered to. 4. The next steps in the appeal process is the Standard Appeal or External Appeal. 12

13 Appeals Each Managed Care Organiza?on may have specific guidelines for ini?a?ng any of these op?ons. They will all be similar but it is important for you to become familiar with the process for each MCO you work with. Medicaid Managed Care Provider Guide h;p:// med- providers- guide.pdf For non- clinical appeals, administra?ve denials, agencies should contact their MCO representa?ves to discuss op?ons. 13

14 Analysis Analysis Review and evaluate the effec?veness of your revenue cycle management and the performance of your payers. Create and analysis standard metrics to iden?fy issues and processes that may need improvement Quan?fy issues related to payers and discuss with your customer service representa?ves Some standard metrics Ø Collec?on ra?o: a total collected to total billed reviewed by payer and payer class 14

15 Analysis Con?nues Ø Aged accounts receivable: Dollar value of accounts receivables tracked by amount of?me they have been outstanding: ü Less than 30 days ü days ü days ü days Ø Denial report percentage and amount of claims denied by reason, clinician, and payer Ø Percentage of claims paid upon ini?al submission Ø Under/Over Report Process improvement Formalized process using your analy?cs to iden?fy problems, create solu?ons, implement change, and measure the results. 15

16 Analysis Con?nues Who is responsible for analysis? How is the informa?on shared and communicated to others? Do individuals understand the analysis and is it ac?onable? Is it clear who is responsible to take ac?on? Process improvement Formalized process using your analy?cs to iden?fy problems, create solu?ons, implement change, and measure the results. 16

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18 Resources As part of the state qualifica?on process plans are required to develop and implement a comprehensive provider training and support program for network providers to gain appropriate knowledge, skills, and exper?se and receive technical assistance to comply with the requirements under managed care. Training and technical assistance shall be provided to BH network providers on billing, coding, data interface, documenta?on requirements, and UM requirements. New providers should have a submission tes?ng environment to work in prior to submikng live claims. 18

19 Resources Resources 19

20 Resources New York State HARP Mainstream BH Billing and Coding Manual provides billing mechanics for all the Medicaid fee- for- service government rate services (including OMH licensed and OASAS cer?fied services). This should be reviewed in conjunc?on with the coding taxonomy, HCBS Fee Schedule, and the rate table. The second sec?on of the manual gives detailed informa?on on OASAS services. There are numerous links in this document, provided for your convenience. h;p:// mainstream- billing- manual.pdf 20

21 Resources Coding Taxonomy This file provides the required coding construct for billing the OMH government rates services. Government rates must be used for the first 24 months of the behavioral health carve- in. Plans will need to program their payment systems to accept these coding combina?ons and then look through the Rate Table to ascertain the correct payment amount for the various unique coding combina?ons (specified using procedure codes, modifier codes, and units of service - all cross- walking to rate code) and the specific provider and BH service (based on MMIS provider ID or NPI and rate code). h;p:// taxonomy.xlsx 21

22 Resources HCBS Fee Schedule This file shows the required coding combina?ons for providers to bill the Plan for the provision of these services. The rate codes that the Plans will use to receive reimbursement from emedny will be provided in the near future and are subject to CMS and NYS DOB approval. h;p:// schedule.xlsx 22

23 Resources Rate Table This will have to be built into the Plan s payment system. It shows the rate amount for each MMIS provider ID and rate code combina?on. h;p:// table.xlsx 23

24 Upcoming Learning Communi?es The four content areas for the RCM Series are: #1 Scheduling & Pre- registra?on and Point- of- service registra?on & collec?on #2 Charge capture & coding #3 Claim Submission and Payer follow- up #4 Remi;ance processing and Appeals, collec?ons, and analysis 24

25 RCM Learning Community- Rest of the State 7/13-7/1 7 7/20-7/2 4 7/27-7/3 1 8/3-8/7 Monday Tuesday Wednesday Thursday Friday July #1 Webinar General Overview (Rest of the State) Office Hours #1 #2 Webinar General Overview (Rest of the State) Office Hours #2 #3 Webinar General Overview (Rest of the State) Office Hours #3 August #4 Webinar General Overview (Rest of the State) Office Hours #4 *All Webinars will be held from 12pm- 1pm 25

26 Please submit any ques?ons between sessions to with the subject line: RCM Learning Community 26

27 Thank you for par?cipa?ng! Please visit h;p:// and h;p:// to sign up for addi?onal offerings and trainings. 27