2012 Adgenda. Office Solutions. Genius Healthcare. Compliance Plans Tech Talk ICD-10 Best Office Practices Tips & Tricks EHR 5010 EDI Reports dt to et

Transcription

1 Genius Healthcare Office Solutions The 2012 Seminar 2012 Adgenda Compliance Plans Tech Talk ICD-10 Best Office Practices Tips & Tricks EHR 5010 EDI Reports dt to et Genius Solutions, Inc Miller Dr. Warren, MI /

2 Benefits Shows a good faith effort that your practice is trying to submit claims properly Streamlines your business practices Optimizes the speed & accuracy of your claim payments Reduces negative audit risks Avoids conflict with self-referral and anti-kickback statuses (*see OIG Guidelines) A compliance plan promotes action. When an employee recognizes a mistake or contradiction, they will feel an ethical duty to report it, so that it can be corrected. 2

3 Compliance Components An effective compliance program includes: Conducting internal monitoring & audits Implementing compliance & standard practices Designating a compliance officer Conducting appropriate training & education Responding appropriately to detected offenses & developing a corrective plan Enforcing disciplinary standards through well publicized guidelines. Internal Reviews Conduct internal monitoring and auditing reviews Two types of review: Standard and Procedural Claim Submission Audit 3

4 OIG Risk Areas Pay Special Attention to OIG Risk Areas: Billing for items or services not rendered or provided as claimed Submitting claims for equipment, medical supplies, and services that are not reasonable and necessary Double billing resulting in an overpayment Billing for non-covered services (as if covered) Knowing misuse of provider id numbers which result in improper billing Unbundling Failure to properly use coding modifiers Clustering Up coding level of service Standard Practices Develop a written plan for your office s risk areas, after your internal audit. Include audit results & your plan to correct & prevent future errors. Update any clinical forms to promote good documentation. Per the OIG, the most common risk areas are: Coding & Billing Reasonable & necessary services Documentation & physician orders 4

5 Compliance Officer Designating an office compliance officer. Pick one member of your office staff. This person will be responsible for developing your corrective action plan and overseeing adherence to the plan. Training & Education Internal Compliance Training Billing Training External Compliance Training Billing Training Final Thoughts Response Responding appropriately to detected offenses & developing a corrective plan. Develop a corrective action plan by planning how you will respond to any future problems. Document any and all effort you make in your compliance program. This is a voluntary program. OIG recommends a step-by-step approach. 5

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11 Do you have a written Business Associate Agreement to meet HIPAA rules? What happens when they lose your data? Do you know how to restore the data, and do you have the instructions and any passwords off-site, in case of fire? In the case of a "data restore" can you pick and choose what data you wish to grab and restore, or do you have to retrieve all the data? Are they keeping multiple sets of backups, or just one. What happens if you have data corruption and don't find out for a few days? How do you know if it is really working? Will the backup system interfere with ethomas? Is the cost actually what you will pay? Many clients have a LOT of data (especially if you maintain patient and insurance pictures) and backup providers charge more for the space required. 11

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20 THOMAS Tips and Tricks ethomas Import Post Inspost by Date Range Guarantor Date Range Valadations dthomas How to Configure for

21 Introduction to AutoCharge For offices who use an EHR (Electronic Health Records) program or another third party program that is able to create an HL7 (Health Level 7) file containing procedure and diagnosis information, the THOMAS Exchange program may be for you! The THOMAS Exchange is an interface program that will convert an HL7 file into data that ethomas can import. For most EHR programs, ethomas can transfer over patient and appointment information and receive back procedure codes to be billed. This makes life much easier for the user since data only needs to be entered into one program! Imported Procedures are procedures that were originally created through an external program. ethomas can read these records in order to create new charges inside of ethomas. ethomas will read the file in order to process the Imported Procedures/AutoCharge. By utilizing the AutoCharge feature the user can either post one record at a time or a batch of records for quick processing of many records. Using ImportPost Users can access and view the imported procedures from the Billing Tab. Displayed will be a list of available imported procedures that are ready to be posted. By default, the system will only show you the non-posted procedures that are still waiting to be posted. However, you can un-check the Non-Posted Items Only box to see all procedures that have been previously imported and had charges posted into ethomas. Editing an Imported Procedure Users can edit or delete an imported procedure before it gets posted into ethomas from the imported procedures edit screen. The information displayed on this screen is used to prepare the claim in ethomas. The following fields will be imported from the client's third-party software via the THOMAS Exchange program: Procedure Code, DOS From and To, T Charge Amount,, Diagnosis Codes 1 10, Doctor Code, Modifiers 1-4 and Quantity. Any fields on the edit screen may be changed, however, it is important that all codes coming in from the THOMAS Exchange exist inside of the ethomas code files prior to posting the charges. The user will have the ability to add any missing code into the appropriate code file before posting the charges.

22 Posting the Imported Procedures for Multiple Patients To begin posting imported charges, go to the Billing Tab then Autocharge. The user may uncheck any procedures they do not want to autocharge. You may edit the imported charges by selecting the Edit button. The Clear All box will uncheck all of the charges displayed. The Select All box will select all of the charges displayed. Click the Post button to generate claims for all of the selected imported procedures. If you have imported codes that do not exist within ethomas, you will be prompted with a screen to either add or change the code. Click Add to add the code into ethomas Code Files. To change the code, type the correct code in the Replace With field and then click the Apply Change button.

23 Once all codes and dates are correct, the system will prompt you with a message stating, Are you sure you want to post these XX items. If the user responds with 'Yes, then all checked procedures will be posted. You will then receive a message window stating how many total lines of service have been posted. Posting the Imported Procedures for One Patient Posting charges can be done from the Patient Tab, Post Charges screen or the Billing Tab, Post Charges screen. If any charges exist, the Imported Procedures screen will come up with a list of available procedures. The user will have the ability to edit the procedure information from this screen. You can choose to post, delete or do nothing to each procedures listed. Click on the drop-down arrow for available actions. The user may select None, Post or Delete. Click EDIT to modify the charges. Click the Post button to continue with posting these charges. The regular posting charges screen will appear prepopulated with the imported information and you can continue to post charges as normal. If any codes were not found within ethomas Code Files section, the user will be prompted that the code was not found.

24 Introduction to Inspost by Date Range There are times when an insurance company may not send a detailed EOB (Explanation of Benefits) along with their payment. This is common for auto insurance, worker s compensation, and attorney payments. It can be very frustrating for the user when trying to post those payments into ethomas. For instances where there is no line-by-line explanation of payment, Genius Solutions has created the Inspost by Date Range feature. This feature will allow you to select a date range, the patient s policy that is paying and the payment amount. Using this information, ethomas will automatically distribute the payments throughout the different claims for you. Using Inspost by Date Range Users can access the Inspost by Date Range feature from the main patient screen under Posting. From the Inspost by Date Range screen, you can fill out the dates of service that the check is for, the payment amount (along with any applicable interest), and choose the patient s policy that the payment is from. Once you have entered all applicable information and click the save button, you will be brought to the insurance payment posting screen. This screen is what you will see when you normally post insurance payments, but you will notice the paid amounts have been defaulted for you.

25 You can change payment amounts if you want, or leave the information that ethomas defaulted. Click the Done button to complete the posting process. The system will then post multiple insurance payments for the total that you entered, spread across all of your claims. You will notice in our example that there is still a balance on the insurance. This is because the total balance was $ but we only got a payment of $ By default, ethomas will leave the remaining balance on the account, in anticipation for additional payment. If no other payments are expected, on the first screen where you entered the date range and the payment amount, you will check the Payment In Full box, which will write off any amounts not being paid.

26 Introduction to Guarantor Date Range There may be instances where a patient wants to have their mail sent to a temporary address. This is common here in Michigan when patients spend their winters in warmer climates. In the past, in order to send statements to the temporary address you would have to change the patient s physical address. Now with the Guarantor Date Range feature, you can enter the temporary address with an effective date range that patient statements should be sent. Using Guarantor Date Range In order to use this feature, you must first activate the system setting GUARANTORRANGE. Users can then access the Guarantor Date Range feature from the main patient screen under the Guarantor button. From the Guarantor screen, you can fill out the dates that the patient s statements should go to the temporary address, as well as choose whether this will reoccur every year. In the sample shown above, the patient s statements will be sent to the address in Orlando, FL from January 01, 2012 through May 01, If this patient will be gone every year at this time, you can check the Repeat Yearly checkbox, and the statement will be sent to that address every January 01 through May 01.

27 VALIDATIONS Validations are custom alerts clients build to help their staff catch errors before a claim is sent. We have two types of validations, Posting and Billing. Posting Validations alert the person entering the claim at the time of posting while Billing Validations show as a pre-billing error or warning. Each office chooses the appropriate option based upon who should be fixing the error. POSTING VALIDATIONS Posting Validations are custom alerts clients can build to help their office staff catch their own errors. Any claim that does not meet the criteria of the Posting Validation will appear as a warning message when the DONE button is clicked on the claim entry screen. This feature is meant to remind the biller and therefore reduce the number of pre-billing errors and/or rejections. The number of Posting Validations should be somewhat limited as each validation adds a bit of time to the saving process. To build a Posting Validation: Under Billing Settings System Settings click the plus sign to add setting POSTVAL with a value of 1 Choose Billing Posting Validations then click the plus sign to add.

28 In this example, we want to ensure that we use a GW modifier for hyperbaric procedures performed in hospice. The three things we need to check for in this example are that the header facility is a hospice, the procedure code is and the modifier is not GW. To accomplish this we clicked the Add Field button 3 times then filled out the lines with the appropriate information. When posting a and using a hospice in the claim header, if the biller has not entered the modifier GW a warning message will be received. They have the option to continue posting charges without correcting the problem or stop and correct the claim before proceeding.

29 Billing Validations Billing Validations allow the biller to create their own pre-billing errors. They are custom alerts clients build to help them catch errors. Any claim that does not meet the criteria of the Billing Validation will appear as either a warning or bad claim on the pre-billing report. This feature is meant to reduce the number of pre-billing errors and/or rejections. After Posting Validations have become habit offices will move them to Billing Validations to allow new Posting Validations to be added. To build a Billing Validation: Choose Billing Billing Validations then click the plus sign to add.

30 In this example, we want to ensure that we fill in the appropriate header information for an auto claim. To accomplish this we set the validation up to first check that the financial code was AA. If this is true, it will then check the claim header to ensure that the auto accident box is checked and that the injury date is filled in. We wanted this validation to stop the claim (to not be a warning) so we did not check the warning box. In our example, the biller forgot to change from the blank OV header when the patient presented with an auto accident.

31 When claims are generated, the Bad Claims List will catch the mistake and allow the biller to fix it by clicking the Edit Claim button. If your office does not use the Bad Claims List the error would also be caught on the pre-billing report. From the Bad Claims List, the biller can edit the claim by adding a corrected header with the necessary fields then re-prepping the claims using the Reprep Claims button on the Bad Claims List. After the correction, the claim shows as good on the pre-billing report.

32 CONFIGURING THOMAS FOR 5010 The ANSI 5010 Compliance deadline is January 1, With that being said, Genius Solutions hopes for a smooth transition from the ANSI 4010 format to the new 5010 format. We have made changes in both ethomas & dthomas in order to accommodate this billing change. You must first make sure that you are on the most current version of THOMAS, which is , or later for ethomas, and 9.01 or later in dthomas. First and foremost, if you are sending 5010 claims prior to the compliance date you should verify that your clearinghouse(s) is ready to accept 5010 claims. Once you have done so, you can begin setting up THOMAS. Within THOMAS, check the 5010 checkbox from inside the Financial Code(s). ethomas Code Files > Insurance > Financial dthomas 5 > 4 > Select Clearinghouse > 2 Once you have the Financial Code(s) selected for 5010, then all claims for that Financial Code will be prepared in the 5010 format. If you find that there are individual insurance companies that still need to be prepared in the 4010 format, you can create an exception for that insurance company for the specific clearinghouse (formgroup) that you want to create an exception.

33 ethomas Code Files > Insurance > Insurance dthomas 4 > 6 C to Change PO BOXES In the 5010 version, the address can no longer be a PO Box or lockbox address. Be sure to verify your address with your payers to ensure a smooth transition to the 5010 version update. THOMAS has a new set of address fields inside of the location file called Physical Address. If you are currently reporting anything other than a physical address in your business address, you should use the Physical Address area within THOMAS to input your physical address. The Physical Address will report out in the ANSI 5010 version of the file. ethomas Utility >Data > Locations A prebilling error will alert you if are using a PO Box or a lockbox and the Physical Address is not filled out. The message will read: *ERROR* Physical Address Required (Busno)

34 dthomas 8 > M > 5 Business Address C to change If you are using a PO Box or a lockbox and the Physical Address is not completed, THOMAS will give you a message when you prepare 5010 claims and will not allow you to prepare until you fill out the Physical Name and Address. 9 DIGIT ZIP CODE In the 5010 version, the 9 digit ZIP code is required in the Billing Provider and Service Facility Location address fields. You can begin updating these fields prior to the 5010 compliancy date to ensure that you will be ready for this change. You can visit the United States Postal Service s website for 9 digit ZIP codes at A prebilling error will alert you if you are billing out a facility or a location without the ZIP+4. The message will read: *Error* Physical Address needs ZIP + 4, Facility Code: XX needs ZIP+4

35 PREPARING BILLING FILES If you are billing out claims in a dual format (both 4010 & 5010) you will have to transmit multiple files. You will notice that the filename is named differently than the 4010 files. It is important to note that in dthomas, you must prepare your 5010 claims prior to preparing your 4010 files. Failure to do so will result in the preparation of a 4010 file. dthomas filename in the 5010 format, notice the b dthomas filename in the old 4010 format, notice the a ethomas Separate files 5010 N & 5010 Y ethomas filename in the 5010 format,..\ansimi c0xxx txt ethomas filename in the old 4010 format,..\ansimi c0xxx txt

36 RECEIVING RESPONSE FILES You will send your files as you always did to your clearinghouse. With 5010, there are some new reports/response files. In place of the 997 report is the 999 and in place of the 277 report is the 277CA report. In addition, you may see a TA1 Interchange Acknowledgement prior to your 999. The TA1 report is an acknowledgment on the header and trailer of the file. If you get a rejected TA1, you should contact our support department. TA1 Interchange Acknowledgment This report will list out the date and time the file was received and the batch or filename. It will list the acknowledgment if the file had errors on the structure on the header or trailer of the file and the reason. If there are no errors under the reason, then you should look for your 999 file. If you receive errors, contact Genius Solutions. The error will need to be resolved and that batch will have to be re prepared and sent back to your clearinghouse. TA1 Interchange Acknowledgment Report with no errors 999 Acknowledgment Report This report will list out the date and time the file was received along with the sender ID and the batch or filename. It will list what type of claims you are sending (production or test) and the status of your file (whether it was accepted or rejected). If it was accepted, that means there are no errors on the file and you should wait for the 277CA reports (which are your individual claim edits).

37 277CA ReportsThis report will list out the Payer ID, Submitter ID, Business Name sending the file, NPI and the break down by Source of Pay (SOP) or lines of business with a total of Accepted and Rejected and a Grand Total.