SCCA Research Revenue Cycle From Set Up to Invoice

Transcription

1 SCCA Research Revenue Cycle From Set Up to Invoice Orientation for Research Study Staff Clinical Research Billing SCCA

2 Training Objectives Understand Key Concepts in SCCA Research Revenue Cycle Patient-Billable and Study-Billable services Complexity of billing compliance processes Review SCCA Research Revenue Cycle Forms Processes Roles and Responsibilities in the Revenue Cycle Revenue Cycle Contacts and Websites

3 Getting Started with Billing Compliance Charge Capture and Compliant Billing Charge Level indications of researchrelated activities CPOE Orders Requisitions & Accessions (peer systems) SCCA Anticipated Research Services Checklists Visit Level direction of research-related activities Medicare Clinical Trial Policy UW Medicine COM -101 Policy UW Medicine Effort Policy Study and Participant Level Billing Documentation Participant registration/association

4 Understanding Patient-billable/Study-billable Services Both need to be understood and communicated for compliant billing Patient-billed in error - High compliance risk to SCCA and study Potential for double-dipping or double-billing by study Study services paid by sponsor AND paid by third party in error Non-compliant to Centers for Medicare and Medicaid Service s (CMS) Clinical Trials Policy Facility overpayment Study-billed in error Lower compliance risk to SCCA, but leads to rework by study staff and Revenue Cycle staff and can result in lack of payment Downstream rework SCCA Clinical Research Billing must identify and correct charges routed in error due to scheduling and ancillary system data entry issues Study staff must identify charges routed in error due to scheduling issues (among other issues) and request correction if missing charges This could hold up payment of services to SCCA Timely filing consideration may prevent facility from getting paid Patient Accounting must make corrections based off of study staff identified correction requests This could hold up payment of services to SCCA

5 Billing Systems Complexity Patient Accrual Association Epic Pt Linking PATS ORCA -Alert -Care Plan Study Set Up Scheduling Visit Linking Epic Charge Capture/Billing Billing Grid/DBT CPOE Research PowerPlans Build - Special Instructions - Study Code and Modifier (R/RS) Scheduling Orders CPOE Daily Orders Automated with CPOE Epic Scheduling Ancillary Systems Requisition & Accessions Visit Specific Forms Checklist Supply Sheet Charge File Charge Capture Charge Review Invoicing Corrections Many systems contribute information to Research Billing Many processes/forms feed information to systems = Areas Monitored

6 Research Revenue Cycle Overview Clinical Research Billing generates and routes invoices to studies Patient Finance generates bills for participants Corrects misrouted charges per study Billing Documentation & collaboration with study staff Processes payments to study invoices Study invoices paid within 30 days of receipt Collections & escalation of delinquent invoices Invoicing/ Corrections/ Collections Study Set-Up sramp Produce Billing Documents o Schedule of Service, i.e. Billing Grid and/or Detailed Budget Tool o Pricing & coding (CPT)s for study related services Clinical Trial registration and Epic study code assignment Protocol Implementation Meeting (PIM) and/or Clinical Trials Implementation (CTI) meetings Research PowerPlans builds Participant Identification Associate prior to scheduling patient to research study/studies in Epic PATS enrollment information triggers Care Plan and STUDY Alert Epic Referral for Clinical Trial Financial Clearance (participant) Review charges against Billing Documents Billing Grid/CTAS CPOE Orders Root cause analysis Correct charges pre-invoicing Monitoring of study billable charges on study Hospital Account Records (HAR) prior to invoicing Special review monitoring Patient/study billing inquires Monitoring/ Charge Review Informing Charge Capture Ordering/ Scheduling Create Daily Orders Research or Generic PowerPlans, inform w/study code & modifier Link visit to study in Epic Epic Referral for Financial Clearance (services) o Scans/imaging o Genetic Testing o Ancillary Services (PT) o High Cost Drug (notify pharmacist) Notification of Charging Systems o Supply Sheet o Anticipated Research Services Checklist Provider Documentation for Coding Computerized Provider Order Entry (CPOE) Orders Appointment notes

7 Study Set Up Study Set-Up Role Responsibility Details Contact the SCCA Research Implementation Office (RIO) to request new study implementation The implementation process includes a step for designation of services required for the protocol Study Staff Request Research Coding and Pricing from the CDM Coordinator Submit study through sramp Produce Billing Documents Schedule of Service, i.e. Billing Grid and/or Detailed Budget Tool Attend Protocol Implementation Meeting (PIM) and/or Clinical Trials Implementation (CTI) meeting SCCA Revenue Charge Mgmt. Coordinator Provides research coding & pricing quotes to study staff during implementation for SCCA services Pricing - Study pricing for study-billable services indicated by the protocol Coding - Current Procedural Terminology (CPT) codes for services indicated by the billing grid and pricing request table Research Pricing quotes are given on a rolling three fiscal year quote structure Each fiscal year the fee schedule is evaluated, current fiscal prices are updated, and an additional year is then quoted once the prior year expires SCCA fiscal year dates from July 1st June 30 th SCCA Clinical Research Billing Analyst (CRB) Inform study staff of any special needs or watch points at the CTI meetings Missing or ambiguous/overlapping timepoints on Billing Grid Confounding language used in the Comments field for a given test/service Clearing up discrepancies and ambiguities in the description of tests/services (asking for more specific/accurate names).

8 sramp (Study Review and Management Portal) Study Set-Up A web-based, single point of entry portal for study submission, implementation review and communication for all studies in the Cancer Consortium

9 Epic Study Set-Up - Study Accounts Creation Study Set-Up A study account is created via the study implementation process The clinical trial is registered and assigned a study account name and an Epic Study Code by UW Clinical Research Budget & Billing (CRBB) Study account name in Epic begins with RRR Study Code general format is RG R for research G for general covers multiple service areas (SCCA, UW, UWP) Numeric portion is study specific Modifiers help ensure proper direction of study or patient-billable research-related charges If study code is on a charge with an R modifier it routes to the study If study code is on a charge with an RS modifier it routes to the patient If no study code is on a charge it always routes to the patient The study code is used in conjunction with modifiers on electronic orders or paper forms to designate the study for activities of ordering, scheduling, accessioning and charge capture within Epic and the ancillary systems

10 Participant Identification Participant Identification Role Responsibility Details Initiate Financial Clearance for patient participation in Epic Study Staff Enter and maintains participant information in Epic and PATS Associate/maintain consented patient to research study/studies in Epic Forward Epic Inbasket notification on inpatient admissions and ED notification for billing purposes to CRBB Epic Clinical Trial referral begins the process of Financial Clearance of participants prior to research study enrollment Enter/maintain accrual information for consented and enrolled patients into PATS (for Fred Hutch only) Status Active Start Date Active End Date Finalize Epic and PATS participant associations with an active end date and status update when all research-related, patient or study-billable services are complete

11 Epic Participant Association Participant Identification Timely (within 24 hours of identification of first DOS with study or patient billable services) participant-to-study association in Epic is extremely important for accurate and compliant billing Allows linking of participant s visits to the study Provides an indication for billing offices of a patient s participation on a study Key Elements of patient-to-study association in Epic Status (active vs. inactive) indicates where the participant is in the billing flow Active Start Date aligns with the first date of research-related, patient or studybillable activity. Triggers the Epic STUDY alert. Active End Date aligns with the last date of research-related, patient or studybillable activity. Triggers the removal of the Epic STUDY alert. Generates notification to study staff in the event of inpatient or Emergency Department (ED) admissions who then forward notification to CRBB Patients must be associated with the study account (RG code) with an active billing status in Epic prior to scheduling research-related services In absence of association, schedulers will not be able to link visit and will schedule without it

12 Epic Clinical Trials Patient Financial Clearance Participant Identification Completed prior to enrollment and/or scheduling for study Study staff request patient-level financial clearance by SCCA using Epic referrals procedure Checks that the patient s insurance plan allows participation in Clinical Trials and determine if SCCA is contracted with the patient s payor Provide protocol-specific patient-billable services to the insurance company for review Study documents may be provided to the payor for evaluation if requested by the payor Denials can be appealed SCCA Patient Financial Clearance Staff coordinators provide assistance with appeals

13 Ordering/Scheduling Ordering/ Scheduling Role Responsibility Details Study Staff SCCA Scheduler/TC Associate participant prior to scheduling Facilitates electronic orders, requisitions and other forms for research/clinical services with study info: Epic study code (RG Code) Modifiers Study RRR name (for remaining paper orders or requisitions at SCCA or UWMC) Special instructions for scheduling Scheduling and linking of research-related (screening and treatment) visits per orders. Each appointment scheduled that has research-related services will: Be linked to the Epic study account (RG Code) Provided on the ORCA CPOE order Include the Mixed Visit flag used at SCCA Have an appointment note populated with study applicable information Contact study staff to request missing information on orders that is needed for research scheduling Include in CPOE Orders Special Instructions field: Epic study code without spaces (include R/RS modifier) RG X Cycle/Day (CXDX) Denote the timepoint e.g. Cycle 1 Day 8, or Week 1, or Visit 3 ) Study coordinator name & contact information Miscellaneous notes; i.e. fasting blood draw There is a risk that the visit will be linked inappropriately or not linked if: Epic study account (RG Code) and billing information is incomplete or not provided Orders are unclear Scheduled visits CANNOT be linked to a study until the study team has associated the research participant with that study with an active billing status in Epic CPOE orders have a Special Instructions section that helps provide information to schedulers.

14 Charge Modifiers for Research Ordering/ Scheduling

15 Research Visit Orders Ordering/ Scheduling Various electronic and paper forms are used to designate research study related services and items to separate systems/workflows ORCA CPOE PowerPlans - scheduling needs related to research Protocol-Specific PowerPlan built to include Epic study codes with the appropriate research modifier for billing related to a specific protocol Generic PowerPlan does not contain any research specific billing details and Epic Study Code and appropriate research modifier need to be entered for each order selected R modifier designates study-billable research related charges RS modifier designates patient-billable research related charges Split Supply sheets (Infusion, Procedures) - study vs patient-billable supplies To initiate pre-printed Split Supply sheets contact SCCA Material Management Lab Orders and Requisitions directs lab-related activities in Epic and other systems Labs are ordered directly and individually in CPOE and the visit needs to be linked to the patient in Epic The Study Code and R/RS modifier must be entered in the ORCA Study Code (Research Only) order entry field for each research lab specimen or test that is to be billed to research Purple Research Requisitions are used for samples that the study will handle and route to an offsite lab for processing and some genetic testing through ORCA orders. These orders are fully informed by study staff, except SCCA AMB Bone Marrow PowerPlans. Radiology Orders - ORCA orders are used for internal radiology research orders (MRI, CT, nuclear medicine, and PET) coming from SCCA Anticipated Research Services Checklist provides guidance for coders working to capture charges from ORCA documentation

16 Anticipated Research Services Checklist Ordering/ Scheduling Anticipated Research Services Checklist Supports all service areas except Profees, Laboratory and Radiology Submitted via to SCCA Research Coding Team at: Used to designate services anticipated for the visit that are research-related billable Examples: MA assisted EKGs Oral Chemo Administration Blood Draws (36415, 36591, 36592) Conscious Sedation Coding will NOT code charges from the Checklist unless the service or visit is documented in ORCA by the providers. Instructions for completing the form are located here and on the Research Staff Resources website.

17 Charge Capture Informing Charge Capture Role Responsibility Details Maintains the Research Fee Schedule for Charge Capture of study billable charges SCCA Revenue Charge Mgmt. Coordinator SCCA Charge Capture/ Operations Systems Maintains the Clinic Fee Schedule to allow for charge capture of patient billable charges Optimizes flow of patient and study billable charge flow through ancillary peer systems and Epic Addresses daily charges that fail to route appropriately into or through Epic Maintains the Research Pricing quotes and research pricing for all SCCA activities Provides price certainty for clinical trials Reviews and analyzes charges daily in Epic Error work queues (WQs) Charges not in the fee schedule and end up in the Error Pool are manually priced Could be a new service Could be a service done infrequently SCCA Clinical Research Billing Analyst Addresses daily research-related charges that fail to route appropriately onto the appropriate patient or study account Re-prices study billable charges based on the Research Fee Schedule This work is done via WQs in Epic Research charges for non-linked visits Charges that are unclear as to whether they are related to research Missing Epic Research Information o Patient not linked to the study o Incorrect visit type o Missing active billing active status

18 Monitoring/Charge Review Monitoring/ Charge Review Role Responsibility Details Performs Daily monitoring and Special Reviews and analyzes charges daily in Epic Review of charges and research Account Monitoring WQs accounts Re-route study billable charges SCCA Clinical Research Billing Analyst SCCA Integrity/ Compliance Office Research-billable charges per Billing Grid and Orders Participant-billable charges per Billing Grid and Orders Charge correction Monitoring of study billable charges on study billing encounters/dos/ (HAR)s prior to monthly invoicing Performs audits of research-related study and patient accounts Provides communication of remediation (corrections) Identifies and tracks charge error trends Review of specific charge flow for root cause of error Coordinates with study Billing Contact for questions related to: Billing Documents Orders Related charges Typically retroactive in nature Communicates with Principle Investigator and Study Staff Communicates with SCCA Clinical Research Billing Department

19 Invoicing/Corrections/Payment Invoicing/ Corrections/ Collections Role Responsibility Details Review RRR account invoice for expected and unexpected charges Study Staff Review, authorize, and pay research invoice in a timely manner Study invoice payment is due 30 days from the invoice date Contact SCCA Clinical Research Billing Analysts when: Study invoice includes incorrect and/or disputed charges Expected but missing" charges are not on the invoice requiring review of patient accounts and charge capture process flow SCCA Clinical Research Billing Analyst Generate invoices to study team for review and payment RRR Invoice Cycle is open for one calendar month at a time Invoices are printed and sent out 15 days after the monthly billing cycle ends Performs collection activities for outstanding study invoices Escalates as needed to leadership Triages study team communications Incorrect or disputed charges on the study invoice Expected but missing charges not reflected on the study invoice Charges billed to the participant in error

20 System Training for Revenue Cycle Epic Fundamentals overview of SCCA Epic system, how to navigate the system and use Epic menus and tools Epic Research Participant Enrollment association of research studies with patients (enrolling in Epic) Epic Referral creation of referrals for financial clearance of the participant for clinical trails Click here for Epic Class Enrollment Information or visit Epic Education on the SCCA Intranet ORCA 100: Fundamentals navigate the electronic medical record to find patient information specific to SCCA ORCA 300: Advanced for Researchers transcribe the consenting process in a clinical note, proposing orders (including prebuilt PowerPlans as well as Generic Templates) and starting regimens Click here for ORCA Training Schedule and Registration Instructions or visit ORCA Education on the SCCA Intranet PATS training entry of accrual information PATS Online Training Module (look under Online Modules) PATS Process and User Documentation (User Guide)

21 Clinical Research Billing Training Role Responsibility Details Develops training based on charge analysis root causes provided from the Clinical Research Billing, Charge Capture and Invoicing departments SCCA Revenue Cycle Education Specialist Performs and tracks research revenue cycle training to study and clinical staff New Users Remedial Collaborates with trainers from Fred Hutch, UWM, and SCCA Epic on content development Follow-up post training General training Semi-annual CRS Clinical Research Coordinators Training Department training Team training One-on-one training Operational/workflow issues Examples: Participants not associated with study Appointments not linked, incorrect study codes used Checklists not received

22 Key Research Revenue Cycle Contacts SCCA Clinical Research Billing (Issues, Invoicing/Collections and Requests for Training) Kris Pedersen: Sakuntra Fulgenzi: Elham Lawson: Joy Westgate: Azure Kraxberger-Unger, Revenue Cycle Education Specialist, , SCCA Patient Financial Services SCCA Research Coding Team (for submitting Anticipated Research Services Checklist) SCCA Revenue Integrity Coordinator (Pricing and Coding Questions) Abby Ewing, SCCA Research Implementation Office Website: (For Forms and Form Completion Instructions) CRBB Clinical Research Budget and Billing General Questions: CRBB Budget: CRBB Billing: UWP University of Washington Physicians

23 Tips for Compliant Billing Associate patient to study in Epic within 24 hours of study billable services Status (active vs. inactive) indicate where the participant is in the billing flow Active Start Date enter the first date of research-related, patient or study-billable activity Active End Date enter the last date of research-related, patient or study-billable activity Update patient Epic enrollment status in a timely manner Associate patient to study in PATS Enrolled date - triggers Epic STUDY Alert Billing end date - triggers the removal of the Epic STUDY Alert Update Billing Grid and/or Detailed Budget Tool and PowerPlans whenever any billing assumptions have changed Complete Orders Correctly Include in CPOE Orders Special Instructions field: Cycle/Day (CXDX) - Denote the timepoint e.g. Cycle 1 Day 8, or Week 1, or Visit 3 ) Study coordinator name & contact information Epic study code without spaces (including R/RS modifier) - RG X Miscellaneous notes; i.e. fasting blood draw Complete the Anticipated Research Services Checklist and submit to Research Coding Reviews RRR account invoice for expected and unexpected charges Contact Clinical Research Billing ASAP with questions or to dispute charges & communicate missing charges Pay invoice within 30 days from the invoice date

24 THANK YOU