OVERVIEW Anniversary of the APR-DRG system implementation – affecting admissions after July 1, 2013. Significant in light of Medicaid-ACA expansion to cover more beneficiaries and DHCS capitation policies. There will be more Medi-Cal eligibles through the Presumptive Eligibility program as well as the elimination of the disability eligibility criteria – - More beneficiaries than ever will have Managed Care cards – - Out of network Medi-Cal Managed Care emergency stays get paid per Medi- Cal APR-DRG. Replaced Selective Provider Contracting - DRG base price and hospital-specific cost/charge ratio allow DHCS to adjust reimbursement to hospitals - 1 -
Services excluded from APR-DRG Payable per diem* & Require a “traditional” per -day TAR • inpatient services provided to Medi-Cal beneficiaries with restricted aid code • administrative day services (2 levels) • psychiatric • acute intensive rehab • OB and Newborn services associated with normal delivery Other* inpatient services require only an Admit TAR * Generally speaking, there are exceptions - 2 -
No more claim splitting to match approved TARs – except... • Interim claims – for stays that exceed 29 days (submitted with bill type 112 and 113 and patient status code 30) • Interim bills pay $600.00 per day. Once the patient is discharged, a 111 bill needs to be submitted – prior interim payments will be voided and retracted and a single APR-DRG payment will be issued. - 3 -
Claim accuracy - “preventive care” • “Clean” or “technically complete claims” are entitled to payment. Cal. Welf. & Inst. Code §§ 14104.5, 14040 (c) and 14040.5 (e) (1)). • Cal. Welf. & Inst. Code §14040 (c) [“...] a "technically complete claim" means any billing request for payment from a provider or the billing agent of the provider, including an original claim, claim inquiry, or appeal, that is submitted on the correct Medi- Cal claim form or electronic billing format, is fully and accurately completed, and includes all information and documentation required to be submitted on or with the claim pursuant to Medi-Cal billing and documentation requirements .” (emphasis added) - 4 -
Common Billing denial reasons RAD 002 and 314 – eligibility problems: • Check claim for errors • If there are no errors , the denial was caused by Medi-Cal FI’s glitch – See March 13, 2014 EPC letter RAD 010 – dates of service overlapping with another claim (for the same, or another provider) • It should be less of a problem after the APR-DRG system went into effect as there should be fewer claims that need to be split because TAR days being separately approved. • It is more likely now that claims will deny because another facility’s billing (e.g., SNF bed holds). Use the Correspondence Unit but make sure claim is appealed at the same time. • Occasionally, this denial affects claims for pregnant women where OB- related procedure is reported twice during 6 months’ period. - 5-
Claim Processing problems related to Medi-Medi patients with part A exhausted and part B payment reported on a Medi-Cal claim. OVERPAYMENTS - When Medicare part B amount is not deducted - Grapevine: Medi-Cal is considering dealing with overpayments through the EPC (ERRONEOUS PAYMENT CORRECTIONS). Until then, overpayments need to be refunded via CIF and/or appeal or check. • http://files.medi-cal.ca.gov/pubsdoco/epc/epc.asp - 6 -
When prevention failed – dealing with denials Perils of rebilling missing the 6 months’ claim timelines deadline Welf. & Inst Code 14115 (c) (1) (A) & Cal. Admin. Code tit. 22, § 51008.5. - 7 -
...dealing with denials continued... Appeals A healthy practice: o addresses denial/other problem with the claim without risking payment reduction; o Acknowledgment and appeal denial letters are forever maintained on ACS’ website; o Appeal is a necessary step if provider wishes to seek judicial remedy. Must be be done according to Medi-Cal timeliness and documentation requirements: Timeliness: Within 90 days following the action/inaction precipitating the complaint (California Admin. Code tit. 22, §51015). Providers who are not satisfied with the decision after completing the appeal process may seek relief by judicial remedy not later than one year after the appeal decision. (Cal. Welf. & Inst. Code § 14104.5.) - 8 -
...dealing with denials continued... Appeals Documentation: http://files.medi-cal.ca.gov/pubsdoco/publications/masters-mtp/part2/appealform_z02.doc Cal. Welf. & Inst. Code §14040 (c) - 9 -
...dealing with denials continued... CIF Acknowledgment sample - 10 -
...dealing with denials continued... PART B PC-PRINT sample - 11 -
...dealing with denials continued... Question: 1) does anyone have ability to create bills with the UB-04 BOX 71 showing a 3M-grouped APR-DRG code INCLUDING level of severity (1-4: minor, moderate, major & extreme)? and, 2) does anyone actually generate such bills and use them to bill Medi-Cal and Medi-Cal Managed Care payers? - 12 -
Case management and its effects on revenue cycle Provider community feedback: Medi- Cal nurses’ review focuses on conditions on admission – most patients are emergent and thus most APR-DRG Admit TARs are approved Per-day review now only applies to the APR-DRG exempt service categories: Psychiatric medical necessity criteria can still be found at Cal. Administrative Code tit 9, §1820.205. Acute rehabilitation criteria are listed in DHCS ’ Medical Necessity Manual Chapter 5.5, Publication R-16-00. - 13 -
Case management and its effects on revenue cycle continued .... Administrative days Documentation of placement efforts – LA County: 10 daily phone calls – to 10 different SNFs except weekends, with documentation of responses • For dates of service August 1, 2011 to date: administrative days Level 1, rev. code 169 pay $416.95 per day + hospital-specific percentage of select ancillary codes) • For dates of service July 1, 2013 to date: administrative days level 2, rev. code 190 (pediatric) pays $894.60 & rev. code 199 (adult) pays $896.67 per day http://files.medi-cal.ca.gov/pubsdoco/publications/masters-mtp/part2/admin_i00.doc - 14 -
Case management and its effects on revenue cycle continued .... Patients with aid code restricted to emergency services only Cal. Welf. & Inst. Code 14007.5 (d). Cal. Admin. Code tit.22, §50302 and §51056 • Generally, Medical Necessity in Medi-Cal context is defined broadly: Welf. & Inst. Code §14059.5 service is "medically necessary when it is reasonable and necessary to protect life, to prevent significant illness or significant disability, or to alleviate severe pain." Also, California Admin. Code tit.22, 51003. • Emergency services are significantly limited: Cal. Admin. Code tit.22 51056 (a) “Emergency services” means those services required for alleviation of severe pain, or immediate diagnosis and treatment of unforeseen medical conditions, which, if not immediately diagnosed and treated, would lead to disability or death. DHCS Medical Necessity Manual Publication R-15-98E Medical care directly related to the emergency will be covered. On the other hand, treatment aimed at a cure or long-term solution to the problem [...] related to the underlying chronic condition [...] shall not be authorized or reimbursed by Medi-Cal program. - 15 -
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