Thoughts About the Affordable Care Act

The reductions in Medicare payments that will result from the implementation of the Affordable Care Act started last year and will continue to increase during the next years. They were supposed to be somewhat offset by the increase in people eligible for insurance–either due to expanded Medicaid eligibility or to the employer insurance mandate.

However, the Medicaid expansion is dependent on the individual states voting in favor of it and the additional federal funds for it don’t start until January 1, 2014. The employer insurance mandate, which was supposed to be effective also January 1, 2014 has now been delayed a year.

On the expense side, ICD-10 implementation is set to begin Oct 1, 2014. Experience in other countries has shown that to be a nightmare, at best. Most countries have experienced their Accounts Receivable tripling!

So, the squeeze is on for hospitals and physicians…

At Omega, we go back 2 years for our Lost Charge Recovery projects and since payments are date of service dependent, we can recoup the charges under the old reimbursement methodologies. So, that’s one way to bring in additional revenue.

On the expense side, we offer advanced technology at basement prices–probably 10% of the price for a large in-house installed system. We can analyze your Chargemaster for compliance, pricing, and completeness. We can analyze your claims on a daily basis for Medicare billing compliance, RAC issues, lost charges–you can even write your own edits for your specific issues! And don’t forget, you always get Omega’s professionalism and service.

So, isn’t it time to give us a look?

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Florida Hospitals … Have you had a Medicaid Outpatient Checkup Lately?

July 1st 2013 Florida Inpatient Medicaid reimbursement changed from a per diem rate to an Inpatient Prospective Payment System. With any major change in payment methodology there are always winners and losers. Regardless of whether your facility will benefit from this change or not, what all hospitals should do in this time of uncertainty is have a Medicaid Outpatient “check-up”.

Medicaid Outpatient reimbursement in Florida is revenue code driven. Medicaid provides a list of revenue codes they will pay once per patient encounter, if care is not taken when selecting revenue codes for Medicaid claims you could be getting drastically underpaid. The easiest, fastest way to find out if your facility is being underpaid by Medicaid is to have a professional Outpatient claim “check-up” conducted. During a check-up claims are reviewed and revenue code assignment is checked for accuracy and appropriateness according to Medicaid guidelines. Incorrectly assigned revenue codes are identified and recommendations are made for changes which will result in additional payment from Medicaid when a corrected claim is submitted.

We would like to offer Florida Hospitals a free “Medicaid Outpatient Check-Up” to ensure that all facilities and healthcare systems in the state are receiving the Medicaid dollars that they are entitled to. It can be done remotely or we can come to you. This process is free and fast, it only takes about 60 minutes (on site) and once we’ve reviewed your claims we will provide you with a complete Medicaid Outpatient “report card” so that you can see if you are receiving all the Medicaid dollars you should and if not how much are you potentially losing. We can also help you recoup those dollars with a full recovery project which takes minimal time and the best part is we do all the work; there is virtually no impact on your internal staff. We do the review, the billing and reporting. The cash all goes directly to the facility, the only thing your employees have to do is post all the payments and that’s a problem we all like to have.

All we need from you to get started is:
1. A recent Medicaid Remit (electronic or hard copy)
2. A signed BAA if you would like the check up done remotely
3. Your total volume of Medicaid Outpatient Claims per year

And that’s it! We will start your check-up immediately and have your report card with the results ready in no time. It is simple, fast and FREE.

Omega Technology Solutions, LLC is a healthcare consulting and software firm. We have been in business for over 20 years and have hospital and healthcare system clients all over the contiguous 48 states. We are experts in Revenue Integrity Analytics specializing in Lost Charge Recovery. We have been conducting Medicaid reviews and audits for Florida hospitals for more than a decade. In just the last 5 years we have collected over $20 million in Medicaid payments on behalf of Florida hospitals. This is revenue that they did not even know they were missing and would never have received without our assistance. For your free Medicaid check-up contact us today at 1-800-559-8009 or through our website at

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What Exactly is Compliance?

I keep hearing “we have to do…to be compliant…or we can’t do…because it would be a compliance issue” and a lot that I hear really doesn’t make sense to me, so I’ve done some research to try to clarify “compliance” issues.
In 1998, the OIG published Compliance Program Guidance for hospitals. That guidance was “intended to assist hospitals and their agents and subproviders…develop effective internal controls that promote adherence to applicable Federal and State law, and the program requirements of Federal, State, and private health plans.”
It goes on to say that, “The adoption and implementation of voluntary compliance programs significantly advance the prevention of fraud, abuse, and waste in these health care plans while at the same time furthering the fundamental mission of all hospitals which is to provide quality patient care to patients.”
Some of the special areas of OIG concern include:
*Billing for items or services not actually rendered
*Providing medically unnecessary services
*DRG “creep”
*Outpatient services rendered in connection with inpatient stays
*Teaching physician and resident requirements for teaching hospitals
*Duplicate billing
*False cost reports
*Unbundling–specifically defined by the OIG as “the practice of submitting bills piecemeal or in fragmented fashion to maximize the reimbursement for various tests or procedures that are required to be billed together and therefore at a reduced cost.”
*Billing for discharge in lieu of transfer
*Patients freedom of choice
*Credit balances–failure to refund
*Hospital incentives that violate the anti-kickback statute or other similar Federal or State statute or regulation
*Joint ventures
*Financial arrangements between hospitals and hospital-based physicians
*Stark physician self-referral law
*Knowing failure to provide covered services or necessary care to members of a health maintenance organization
*Patient dumping
In 2005, the OIG issued “Supplemental Compliance Program Guidance for Hospitals”. In that document they state “Perhaps the single biggest risk area for hospitals is the preparation and submission of claims or other requests for payment from the Federal healthcare programs.” Further stating, “Common and long standing risks associated with claims preparation and submission include inaccurate or incorrect coding, upcoding, unbundling of services, billing for medically unnecessary services or other services not covered by the relevant healthcare program, billing for services not provided, duplicate billing, insufficient documentation, and false or fraudulent cost reports.”
Sound familiar? Does the OIG ever say that correcting a mistake–whether it’s adding a charge to the CDM for something that was not on it, or fixing an incorrect price–is a compliance issue? I don’t see that. So long as the documentation for the charge exists, it should be billed. Not billing for services provided is just as non-compliant as billing for services that aren’t documented.
In a transmittal dated March 13, 2009, CMS reiterates that “The hospital should include charges associated with medical and surgical supplies on claims so their costs are incorporated in rate setting, and payment for these supplies is packaged into the payment for the associated procedures under the OPPS in accordance with 42 CRF 419.2(b)(4).”
In the 2005 supplement, the OIG highlights other risks involving outpatient procedure coding:
*Billing on an outpatient basis for “inpatient only” procedures
*Submitting claims for medically unnecessary services
*Submitting duplicate claims or otherwise not following NCCI guidelines
*Submitting incorrect claims for ancillary services because of outdated CDM’s
*Circumventing the multiple procedure discounting rules
*Improper Evaluation and Management code selection
*Improper billing for observation services
Omega’s core business is auditing claims for accuracy and completeness of charges and rebilling the corrected claims. In addition to that service, we review payments for accuracy and completeness. We address the CDM issue that the OIG discusses by providing our Lost Charge Recovery clients with free access to our web-based CDM compliance tool. And finally, we use OCExaminer to ensure that all claims are NCCI compliant before they go out.
For compliant claims, Omega has you covered. Isn’t it time you let us check you out?

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Don’t Let Medicare (Exclusively) Dictate Your CDM Content

When we started as a healthcare consulting firm, 20 years ago, none of our hospital clients had a chargemaster coordinator on staff, let alone a chargemaster committee. Individual hospital departments operated in a vacuum from a charging perspective. These days things are very different and almost every hospital and health system we work with has a CDM coordinator, a committee that includes representatives from multiple departments and in most cases, some type of CDM maintenance software to help keep everything current, compliant and priced competitively.

When it comes to maintaining a compliant hospital chargemaster there are two things to consider; statutory compliance and contractual compliance. Statutory compliance issues arise from governmental payers such as Medicare and  most CDM coordinators spend a lot of time and resources trying to ensure that items added, changed or removed from the chargemaster are compliant with CMS and won’t affect reimbursement or create coding or RAC issues. The rules and regulations that govern statutory compliance can often be convoluted and even contradictory but again this is only one type of compliance.  Contractual compliance is based on the many contracts a hospital or health system has negotiated with other third party payers and these issues are often over looked or overshadowed by the fear that a change could affect Medicare claims. I am frequently asked by hospital CDM coordinators how a potential CDM change will affect Medicare or what CMS recommends for a given item or service.  My response is always the same; Medicare is only concerned with what is on the final claim, not the content of the chargemaster, and while the chargemaster does drive claim content, so does the coding department, front end scrubber and manual charge entries. You need to look at the contracts for your top four or five commercial payers prior to making any changes in the CDM and not focus too heavily on CMS. Remember, your facility has contractual obligations as well as internal obligations that may be very different than what CMS would recommend and most statutory regulation does not provide guidance or instruction on how to handle many CDM issues. 

Take for example revenue codes. CMS does not provide specific instruction when assigning most revenue codes as you can see below in an excerpt from the Medicare Claims Processing Manual Chapter 4 – Part B Hospital.

20.5 – Clarification of HCPCS Code to Revenue Code Reporting

(Rev. 1487, Issued: 04-08-08, Effective: 04-01-08, Implementation: 04-07-08)

Generally, CMS does not instruct hospitals on the assignment of HCPCS codes to revenue codes for services provided under OPPS since hospitals’ assignment of cost vary. Where explicit instructions are not provided, providers should report their charges under the revenue code that will result in the charges being assigned to the same cost center to which the cost of those services are assigned in the cost report.

Now stop for a second and think about how other third party reimbursement could be affected by revenue codes.  Florida Medicaid for example pays all outpatient claims based exclusively on revenue code assignment. If you run a hospital in Florida you could be losing millions of dollars every year in Medicaid reimbursement if you are not very careful about how you assign revenue codes, especially in the ED and on Observation patients where injections and infusions will go unpaid if the revenue codes are not correct. Meanwhile, that same ED or Observation visit for a Medicare patient will be paid regardless of the revenue code assignment because they are paying based the CPT/HCPCS codes and the corresponding APCs.

There is no doubt that an up to date, compliant and properly priced chargemaster is a cornerstone of a hospital’s financial health.  Just remember that all hospitals have statutory, contractual and internal obligations that must be balanced when considering chargemaster maintainence.

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Is Automation Killing Your Bottom Line?

Automation can be a wonderful tool in the healthcare revenue cycle.  It can cut down on payment processing time, provide real reimbursement numbers for reporting and free up personnel for other tasks.  But like most other industries, there are pitfalls to automating your accounts receivables.  Even when systems do exactly what they are programmed to do, human intervention and analysis is required.

Take for example the managed care systems that are available today.  With these software systems you can load all your payer contracts, scrub your bills, fire your bills electronically to almost any carrier, calculate expected reimbursement and post payments, all automatically. When this process works it is seamless and completed start to finish with very little, if any, human intervention…and that’s where the trouble starts. Let me give you an example of how these systems can have “leaks” that can only be identified with human eyes. 

A large health system from the mid Atlantic region uses a very popular and efficient managed care system. They have one contract that pays their outpatient procedures based on revenue codes. The contract divides revenue codes into two categories; primary and non-primary.  If a claim contains any of the primary revenue codes then the reimbursement is based on a fee schedule.  If the claim contains only non-primary revenue codes then the claim is reimbursed on a percent of charge basis.

This hospital system has a very busy chemotherapy department and several of their patients treated in this department have coverage that falls under this contract. Now, the contract is loaded into the managed care system correctly, and the system correctly calculates expected reimbursement based on the contract, but there is a problem.  On several of these claims there is a $600 charge for “declotting vascular access port” and this service is listed in the charge master with a 361 (Minor Procedure) revenue code, a primary revenue code according to the contract. This one minimal charge caused the whole chemo claim to go into a fee schedule rather than pay at the >60% of charges that it should have paid.  The system handled the claim correctly, the fee schedule payments came in and were posted, any additional adjustments made and the claims went to zero balance. We found 13 claims like this over a 12 month period. These 13 claims produced additional $183,000 cash after we removed the 361 and resubmitted them.  Hospital personnel did not catch this because of automation.

Does your health system utilize automated A/R software and if so, how can you be sure automation isn’t killing your bottom line?  Contact us to find out what you’re missing.

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Follow THEIR Rules

So, let’s think about this: all of the big payers–Medicare, Medicaid, Blue Cross, Aetna, United, Cigna, Harvard Pilgrim, etc–have their own reimbursement rules. So, why do you bill them all according to Medicare’s reimbursement rules? And please note, payment rules are NOT billing rules. But that’s another article…

Medicare doesn’t care how you bill other carriers so long as you don’t bill Medicare more than anyone else. Medicare pays outpatient claims based on CPT codes and in general, doesn’t care what revenue code you use.

Pub 100-04 Chap 4 states:
20.5 – Clarification of HCPCS Code to Revenue Code Reporting
(Rev. 1487, Issued: 04-08-08, Effective: 04-01-08, Implementation: 04-07-08)

“Generally, CMS does not instruct hospitals on the assignment of HCPCS codes to revenue codes for services provided under OPPS since hospitals’ assignment of cost vary. Where explicit instructions are not provided, providers should report their charges under the revenue code that will result in the charges being assigned to the same cost center to which the cost of those services are assigned in the cost report.”

Other carriers, however, have very different payment rules. Many pay based on what revenue code you bill, regardless of CPT code. It seems to me, that billing other carriers according to what you think are Medicare’s rules and expecting to be paid appropriately according to the carrier’s rules, is like trying to force a square peg into a round hole.

How many of you have taken the time to look at a UB Editor lately?  There are numerous revenue codes that are suggested for individual CPT codes.  And, there are NO suggested revenue codes for other CPT codes.  So, where does all of the “you CAN’T do that” come from?  I have no answer to that question.  But I do know that, back in the 90’s, United Healthcare bought St. Anthony’s Publishing–the bible of hospital billing.  I don’t know what has happened since, but I’ve always been leery of anyone’s interpretation of regulations ever since that happened.  I prefer to go directly to the source documents.  That’s what you will get from us.

We are getting ready to publish a great example from one of our clients’ contracts.  Here’s my first piece of advice:


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Are you afraid?

Are you so afraid of the new laws that you’ve become paralyzed?
Are you so afraid that charging for your services will be called “non-compliant” that you’re giving your services away?
Are you so afraid of being “non-compliant” that you’ve forgotten that in order to accomplish your mission you need cash?
Are you so afraid that your staff will disagree with you, that you’ve lost the courage of your convictions–that you don’t trust your own knowledge and common sense?
Have you listened to “experts” telling you what you CAN’T do for so long that you just follow their advice whether it makes sense or not?
Are you so afraid of making a mistake that you’ve abdicated your leadership role?
Are you so afraid of being accused of abuse that you are abusing yourself?

We’re tired of having hospitals give their services away for no reason. Therefore, we’ve decided to start a series of articles that tell you what you CAN do to bring in cash TODAY. We will debunk the myths that have been circulating for the last few years by giving you DOCUMENTATION to support your charging practices. And we will give you ideas to increase your bottom line with just a few “tweeks” of your bills.

We are very excited about this new series and we look forward to your questions and comments.

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