Harmony Healthcare Blog

Harmony named in INC Magazine's fastest-growing Private Companies

Harmony has been named by INC Magazine as one of the top 5000 fastest-growing private companies in America.  Past companies include Intuit, Zappos, Under Armour, Microsoft, Jamba Juice, Timberland, Visa, Clif Bar, Patagonia, Oracle, etc.

Harmony has become the leader across the nation for LTC news, training, Medicare and Medicaid Reimbursement and Compliance.  Hiring the most talented staff in the industry has led to rapid growth and diverse clientele from small SNF's to large public traded companies increasing each facilities revenue from $100k-$5M+ annually.

Find out why everyone is is using Harmony

 

 

Harmony is proud to announce Susan Lounsbury has joined our team

Susan is a Billing/Financial Consultant with more than 10 years of experience in Physician/Outpatient Medical Office Billing/Collections, and Operations, and 11 years of experience in Skilled Nursing/Long Term Care Billing/Reimbursement, Collections, and Financial Operations. Susan also has 18 years of experience in Healthcare Information Technology Consulting, Education/Training, and Support.

Our service will provide full Business Office Evaluation/Audit to include the review and evaluation of all Policies and Procedures for Billing/Collections, and all Business Operations, in Long Term Care/Skilled Nursing. Susan can also provide staffing Evaluation, Education/Training, and Software Evaluation and Education/Training, as well. We can offer facilities a full assessment of all Financial/Billing Operations, and will make recommendations which will enhance productivity, ensure Billing Compliance, improve Collections, and increase Revenue.

To get more information on this service click here
 

Harmony Is proud to announce its new Medicare Billing Service

Available Services with our Financial Consultanting Service:

Evaluation of Business Office Staff

Evaluation of Bus Office Policies and Procedures

Consultation and Training on recommended changes

Audit of Bills and Billing Procedures

Audit of Patient Trust Procedures

Training of Bus Office Staff/Billers:

Billing:  All Billing/Compliance and HIPPA rags: UB-04, use of 837

The Fund Check/Phone Call checking Payor/Financial Sources

Billing questions/required information upon Admission

Medicare Billing

All Medicare billing requirements/deadlines, etc

Understanding the Medicare UB04

Review of Medicare UB-04 vs. RUGs scores, etc

No Pay bills, Billing BANS, Demand Bills

Medicaid (State Assistance) Billing

Eligibility/Certification and re-Certification

Rate codes, Diagnosis coding, etc

Commercial Payor Billing

Understanding Commercial requirements/Avoiding pitfalls & delays in Reimbursement

Private Pay Billing-

Use of Early Statements

Dealing with Families

Dealing with Attorneys/sending accounts to Collection

Collections:

Evaluation Productivity and Collection Practices

Consultation on recommended changes/additions to Collections practices

Understanding/interpreting and working with the 835 -Electronic Remittance

Collections/Reimbursement Status Meetings, etc

How to handle Billing rejections/requests for additional Financial or Clinical info

Interpretation of the 835S and EOB codes/notices

Collections calls with Medicare/State Payors

Collections/Follow-up Calls with Commercial Payors

Collections/Follow-up Calls for Private Pay

Reimbursement/Collections Management

Evaluation/Consultation AR % per Bed

Evaluation/Consultation- Revenue Testing

Training/Consultation on Management Reporting

How to manage and Motivate your Staff

Training/Consultation- Use of FI computer systems

Evaluation/Training on Business Office billing software

Evaluation/Training on MDS and/or Rehab billing software

Cross Training with Clinical Departments (i.e. MDS/Nursing, & Rehab)

MDS-Importance of timely submissions w// respect to Billing

Rehab-Therapy Caps, non coverage

Required Coding/Modifiers

Training of Billers-Re: review of Medicare UB-04 vs. RUGs scores

Consultation:  Mock Survey/Quality Assurance

Resulting Efficiencies

More competent/confident and productive Bus office staff

Increased charge capture

Increased accuracy in Billing

Decrease in Billing Rejections

Increased productivity in Collections

Increases in Revenue %

Greater cross knowledge Clinical and Financial Departments/Staff

More competent/confident and productive MDS staff Find out more about our Billing Services today

Update CMS Part B Rate Cut

CMS 2011 Proposed Physician Fee Schedule Rule Contains Proposed Pay Cuts for Outpatient Therapy Services

The Centers for Medicare & Medicaid Services (CMS) recently issued the proposed physician fee schedule rule that would implement key provisions of the Patient Protection and Affordable Care Act of 2010 and update payment rates under the physician fee schedule for services furnished on or after January 1, 2011 (CY 2011), notes the American Physical Therapy Association (APTA).

If this rule becomes effective, physicians, physical therapists, and other health care professionals would receive a 6.1% cut to their Medicare payments starting January 1, 2011 in addition to the 21.3% reduction that has been delayed several times already this year due to the flawed Sustainable Growth Rate (SGR) formula, according to APTA. This reduction was replaced with a 2.2% update until November 30 when the President signed the Preservation of Access to Care for Medicare Beneficiaries and Pension Relief Act of 2010 on June 25.

CMS also proposes a multiple procedure payment reduction policy (MPPR) that would result in significant reductions in payment for outpatient therapy services. The agency proposes to make full payment for the therapy service or unit with the highest practice expense value and payment of 50% of the practice expense component for the second and subsequent procedures or units of the service furnished during the same day for the same patient.

The proposed multiple procedure payment reduction policy would apply to the services paid under the physician fee schedule (PFS) that are furnished in the office setting and those services paid at the PFS rates that are furnished by outpatient hospitals, home health agencies (Part B), skilled nursing facilities (Part B), comprehensive rehabilitation facilities, and other entities that are paid by Medicare for outpatient therapy services.

It is estimated that if the multiple procedure payment reduction policy were implemented, payment for outpatient therapy services would be reduced by approximately 13% in addition to the projected SGR payment cut for CY 2011, says the APTA.

The APTA says CMS's proposal to apply the multiple procedure payment reduction to outpatient therapy services is based on flawed presumptions, and the organization will work to halt implementation of the proposed MPPR policy and the SGR payment reductions.

Learn how to offset these cuts

Return to Skilled Benefits within the Medicare 30 Day Window

Return to Skilled Benefits within the Medicare 30 Day Window:  Harmony reviews their clients process of re-accessing benefits within the Medicare 30 day window.  There appears to be a misconception within many facilities regarding returning the patient to skilled care within this window.  This window is not in place to allow the provider to "change their mind and rescind the original notice of non-coverage."  This practice is inappropriate and may yield financial loss for the provider.  Consider the following scenario:

• Ø The beneficiary is issued a notice of non-coverage as deemed no longer requiring a skilled level of care.
• Ø The completed MDS and daily documentation supports stability while the MDS yields a Medicare lower 18 RUG level.
• Ø Once off skilled coverage, daily documentation is no longer required, thus leaving gaps in supporting that skilled care was provided on a daily basis.
• Ø The patient has a period of exacerbation or acute illness entitling access to remaining Medicare Part A days within the benefit period.
• Ø Merely retracting the notice of non-coverage and continuing on days as though the beneficiary had never come off of coverage continues reimbursement in the Medicare lower 18 rate or reimbursement.
• Ø The Medicare lower 18 rate does not reflect or reimburse the facility for the patient's increased utilization of nursing staff resources, medications, costly labs, x-rays or skilled rehabilitation.
• Ø It is required and appropriate to:
• Return to Medicare Part A benefits with the new day 1 identified the day the team determined the patient was at a skilled level of care. Keep track of previously used days within the benefit period.
• Begin the Medicare Calendar with a return assessment within regulatory time frames.
• Complete the MDS to obtain a more accurate Medicare RUG level reflecting the current level of resource utilization and actual clinical status of the beneficiary.
• § Example 1: Patient at IA1 when issued a notice of non-coverage. Returns to Medicare Part A within 30 day window following an ER visit in which the patient presents with fever and received IV medications, IV fluids for hydration and oxygen for pneumonia.
• §Completing the return assessment in this scenario yields the SE3 vs. the previously attained IA1.
• § The financial impact is as follows: SE3 vs. IA1 = $399.09 - $164.10 = $234.99 x 14 days = $3,289.86 (potential starting the PPS schedule of assessments)
• § Example 2: Patient at PA1 when issued a notice of non-coverage. Returns to Part A within 30 day window for exacerbation of COPD. The patient is placed on oxygen and nebulizer therapy and requires daily skilled assessments.
• § Completing the return assessment in this scenario yields CA1 or SSA (with RT captured).
• § The financial impact is as follows: CA1vs. PA1 = $254.83 - $167.05 = $87.78 x 14 days = $1,228.92 (potential starting the PPS schedule of assessments)
• § The financial impact of RT is as follows: SSA vs. CA1 = $303.55 - $254.83 = $48.72 x 14 days = $682.08 (potential with RT tracking)

The Medicare 30 day window is in place to allow a beneficiary access to remaining skilled days after a period of non-skilled level without requiring another 3 day qualifying hospital stay. In order to re-access benefits the new condition must be related to a condition or problem the resident received care for during the 3-day hospital stay or during the SNF stay following the 3-day hospital stay. Please refer to the Medicare Benefit Policy Manual, Chapter 8, Section 20.1:

 

• Ø To be covered, the extended care services must have been for the treatment of a condition for which the beneficiary was receiving inpatient hospital services, including services of an emergency hospital, or a condition, which arose while in the SNF, or for treatment of a condition for which the beneficiary was previously hospitalized.

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Medicare 30 Day Window

Medicare 30 Day Window: 

Return to Skilled Benefits within the Medicare 30 Day Window:  Harmony reviews the process of re-accessing benefits within the Medicare 30 day window.  The Medicare 30 day window is in place to allow a beneficiary access to remaining skilled days after a period of non-skilled level without requiring another 3 day qualifying hospital stay. In order to re-access benefits the new condition must be related to a condition or problem the resident received care for during the 3 day hospital stay or during the SNF stay following the 3 day hospital stay. Please refer to the Medicare Benefit Policy Manual, Chapter 8, Section 20.1:

• Ø To be covered, the extended care services must have been for the treatment of a condition for which the beneficiary was receiving inpatient hospital services, including services of an emergency hospital, or a condition, which arose while in the SNF, or for treatment of a condition for which the beneficiary was previously hospitalized.
• Ø The patient has a period of exacerbation or acute illness entitling access to remaining Part A days within the benefit period.
• Ø Complete the MDS to obtain a more accurate RUG level reflecting the current level of resource utilization and actual clinical status of the beneficiary.

Example 1:  Patient at IBI when issued a notice of non-coverage.  Returns to Part A within 30 day window for exacerbation of CHF.  The patient is placed on oxygen and nebulizer therapy and requires daily skilled assessments. 

• § Completing the return assessment in this scenario yields CC1 or SSC (with RT or skin captured).
• § The financial impact is as follows: CC1vs. MMQ = $253.58 - $185.00 = $68.58 x 14 days = $960.12 (potential starting the PPS schedule of assessments)
• § The financial impact of RT/Skin is as follows: SSC vs. CC1 = $279.40 - $253.58 = $25.82 x 14 days = $361,48 (potential with RT tracking)

The process of reviewing patients in the 30 day would benefit from further review.  Harmony suggests additional education with the unit staff to assist in the identification of conditions that would require review by the team to determine if a return to skilled coverage is warranted.  

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MDS Accuracy

MDS Accuracy:  It will be important for the facility to ensure that the therapy minutes recorded on the MDS are for the dates covered by the Assessment Reference Date on the MDS. This will require close communication between the therapy department and the MDS Coordinator to be sure that the dates selected are verified.

The Department of Health and Human Services' Office of Inspector General (OIG) released a new report titled "A Review of Nursing Facility Resource Utilization Groups" in February 2006. The report found that 26% of RUGs III on claims submitted by skilled nursing facilities (SNFs) were different from the ones generated based on evidence in the rest of the medical record.

Key Findings:

• Based on a comparison of the MDS and evidence in the rest of the medical record, 26% of RUGs III on claims submitted by SNFs were different from the ones generated based on the medical record (71 of the 272 claims).
• Ø 22% of the claims in the sample had a RUG III with a higher associated payment rate than the one generated based on evidence in the medical record, representing potential overpayments.
• Ø 4% of the claims in the sample had a RUG III with a lower associated payment rate than the one generated based on evidence in the medical record, representing potential underpayments.
• Ø These differences represented a net $542 million in potential Medicare overpayments in 2002.
• Only 11 MDS items accounted for 54% of the assessments that had a RUG III different from the RUG group generated based on the medical record. These 11 items had one or more of the following characteristics:
• Ø A look-back period (i.e., observation over time),
• Ø Multiple assessors (i.e., assessment by two or more staff), or
• Ø Calculations (i.e., person completing MDS has to calculate number of days, number of treatments or number of minutes for four of these items)
• The 4 of the 11 MDS items most frequently inconsistent with the rest of the medical record are related to recording of therapy days and minutes:

•1.      P1bbb - Occupational Therapy, Minutes

•2.      P1bcb - Physical Therapy, Minutes

•3.      P1bba - Occupational Therapy, Days

•4.      P1bca - Physical Therapy, Days

OIG Recommendations:  The OIG recommended that CMS take the following steps to ensure the MDS is accurately completed and assigns each resident to the correct RUG III:

1. Continue the type of analysis conducted by the DAVE project; and
2. More carefully examine the 11 MDS items found to be most often inconsistent with the rest of the medical record.

CMS has concurred with the OIG recommendations and has taken, or agreed to take, the following actions:

• DAVE2:  Will expand on the DAVE project to assess the accuracy and reliability of national CMS data through focused onsite reviews of the MDS assessment.
• Education:  CMS plans to incorporate the findings of this report into educational efforts to improve the accuracy of the MDS and in developing a web-based training program for the Resident Assessment Instrument (RAI) Manual.
• Continue to have Fiscal Intermediaries and Program Safeguard Contractors assess MDS information through the routine medical review process.
• Calculate quality measures/indicators reflective of care delivered in your facility.

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Combining Medicare Assessements

Combining Medicare Assessments:  Questions at exit arose regarding the appropriate combination of Medicare required assessments. The following information is provided for the staff on this topic:

Under the SNF PPS, there are situations when two assessments may be needed to fulfill Medicare requirements. Rather than requiring such duplication of effort, providers have the ability to combine assessments (see Chapter 2 for more detailed information). For example, if an OMRA is required during the assessment window for a Medicare 30-Day assessment (i.e., days 21-34), the SNF is required to perform only one assessment. There is no way to code two Medicare Reasons for Assessment.  The combined OMRA/30-Day Medicare assessment is coded on the MDS as an OMRA and identified on the Part A billing by using a HIPPS modifier code of "28". The combined assessment can then be used when billing the Medicare claim. Similarly, if an assessment is a combined 30-Day and an SCSA, the SCSA is coded as the Primary Reason for Assessment.  The 30-Day is shown as the Medicare Reason for Assessment, and the HIPPS modifier code used for billing is "32".

30.2 - Special Billing Requirements Where a Single OMRA, SCSA, or SCPA ARD is Set Within the Window of a Medicare-Required Assessment Rev. 1, 10-01-03)  PM-A-01-56, PM-A-01-124 (CR-1655):  For a full explanation of the assessments required that support billing see §2837 of the Medicare Provider Reimbursement Manual.  Where an OMRA, SCSA, or SCPA is the only assessment that occurs during the assessment window of a Medicare - required assessment, the SNF must use the HIPPS rate code generated from this assessment in place of the HIPPS code generated from the Medicare-required assessment to bill Medicare.  The HIPPS rate code generated from the OMRA, SCSA, or SCPA that "replaces" the Medicare-required assessment must be billed beginning with the ARD found on the replacement assessment only if the ARD was not set on a grace day.  Where the ARD for the replacement assessment is set on a grace day, the HIPPS rate code generated from the replacement assessment must be billed beginning on the day the payment rate would have changed for the Medicare-required assessment that was replaced.

• Ø EXAMPLE 1: The ARD of an OMRA is set on day 22 of the Part A covered stay. The OMRA is the only assessment performed within the assessment window for the 30-day Medicare-required assessment; therefore, the OMRA replaces the Medicare-required 30-day assessment. The HIPPS rate code derived from the OMRA is billed beginning on day 22 and may continue for up to the number of days in between the ARD on the replacement assessment until the next assessment, assuming the receipt of medically necessary covered services.

• Ø EXAMPLE 2: The ARD of an OMRA is set for day 32 of the covered Part A stay. The OMRA is the only assessment performed within the assessment window for the 30-day Medicare-required assessment; therefore, the OMRA replaces the Medicare-required 30-day assessment. The HIPPS rate code derived from the OMRA is billed beginning on day 31, since the ARD for the OMRA replacing the 30-day Medicare-required assessment was set on a grace day.

30.3 - Special Billing Requirements Where There are Multiple Assessments (i.e., OMRA, SCSA, or SCPA) Within the Window of a Medicare-Required Assessment (Rev. 1, 10-01-03):  While not a common occurrence, there may be situations in which multiple assessments are performed within one Medicare-required assessment window, including the grace days.  In these instances, the OMRA, SCSA, or SCPA that occurs first must replace the Medicare-required assessment.  Any other assessment performed in the assessment window, including the grace days must be billed as a stand-alone assessment and cannot replace the Medicare-required assessment.  The SNF is required to bill the HIPPS rate code derived from the replacement assessment beginning with the Assessment Reference Date on the assessment.  The HIPPS rate code derived from the replacement assessment may continue until the Assessment Reference Date on the next assessment, assuming the receipt of medically necessary covered services.

• Ø EXAMPLE 1: A SNF sets the Assessment Reference Date for a SCSA on day 22 of the covered stay. The beneficiary is "grouped" into a rehabilitation RUG. Therapy ends on day 24, and the SNF performs an OMRA with an Assessment Reference Date of day 33. The SNF must use the SCSA with the Assessment Reference Date of day 22 of the covered stay to replace the Medicare-required assessment. The OMRA with an ARD that fell on day 33 of the stay cannot replace the Medicare-required assessment since it has already been replaced by the SCSA. Payment to the SNF will change on day 22 (the ARD of the SCSA), since the SCSA must be used to replace the Medicare-required assessment, and then again on day 33 of the covered stay, based on the OMRA. The payment associated with the RUG code derived from the OMRA may continue for up to the number of days in between the Assessment Referecen Date on the OMRA and the next assessment, assuming the receipt of medically necessary covered services.

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ICD 9 Coding

ICD 9 CODING Q: Where can I find a list of commonly used PT ICD-9 codes that have been deleted as of January 1? A: ICD 9 code changes take effect October 1 of each year. CMS publishes these changes on its Website at www.cms.hhs.gov/ICD9ProviderDiagnosticCodes/07_summarytables.asp Keep in mind that several Medicare contractors’ local coverage decisions (LCD), as well as Aetna’s therapy policies, contain a list of ICD 9 CM codes that support medical necessity for all outpatient therapy services. To be considered for reimbursement, at least one of the ICD 9 CM codes contained in the LCD or Aetna policy must be present on the claim form to support the medical necessity of all services provided during that billing period. If the claim submitted does not contain an ICD 9 CM code that is in the LCD or Aetna policy, the entire claim will be rejected or denied. Several other Medicare contractors’ LCDs link ICD 9 CM codes to CPT codes. For each CPT code to be considered for reimbursement, at least one of the ICD 9CM codes listed under each CPT code in the LCD must be presented on the claim form. If an individual CPT code submitted on a claim form for payment does not have an ICD 9 CM code on the claim form to support its medical necessity, the individual line item will be rejected or denied. Contact your fiscal intermediary’s provider inquiry department to obtain clarification about why it considers this specific ICD 9 code to be nonpayable for skilled therapy services.

Source: Outpatient Rehab Reimbursement and Regulations, Oct. 2007

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Medicare Audits-Assessments in the Lower 18

Medicare Audits-Assessments in the "Lower 18":  Harmony notes that the facilities that have patient days that feal into the "lower 18" RUG categories are at a risk of a Medicare Audit.  This sparks an interesting discussion about Medicare eligibility and the facilities responsibility to provide an entitled service.

It is important to emphasize that a patient's Medicare eligibility is not determined by what RUG group the patient falls into.  If a patient meets eligibility criteria, he/she is to remain "skilled" until that treatment regimen is essentially stabilized and the patient no longer demonstrates a need for skilled services.

It is also true that patients who fall into the "lower 18" are at an increased risk for detailed audit for Medicare eligibility.  As such, patients who are in these lower nursing care categories must have their skilled eligibility clearly documented to avoid payment denials.  Harmony would suggest that if a skilled patient is anticipated to fall into the "lower 18" groups that an in-house audit is preformed by the management staff.  The patients' skilled needs should be clearly outlined and communicated to the staff to ensure that supportive documentation is present in the medical record on a daily basis.  If no skilled needs are noted at that in-house review, and there is evidence that the patient's treatment regimen is essentially stabilized, the patient should be put on notice for denial of benefit.

Learn more on how to prevent denials or get help with you current Audit