I.

COMPLIANCE & THE DIRECTORS

II. UPDATE ON THE 3PB REVENUE
ENHANCEMENT PROJECT
III. OPERATIONS AND THE REIMBURSEMENT
SYSTEM BEST PRACTICES
IV. DASHBOARD FOR MANAGING THE
REIMBURSEMENT SYSTEM
HEALTH CARE COMPLIANCE
Deliberate ignorance
COMPLIANCE PROGRAMS

• Voluntary in 2000…..Mandatory now

• Evolved into Compliance and Ethics Programs
• Affordable Care Act - Indian Health Care programs are
deemed Essential Community Providers therefore
ACO’s must include. ACO membership mandates the
implementation of a compliance program
DUTY OF CARE - BOARD RESPONSIBILITY
• Must demonstrate good faith judgment
• Must act in a manner an ordinarily prudent person
would exercise under similar circumstances
• Must act in a manner believed to be in the best interest
of the corporation
• Must perform reasonable inquiry – Is compliance
program reporting and information system adequate
from an oversight not operational perspective
REASONABLE INQUIRY
 Ask knowledgeable and appropriate questions
 Structural Questions – designed to explore the
adequacy of program breadth, reporting relationships
and resources to implement the program
 Operational Questions – directed to an evaluation of the
adequacy and vitality of the compliance program
2 CATEGORIES OF QUESTIONS ARE
SUGGESTED FOR DIRECTORS:

• Operational Questions – directed to an evaluation of the

adequacy and vitality of the operations compliance program

• Structural Questions –scope of the organization’s

compliance program; designed to explore the adequacy of
program breadth, reporting relationships and resources to
implement the program
STRUCTURAL QUESTIONS
Compliance Infrastructure
• How is the compliance program structured and who are the
key employees responsible for its implementation and
operation?
• Do the personnel have sufficient authority, autonomy and
resources to perform assessments and respond
appropriately to misconduct to implement the compliance
program?
• Are employees held accountable for meeting these
compliance-related objectives during performance reviews?
STRUCTURAL QUESTIONS
Measures to Prevent Violations
• What is the scope of compliance-related education and training
across the organization?
• Has the effectiveness of such training been assessed?
• What policies/measures have been developed to enforce training
requirements and to provide remedial training as warranted?
• How is the Board kept apprised of significant regulatory and industry
developments affecting the organization’s risk?
• How is the compliance program structured to address such risks?
STRUCTURAL QUESTIONS
Measures to Respond to Violations
• What is the process by which the organization evaluates and
responds to suspected compliance violations?
• Does the organization have policies that address the
appropriate protection of “whistleblowers” and those accused of
misconduct?
 SMALL GROUP PRACTICE GUIDANCE OIG 2000
7 KEY COMPONENTS
1. Conducting internal monitoring and auditing
2. Implementing compliance and practice standards
3. Designating a compliance officer or contact
4. Conducting appropriate training and education
5. Responding appropriately to detected offenses and developing
corrective action
6. Developing open lines of communication
7. Enforcing disciplinary standards through well publicized
guidelines
BOARD ACTIONS
• Peer Review and Credentialing & Privileging
• Policy and Procedures with controls for risk areas
• Periodically evaluate the effectiveness of the
compliance program
• Ensure access to resources
OPERATIONAL RISK AREAS
• Coding and Billing Errors
• Safety for patients and staff
• Quality of Care
• Contracting
• Accuracy of reporting
• Conflict of interest
• Privacy and Security Rules
• Harassment or intimidation
• Culture of business environment
• Social Networking
RESOURCES
• Participate with local hospital or physicians association
programs
• Health Care Compliance Association
• American Academy of Professional Coders
• American Health Information Management Association
• Office of Inspector General
• Center for Medicare and Medicaid Services
3PB REVENUE
ENHANCEMENT PROJECT
3RD PARTY REVENUE ENHANCEMENT UPDATE
• VISITED SITES
• HOSTED 2 GATHERINGS
• HOSTED 7 WEB-EX TRAININGS 1 MORE TO DO
• 8 WEB-EX INTENSIVE SERIES FOR CODING PLANNED
• IMPLEMENTING 3PB SYSTEMS AT 14 SITES
• SUPPORTED SITES WITH FQHC APPLICATIONS
• DEVELOPMENT OF SLIDING DISCOUNT SCHEDULES
• ASSIST COORDINATION OF AREA OFFICE SUPPORT
COMING UP
• ACCOUNTS RECEIVABLES MANAGEMENT
• INTENSIVE CODING SERIES
• INTENSIVE MEDICARE SERIES
• ICD-10 IMPLEMENTATION PLANNING
• COMPLIANCE PROGRAM DEVELOPMENT
FINDINGS
• Need consistent support
• Need for Electronic Health Record & Meaningful Use
support
• Need for regular coding and billing training
• Need assistance processing Medicare/Medicaid FQHC
applications
• Practice Management systems being retired
 DASHBOARD
• REAL MEANING OF ALL CAUGHT UP
• PRODUCTIVITY MEASURES – Provider, Coder/Auditor, Biller
• AGED RECEIVABLES – 0-30 31-60 61-90 91-120 120+
• COLLECTIONS AND REASONS FOR WRITE OFFS
• SCHEDULE COLLECTION GOALS
• MANAGE WARNING SIGNS AS ALERTS
• BALANCE WITH FINANCE
• TRAINING REQUIREMENTS

• DIRECTORS 3RD PARTY REIMBURSEMENT MANAGEMENT WORKSHOP

CONTRACT CAUTIONS………
• What is your reimbursement under this contract? And when are rates
renegotiated?
• Can the health insurer unilaterally change the terms?
• Is the health insurer obliged to pay you promptly?
• How is medical necessity defined? Who qualifies?
• Does the contract or manual designate all services and procedures that are
subject to prior authorization requirements?
• Are electronic 837 claims accepted in the 5010 format (now)?
• Are electronic remittance 835 available now and do they include adjustments
with payments
• How is eligibility determined? Online or by phone?
 AGE IS MORE IMPORTANT
0-30 31-60 61-90 91-120 120+ Balance

A/R $212,245.60 $77,823.39 $56,598.83 $7,074.85 $0 $353,742.66

Balance

60% 22% 16% 2% 0%

WHERE IS REVENUE MADE AND LOST?
Revenue Made Revenue Lost
Training is ongoing When rules change and no-one notices
Proactive practices Fall behind – timely filing ~30-365
A/R Follow up – Denial Management No A/R management - Rebilling
Front desk skilled interpreting benefits and Ineffective front end management
promoting enrollment
Tracking and measuring the right things Accountability is lacking
Policies, Procedures and Tasks are done Everyone is doing their own thing
 RADAR
2012 2013 2014 2015
Terminology & 10/01/2013 -2014
ICD-10
Anatomy/Physiology ICD-10 compliance date
Improve denial I10 coding training for
Process
management providers, support and
Improvements
process coder/billers

MEANINGFUL Stage 1 Stage 2 Stage 3

USE OF E H R requirements requirements requirements

Hospitals outcome Payment Paying

Insurance
based payment bundling for physicians
Exchanges &
ACA (10/01/12) outpatient based on “value”
133% Newly
“Value Based with not volume
Eligible's
Payment – VBP” inpatient
http://www.healthcare.gov/law/timeline/
 ELIGIBLE PROFESSIONALS: MEDICARE
INCENTIVE PAYMENT EXAMPLE
Amount of Payment Calendar Year EP Receives a Payment
Each Year of
Participation
CY 2015 and
CY 2011 CY 2012 CY 2013 CY2014 later
CY 2011 $18,000

CY 2012 $12,000 $18,000

CY 2013 $8,000 $12,000 $15,000

CY 2014 $4,000 $8,000 $12,000 $12,000

CY 2015 $2,000 $4,000 $8,000 $8,000 $0

CY 2016 $2,000 $4,000 $4,000 $0

TOTAL $44,000 $44,000 $39,000 $24,000 $0

 ELIGIBLE PROFESSIONALS: MEDICAID
INCENTIVE PAYMENT EXAMPLE
1st Calendar Year EP Receives a Payment
Amount of Payment
Each Year if
Continues Meeting
Requirements CY 2011 CY 2012 CY 2013 CY 2014 CY 2015 CY 2016
CY 2011 $21,250
CY 2012 $8,500 $21,250
CY 2013 $8,500 $8,500 $21,250
CY 2014 $8,500 $8,500 $8,500 $21,250
CY 2015 $8,500 $8,500 $8,500 $8,500 $21,250
CY 2016 $8,500 $8,500 $8,500 $8,500 $8,500 $21,250
CY 2017 $8,500 $8,500 $8,500 $8,500 $8,500
CY 2018 $8,500 $8,500 $8,500 $8,500
CY 2019 $8,500 $8,500 $8,500
CY 2020 $8,500 $8,500
CY 2021 $8,500
TOTAL $63,750 $63,750 $63,750 $63,750 $63,750 $63,750
Focus points…
• Fundamentals
• Change
• Goal
• Similarity of processes
• 3rd Party revenue
• Work to do
• It’s why we are already here