2015 PCC Optimization Workshop

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Presentation transcript:

2015 PCC Optimization Workshop Keys to Success in the Billing World Presented by: Dottie J. Hauman, Revenue Cycle Consultant hauman@hwco.com Kelly J. Sorensen, Sr. Revenue Cycle Consultant sorensen@hwco.com

No Pay Claims…. Are you complying? Are you having issues? Are you experiencing pitfalls? Let’s talk about it…. Copyright © 2015 HW&Co. All Rights Reserved. 2

How-To Generate No Pay Claims in PCC Go to A/R Configuration under Set-up and check the following boxes for automatic generation. Copyright © 2015 HW&Co. All Rights Reserved. 3

How to Set Up in PCC Copyright © 2015 HW&Co. All Rights Reserved. 4

No Pay Sample Claim Copyright © 2015 HW&Co. All Rights Reserved. 5

No Pay claims-How would you start this process?? A good place to START would be in review of your current month’s census, during part A billing. Look for resident’s that were cut from skilled care and remained in your facility. PCC should generate these claims for you correctly. If you need to play catch-up, you are permitted to lump multiple months/years into one claim and submit to Medicare for processing. Copyright © 2015 HW&Co. All Rights Reserved. 6

No Pay Claims – General Notes A successfully processed No Pay claim will return with an “R” and code: 39934 (this is good !) Most common rejections of No Pay claims C7010-Overlaps Hospice election 15202-Number of Units Issue 38020-Overlaps with IP Claim 38119-Out of sequence 38117-Out of sequence Are you seeing other rejections that you would like to discuss? Copyright © 2015 HW&Co. All Rights Reserved. 7

Benefits Exhaust Claims How long must I submit Benefits Exhaust Claims to Medicare? How will I know when to stop submitting Exhaust Claims? PCC generates Exhaust claims along with current Medicare A claims. Any issues with Exhaust Claims processing correctly? How are Exhaust Claims different than No Pay Claims? . References: CGS Quick Reference: www.cgsmedicare.com/parta/pubs/news/2013/0613/22579.html MLN Matters 4292 (10/24/12): www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM4292.pdf Copyright © 2015 HW&Co. All Rights Reserved. 8

Benefits Exhaust Claim Example Copyright © 2015 HW&Co. All Rights Reserved. 9

HMO Information Only Claims Are these really necessary? What is the best way to handle this task? Is affixing Condition Code 04 my only coding requirement to comply on this task? Only required for Part A Claims! Don’t forget to submit Info Only claims for the skilled MyCare stays. Make sure you have the Medicare HIC # Copyright © 2015 HW&Co. All Rights Reserved. 10

How to Set-up in PCC Don’t forget that you need a checkmark in the Insurance link screen to signify that a information only claim should be generated. Copyright © 2015 HW&Co. All Rights Reserved. 11

HMO Information Claim Only Example 2015 PCC Opimization Workshop Copyright © 2015 HW&Co. All Rights Reserved. 12

Medicare Secondary Payer (MSP) Claims What is an MSP, anyway? When do I send these claims? Will Medicare really pay? CMS Guidelines and Resources for Medicare Secondary Payer: http://www.cgsmedicare.com/hhh/education/materials/MSPResources.html CMS Billing & Adjustment Guide: (awesome tool) https://www.cgsmedicare.com/hhh/education/materials/pdf/MSP_Billing.pdf Medicare MSP Questionnaire: http://www.cms.gov/Medicare/Coordination-of-Benefits-and-Recovery/ProviderServices/Downloads/CMS-Questionnaire.pdf Claim Adjustment Reason Codes: http://www.wpc-edi.com/reference/ MSP Copyright © 2015 HW&Co. All Rights Reserved. 13

The process is fairly simple, and carries BIG benefits. When: October 1, 2015 If you are an Ohio Medicaid Trading Partner, you should make plans to send some test claims to ensure that any issues are resolved before 10/1/2015. The process is fairly simple, and carries BIG benefits. The Ohio Department of Medicaid has an ICD-10 webpage at: http://medicaid.ohio.gov/PROVIDERS/Billing/ICD10.aspx. ICD-10 information such as Provider Q&A, trading partner testing, free coding practice for providers, OhioMHAS coding resources, and other documents and resources have been posted there. Copyright © 2015 HW&Co. All Rights Reserved. 14

ICD-10 : What to do now... In PCC, the facility can begin to add new Diagnosis sheets containing ICD-10, for the October 1, 2015 starting date. No need to wait! On the PCC home page, there are training opportunities available. Copyright © 2015 HW&Co. All Rights Reserved. 15

Vaccination Billing Set-up Vaccine Payers for most efficient claim processing. Pneumococcal Vaccine Influenza Vaccine No More Roster Billing Quick turnaround of payment Reduce the pain Copyright © 2015 HW&Co. All Rights Reserved. 16

Vaccination Charge Code Setup Copyright © 2015 HW&Co. All Rights Reserved. 17

Create your New Payer and Add Your Template Copyright © 2015 HW&Co. All Rights Reserved. 18

Helpful Websites Insurance claim status/eligibility: www.Availity.com CGS Web Portal: www.cgsmedicare.com/mycgs/index.html NPI Look-up Portal: https://nppes.cms.hhs.gov/NPPES/Welcome.do MyCare Aetna Portal: https://medicaid.aetna.com MyCare Buckeye Portal: www.buckeyehealthplan.com/for-providers/providers MyCare CareSource Portal: https://providerportal.caresource.com MyCare Molina Portal: https://provider.molinahealthcare.com MyCare UHC Portal: https: //unitedhealthcareonline.com Ohio MITS Portal: https://www.ohmits.com/prosecure/authtam/login?HOSTNAME=ohmits.com Copyright © 2015 HW&Co. All Rights Reserved. 19

Copyright © 2015 HW&Co. All Rights Reserved.

Thank You! Dottie J. Hauman Kelly J. Sorensen Revenue Cycle Consultant Sr. Revenue Cycle Consultant 23240 Chagrin Blvd., Suite 700 Cleveland, OH 44122 P. 216.831.1200 F. 216.831.1842 460 Polaris Parkway, Suite 300 Westerville, OH 43082 P. 614.794.8710 F. 614.794.8712 8800 Tyler Blvd. Mentor, OH 44060 P: 440.951.1777 F: 440.951.2143 www.hwco.com 877.FOR.HWCO This educational offering has been reviewed by the National Continuing Education Review Service (NCERS) of the National Association of Long Term Care Administrator Boards (NAB) and approved for 8.75 clock hours and 5.50 participant hours. Program Approval Number: 3072015-8.75-14852-in. For comments please email cecomments@habweb.org. Copyright © 2015 HW&Co. All Rights Reserved.