The Voice December 2000
Being a Bad-News Bearer
Keep these don'ts in mind in case you have to deliver bad news to your boss or those you manage:•Don't say a word until you rehearse. Prepare answers to questions you anticipate hearing. You might even role-play different scenarios of what you'll say with a neutral third party.
•Don't waste time on who's to blame. Just describe how the problem occurred and explain how to solve it. But don't dwell too long on any one option. List several. And invite advice and other input from those getting the bad news.
•Don't try to cushion the blow by bending the truth or speaking in generalities. Cushioning often leads to confusion but you might try to avoid the word "problem" altogether if you can. You might say, for example, "We're faced with a situation that didn't turn out the way we expected."
•Don't let emotion get the upper hand. Example: If you expect the boss to blow a gasket, be sure you're ready to respond calmly with the cold, hard facts.
•Don't give in to the temptation of delivering the bad news by memo, e-mail or voice mail. Reason: you lose the benefit of the visual messages you send when you're face to face.
Source: Morey Stettner, writing in Investor's Business Daily.
Message from the President
Happy Holidays!
I'm sure that most of you are in the midst of trying to balance work and everyday activities with holiday preparations and parties. That seems to get more difficult each passing year, but my wish for you all is that you are able to ENJOY this wonderful season with family and friends. (At least we won't have Y2K to contend with this year!)
I was delighted to see so many of you at our October Quarterly Workshop in Chula Vista. Our speakers were outstanding, and I have heard very positive comments from many of you about the information presented. Those of you in attendance will recall that there were some questions that remained unanswered by UGS that day, and Barb Hensley and Teena Wigley promised to continue researching for answers. I was in attendance at a Workgroup meeting with Wisconsin Hospital Association and UGS on November 1, 2000, at which some of those questions were answered. Please look for an article in this addition of VOICE for UGS's written responses.
I hope that you are all planning to attend the December 8th Quarterly Workshop at the Crowne Plaza in Madison. Jennifer Tarantino has prepared a terrific agenda that you won't want to miss.
Blessings of the season to all of you!
Deborah Gustafson
WMCA President
Board of Directors Meeting Highlites
The Board of Directors meeting for the Wisconsin Medical Credit Association was held October 12, 2000 at the Chula Vista in Wisconsin Dells.
The meeting was called to order by Deborah Gustafson at 5:15 p.m.
Financial Report
The financial reports for August 2000 and September 2000 were presented by Steve Baseley.Membership Report
Steve Baseley reported that we had two new members:1. Jefferson Dodge
2. Children's Hospital of WisconsinSurvey's
Deborah questioned the need for a membership survey; We all feel that the comments we get on the quarterly evaluation forms were sufficient for members concerns.Committee Reports
Annual Institute (2001)
Jennifer reported on the discussion from the Annual Institute Committee, which was held at 4:00 p.m. prior to this meeting. The format for 2001 will
be the same as this years with the Vendor Fair and Cocktails on Wednesday evening, Thursday seminar with Banquet and entertainment in the evening and 1/2 day seminar on Friday with golf in the afternoon.Quarterly Workshops
Possible topics for upcoming meetings: Up front cash collections, ABN's, William Sturm with legal issues, Badger Care, and APC's.Adjournment
At 6:45 p.m. a motion to adjourn was made by Jennifer Tarantino, seconded by Jackie Lippe, motion carried.Respectfully Submitted by
Julie Smith
WMCA Secretary
UGS Provides Answers Some Questions
Posed by Wisconsin ProvidersAt the November 1, 2000 meeting of the Wisconsin Hospital Association/Fiscal Intermediary Workgroup, UGS provided written responses to some questions posed by WMCA members at the October Quarterly Workshop, as well as some issues which were brought up by members of the WHA/UGS workgroup. UGS is still researching several other issues, and WMCA will provide its members with those responses as soon as they become available.
Following are the answers that UGS provided at the
November 1st meeting:
WISCONSIN HEALTH AND HOSPITAL ASSOCIATION
FISCAL INTERMEDIARY WORKGROUP MEETING NOVEMBER 1, 2000Questions and answers UGS
Medical Review
1. We have a patient that comes in monthly to have his trach tube changed. We are currently using CPT code 31500. Is there a more appropriate CPT code that we should be using?ANSWER: Use CPT code 31502.
Claims
1. Those hospitals who are still billing covered and non-covered on the same claim are saying that when they send these claims back to Medicare after correcting an RTP edit-the non-covered charges are being dropped from the system.ANSWER: When a provider bills a charge in non-covered either in total or in part it is identified by the system and reason code 31948 and 31947 are applied to the line item. Please provide an example of these non-covered charges being dropped from the system after correcting a rtp'd claim.
2. Immosuppressives were supposed to be billed as revenue code 636 with the appropriate J code starting 4/1/00. FISS has not been able to accommodate this and we have been given a work around by reporting the J code but using revenue code 250. Now with APC's these are all falling on to RTP with reason code W7027 "incidental services only". Is this because of the revenue code? If we could file these the way we are supposed to with revenue code 636 would this be an issue?
Answer: We have just learned that there may be a problem with W7027. We have changed the reason code to suspend rather than RTP so that we can investigate this issue. There should not be a problem with billing revenue code 250 for these services.
Medicare Application Support
1. Many hospitals voiced concerns with CPT4 codes that are listed as valid for APC but are not on Medicare's system and so are being denied-including 99212. Also issues where certain procedures in the surgical range (10000-69999) that are not considered valid with a clinic revenue code (510) when the directions given by Medicare were very clear to use the revenue code related to where the procedure is done.Answer: According to the OPPS manual, Chapter 2 section HCFA Common Procedure Coding System, it states (in bold) "It (the chart) is intended to be used as a guide by hospitals to assist them in reporting services rendered." Not all codes in the guide are Medicare covered or reimbursable. Also, in Program Memorandum A-00-36, under the section HCPCS/Revenue Code Chart, it states (redlined) "Hospitals that are currently utilizing different revenue/HCPCS reporting may continue to do so."
HCPCS 99212 is on our file with an effective date of 010193 billable for all revenue codes. If providers have examples of claims where 99212 is not being allowed, please share them with Provider Inquiry for further investigation.
2. Do you have any statistical information on provider claim submission error rates under outpatient PPS?
Answer: No.
3. What is the timetable to clean up some of the errors in logic within the system, which result in inaccurate payments?
Answer: HCFA determines the timetable for changes for FISS and we are not aware of their current plans for fixing specific edits.
Provider Relations
1. Is there future "post implementation" training sessions planned for Outpatient PPS?Answer: UGS, LLC will provide follow up OPPS training in the first quarter of next year (2001).
2. How is the new Home Health PPS system working so far and is the HIQH system up and running yet?
Answer: Currently, HIQH is not available. Our systems staff has been working with the Common Working File (CWF) daily on the new file. Access will be available very soon.
Home Health PPS- On Monday October 30, the Request for Anticipated Payment (RAPs) was released for payment. A contingency plan was put in place where special payment was made to providers during the PPS transition.
UGS has been communicating with the Fiscal Intermediary Standard System (FISS) our data base center as well as HCFA on a daily basis to assure a smooth transition into HHPPS.
3. Clarification is needed on the appropriate way to bill covered and non-covered services. There was significant differences in how each of the hospitals have interpreted the information we have received and also significant issues on how payment has been processed.
Answer: If there are non-covered services that are part of a procedure that is being performed on a patient, these services s/b listed on one claim under non-covered with the appropriate charges. Providers should not confuse non-covered services noted above with condition code 20 or 21 billing. Condition code 20 and 21 should be used for entire billings only.
Condition code 20 is used when the provider has determined that the bill is for a non-covered level of care but the beneficiary wants Medicare to make an independent determination. Condition code 21 is used when the provider realizes services are non-covered but needs a denial notice for a secondary payor.
4. Pass through payments-beyond just the general issues of how difficult it is to maintain it seems that the drug component has raised issues. One I know I already shared with you is that the codes themselves are at dosages that do not match with how the drug is administered. A second issue is concerning waste, there seemed to be consensus that if the patient was given 8 mg of something and the code for the drug is in units of 5 mg it would be appropriate to bill the patient for two units. The concern came when the drug comes in a vial of 10 mg but the patient is given 8 mg. The J code reads per 1 mg. Can the hospital bill for 10 mg. because the other 2 mg are wasted and cannot be used-or do they only bill for 8.
Answer: The concern above is addressed on HCFA's website under question #25. They should use the unit field to report multiples of the dosage identified in the code descriptor. Fractions of the dose specified in the code descriptor may be reported as 1 unit or additional unit as appropriate. That is, if the amount of the drug administered to a patient is less than the amount described by the HCPCS code, a hospital may bill for one unit. This requirement has not changed under OPPS.
Examples are below:
1) Adenosine 3-mg IV (J0150) is drawn from a 6-mg ampule and administered to convert a supraventricular arrhythmia. Report HCPCS code J0150 once, even though the entire 6mg ampule dose was not administered.
2) One gram of Immune globulin (J1561) is administered from two 500-mg vials. Report HCPCS code J1561 with the number two in the units field to indicate that two, 500mg dose vials were used.
5. We need clarification on how much bundling APCs require. There was a lot of disagreement by the group as to the appropriateness of billing supplies and / or drugs separately.
Answer: We are not sure what is meant by "clarification on how much bundling APCs require." Question #93 under OPPS Q & A's addresses this issue. Packaged services do not need HCPCS code, however they should be reported to capture the charges. Also question #96 addresses supplies. It says, "how do we package recovery, supplies, and anesthesia into the surgery HCPCS code? Or do we have to? Can we bill these services per line item and just be denied?" Answer: These services should be coded under each applicable appropriate code. We will not deny the lines. They will simply not receive a separate APC. Packaged items may affect reimbursement of outliers and TOPS.
6. There was a great deal of concern about the quality of the service that providers are receiving from provider support. They all have stories about leaving messages and never getting a response. Or leaving a detailed message about an issue and then getting a call back days later when they are not at their desk and the message left with them is "I'm returning your call please call back". They talk about getting wrong and conflicting answers. They give examples of talking to provider relations staff telling them to change CPT 4 Codes to one that will work.
Answer: Specific examples are welcomed so that appropriate research and follow-up can be completed. Internal training can then be done to ensure proper understanding and consistency. We strive to make call backs as quickly as possible. Typically, they are made within two working days. The provider has the option of holding to speak directly with a representative.
If they choose to leave a message a call back will be made. The representative will leave an answer to a specific question. If a general message were received the representative would not know what to check for the provider.
7. Now that we are moving along with APC's some additional training or review of a few issues for providers would be real helpful. Are there any plans for that based on what you are seeing on the claims?
Answer: This question was answered in number one above.
8. There is a general concern about the amount of claims that are being held up because of edits that are misfiring and inpatient only claims that will fall off the list sometime in October but will deny if sent in before.
Answer: If "inpatient only" claims that fall under the PM-A-00-45 were received by UGS, LLC prior to October 1, the claims rejected. Intermediaries were instructed by HCFA to reprocess those claims that rejected as "inpatient only" no later than November 30, 2000.
9. We have been noticing pathology charges being paid using the fee schedule methodology. In the past most of these were paid on a cost basis.
Has there been a major change in the way Medicare pays for these services?
Answer: Please provide a claim example.
10. Oxygen hourly rate - Should we use revenue code 410 or 270?
Answer: If the provider is inquiring about the "delivery of oxygen concentration: the appropriate revenue code for billing is 410 (respiratory therapy services). If the provider is inquiring about the reimbursement for the oxygen, the appropriate revenue code for billing is 270 (supplies).
This information can be found on HCFA's website in the Medicare Intermediary Manual 13-3, section 3101.10 and the Provider Reimbursement Manual 15-1, section 2124.
Provider Reimbursement
1. Transitional corridors - we are seeing some payments but when we ask UGS for the data used to make the calculations we are being told that they don't have the information.
Answer: On a monthly basis there is a job ran where the system calculates the transitional corridor payments. The TOPS payment amount is included on the remittance advice as a separate payment. We are recommending that providers handle these payments in a similar manner to pass through payments since there will be a final settlement on the cost report. The payment section in the OPPS training manual goes into detail as to the calculation of the payment.
2. Since Outpatient PPS began, how do payments look for the period from implementation to current versus the same time frame last year?
Answer: This information is not currently available.
3. What is the latest word on the transitional payments and loss corridor payments?
Answer: See answer # 1 above.
Achieve Peak Performance Levels
Peak performance levels occur when you use all your knowledge and skill to perform job tasks at the height of your ability. Everyone strives for peak performance. Many people attain peak performance levels once in a while, but cannot sustain them and soon drop back to previous levels. It is hard to keep performance up all the time. That is where attitude comes in.When your performance determines your pay, you want to do everything you can to improve it. Remember what happens when you think pleasant thoughts and act happy? You become smarter, better at solving problems and full of energy. It is important for you to realize how interconnected your attitudes and emotions are, and that maintaining a positive attitude leads to changes that encourage you to perform at your best. To reach this optimal performance level you must:
Have a realistic confidence in yourself. Believe in yourself and the skills and abilities you have or which are within your reach. (Attempting a task you do not have the qualifications to handle is foolish because it could lead to failure and undermine your positive attitude.) Saying "I know how to do this and I'm good at it," helps build confidence which interacts with other factors related to peak performance. Gaining skill and knowledge in your field through training also gives you the confidence to try another way if the first isn't successful and the ability to figure out why one method works and another doesn't. In addition, as part of this learning process, you build a repertoire of options based on actual experiences.
Be honestly committed to the idea that the challenge is worth meeting. When you really believe in the challenge facing you, a positive mental attitude is created that helps provide the emotional energy needed to meet it (remember the biochemical changes positive attitudes create internally.) If you don't believe in what you are doing, find a way to believe in it or find something else to do that you consider to be worthy of your time and energy.
Create positive attitudes internally, don't permit them to be formed by external events. This enables you to give consistent performances. Everyone experiences success once in a while, and there is no doubt these successes produce a positive attitude. But attitudes produced this way only last until the next challenge arrives, then they often fizzle out. When you depend on these hit-or-miss successes to provide a positive attitude, you are depending on uncontrollable external forces to determine your emotional climate.
Reprinted with permission of American Collectors Association, Inc. "Collector"
state of Wisconsin
Personally Speaking
Due to a remarkable lack of response to my plea for news, this column continues to be about our family.
First, the good news. Grandchild number 18 was presented to us by our daughter Kari and husband Tim. Patrick was born on September 11th, the first redhead among his 17 cousins.
The bad news is that our family dog of 15 years, Maggie, passed away. I never particularly liked the dog, but other family members did and sympathize with them in their loss.
Good Bye
And for those of you who are wondering if I will ever stop with his family stuff, the answer is "yes." In fact, as I searched for other ideas and news to share, I realized I don't have any. Therefore, this seems to be an appropriate time to bring this column to an end.
I thank those of you who have shared information and favorable comments over the past almost six years.
Best wishes for the continued success of the Voice!
Editors Note: I will miss receiving and reading Buds column. However, I also know the difficulty in always finding "news" or "copy" to complete a column. Thanks Bud for your input in the Voice over the years. If anyone has any thoughts to share, please let Bud know.
Crash Course on Conflict
Effective teams see diversity as a strength, and members are supported to articulate ideas, surface information, and discuss their feelings in a positive manner. Teams use different methods to resolve their conflicts. Which does your team rely upon?
•Denial. Team members simply do not recognize or acknowledge the dissension. They go about their business, without the blink of an eye.
•Smoothing over. Some members believe that talking about a problem or conflict only makes it worse.
•Power. One team member may control the others' behavior. When conflicts arise, members know to turn to that person for the final word.
•Compromise. It might look good on the outside but it's unsatisfying in the end. "Splitting the difference" won't lead to satisfaction - it only minimizes dissatisfaction.
•Problem solving. The best, yet most difficult, method. Establish a climate for civilized disagreement by:
•Maintaining an objective, analytical approach to differences.
•Being flexible and open to all points of view.
•Diffusing overt hostility.
Team Players and Teamwork, Glenn M. Parker. Jossey-Bass, 350 Sansome St., San Francisco, CA 94104
Turn Self Pay Into Cash Cow
Start now to maximize your most profitable financial class
By David ZimmermanHere's one of the industry's best kept secrets - self pay is now the most profitable financial class in the entire hospital payer mix. With Medicare, HMO's and Medicaid and other payors taking cuts in payment driving hospitals net revenue to nearly one-half of gross, self-pay alone now emerges as the most profitable financial class.
With hospital cost shifting to offset all of the discount payors, self-pay now stands alone as the financial category that brings the biggest bank for the buck. It can and should be a cash cow for hospitals, but it's not. Too many hospitals treat self-pay as a "throw-away."
That's unfortunate because patients now make up a greater portion of hospital's net revenue than at any time since the early 1960's. Our studies indicate as much as 20 percent of the hospital's net revenue comes directly from the patient. Fifteen years ago, self-pay made up less than 10 percent of net revenue. Increasing deductibles and contractual allowances have changed the percent of patient pay to net revenue dramatically in recent years.
According to the 4th quarter report from HARA, nearly 15 percent of the nation's hospitals total accounts receivable outstanding is in patient pay. It ranks right behind Medicare (25 percent) and HMO (25 percent). Unfortunately, more than 30 percent of all the hospital's patient-pay is written off to bad debt.
While the nation's hospitals are watching their operating profit margins hover around the low three percent mark, they also are witnessing bad debt figures that have become equally staggering and concerning.
It is estimated, based on our projections, hospitals could write off $30 billion to bad debt in 2000. Add charity write-off to that number, and you're looking at an uncollectible total that could reach nearly 40 billion. It was less than $3 billion back in 1980. Figures from a Zimmerman & Associates national survey put the hospital bad debt average nationally at approximately 4 percent. In our opinion, the bad debt is about twice as high as it should be. Our experience shows most hospitals pay little attention to collecting self-pay. Efforts to collect self-pay accounts most often are sporadic and ineffective. As a result, millions are written off each year that should be cash and profit.
In short, when self-pay builds up in receivables; not turning into cash quickly and bad debt write offs climb into the 4 percent range, the profit potential evaporates. What should be an extremely profitable payer winds up just another discounted financial class. Our contention is you should see self-pay as having great profit potential and do everything you can to maximize payment.
With that in mind, here are some strategy suggestions to consider to turn your self-pay into a regular "cash cow."
Approach to Maximize Self-Pay Collections Once you have determined in your mind self-pay is a financial class worth your effort, the three main ingredients to maximize self-pay collection and profit would be:
1. developing self-pay strategy
2. obtaining and training staff
3. designing process that works1. Developing Self-Pay Strategy
• The most important aspect of this strategy is your determination to improve self-pay.
• Design a one-sentence policy that states, "patient amount due at time of service."
• Develop separate strategy for collection of inpatient self-pay from outpatient and emergency room accounts.Inpatient Strategy: identify patients' portion of bill prior to discharge and take all the steps necessary to collect.
- Do not carry these accounts on installments; instead sell patients on using credit cards, or set up bank financing to get payment now.
- Design discharge process so that every patient who owes a sizeable amount (over $200) must see a financial counselor or pay cashier at discharge. Outpatient/Emergency Room Strategy: Basically identify and collect patients portion if possible.
-Always explain their balance due when they receive bill.
2. Obtaining Staff and Training
• Determine what you need in number of financial counselors or collectors (or whatever you want to call them) and sell your boss on staffing properly to collect this most profitable financial class.• When you have the staff spend a good amount of time in training them on collection from patients consistent with favorable patient relations. It can derail the entire process and put you in hot water with your boss.
3. Designing The Process
Prorate: Identify Patient's Portion Compounding this problem of self-pay is the fact that many hospitals do not utilize their patient accounting system properly and therefore cannot even identify the inpatient's portion of the total bill until the insurance pays. They can't make financial arrangements with the patient when he leaves the hospital as an inpatient. Moreover, they can't even bill the patient for his portion until the insurance pays - anywhere from 30 to 90 days after discharge.In addition, those hospital aging of accounts receivable computer reports do not reflect true dollars outstanding in any of the financial classes. They are constantly looking at bad numbers. It's been around forever, but some 50 percent of the nations's hospitals still don't use proration. Proration is simply verifying insurance benefits, and then estimating how much the inpatient owes. Then, inform the inpatient of what they owe as early as possible.
Therefore, one of the most important aspects of the process of maximizing cash from self-pay is to prorate and identify the inpatient portion of the bill.
The simple truth is that you can't afford not to prorate, and you have to make it work, with or without the computer. Most hospitals don't attempt to use their computer to prorate insurance coverage and patient portion because they feel it's too complicated to establish and maintain.
The psychological advantage you have in collections at preadmission and inpatient discharge almost totally deteriorates a month after discharge. You have complete advantage in making almost any kind of request before service is rendered - a little less at the day of admission and while in-house.
Here is a brief snapshot of the proper "self-pay collection flow" within the five control points.
1. Initial Contact - Patient scheduled, record necessary information.
2. Pre-Admission - Obtain critical financial information of the patient.
3. Insurance Verification - Verify the insurance of the patient ahead of the actual admission.
4. Calculating the Patient's Part of the Bill - Most insurance policies have deductibles and exclusions. Calculate the portion of the patient's estimated bill which will not be covered by insurance according to the estimated length of stay, changes to be incurred, etc. This is where proration plays an important role.
5. Discussing Financial Arrangements with the Patient - Talk to the patient before the day of admission. Make sure the patient understands and agrees to financial arrangements. Have a staff of qualified financial counselors to fill this role
6. Admission - When the patient arrives, review all information. Refer the patient or family to the Patient Account Representative if necessary.
7. During the Hospital Stay - Monitor the patient's stay to see that the original financial arrangements are adequate. Prior to the end of the patient's stay, write financial discharge instructions for the cashier.
8. Discharge - With an estimate of the patient's bill and the discharge instructions in hand, the cashier collects any money which the patient is expected to pay. The cashier gives a receipt to the patient and credits the account.
9. Follow-up with the Patient - If a payment is overdue from the patient, followup to collect the account.
10. Collections of Accounts - when you have completed the follow-up procedures and payment is still not forthcoming, recommend accounts for write-off to collection agency. Forward to the Supervisor for review. The Supervisor reviews all accounts and coordinates collection activities with an outside collection agency.This article, written by David Zimmerman, chairman of Zimmerman Communications and Zimmerman & Associates, is reprinted from the Hospital Receivables Management newsletter published by Zimmerman Communication. If you would like to receive a FREE copy of this newsletter, contact Christy Zimmerman, 888-577-7445 or e-mail your request to christy@zimm-assoc.com or fax 414-425-2035.
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