The Voice is a technical magazine for health care accounts receivable managers and is the official publication for the Wisconsin Medical Credit Association. It is published bi-monthly since 1964.
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Vol. 37 No. 1
THE VOICE January 2001
The VOICE is a technical magazine for health care accounts receivable
managers and is the official publication for the Wisconsin Medical Credit
Association. It is published bi-monthly since 1964.
WMCA President's MessageHappy New Year to all of our Members and Friends!
Fortunately, WMCA has two outstanding workshops planned for the next two months to provide a break from your winter doldrums. On February 9 200 1, we will welcome the WAHAM organization a our joint workshop at the Paper Valley Inn in Appleton. On March 9, 200 1, we will join HFMA for another joint workshop at the Hotel Mead in Wisconsin Rapids. We always look forward to getting together with our friends from these two organizations, and outstanding agendas have been planned for both events.
January, February, and March are, for many of us, very LONG months. The thrill of the first good snowstorm is over, and we are now left to survive three months of cold, slush, and rapidly increasing heating costs.
Many of us on the Board of Directors reflect frequently about the support that WMCA receives from its Associate Members, and I want to take this opportunity ere
to recognize their contributions and ex ere appreciation. Their
sponsorships of some of our workshops, their presence as guests at our Board
Meetings, and their expertise in their various industries are invaluable to this
organization. Many of our Associate Members have been with WMCA for (literally)
decades, and they all deserve our recognition
Looking forward to seeing you all soon!
Deborah Gustafson
President
VOICE ARTICLES - Material for the VOICE should be sent to:
Editor, VOICE, % Reedsburg Area Medical Center, 2000 N. Dewey Ave., Reedsburg, WI 53959.
Subscription rates $50.00 a yew. Subscribers outside the U.S. and Canada add $1.00 a yew for postage. Individual copies $10.00. All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording or any information storage and retrieval system, without permission in writing from the editor. Address: % WMCA VOICE, Reedsburg Area Medical Center, 2000 N. Dewey Ave., Reedsburg, WI 53959,608-524-6487.
Board of Directors Meeting Highlites
The Board of Directors meeting for the Wisconsin Medical Credit Association was held December 7,2000 at the Crowne Plaza in Madison, Wisconsin.
Call to Order
The meeting was called to order by Deborah Gustafson at 5:00 p.m.
Approval of Minutes
A motion was made by Lynn Johnson to approve the October 2000 Minutes with the addition of recognizing Chuck Worgull as a visitor being present at our last meeting. Jennifer Tarrentino seconded, motion carried.
Membership Report
No new members to report.New Business
Quarterly Meeting Fees
Cindy Lichter motioned to raise meeting fees to members $95.00 and non-members $125.00 (currently $80.00 and $ 100.00). Mary Debilzen seconded motion. Motion carried, effective February 2001.
2000-2001 Meeting Sites
Jim Kluge reported on possible future meeting sites:
October 12, 2001 - Ramada Inn, Wausau
December 2001 - Crowne Plaza, Madison
February 8, 2002 - American Club, Sheboygan
Committee Reports
Quarterly Workshops
Jennifer reported on some possible subjects for future meetings; Lori Zindahl from Outsource, Registration an Business Office, Medicare Second Payer (MSP). Jennifer will also continue to try to get Region 5 for the March join meeting with HFMA. Other suggestions for future meet ings included round table discussions on APC billing is sues specific to vendors.
Nomination Committee
Steve Marg and Julie Smith's terms will be up next year
Other Business
It was suggested that we allow vendors to sponsor a break fast, break, or lunch at the meetings. As a group we felt that we would not want to solicit for the donations but would be willing to accept and announce such a sponsorship. Lyn Johnson motioned we accept these donations, Jim Klug seconded, motion was carried.
Adjournment
Jackie Lippe made a motion to adjourn the meeting, Cindy Lichter seconded the motion, motion carried.
Respectfully submitted by
Julie Smith, WMCA Secretary
Take Action on Collection Rejection
In the collection seminars he teaches, ACA Certified Instructor Ron Brown shares his philosophy about countering rejection. He talks about certain words that seem to provoke negative reactions from most of us. One word we don't like to hear is "no. " Brown's challenge to his students is this:
Whether it's the word "no" you hear repeatedly, the frustration of another promise to pay that hasn't materialized, or the dead air that rings in your ears following the "click," experienced collectors know that rejection is part of the collection process. Of course, that knowledge doesn't make rejection any easier to take. What will make it easier though, is to understand that "no" is not the same as "never" and rejection does not equate with failure.
"Consider hearing the word 'no' from a different perspective. If eight out of ten consumers tell you 'no' or otherwise reject your attempts to collect, then each time you face rejection you move closer to those two consumers who will pay their accounts. Collection becomes a numbers game that is much easier to play and win," Brown said.
But why does is it always happen to me?
Collectors are not the only professionals who encounter daily rejection. Virtually any professional who isn't satisfied with "as is" and who knows that in order to succeed, 11 stagnant" cannot be a part of their vocabulary will hear the word "no" - and hear it often. History is full of people who have faced rejection, adversity and doubt before finally finding success. Face it - you will hear "no".
Correction of your rejection reaction Just as professional collectors learn tools of the trade, such as the eight steps of a collection call, the FDCPA and successful negotiation techniques, collectors can also gain tools to help them shrug off rejection and move on to the next call. Try these tips to adjust your rejection reactions:
Remain optimistic. Remind yourself that with each rejection you're one step closer to a "yes. " Think of all the famous people - as well as all the average people you know-who have endured rejection on their paths to success. Picture yourself as a winner.
Continue to improve. Analyze each call and list improvements you could make or techniques you could try. Use one of your ideas on the next call. If you master just one new technique each day or each week, you'll establish a pattern of growth and improvement that will boos your confidence and your performance.
•Don't expect perfection. You're going to win some an you're going to lose some. Go into each call prepared an positive, but be realistic. Every call may not result in "yes.
•Get to the root of the objection. Don't take the consumer' first " no " as the final answer. Try to uncover the reason b asking "why?" Satisfy that objection and work toward solution.
•Give yourself a pep talk. Remind yourself that you are good collector and you won't allow rejection to stand i your way. Convince yourself the next call will have bette results.
•Use humor. Laughing takes the sting out of rejection Make humor a part of your daily routine. Read the com ics. Listen to comedy on the way to work. Post some joke or cartoons in your work area and read them when you need a lift.
Professional debt collectors find many creative ways to overcome rejection and move on to the next call. Each rejection you experience brings you closer to hearing those magic words: "Yes, I will pay the account." Rejection may never become easy to take, but it should not stand in your way of success.
Paula Schwartz is an instructional designer in ACA's Education Department.
Reprinted with permission of American Collectors Association, Inc. "Collector" December 2000
Information Systems
Overall, BEST performers have a wide array of reports to manage their receivables. ALL BEST performers are able to accurately track medical record status of a claim prior to billing, while only about half of the WORST performers have this ability.
Results have shown 100 percent of satisfaction among the BEST performers with electronic remittance, patient accounting and automated collection follow-up software. WORST performers were far less satisfied.
Zimmerman Communications is a multi-media company that provides a variety of publications and services to healthcare providers. The company produces newsletters, books, audio prorams, video training programs, packaged in house training prorams, white papers, and special reports.
Zimmerman Communications, affiliated with Zimmerman & Associates, also provides specialized training in a variety of topics for healthcare employees. For a copy of our catalog of publications, programs and services write to P.O. Box 405, Hales Comers, Wl 53130, call 888-577-7445 or fax 414-425-2035.
WMCA MEETING
CALENDAR 2000 - 2001
February 9,2001 - WAHAM Joint Workshop
Paper Valley Inn - Appleton
March 9,2001 - Quarterly Workshop
The Hotel Mead - Wisconsin Rapids
May 11, 2001 - Quarterly Workshop
Stoney Creek Inn - Wausau
August 8, 9, & 10, 2001 - Annual Conference
The Pioneer Inn - Oshkosh
Benefits of Adding Interest to Bad Debt Accounts
By Kenlyn Gretz, Americollect, Inc.
Has your curcent collection agency offered to add 5% interest on the amounts that you list for colleciton?There are many benefits to adding the 5% interest per annum. The requirements are simple: The healthcare provider must authorize the agency in writing to add the 5% to all accounts listed from that point forward. The agency interest authorization should be approved by the state. The agency should notify the patient they are going to be charged the interest The agency must cancel the interest if the account is disputed or if they cannot notify the patient that they are charging the interest (mail returns). To start the interest rolling should be as simple as signing the form.
The Benefits
· The consumer has an incentive to pay your account more quickly.
· The consumer will pay your account over a non-interest bearing account
· Your Healthcare Facility will offset the collection expense by adding the interest.
· Your collection agency can use the interest as a negotiating too] on your account to collect it more quickly.
- The agency calculates and maintains the interest balance.
If you currently are charging interest with your current agency, give the agency the discretion to cancel or discount the interest without calling to get your permission on every single account. If you are questioning whether or not you want to deal with the interest posting because your billing software may not be "interest friendly, "you may choose to use the additional \income to decrease the collection expense or allow your agency to keep 100% of the interest. If you allow the agency to keep 100% of the interest or a greater percentage than the principle of the account, it must be in writing and the agency must collect the interest last. You may want to negotiate the commission rate down a percent or two if they are going to be allowed to keep 100% of the interest.
The biggest benefitis that you can use it as a tool to collect the account before you list the account with your collection agency. Add this to your statement: "Currently, Wisconsin's Best Hospital has not been adding interest to your account. In the event that you do not pay the balance, we will be listing this account with our collection agency. The collection agency is allowed to add 5% interest per annum to the outstanding balance. Please pay the balance or call for arrangements to avoid this additional expense. "
If you would like a copy of the statute that allows you to give permission to add the interest of if you would like to see our interest authorization please call me at 1-800-838-0100 or kenlyn@americollect.com or toll free fax 1-877- 536-5339.
Results prove the best performers focus more on collecting high-dollar inpatient accounts with extremely tight control on all collection activity than worst performers. Best per formers also utilize all aspects of automation to accelerate collection from receivables, more than the worst-performing hospitals.
Best Performing Hospitals Focus on High Dollar Inpatient Accounts to Accelerate Collections
Best practices revealed in national survey
Hospitals with the best days revenue and bad debt have revealed the practices that make them winners in a national survey conducted by Zimmerman Communications.
Those hospitals that qualified as "best performers" averaged 51 gross days revenue outstanding and 2.4 percent of gross revenue in bad debt. These numbers are considerably better than the 1999 national averages of 70 GDRO and 4.6 percent bad debt. Those hospitals at the opposite end of the spectrum averaged GDRO of 80 and 6.4 percent bad debt, which is far above the national average.
Here's a breakdown of revenue cycle management practices, comparing the best performers to those hospitals with highest days and bad debt.
Pre-registration
BEST performers are consistently pre-registering scheduled patients and focusing on third-party payor information. Specifically, their pre-registration procedures include collection of full demographics, insurance eligibility and verification of benefits, as well as all required pre-authorization and pre-certification requirements.
The BEST performers also reported that they consistently pre-register more than 50 percent of scheduled patients. Only one-third of the WORST performers have achieved this level of compliance.
In-house Collections
BEST performers focus on inpatient collections. Over 80 percent verify insurance while patients are still in-house, and over one-third request that inpatients stop at the cashier's office prior to discharge.
Billing Practices
They also submit over 80 percent of their claims electronically, and generate Medicare secondary bills automatically. Only about one-fourth of the WORST performers have achieved this level of billing automation.
BEST performers drop a bill about two days faster than the WORST performers for both inpatients and outpatients.
Over 80 percent of the BEST performers assign work based on payor, but only about half segregate billing and followup activity.
Collection Practices
BEST performers consistently track collector performance by both dollars collected and calls made. WORST performers reportedly track dollars collected, but only about 15 percent track activity (calls made).
Self-Pay and Agency Activity
Over two-thirds of the BEST performers contact higher balance self-pay accounts by phone, whereas less than half of WORST performers make calls. BEST performers rely on their automated dunning cycles for outpatient claims, and over a third get a statement to patients within 20 days of service.
BEST performers' self-pay collection cycles are very tight. Roughly two-thirds route outpatient self-pay to agencies within 120 days of service, and almost half route inpatient claims within that time frame. WORST performers consistently allow self-pay to age over 180 days.
Over one-third of the BEST performers are actively using credit cards to collect co-pays. Only one in 10 of the WORST performers use credit cards.
Interestingly, about half of the BEST performers have three or more agencies competing for business. WORST performers use fewer agencies.
Average Bill Hold Days BEST Performers WORST Performers
Inpatient 4.4 6.0
Outpatient 5.0 6.7
Outpatient Ancillary 5.0 7.7
Emergency Department 5.0 6.5
Reining in Rambling Speakers
To end conversations when you don't have time to listen to idle chatter:
Avoid asking open-ended questions. Instead, set limits to the chatterbox's responses by asking questions that call for specific information or a simple "yes' or "no". Bad question: "What's going on with the report you're working on?" Good question: "How do the third-quarter results compare with those of last year?"
- Ask "concluding" questions. Examples: "In a nutshell, what's the significance of that?" "To wrap, up, what's the next step?"
Repeat your questions. Some babblers won't answer your questions directly. They'll hedge or drift off the topic. Just calmly repeat your questions until the message gets through that you expect an answer. Important: Don't rephrase or pose another question.
Use the same wording each time you ask the question.
- Use visual aids. Ask chatterers to draw a diagram or refer to a chart or graph to make a point. Draw a line on a piece of paper and ask, "where are you on this line?" Payoff. People talkless when they're trying to express their ideas on paper.
Source: Investor's Business Daily.
AEGIS GROUP
23875 Novi Road - Novi, Michigan 48375-3243
(248) 344-1450 - Fax (248) 347-2231
http://aegis-group.com - e-mail:resume@aegis-group.com
On behalf of our client, Providence Hospital and Medical Centers (PHMC), Southfield, Michigan, we extend an invitation to qualified patient financial services professionals to interview for the position of Manager of Patient Financial Services. This position offers a unique and challenging opportunity to direct, coordinate and plan the activities of the business offices: insurance verification, receivables, the activities of patient accounting and collections to ensure efficient and proper gathering of demographic, insurance and patient financial information. Reporting to the Director of Patient Financial Services, this position is responsible to:
· Oversee coordination and supervision of the procedures and practices of the department information systems are in compliance with the standards established by the corporation and conforming to those of outside regulatory agencies.
· Participate and assist in the development of internal controls to ensure proper UB92 billing, follow-up and collection, cash posting, clerical, insurance verification and customer service procedures of accounts receivable for the corporation.
· Oversee coordination and supervision of the third party systems (HART, HCSC, AC CESS) for securing benefits, eligibility and authorization for open accounts receivable.
· Respond to complex patient complaints, inquiries and initiate problem-solving action.
· Stay current with reimbursement, billing procedures and requirements of major third party payers.
· Maintain good working relationships with internal departments (i.e., medical records, information services, clinical departments, etc.) to develop maximum benefit to the organization. · Demonstrate leadership skills with the mission and values of the organization to select, train, develop, empower, coach, delegate work assignments, schedule, evaluate performance, assess competency and administer corrective action.
· Assists in assuring the appropriate use of all of the department information systems, i.e. mainframe, personal computer software applications, voice mail, e-mail, facsimile machines, pagers, etc.
· Develop, submit and administer capital operations and manpower budgets.
· Support the hospital's commitment to quality improvement by leading the staff to support this mission.
· Assists in developing, submitting and administering departmental policies and procedures.
· Direct human resources and all other activities within the patient financial services area (i.e., recruitment of personnel, coordinates ongoing educational programs, reviews/ approves policies and procedures, fosters professional development and affiliation, participates in continuous quality improvement activities, etc.)
Sponsoring Institution
PHMC consists of a fully accredited, community-based 462-bed acute care, teaching hospital located in Southfield, Michigan. More than twenty freestanding ambulatory care facilities are located throughout the northwest suburbs of Detroit, providing primary and
specialty care services. PHMC is part of the Ascension Health System; a recent co sponsorship Catholic Health care ministry between the Daughters of Charity and Sisters of St. Joseph Health Systems. This new co-sponsorship, as part of the largest not-for-profit
hospital system in the country that includes more than 60 hospitals nationwide, services to strengthen the presence of Catholic health care not only in Michigan but also through out the country
Qualifications
Requirements for this position include a BA degree, with 5-7 years experience in the management of Patient Financial Services, preferably in a multi-site organization. Strong interpersonal skills, a proven track record of success, oral and written skills to work and
communicate with all levels of management within the corporation, and an understand ing of capabilities and usage of both PC and mainframe information systems are required.
Qualified and interested individuals are asked to please forward their curriculum vitae in confidence to Linda Gadde, Search Consultant, at the above address or email: Igadde@aegis-group.com
Another example is found in PMAB-00-121, dated 12/5/00. This PM addressed the first calendar year 2001 quarterly update (release) for the Medicare system. HCFA stated that this update was originally scheduled for January 1, 2001 but was delayed and targeted for implementation on January 8, 2001 to allow the intermediaries more time to test the release. Again, at the end of this PM, was an instruction to the intermediaries that stated, "If you receive calls from providers, inform them that the implementation date simply refers to the date when Medicare systems will be ready to process these claims. Because of the payment floor, an implementation date of january 8,2001 should not result in any payment delays. Intermediaries do not need to initiate special notices to inform providers about the delay. " Although no adverse impact is anticipated by HCFA, we know that historically, "Murphy's Law" is alive and well in the Medicare Program. Consequently, you should regularly check HCFA's website for notices that involve system updates. Being aware of scheduled system updates and related issues can help you prepare for the unanticipated problems that tend to arise from time to time.
These are just a few issues that emphasize the need to be vigilant on obtaining current HCFA's instructions and to incorporate them as necessary into your procedures. I would caution you on scrutinizing any "interpretations" you receive from any source (yes, even me). Maintain a file for correspondence (written and verbal) of Medicare issues. Each department should have access to Medicare resources, e.g., manuals, bulletins, HCFA/intermediary websites, or at least an established procedure to access this information through an assigned staff member. Updates to your policies, procedures, and system data (charge masters) should be controlled with limited access by authorized staff. This is important now and will be even more critical with the approach of HIPAA criteria.With hospitals coming under more scrutiny than ever before, it is in your best interest to review your processes, records, and data files thoroughly and on a regular, scheduled basis. Corporate Integrity Agreements (CIA), mandated for some providers found to be noncompliant with Medicare Program requirements, include a provision that require the providers to have an audit performed by an outside source (at least annually, but sometimes more often) for a specified period of time may, e.g. 2 to 5 years. We may see this provision becoming more predominant in the near future as HCFA and the OIG expect providers to maintain verifiable proof that compliance with all Medicare Program criteria are being met. Consequently, I would encourage you to have regular reviews conducted by your utilization/quality staff and by outside resources (qualified consultants) of your data/charge entry processes, information flow through your internal systems, chargemaster modifications, processed claim records, etc. so that potential sources of inaccurate reporting can be identified and corrected to prevent revenue losses while ensuring compliance with Medicare criteria.
How Soon to Act on an Account
Receiving payment at the time services are provided is every creditor's preference. But in many cases, especially when providing medical services, this isn't always feasible. Nevertheless, you can increase your account receivables by incorporating prompt billings and open communication into your normal procedures.
Speed and Communication are Key to Successful Collection
By Wendy Kasten, Collection Operations Manager, Credit Bureau Data, Inc. Secretary Treasurer, Wisconsin Collectors Association
Whenever possible, discuss your terms of payment with the customer at the time of providing services. Update all customer information including home address, home telephone number, employer's name and telephone number, spouse's name, spouse's employment and necessary insurance information, if applicable. If payments are needed, establish a payment plan up front and submit a billing statement following the date services are provided.
The longer an account remains unpaid, the tougher it is to collect. Taking preventive measures when first extending credit, along with prompt billings and open communication, can save you endless costs, time, and effort. The sooner you act on an account, the better your results.
Post - APC Issues
By John R. Bartell
John R. Bartell, R.N., BSN, is a Senior Manager for Certus Corporation, a knowledge-based consulting and information technology company that currently serves more than 1500 of the country's most prominent health systems. Formerly the Customer Service Manager for United Government Services, LLC., Mr. Bartell now assists hospitals on Medicare compliance issues, including accuracy of charge masters, APC implementation analysis and related billing requirements. Mr. Bartell is a member of the Wisconsin Medical Credit Association and the Wisconsin Health and Hospital Association. You can contact John at (414) 258-4432, fax (303) 874-4181, Email - jbartell@certuscorp.com.After intense preparations for HCFA's Ambulatory Payment Classifications (APCs) and subsequent implementations in your organizations, I hope that all of you had the opportunity to take some time off during the holidays to 11 recover" from these activities. Having spent most of the past spring, summer, and fall helping hospitals here and across the country with pre and post-APC projects, I can fully appreciate the challenges and frustrations encountered with this new payment methodology. During this time, I have also discovered several issues that are problematic for many hospitals. This article is intended to identify these issues for you and provide recommendations for resolving them.
#1 "Packaged" Services versus "Reportable" Services
Many facilities are under the impression that HCFA's definition of "packaged" services under APCs means that these services should not be reported on the claims. This is incorrect! The Federal Register of April 7, 2000, states, in part, "...We will package into the APC payment rate for a given procedure or service any costs incurred to furnish the following items and services: Use of an operating suite, procedure room or treatment room; use of the recovery room or area; use of an observation bed; anesthesia: medical and surgical supplies and equipment; surgical dressings The key part of this statement is "We will package into the APC payment rate...", meaning that the payment for these "packaged" items are included in the APC payment rate. This instruction does not imply nor explicitly prohibit reporting these items and services. An example of this requirement is observation services. Even though the payment for these services is "packaged" under APCs, you are still required to report them on your claims under Revenue Code 762 with HCPCS 99218 - 99220.
Whether or not an item or service is separately reimbursed under APCs should not be a determining factor for deciding to report them on the claim. In fact, you should still report all items and services (except those identified in prior HCFA instructions for bundled services) with the appropriate revenue and CPT/HCPCS codes. Failure to properly report items and services rendered may result in potential investigations for claim reporting errors and may impact your cost-to-charge ratios (CCR) for cost report settlements and future payment rate calculations. You should continue to report items and services just as you did prior to APCs For example, drugs under Revenue Codes 250,255,258,636 (w/ HCPCS); nonroutine supplies under 271, 272, (or 621/622 if appropriate), 274 (w/HCPCs), 275, 276, 278; anesthesia under 370, 371 and 372; and so on.
#2 Routine versus Nonroutine
This issue has been a thorn in all of our sides for many years. I find it interesting that the response from most Medicare intermediaries on this issue is that there are no guidelines to assist hospitals in determining what Medicare considers routine and nonroutine. The following guidelines are excerpts taken from the Medicare Provider Reimbursement Manual that provide guidance on HCFA's intent for "routine" and "nonroutine":
Section 2202.6
Routine Services.-Inpatient routine services in a hospital or skilled nursing facility generally are those services included by the provider in a daily service charge-sometimes referred to as the "room and board" charge. Routine services are composed of two broad components: (1) general routine services, and (2) special care units (SCU's) including coronary care units (CCU's) and intensive care units (ICU's). Included in routine services are the regular room, dietary and nursing services, minor medical and surgical supplies, medical social services, psychiatric social services, and the use of certain equipment and facilities for which a separate charge is not customarily made.
Section 2202.8
Ancillary Services.-Ancillary services in a hospital or SNF include laboratory, radiology, drugs, delivery room (including maternity labor room), operating room (including post-anesthesia and post-operative recovery rooms), and therapy services (physical, speech, occupational). Ancillary services may also include other special items and services for which charges are customarily made in addition to a routine service charge.
Section 2203
The cost of those items and services specifically classified as routine in S2202.6 are always considered routine service costs, and the costs of those specifically classified as ancillary in S2202.8 are always considered ancillary service costs for purposes of Medicare reimbursement. A separate ancillary charge for a particular item or service other than those listed as ancillary in S2202.8 is not recognized and the cost of the item or service is not included in an ancillary cost center, where the common or established practice of providers of the same class (hospital or SNF) in the same State is to include the item or service in the routine service charge.
Section 2203.3
Rental of Equipment.-Rental of equipment by a provider from an outside vendor does not in itself give rise to an ancillary charge. Where a provider rents equipment, the reasonable rental charge is included in allowable costs of the appropriate department and is subject to apportionment in the same way as other costs of the same department.
Section 1412.1(c)
No allowance may be added to the guidelines if the equipment is owned by the provider and is leased to the outside supplier because these costs are already included in the appropriate cost center.
Note that Section 2206.6 refers to inpatient services. Although the Medicare manuals do not have a corresponding section that is specific to "outpatient" services, this same rationale should be applied to outpatient services. Many intermediaries 'Provider Audit and Medical Review departments consider this section as a basis for determining routine/nonroutine for both inpatient and outpatient. For example, the "daily room charge" for inpatients is considered parallel to the "procedure" or "visit" charge for outpatients.
To summarize the rules stated above, outpatient routine items and services are those that the hospital uses for all or a majority of their outpatients and the costs are included in the procedures or visits. For example, the cost of gloves, gowns, masks, drapes, sponges, standard sutures, syringes, needles, IV sets, reusable instruments and equipment (e.g., monitors, suction and supplies and machines, etc.) should be included in the cost of the procedures performed because they are used "routinely" for most OR ambulatory procedures. These items cannot be reported separately on the claim. Examples of nonroutine supplies may include special needles, e.g. spinal needles, sterile trays for specific procedures, e.g. bone marrow extraction, specialty instruments, additional/special sterile gauze or medicated gauze, etc. These may be reported separately on the claim, usually under Revenue Code 272. Prosthetics/Orthotics, pacemakers, intraocular lenses and other implants should always be reported under the appropriate revenue code.
#3 HCFA Instructions
A commonly overlooked area that can have significant negative financial consequences for some hospitals is that of revised HCFA instructions. Everyone, including HCFA and its contractors, are burdened with continual updates to claim processing issues. Sometimes, these updates result in prior claims being adjudicated improperly or rejected because of incorrectly its in the intermediary's system or the Common Working File (CWF). Other times, updates to the Medicare claims processing system may result in unanticipated delays in payments. Many years ago (when I had much less gray hair than now), HCFA would instruct its contractors to retroactively look for these prior problem claims and perform "mass adjustments. " Although this was a very efficient method for the providers, it was very labor-intensive for the Medicare contractors' staff.
Well my friends, the good ol' days are gone. The responsibility of identifying these issues now rests with you. Even though all of HCFA's instructions may not be issued in the intermediary's bulletins, it is clear that HCFA expects hospitals to check their website as well as the intermediary's website to obtain current instructions. Two (2) recent examples of this issue can be found in Program Memorandums (PM) A-00-8 7 and AB -00- 12 1. PM A-00 -87, dated 11 / 2 1 /00, addressed the issue of 2 oral chemotherapy (cancer) drugs Methotrexate (HCPCS code J86 10) and Cyclophosphamide (HCPCS code J8530) that may also be used in immurrosuppressive therapy for patients who have had organ transplants. Apparently, CWF was not updated to accept claims containing these drugs for immunosuppressive therapy with no cancer diagnosis for dates of service January 1, 2000 and later. Consequently, these claims did not process correctly. HCFA has subsequently corrected CWF and the intermediaries have been instructed to begin releasing the affected claims for payment on April 1, 200 1. However, please note the following instruction to the intermediaries stated at the end of this PM, "Do not search for previously adjudicated claims. However, reopen and reprocess claims brought to your attention. Inform your providers of these instructions through your regularly scheduled newsletter. "
Obviously, the onus of finding these previously adjudicated claims and notifying the intermediary rests with the hospitals. For some facilities, these prior claims may result in significant additional revenues. If you believe that your facility may have had claims with these drugs rejected or improperly adjudicated, you will need to supply the intermediary with, at a minimum, the patients 'HICNs, names and dates of service. You should contact them directly for specific additional information they need in order to reprocess these claims.
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