Volume VII Number 4

November 2001

The Newsletter of

D E K A Y E  Consulting, Inc.

231 Oakview Avenue
Oceanside, New York 11572
Phone / Fax: (516) 678-2754
E-Mail: Adkcmpa@aol.com
E-Mail: DKConsult1@aol.com
URL: http://www.dekaye.com



Autumn in  New York

ON A PERSONAL NOTE....

While On Target has provided me with a vehicle to discuss my thoughts about issues and solutions related to the cash flow cycle, I had never envisioned this newsletter being a commentary on world and national events. Perhaps it is what we all saw and felt on and after September 11, 2001 that requires that this preface be written.

Our thoughts and prayers go out to all those who suffered losses from this tragedy. We are grateful to the individuals, who, knowing of our proximity to New York City, and our propensity to travel around the country, contacted our offices in the days following these events to ask about our safety. One who contacted us, later advised that she was awaiting activation orders from her reserve unit. We wish her safety, and a safe return.

In our subsequent travels, we received especially warm receptions in each city or town we visited. They were glad we came, and we were glad we went. Staff from one hospital told me about a unique way in which employees made contributions. They were allowed to donate some portion of their accrued vacation hours to the various relief funds. Impressive. Creative. Appreciated.

I saw hospital staffs go on "alert." Those in the cash flow cycle took up alternate posts. Empire Blue Cross was especially hit hard with offices at the World Trade Center. They like many other payers were quick to respond to the hospital’s need for cash flow. In some cases electronic payments continued to flow. However, many banks and lock boxes also were also affected. In some instances, lost checks were reissued. Outsource vendors had telecommunications interrupted. Collection agencies took a few days off from making calls–even after normal service was restored. Most hospitals’ A/R took a hit in September. In October, they are rebounding.

There’s a saying on Broadway: "The Show Must Go On...."

Allan P. DeKaye

Vital Signs

OVERCOMING CLAIM DENIALS:
Top Ten "To Do" Checklist: Preventing Claim Denials

By Allan P. DeKaye, MBA, FHFMA, President and CEO, DEKAYE Consulting, Inc.

The following Claim Denial Checklist was prepared to help you identify tasks you may not have considered. They are intended to help your organization prevent claim denials. A list of additional reference resources appears at the end of the checklist.

The Checklist

_____1. Establish effective patient pre-admission procedures to ensure eligibility verification  and utilization management compliance.

_____2. Control the patient access (Admitting and Registration) processes to ensure complete and accurate patient demographic and financial data.

_____3. Conduct periodic managed care contract reviews to ensure conformance to contract terms and conditions.

_____4. Communicate changes to managed care contracts to the Access and Patient Accounting departments.

_____5. Define, measure and report all denial conditions that occur, and assign staff and departmental responsibilities to identify issues and impediments.

_____6. Determine if "provider" or "payer" fault is responsible for claim denials.

_____7. Audit claims and records to assess compliance with internal protocols.

_____8. Implement electronic coding and claim "scrubbing" (editing) routines to catch problems.

_____9. Provide feedback to staff on both "positive" and "negative" occurrences.

_____10. Meet with payers who fail to honor contractual commitments before taking more extensive remedies.

Additional Resources

Capturing Lost Revenues: Best Practices for Minimizing Managed Care Denials, Health Care Advisory Board, Washington, DC, 2001. [Copies available to subscribing hospital members, or to order, call: 202-672-5920.]

Claim Denial Appeals Process with Sample Appeal Letters and Sample Spreadsheet (in Excel format).
Provided with permission from: Jeffrey W. Shutak, CHFP, Patient Accounts Manager, The Memorial Hospital, North Conway, NH. [Go to: www.dekaye.com, Select: On Target Newsletter; January 2001 issue to access and download material.]

"Measuring Claim Denials"
by Allan P. DeKaye, MBA, FHFMA, President and CEO, DEKAYE Consulting, Inc. [Go to: www.dekaye.com, Select: On Target Newsletter; October 1999 issue to access and download article.]

 

Perspectives and Commentary

Developing Career Path Opportunities In the Cash Flow Cycle

By Allan P. DeKaye, MBA, FHFMA, President and CEO, DEKAYE Consulting, Inc.

All too often, cash flow cycle managers, whether in the Access or Patient Financial Services departments, complain about difficulties in recruiting and retaining qualified staff. The dilemma intensifies, when an authorized vacancy or new position is actually approved. You finally attract a candidate who, while likeable, has no experience. But the fact that this is a "warm body," someone who breathes and (hopefully) can communicate, they are hired in order to fill the vacancy.

This is not to say that there aren’t any "diamonds in the rough," but experienced individuals who have a working knowledge of insurance benefits, billing, collection or related areas, can fit in and more quickly adapt to operational sequences in the revenue cycle. The role of supervisor and manager is to train staff, and measure and monitor their performance. So we should be capable of molding most staff into productive members of our team. Think about it; we also complain about our existing staff. They’re not motivated. They don’t perform. They’re average. What can we do about it?

Supervision is an Important Ingredient

Supervisors play an important role in helping new staff acclimate to their role and responsibilities. Pro-active, hands-on training is an important first step. Many times, this task is relegated to a co-worker. Good work habits are passed on; so are bad ones. Supervisors need to play an direct role in staff training (unless you are fortunate to have a full time training staff or trainers). Setting expectations about performance, appearance, customer focus, etc., are critical skills that when practiced, improve the success outcomes for staff.

Paving the Way; Paying the Freight

The cash flow cycle can be a "dead end" job. Unless you enter the supervisory or management ranks, individuals can languish as billing clerks, registrars, or collectors. In some instances, we elevate staff to "senior" representative or lead worker positions. This tends to occur in unionized facilities. In city or county facilities, there may actually be civil service exams that help order the promotion to various higher levels within a structure. But the same is true in non-union environments, too.

While those who manage in a unionized environment often begrudge this bureaucracy, it does order the progression. There is a union contract, and it should be viewed as working for management, as well as for the unions.

These agreements also provide some relief (albeit limited) in the pay raises ascribed to "time in grade" and "time in service." While not an advocate of "incentives," per se, a pay-for-performance, or reward for performance has even found its way into some collective bargaining agreements, especially when the alternative is layoffs and/or loss of positions. Under the right set of circumstances, they can provide a level of motivation that can help individuals and departments reach higher levels of productivity, as well as increased accuracy in the work that is done.

Having some way to advance, even if it is to earn the next incremental pay level, will be important to some individuals. Others will be content "not to rock the boat." Hopefully, these individuals will give a good day’s work for a good day’s pay–with "good" being a relative term acceptably defined by both superior and subordinate.

As managers, we are demanding more accuracy to detect hidden insurances, distinguish PPO from POS plans, apply contractual allowances, and determine when advanced beneficiary notices should be issued. The level of complexity in the core functions of the cash flow cycle require that staff does more than simply register, bill and collect. Even the biller, responsible for electronic transmission, needs to assure that claims are transported to and from clearinghouses, as well as delivered to their final payer destination.

Collectors need to know payment terms and rates to ensure that payments are at the proper levels, and that time frames have either been exceeded or met. Registrars may need to know how and when to handle "deferral of elective, non-emergent" care situations (if that is the hospital’s policy), or know when it is appropriate to engage an ER patient about financial information, keeping in mind EMTALA regulations.

All this and more, and some staff can earn higher salaries working in fast food or convenience stores. Though not meant to demean the latter, but we are now requiring and insisting on more in terms of an individual’s skill sets. Yet in our medical centers and other health care facilities, we pay relatively little in comparison to these other jobs. If we are going to place this higher level of job responsibility on the staff who occupy the "front" and "back" office operations, we, as an industry will need to develop pay scales that are commensurate with the function. This will mean a greater investment in terms of salary and training, if we are to attract higher caliber individuals.

Recruiting: Select Don’t Settle

Recruiting needs to be more selective. Make sure that you post positions, and start your search before the need is urgent. This may entail getting senior management budget approval more quickly. Work towards upgrading job descriptions. While salary scales may present both budgetary and other labor issues, try to tie increases to demonstrable job characteristics.

Use probationary periods to weed out those who won’t meet your needs. In order to accomplish this, supervisors need to be more involved in the training and performance review process. The interview process can be a helpful tool in screening for excellence. Ask tough questions. Try to gauge how people will react in difficult situations that are likely to occur in that position.

Create an environment that will cultivate success. A self-fulfilling prophecy of defeat can easily be conveyed from the top down. That is not to say that all supervisors and managers should do is be "cheerleaders." Quite the contrary, the leadership they provide should provide motivation, expectation and acknowledgment. Advocacy for your staff is an important characteristic for those who manage and direct operations. Look to hire those who can accept a challenge. To paraphrase Browning: "one’s reach should exceed one’s grasp." At least, that is what we should be aiming for.

   DEKAYE Consulting Inc. is pleased to announce that its President and CEO, Allan P. DeKaye, MBA, FHFMA, published an article entitled: "Do No Harm: Consultants and Compliance."  The article appeared in the October 8, 2001 issue of "CCH Healthcare Compliance Letter."  The article appears in .pdf format.

The Contributor's Corner

Home Health Care Update 2001

by Andrew B. Shulman, Manager, Holtz Rubenstein & Co., LLP

Federal Government Responds to September 11th Attacks

To facilitate necessary care and treatment caused by the September 11th attacks, the Centers for Medicare and Medicaid Services (CMS) has come through to assure that all beneficiaries will have access to the emergency or urgent care they need. The New York State Department of Health has also made it known that patient care was its most basic concern and policy decisions like OASIS assessments, would take a back seat. Needless to say, the home care community has been compassionate in fulfilling its mission, as it seeks to heal and help rebuild.

Good News on the Way

A much anticipated study just released has shown nearly a whopping 88% of the total certified HHA community (approximately 7,000 agencies) are profitable. Prospective Payments has generally been good news for the home health industry, despite a wish list of how associations and member providers would like to see CMS reduce the regulatory burden placed on providers.

Now, over the last several weeks, the spotlight has shifted to Tom Scully, new CMS administrator, to begin easing policies and procedures, and assuring the certified home health community that the 15% cuts for PPS payments will not go into effect beginning October 1, 2002. The focus is still on positioning home care for future growth by hopefully making Medicare and Medicaid regulations less burdensome. This might include eliminating start-of-care OASIS questions, and the current requirement that HHA’s collect OASIS data from non-Medicare/non-Medicaid patients, etc.

Industry Still Facing Staff Shortages

In order to assure that eligible beneficiaries are getting access to home care, the current shortage of nursing professionals is high on the "concern list." It is both a long and short-term issue that will need to be addressed by those connected in Washington. The National Association for Home Care (NAHC) supports congressional efforts designed to alleviate the nursing shortage through increases in Medicare reimbursement.

Moreover, NAHC recognizes that home health agencies and hospices are not only experiencing a shortage of skilled nurses, but of other essential workers, such as personal care attendants and home health aides. NAHC has called for changes under the Medicare program so that, potentially, home health agencies would be on an equal footing with hospitals in competing for staff. Also, it has been suggested to put out health insurance subsidies, and other incentives to home health care-givers in an effort to make such positions a more desirable employment option.

     Health Care On The Web

Recent Health Care press releases:

Medicare

CMS : CMS ANNOUNCES PHYSICIAN PAY CHANGES FOR 2002
CMS: MEDICARE SIMPLIFIES ENROLLMENT FORM
CMS: MEDICARE ANNOUNCES PAYMENTS FOR HOSPITAL OUTPATIENT SERVICE

Medicaid

CMS STATEMENT OF TOM SCULLY, ADMINISTRATOR CENTERS FOR MEDICARE & MEDICAID SERVICES ON MOTION TO STAY PROCEEDINGS IN FEDERAL COURT CONCERNING MEDICARE-ENDORSED RX DRUG DISCOUNT CARD INITIATIVE

Compliance

OIG: WHAT'S NEW

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D E K A Y E Consulting, Inc.
231 Oakview Avenue, Oceanside, NY 11572  Phone/Fax: (516) 678-2754
URL: http://www.dekaye.com E-Mail: Adkcmpa@aol.com or DKConsult1@aol.com