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General
Cash Crunch
By Peter Cohen
President, P.C. Planning & Benefits, Inc.
“Money out the window” is probably the biggest single nightmare a provider’s CFO faces. There is a lot that contributes to the problem yet, there are creative solutions that can be used to alleviate problems caused by reduced cash flow. But, knowing where it is and mining it are separate issues.
First of all, hospitals can lose money by simply using the wrong code on the Medicare Federal Claim Form. What the hospitals need is a system that can electronically edit the Medicare Claim Form before it goes to the fiscal intermediary for reimbursement. Since Medicare is the single largest payer to hospitals and the challenge is obtaining full reimbursement for services. Hospitals need to adapt traditional billing practices to meet the requirements for compliance with the Medicare Correct Coding Initiative.
Hospitals throughout Massachusetts have implemented an internet-based automated compliance checking for its patient billing process. This makes it easier to verify the accuracy of the claims for compliance and medical necessity before they are submitted for payment.
As the only company offering an ASP solution to administer its programs, Claimtrust’s system is uniquely suited to help its provider customers deal with Medicare’s constantly changing coding regulations. Claimtrust continuously updates its central database containing all of the Medicare rules and regulations necessary to audit Medicare outpatient claims. In turn, providers using the system can access this expert coding engine in order to review inaccurate claims coding via a private and secure extranet network. The federal and state government’s compliance laws directed at Medicare fraud and abuse have not only dictated that providers implement a comprehensive coding and compliance program, but also impose civil and criminal liability for those found to be in noncompliance.
Claimtrust currently provides two integrated products to deliver an advanced correct coding and compliance solution for providers, Medessary and Comply.Net.
Medessary is a medical necessity pre-screening system that assists the providers’ staff during the scheduling and registration process. Medessary is Medicare Fiscal Intermediary specific and contains all the CPT-4/HCPC-II to ICD-9 relationships. The system allows coding staff to check for diagnosis description codes and also shows the user which CPT codes are correct for the diagnosis. In addition, Medessary is able to identify which treatment Medicare covers by their CPT codes. If the treatments are not covered, Medessary generates an Advanced Beneficiary Notice (ABN). By signing the ABN, the patient acknowledges his or her understanding that the proc4edure is not covered and, therefore, must be paid for privately. At the same time, the provider fulfills its legal obligation of advance notification.
Comply.Net, a state-of-the-art web-based automated coding and compliance system, delivers over 100 million editing permutations per claim at all three edit levels—compared with the typical 20,000 to 30,000 first level edits of most other claims editing systems. This makes this the most complete and up-to-date claims editor on the market. Among the coding risk areas Comply.Net checks for APC/OCE’s; mutually exclusive code pairs; outdated codes; standards of care; time-based codes; geriatric, pediatric and neonatal-specific codes; bundling/unbundling; and medical necessity issues. Comply.Net’s detailed reports evaluate claims based on nationally recognized clinical criteria, as well as specific plan rules. The system’s on-demand reports significantly reduce line item and full claim denials.
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