Data Quality: UBO & TPOCS Tom Sadauskas, TMA UBO Deputy PM Jerry Robinson, RITPO

OUTLINE Uniform Business Office (UBO) MTF Revenue Cycle Data Quality Characteristics Data Quality and How it Affects Each Phase of the Revenue Cycle UBO Success Factors Third Party Outpatient Collection System (TPOCS) Resources

UNIFORM BUSINESS OFFICE Third Party Collections (TPC) Medical Services Account (MSA) Medical Affirmative Claims (MAC)

UBO Organization Chart Dr. William Winkenwerder ASD (Health Affairs) Director, TMA Secretary of the Army, Navy, Air Force Command – Control - Execution Policy & Guidance Army, Navy, Air Force Chief of Staff MG (sel) Elder Granger Deputy Director, TMA Army, Navy Air Force Surgeons General Mr. John Kokulis CFO, TMA Mr. David Fisher Director, Management Control & Financial Studies Army MEDCOM BUMED AFMS UBO Work Group Members: *TMA UBO Program Manager *Voting members *Army UBO Program Manager *Navy UBO Program Manager *Air Force UBO Program Manager Service IM/IT, Legal reps and subject matter experts (SME) TMA/IM Manage the Business rep Clinical Information Technology Office (CITPO) Resource Information Technology Office (RITPO) Unified Biostatistical Utility (UBU) MEPRS Management Improvement Group (MMIG) TriService Information Management Program Office (TIMPO) UBO Advisory Work Group Lt Col Jeanne Yoder TMA UBO Program Manager Service UBO Program Managers (Army, Navy, Air Force) Intermediate Commands HSO/MAJCOM (Army, Navy, Air Force) Service IM/IT, legal reps & subject matter experts (SME) TMA/IM, Unified Biostatistical Utility (UBU), Clinical Information Technology Program Office (CITPO), Resources Information Technology Program Office (RITPO), MEPRS Management Improvement Group (MMIG) MTF UBO

Direct Care TPCP FY02 – FY05 - Billed & Collected ($ Millions) Service *FY02 Billed -- Collected *FY03 *FY04 *FY05 Outpatient Army $45.1 $27.4 $37.6 $18.5 $40.8 $21.9 $48.6 $24.7 Navy $23.7 $15.2 $19.0 $10.8 $21.6 $14.6 $24.2 $13.4 Air Force $52.8 $26.8 $49.5 $18.3 $67.2 $30.6 $70.2 $26.1 Total $121.6 $69.4 $106.1 $47.6 $129.6 $67.1 $143.0 $64.2 Inpatient $61.4 $25.7 $44.6 $20.9 $42.8 $22.5 $39.3 $21.4 $34.9 $13.8 $19.5 $9.3 $19.9 $10.0 $20.1 $9.4 $37.8 $15.5 $33.9 $13.6 $26.9 $14.3 $26.7 $11.3 $134.1 $55.0 $98.0 $43.8 $89.6 $46.8 $86.1 $42.1 Billed value is the cumulative billed value for three quarters. Collected value is the cumulative collected value for three quarters; however, included in that amount is collections for services billed from current and prior years. *NOTE: Collected includes dollars for healthcare services provided in previous FYs and may exceed current FY billings. Different billing methodologies in place for outpatient billing. FY02 used an all-inclusive/flat rate based upon MEPRS clinic; FY03 involved a transition to Outpatient Itemized Billing (OIB). Data source: MTF DD 2570 as reported to the TMA UBO Metrics Reporting System

Direct Care TPCP Draft 1st Qtr - Billed & Collected ($ Millions) Service *FY03 Billed -- Collected *FY04 *FY05 *FY06 Outpatient Army $2.0 $6.1 $3.1 $4.8 $4.8 $5.6 $7.5 $6.4 Navy $0.5 $3.3 $1.8 $3.2 $2.9 $3.4 $3.0 $3.4 Air Force $3.5 $4.4 $8.6 $5.9 $8.3 $3.7 $13.6 $7.6 Total $6.0 $13.8 $13.5 $13.9 $16.0 $12.7 $24.1 $17.4 Inpatient $6.2 $6.1 $7.0 $4.7 $6.8 $5.9 $7.8 $4.4 $4.1 $2.2 $2.1 $1.9 $3.8 $2.1 $3.9 $2.0 $7.6 $2.7 $5.4 $3.7 $5.4 $1.8 $3.8 $2.8 $17.9 $11.0 $14.5 $10.3 $16.0 $9.8 $15.5 $9.2 Billed value is the cumulative billed value for three quarters. Collected value is the cumulative collected value for three quarters; however, included in that amount is collections for services billed from current and prior years. *NOTE: Collected includes dollars for healthcare services provided in previous FYs and may exceed current FY billings. FY03 numbers reflect a transition to Outpatient Itemized Billing (OIB) and away from the previous all-inclusive/flat rate based on MEPRS clinic. Data source: MTF DD 2570 as reported to the TMA UBO Metrics Reporting System

DATA QUALITY CHARACTERISTICS Accurate Complete Concise Cost-effective Relevant / Timely / Up-To-Date Presentation Consistent The move to OIB has made data quality very important. The following are a list of data quality characteristics and we will talk about these characteristics as you are introduced to the MTF revenue cycle. We will show you where these characteristics come into play. Data is the catalyst that initiates action and is the element around which applications and systems revolve, such as DEERS, CHCS/ADM, and TPOCS. Accurate: correct and valid data Complete: comprehensive; all information to make informed decision Cost-Effective: does value gained equal or outweigh costs of providing the services Relevant / Timely / Up-to-date: assist/hinder decision making, does data appear at appropriate time for decision making, does data reflect current knowledge Presentation: presented so data is clearly understood Consistent: standardized procedures Collection of OHI Consistent follow-up of denials All of these characteristics must be present at EACH phase of the revenue cycle!

UBO SYSTEMS CHCS I DEERS TPOCS EAS IV MDR M-2 Legend PDTS ADM WAM TPC Claims MAC Claims MSA Claims Inpatient Claims EAS IV Financial Personnel Workload MDR M-2 ADM Legend Database Subsystem Data Documents WAM PDTS Real Time Rx Billing (future) To support the MTF Revenue Cycle, there are various DOD systems in place to accommodate the business practices. Data Quality starts with both CHCS and DEERS. This data is fed to TPOCS (Third Party Outpatient Collection System), which performs outpatient billing for the TPC program only. Any errors found in TPOCS that have to do with coding, etc. must be corrected in the source system (i.e., CHCS/ADM). Inpatient and MSA billing is done through CHCS. CHCS also feeds EAS IV, MDR, and M-2. Data from these systems are used in developing some rates that are billed. The data is also used to look at practice patterns and efficiency.

MTF REVENUE CYCLE Information / Data Cash O&M Collections Cash Flow $$ INFRASTRUCTURE (MTF Commander and Other Leaders) Patient Registration Provider Encounter Data Patient Registration Coding Billing Accounting INFORMATION SYSTEMS Focus on the big picture. UBO and OIB fits into what we refer to as the MTF revenue cycle. The revenue cycle is made up of the administrative functions that contribute to the creation of billable events, submission of bills, collection, payment and posting. The revenue cycle is paramount for the success of OIB. We must minimize the “leaks”. There now exists an interdependency among all MTF staff from the registration clerk (in the collection and confirmation of OHI) to the provider (for accurate documentation), to the coder and biller. All these people are interconnected to make the UBO Program successful. The MTF Commander and other leaders must communicate to all involved parties in order to generate support for data quality. Data quality is critical!!!!! Why? Every phase of the revenue cycle is highly dependent on the completeness and accuracy of the data collected. Starting from the beginning of the revenue cycle, every data point is passed along to the next person and ultimately affects reimbursement for the MTF. An error in one part can affect the whole cycle. As you can see, all disciplines have responsibility and impact regarding data quality. We will be going more in detail about this in the next slides. O&M Collections Cash Flow $$

GAO REPORT FINDINGS Results from a February 2004 GAO report identified breakdowns in each phase of the revenue cycle and the resulting adverse effects on collections Breakdowns reduce DOD’s Third Party Collections $ $ $ $ $ Medical documentation Billing Accounts Receivable Patient intake Coding Some billable care is not identified due to coding or systems problems Staff issues Failure to collect & maintain insurance information Missing medical records Poor medical record documentation Inadequate follow-up Legal issues Incomplete Inaccurate Process Breakdowns Source: GAO-04-322R

PATIENT REGISTRATION Information / Data Cash PATCAT Entry Collection & Validation of OHI DQMC Assessable Unit Information / Data Cash INFRASTRUCTURE (MTF Commander and Other Leaders) Now that we know about the revenue cycle and data systems, let’s look at the impact of the revenue cycle and data quality on the stakeholders. Patient data collection begins with the Registration Clerks. PATCAT: accurate? The PATCAT is looked at by systems when making a decision about data. PATCAT reflects billable or non-billable events – e.g., if active duty, not billable, MSA PATCAT? Collection & Validation of OHI: accurate, complete, up-to-date and timely? For any TPC billing to take place, the OHI must be entered into CHCS within a 3 day timeframe otherwise the data is not pushed to TPOCS for billing purposes. After that timeframe, billing must be done manually, and that is only if the biller knows there was an encounter and has all the information. OHI: consistent – is the collection of OHI a standardized procedure? Is the entry consistent with the SIT table? E.g., BCBS vs Blues. GAO Report 04-322R dated 20Feb04: The report indicated that, “the single biggest obstacle to increasing collections is inadequate identification of patients with third party insurance.” Millions of dollars are not collected each year because of the lack of effective systems and processes for obtaining and updating insurance information for patients who have OHI. This includes verifying the accuracy of the data. For example, based on work performed by service auditors at five MTFs, they found that while MTF records identified 4.5% of the outpatients as having OHI, in fact about 9.8% of the outpatients had OHI, more than doubling the number of patients with insurance and projected to include an additional 96,000 patients. Patient Registration Patient Registration Provider Encounter Data Coding Billing Accounting INFORMATION SYSTEMS

Importance of Accurate PATCAT Entry Patient Category (PAT) determines the reimbursable rate (if any) for healthcare Over 300 PATCATs to select from Challenge of Patients with Multiple PATCATs Spouse of AD Member who is a Reservist and employed as a Federal Employee Whose responsible for training/accuracy? Form the UBO perspective, the three Services have POCs available for additional information/guidance (on UBO website).

Medical Affirmative Claims (MAC) Are all patient injuries being identified for JAG review as possible MAC cases? Active Duty Included Is anyone training your intake personnel to identify potential MAC claims? If no one is responsible then it’s not getting done How much is your MTF losing in unidentified MAC cases?

Other Health Insurance (OHI) Information Use DD Form 2569 to capture OHI information about your patients All Non-Active Duty Patients required to complete it every 12 months or if data changes OHI needs to be entered into CHCS or it “doesn’t exist” for billing purposes Direct correlation between presence of a current DD Form 2569 in patient record and rate of TPC billing Reported monthly in Commander’s DQ Report

PROVIDER DATA Information / Data Cash Medical Record Availability Documentation Information / Data Cash INFRASTRUCTURE (MTF Commander and Other Leaders) Encounters of Providers listed with a CHCS Provider Specialty Codes above 905 DO NOT come over to TPOCS. Example of 932 - Internal Medicine instead of 011 - Internist. 915 - Cardiology instead of 014 – Cardiologist. TPOCS is screwed Up!!! Had 954 - Psychology instead of 703 - Psychology Social Worker Documentation: is this accurate, complete, concise, relevant, timely, consistent – coding depends on documentation, codes are put on a claim for billing. Many providers use Superbills/Templates POSITIVE: helps with coding, should be tailored to their specialty NEGATIVE: may not contain all codes that are needed. Has to be updated annually to reflect current codes. NEGATIVE: easy to get in a habit of simply checking the same E/M codes for care rendered in a specific specialty area. FUTURE FEATURE: Provider GUI software, Superbills will be enhanced by a Coding Compliance Tool. One touch documenting. GAO Report (20Feb04): One independent study conducted at 50 MTFs found that approximately 17% of the records reviewed did not contain documentation for the specified date of the outpatient visit and about 35-47% of the time, reviewers could not find documentation in the medical record for the diagnosis or procedure performed. If there is no documentation, it didn’t happen!!! Patient Registration Patient Registration Provider Encounter Data Coding Billing Accounting INFORMATION SYSTEMS

CHCS Provider Specialty Codes (PSC) Set of codes unique to CHCS Current business rules preclude TPOCS from receiving ADM encounters with blank PSCs or PSCs > 900 (exception of 901 – Physicians Assistant) 702 (Clinical Psychologist) versus 954 (Psychology) Site visit to large medical center found 20% of PSCs fields were blank Billable ADM encounter never reaches TPOCS

Correcting the CHCS Provider Specialty Codes (PCS) Get your site’s most current CHCS Provider Profile and review the PSC fields for accuracy No blank fields Billable providers have PSC under 900 (plus 901 – Physicians Assistant) Determine whose responsible for maintaining the PSC fields and TRAIN THEM!!! Periodically review the PSC fields to make sure the problem really has been permanently fixed

CODING Information / Data Cash HCPCS/CPT-4 Modifiers, ICD-9-CM Units of Service Information / Data Cash INFRASTRUCTURE (MTF Commander and Other Leaders) Ability to code based on specific care provided to patients using modifiers, units of service and multiple E/M codes. Coding must match documentation. Presentation. Coders must work with both providers and billers to ensure what is sent out is an accurate picture of what occurred. As long as diagnostic and procedural coding serves as the basis for payment methodologies, ensuring accuracy of coded data is a shared responsibility between coders, billers, and providers. Correct documentation and coding provides a complete picture of the encounter for other health professionals to use in subsequent care. Coders should thoroughly review the entire medical record as part of the coding process in order to assign the most appropriate codes. Adhere to all official coding guidelines. Cost-effective, relevant – complete and accurate diagnostic and procedural coded data is necessary for research, epidemiology, outcomes and statistical analysis, financial and strategic planning, reimbursement, evaluation of quality of care, and communication to support the patient’s treatment is more critical than before. M-2 and MDR data is used by the MHS to make decisions. Patient Registration Patient Registration Provider Encounter Data Coding Billing Accounting INFORMATION SYSTEMS

BILLING Information / Data Cash Insurance Verification Claim Form Data & Line Item Billing Information / Data Cash INFRASTRUCTURE (MTF Commander and Other Leaders) Insurance Verification - Billers are the ones that send claims out the door to payers. They must choose the accurate payer to send the bill to process. Claim form data – With OIB, line item billing and data elements on the claim form must be clean. The goal is clean, accurate claims. Accurate – if medications and services are not provided but billed to patients and insurers, the time-consuming and costly process of error correction is initiated. Complete - When medications and service are supplied but not billed, the problem often goes unnoticed and revenue goes uncollected. Timely – the longer a claim is not sent, the harder it is to collect money. Presentation – is the claim form clean? Are the data in the correct fields? Does additional supporting documentation need to be sent with the claim? Improved data quality can prevent fraudulent insurance claims, which drive up the cost of insurance and healthcare for individuals and employers. The insurance that is sent from CHCS to TPOCS must also be correct. The OHI must be entered into CHCS within 3 days in order for data to be pushed to TPOCS. Patient Registration Patient Registration Provider Encounter Data Coding Billing Accounting INFORMATION SYSTEMS

ACCOUNTING Information / Data Cash Account Follow-Up Payment Posting Denial Management Information / Data Cash INFRASTRUCTURE (MTF Commander and Other Leaders) EOBs: accuracy - In order to account for money coming in the door to the MTF, the accounting staff must accurately read and interpret EOBs. Timely – is the revenue posted in a timely manner? Denial management: Denial codes Accuracy – is this the accurate and correct reason? Consistent – is there consistent follow-up of denials? Web-based Metrics Tool – the UBO has a web-based metrics tool in which MTFs report out the collections for each month and it is consolidated, validated and tracked at both the Service level and TMA level. The tool lets all levels of the UBO benchmark and trend their MTF, Region or Service by time periods or against other MTFs, Regions, or Services. Timely – this must be done on the last day of the month. If this snapshot is not taken then, any postings done will be counted during that timeframe. This is because the DD 2570 is a snapshot in time and does not cut off on a certain date of service. Remember the money collected is used for the business operations of the MTF. This money can be used to optimize services or staffing. Patient Registration Patient Registration Provider Encounter Data Coding Billing Accounting INFORMATION SYSTEMS

UBO SUCCESS FACTORS What are the Focus Points? MTF Revenue Cycle Team Effort (not the just the UBO’s challenge) Staff Education & Training Electronic Interfaces Leadership Involvement Stress the need to complete the OHI forms (DD2569s) Brief them on UBO Performance (OHI Capture, Billings & Collections) With every entry point in the MTF Revenue Cycle, it is important that all data be accurately recorded and tracked. Data must be entered correctly the first time. Staff education - Most of the clinic personnel responsible for the data input were not trained to complete the fields properly. Nor are they aware of the impact of the data on their clinical and business operations. Our facilities found that if they could show how the data directly impacted collections, there was a dramatic improvement in the accuracy/quality of the data. Some sites eliminated access to SIT/OHI entry to those who were not specifically trained to enter the data. The information is sent to the few personnel authorized to enter the data. Four facilities also improved their OHI identification by over 20%. This has led to a doubling of their collections in 3 of the facilities. The SIT is now standardized and updated quarterly. Specifically train on coding and target providers on E&M coding. Alternatively, hire coders, hire someone to audit to provide a baseline, educate internally, educate externally, invite coding students to intern, contract centrally through your MAJCOM,, pay for coders at another MTF to provide training to your staff, etc. Electronic Interfaces - Using the CHCS and ADM electronic interfaces, existing patient and insurance information can be imported into TPOCS, thereby reducing data entry time. However, with inaccurate data bases, the downloads drop large quantities of records. Instead of correcting the problem, most sites have opted to continue manual entry. However, manual entry is time-consuming and can also lead to mistakes. Leadership involvement is important for ensuring business processes are followed, such as OHI collected. This directly affects collections.

TPOCS: BILLING SYSTEM What is TPOCS? Relationship to other systems OHI in CHCS Provider Specialty Codes Future enhancements Centralized OHI Repository on DEERS Patient Accounting System (PAS)/ Charge Master Based Billing (CMBB) to replace TPOCS and CHCS MSA Module for TPC billing Questions MTFs have the authority to collect private health insurance benefits for health services provided to insured military dependents with other health insurance. TPOCS is the system designed to assist in fulfilling this requirement. TPOCS is both a recipient of data from source systems such as CHCS and ADM as well as a data entry point.

TPOCS / CHCS / ADM CHCS TPOCS Provider GUI Master Files Demographics (12) (13) M/Objects Master Files Demographics Admissions Outpt Appts/Visits ADM 3.0+ LAB-RAD MSA/DD7A Billing CHCS Provider GUI TPOCS Appt List Outpt Coding Level 1 Edits Order Entry ORE Dx Links Results SIT OHI PROVIDER ADM SADR (9) Templates Claims Processing Interfaces: 10 – TPOCS UB-92/1500 to 3M Audit Expert Outpatient 11 – Error Report 3M Audit Expert Outpatient to TPOCS Provider GUI Interfaces: 12 – CHCS to/from Legacy Gateway Server 13 – Legacy Gateway Server to/from Provider GUI Local File Server 3M Audit Expert Outpatient (Omega) 10) (11) One of the problems we are trying to work on is the variation among MTFs as to which version of TPOCS and its various components sites are currently using. In an effort to improve data quality, a workgroup was convened to review the CPT update process and the end result was the release of the CPT tables on time (which is before or by the January 1 effective date). Efforts were also made to synchronization the loading of the tables among the various systems that use CPT tables. An issue for TPOCS upgrade was obtaining a CoN (Certificate of Networthiness) from the Air Force due to security issues. Delayed the delivery of all AF TPOCS servers and continues to have an impact on billing process for OIB.

RESOURCES UBO Web Page http://tricare.osd.mil/rm/ubo_home.cfm RITPO Web Site https://ritpo.satx.disa.mil/main.asp TPOCS Help Desk Web Site http://tpocshelpdesk.com CHCS Web Site http://citpo.ha.osd.mil/index.cfm?body=chcs Form the UBO perspective, the three Services have POCs available for additional information/guidance (on UBO website).

QUESTIONS? Tom Sadauskas TMA UBO Deputy PM 703-681-3492 x4069 Thomas.sadauskas@tma.osd.mil Form the UBO perspective, the three Services have POCs available for additional information/guidance (on UBO website).