Provider Bills: The Wild World of Hospital Chargemasters

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Provider Bills: The Wild World of Hospital Chargemasters

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Supply/Implants Price. 4 BONE DWL FZ 18X23 4012 $66,000.00. 2 BONE GRAFTON PUTTY 10C $12,962.50 ... Surgical Misadventures: unused and/or incorrectly billed hardware ... – PowerPoint PPT presentation

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Title: Provider Bills: The Wild World of Hospital Chargemasters


1
Provider Bills The Wild World of Hospital
Chargemasters
  • Stacy M. Borans, MD
  • Chief Medical Officer
  • Advanced Medical Strategies

2
Learning Objectives
  • Understand how to assess provider bills for
    unbundled charges, inflated charges, billing
    errors, level of care issues, and coding errors.
  • Be aware of the bill adjudication options.
  • Know when to refer a bill for an audit.
  • Know the differences among the various audits
    available.
  • Understand the role of the Stop Loss Policy/Plan
    Document in a Provider Bill Audit.

3
Provider Bills Golden Rule
  • If youve seen one claim, youve seen one claim.

4
Provider Bills The Basics
  • Required Elements for Evaluating Claims
  • UB 92 or HCFA 1500
  • Itemized Claim
  • Stop Loss Policy/Plan Document Language
  • Operative Report if Procedure Completed
  • Spinal FusionImplants
  • Gastric Bypass
  • Cochlear Implants

5
Provider Bills Medical Necessity
  • Critical Care Levels easiest to assess
  • Ventilator without tracheostomy
  • Blood Pressure support drugs-Dopamine,
    epinephrine, etc.
  • Invasive lines-Swan Ganz, arterial lines
  • Other levels of care are more difficult to assess
  • Telemetry-Monitored Setting
  • Acute Medical, Surgical or Rehab
  • Subacute Medical or Rehab
  • Skilled

6
Provider Bills Medical Necessity
  • Be aware of potential experimental/investigational
    issues
  • Gamma Globulin
  • Avastin, Erbitux, Rituxan-Other Chemotherapeutic
    Agents
  • CellCept-primarily used to prevent rejection in
    transplant patients
  • Epogen, Neupogen, Remicade and Growth Hormone
  • Always helpful to have a clinical opinion before
    reimbursing or denying the claim

7
Provider Bills Infants
8
Provider Bills Infants
  • Indications for Nitric Oxide Use
  • Infants gt34 weeks gestation
  • Hypoxic respiratory failure with pulmonary
    hypertension
  • Conventional treatments have failed
  • Should be performed in centers with ECMO
    capability

9
Provider Bills Infants
  • NICU has multiple Levels of Care
  • Level 4 Cardiac ICU/ECMO
  • Level 3 Neonatal ICU
  • Level 2 Transitional Nursery/Step Down
  • Level 1 Well Baby Nursery

10
Provider Bills Inflated Charges
  • Case Study
  • 53 year old female with past medical history
    significant for multilevel degenerative disc
    disease. Admitted to hospital for anterior
    discectomy and fusion.
  • LOS 6 days
  • Total Billed Charges 235,000
  • PPO discount 20

11
Provider Bills Inflated Charges
  • Quant. Supply/Implants Price
  • 4 BONE DWL FZ 18X23 4012 66,000.00
  • 2 BONE GRAFTON PUTTY 10C 12,962.50
  • 2 TSRH3D PC CON ROD 6.35 3,430.00
  • 1 TSRH3D CONN MED 837913 4,968.00
  • 2 SCREW TSRH3D 637-635 4,344.00
  • 2 SCREW TSRH3D 637-640 4,344.00
  • 2 SCREW TSRH3D 837-735 4,344.00
  • 2 BONE OSTEOPHIL RT 10CC 14,220.00
  • 5 TSRH3D CONNECTR 6.35-S 24,840.00
  • 6 TSRH3D LOCK SCRW 82812 3,963.00
  • 2 INFUSE-MED 7510400 52,600.00
  • SUBTOTAL 196,265.50

12
Provider Bills Inflated Charges
13
Provider Bills Inflated Charges
14
Provider Bills Inflated Charges
15
Provider Bills Inflated Charges
16
Provider Bills Inflated Charges
17
Provider Bills Inflated Charges
  • Potential Charge Issues
  • Implants/Devices greater than 50 of total billed
    charges
  • Daily Room Rates-ICU Bed Rate gt2,000/day,
    Med-Surg Bed Rate gt1,000/day
  • Dialysis-Monthly Charges greater than 7,000 or
    individual Dialysis Charges greater than 2,000
  • Erythropoietin (EPO)-Charges greater than 1,000
  • Individual Chemotherapy/Radiation Therapy Claims
    greater than 15,000

18
Provider Bills Inflated Charges
  • Hospital of The University of Pennsylvania
  • Philadelphia, Pennsylvania, 19104
  • Hospital type Voluntary Nonprofit Other
  • Data for the period ending 6/30/2006

19
Hospital Charge Comparison(http//www.hospitalvic
tims.com)
  • UPenn
  • Hospital Mark-Up 473
  • Cost to Charge Ratio 0.21
  • Total Costs to Hospital 845,781,104
  • Total Charges to Patient 3,997,318,578
  • Johns Hopkins
  • Hospital Mark-Up 122
  • Cost to Charge Ratio 0.82
  • Total Costs to Hospital 1,088,071,198
  • Total Charges to Patient 1,327,547,538

20
Provider Bills Inflated Charges
  • Mathematics 101 Inpatient Bills
  • General rule of thumb to assess charges
  • Divide the total billed chargesby the length of
    stay.
  • This will give you the average billed
    charges/day.
  • Assess excessive charges in the context of level
    of care provided.

21
Provider Bills Billing Errors
  • Billing errors come in a variety of forms
  • Duplicate Charges
  • Incorrect Quantities Cochlear Implants
  • Incorrect Pricing
  • Surgical Misadventuresunused and/or incorrectly
    billed hardware
  • 28 hour days for ventilator or respiratory care
  • Equipment used for multiple patients

22
Provider Bills Billing Errors
23
Provider Bills Billing Errors
24
Provider Bills Billing Errors
25
Provider Bills Billing Errors
26
Provider Bills Unbundled Charges
  • Tests and other services that are automatically
    performed as a panel,group or set, should be
    billed asa single service.
  • When a provider breaks these servicesout of the
    bundled group and bills them individually, the
    provider is deemed to be "unbundling."

27
Provider Bills Unbundled Charges
  • Daily Nursing Charges or daily ventilator charges
    in addition to room and board
  • Lab drawing fees for blood tests
  • Airway clearance and oxygen in addition to
    ventilator charges
  • Chemistry Panel Charges plus individual
    electrolyte charges
  • Solutions and mixture charges for IV medications

28
Provider Bills Unbundled Charges
29
Provider Bills Unbundled Charges
30
Provider Bills Multiple Issues
31
Provider Bills Adjudication Options
  • Adjudicate claim with the PPO discount
  • Attempt negotiation with hospitaleven if PPO
    discount is in effect
  • Clinical Review if Medical Necessity Issues
    identified.
  • Provider Bill Audit if excess charges/billing
    errors identified.

32
Policy Language(Both Stop Loss and Plan Document)
  • Detailed UCR Language is to your advantage.
  • Carve out drugs 200 of AWP
  • Carve out Implants Invoice plus a percentage
  • Percentile at which charges will be covered for a
    geographic region75th, 85th, 90th
  • Cite sources Ingenix, Red Book, etc.

33
Policy Language(Both Stop Loss and Plan Document)
  • Specific and Detailed Definitions are most
    helpful
  • Experimental/Investigational Language
  • UCR Language
  • Medical Necessity/Custodial Care
  • Proactive Language is also helpful
  • 50 notices
  • Premium discounts for aggressive claim management

34
Provider Bills In Summary
  • All claims are NOT created equal.
  • If you think you have a billing issue, you
    probably do.
  • Many billing issues can be identified internally
    by reviewing complete claim information.
  • Identify trusted resources for assistance.
  • Investigate all your options prior to
    adjudication
  • Detailed Stop-Loss Language is helpful

35
Audit Options Reasonable Customary
  • Advantages
  • Significant Savings
  • Prompt Turnaround
  • Disadvantages
  • No Opportunity to look at Medical Necessity
  • Provider Appeals
  • Possible confliction with PPO contract

36
Audit Options Billing Errors
  • Purpose Identify billing errors and
    discrepancies.
  • Resources
  • Coding Expertise
  • Clinical Expertise
  • Process
  • Review of Plan Document
  • Line-by-line adjustments made to itemized charges
  • Removal of Inappropriate Charges
  • Duplicate Charges
  • Unbundled Charges
  • Coding Errors
  • Adjustments to LOS, LOC and Utilization

37
Audit Options Billing Errors
  • Generate Report
  • Presentation to Provider
  • Sign-off
  • Appeal
  • Negotiation/Settlement/Sign-off
  • Advantages
  • Provider Less Likely to Appeal
  • Disadvantages
  • Audit Does Not Address RC and May not Yield
    Significant Savings
  • No Opportunity to Review the Medical Record and
    Medical Necessity

38
Audit Options in Summary
  • Weigh the Advantages and Disadvantages Between
    Audit Types
  • If the Claim is In-Network Ensure the PPO
    Contract Supports the Audit Process. Avoid
    Accessing Contracts With Audit Restrictions.
  • Every Claim is Unique Find the Most Appropriate
    Audit Solution
  • Understand and Enhance Policy Language to Support
    the Audit Process

39
Questions/Comments
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