MD - Health Care Compliance Association

More documents

Recommendations

Info

Improving revenue through compliance ...continued from page 9 nessed the refusal to sign, sign the form. The witness can write “pt. refused to sign” on the form and then sign and date it themselves. This makes the form as legally binding as if the patient had signed the form. Initial audit results Our initial audit, which was run on both medical sites and billing clients, yielded poor results. All site/billing clients failed the audit. Some of the problems encountered included: ■ Not using federal form CMS-R-131 G ■ Unable to produce the ABN ■ Essential field elements not completed ■ No options checked off ■ Estimated cost not filled in ■ Form not signed or not dated As a corrective action plan, an aggressive mandatory training program schedule was made and all sites, along with numerous clients, were trained on the proper use of ABNs. A reference guide was developed as a tool to help in the decision-making of when to use an ABN and the corresponding modifiers. Reminder stickers for the –GA and –GY modifiers were given to data entry personnel to place on their monitors. Use of Modifiers –GA & –GY One of the problems revealed by the audit was that data entry staff did not know how or when to append the appropriate modifiers. Since most of the sites and many of the clients perform this function at the medical office, it was imperative to educate these staff members on the modifiers. The –GA modifier signifies that an ABN has been signed. Any service provided where medical necessity may be in question should have an ABN signed and be billed with the –GA (see Figure 1: ABN Reference Guide on page 13). An example would be an EKG performed as part of a preventive care visit for a patient with hypertension. The fact that the patient has hypertension as a secondary diagnosis (with the primary diagnosis as V70.0 routine PE) may be enough for Medicare to reimburse for the EKG. However, since it is being done as part of a routine PE, it may not be covered. Another example would be a patient receiving a pneumonia vaccine. This particular vaccine is a once-in-a-lifetime benefit under Medicare. So, if the patient is 80 and had a pneumonia vaccine when he or she was 65, or had one previously from another provider and doesn’t remember, the claim will be denied. Therefore, this vaccine should also have an ABN obtained and be billed with the –GA modifier. In this case, it is more than the service that would be given away should it turn out that the patient already received the once-in-a-lifetime—the initial outlay of cash by the practice for purchasing the vaccine would also be lost. For vaccines and injectables, the administration for the vaccine should also be billed with the –GA modifier. Any exams, tests, or services that have frequency requirements should also have an ABN obtained to safeguard your ability to balance bill if the claim is denied. An example of such a situation would be a screening pelvic/breast exam (G0101) and pap smear (Q0091). This is a covered benefit only every two years. If you are performing this annually or the patient had it done elsewhere and you don’t know about it, then you will lose the revenue without a signed ABN and claim billed with the –GA. An ABN does not have to be completed for services that are statutorily non-covered (see Figure 1 on page 13). In the situations where statutorily non-covered services are performed, the data entry person needs to append the –GY modifier, signifying that it is excluded as a Medicare benefit. Using the –GY will fulfill the “demand bill” requirement and allow a medical office to collect payment for the service(s) at the time of service (just as you would collect a co-payment on the same day as a visit). Claims billed with the –GY will be denied by Medicare and allow balance-billing the patient if payment was not collected up-front. An example would be for a routine or annual physical. This service is statutorily non-covered by Medicare, so you would bill the 99387 (new patient) or 99397 (established) with the –GY modifier and collect payment up-front. The caveats here are (1) if the patient has additional commercial insurance, the preventive care visit may be covered, so wait for a denial before balance-billing, and (2) although the PE itself is non-covered, you will still need to obtain an ABN for any screening tests that are performed as part of the physical i.e., EKG, PPD, vaccines etc. Re-audit in six months After the staffs received their initial training, a second audit was run at 6 months. Expectations were high that there would be vast improvements and that everyone would pass. Unfortunately, this did not happen. However, there were improvements in that the –GA modifier was being used more often and offices were able to produce a corresponding ABN in most cases. Phase 2 of the ABN training was now in effect. All errors from the second ABN audit were compiled and analyzed. They were broken down into two areas: form completion and modifier use. With the details of the audit errors, an ABN Refresher Program was developed. The errors included: ■ Some sites still could not produce an ABN when the –GA modifier was used ■ ABNs were used for covered services and sick visits January 2006 10 Health Care Compliance Association • 888-580-8373 • www.hcca-info.org
■ ABNs were used for preventive care exams (this is statutorily non-covered) ■ Forms were not completed fully (missing critical elements such as services, reason, option, estimated cost, signature/date) ■ Some client offices decided not to use ABNs The last error on the list is an interesting one. It really is not a matter of choice as to whether or not an office uses an ABN. The Office of the Inspector General (OIG) may consider failure to use ABNs or to balance-bill to be inducements for patients. Inducements resulting in a Stark II violation as a perceived kick-back may result in civil monetary penalties. True, CMS is more interested in recouping its own lost revenue rather than the lost revenue of a provider, but that does not make it any less of an infraction. Revise the corrective action plan Using the errors from the re-audit, a revised corrective action plan and training program was developed. Beginning with the form errors, each line of the form was incorporated into the training program with examples of “do’s and don’ts.” For example: the BECAUSE section was often completed incorrectly with ICD-9 codes or written diagnoses instead of the reason why the provider thought the service may not be covered. This and other form completion problems with the SERVICES and BECAUSE sections led to the development of a modified ABN that already has services and reasons available for check-off. The use of a modified form with check-off boxes enables a provider to: ■ prompt the proper use of the ABN ■ increase readability by limiting handwritten items ■ improve efficiency by making it faster and easier to complete these sections ■ improve accuracy The modifications can be customized to the services offered by the office or specialty without compromising the integrity of the form (see Figure 2 for a sample modified form on page 14). The training program addressed each section and provided examples of when to use and not use the ABN. The refresher program was also offered to all staff members from registration personnel, clinical staff (including providers), and check-out/data-entry clerks. It was clear from the second audit results that there needed to be a full awareness and coordination among all of these people in order to make the use of ABNs successful. Continued on page 12 Health Care Compliance Association • 888-580-8373 • www.hcca-info.org January 2006 11
Page 1 and 2: Volume Eight Number One January 200
Page 3 and 4: ASK ON THE LEADERSHIP ONCALENDAR JO
Page 5 and 6: Join us for the following HCCA Audi
Page 7 and 8: in 2006 will assess hospital compli
Page 9: By Susan C. L. Theuns Editor’s no
Page 13 and 14: Figure 1: ABN Reference Guide Servi
Page 15 and 16: feature article Editor’s note: Th
Page 17 and 18: GJ: Yes. The Fraud, Waste, and Abus
Page 20: ■ There will be Compliance expert
Page 23 and 24: Here’s your chance to share your
Page 25: espective nonprofit law compliance
Page 29 and 30: suffix that identifies package size
Page 31 and 32: By José A. Tabuena JOSÉ A. TABUEN
Page 33 and 34: AP: As far as the Auditing and Moni
Page 35 and 36: that would provide the intelligence
Page 37 and 38: Case study of Dana Farber Cancer In
Page 39 and 40: JOSEPH M. WATT ■ Solicit staff an
Page 41 and 42: including the three objectives set
Page 43: expect a measurable impact of compl
Page 46 and 47: New HCCA Members ...continued from
Page 48: C ORPORATE C OMPLIANCE & ETHICS: G

MD - Health Care Compliance Association

You also want an ePaper? Increase the reach of your titles

Delete template?

Save as template?