Month: October 2021

Contract Consulting

Posted on by EM Squared
Revenue Capture

Complex reimbursement methodologies and ambiguous contract language are often the reason behind underpayments. Our review begins with a comprehensive analysis to identify the risks associated with each contract. We’ll collect the insurance revenue you’re due, and help you close contractual loopholes in future negotiations.

Our review begins with a comprehensive analysis of payer agreements, regulations, and legislation to identify the risks associated with each contract. We take special note of high risk contract language such as readmission clauses, coordination of benefits, and carve-outs for special services. We then utilize this analysis to complete an in-depth review of all related claims to identify underpayments.

Regular project updates are customized to inform your team of the top underpayment trends we uncover. We work directly with your team to ensure revenue integrity by implementing processes to strengthen controls, close payer loopholes, and provide contract language recommendations for future negotiations. In situations where the standard appeal process does not yield results, PARAREV can assist in escalating major underpayment issues to achieve resolution.

Managed Care Remit Reconciliation

Posted on by EM Squared
RevTeg
Revenue Integrity

Available as part of the overall Contract Analysis or as a stand-alone service, the Managed Care Remit Reconciliation provides an analysis of payments reconciled against contract rate sheet.

In order to ensure claims are properly paid per contracted terms and improve your overall billing process, we will analyze your 835 remits with managed care settlement terms  to identify improperly paid claims, creating actual versus expected reimbursement. From there, we provide a report to review claims by payer to identify trends that can be addressed to maximize reimbursement or improve the billing process.

We will provide a comprehensive report package outlines charges, adjustments, allowed amounts, payment amounts, and projected payment amounts.

Contract Analysis

Posted on by EM Squared
RevTeg
Revenue Integrity

Contract management and analysis is one of the most critical focus points of revenue cycle management to ensure effectiveness and better reimbursement. Hospital Financial Managers need a tool to manage, evaluate and optimize reimbursement to achieve the required returns.

There are three components to the process:

1. The Payer Scorecard – a high level snapshot of denials from your top ten payers

2. Remit Reconciliation – analysis of payments reconciled against contract rate sheet

3. Pro Forma Analysis – comparison of existing terms to proposed terms to analyze the impact

The Scorecard exports an Excel spreadsheet with a summary that displays information by payer including total charges, contractual adjustments, allowed amounts, patient responsibility amounts, and paid amounts. That is followed by the summary of denials, and an analysis of performance by patient type. Users can choose to examine the remittance denial codes within one or more individual remittances, or among all remittances within a date range. This review can be done within the tool, or a package of reports can be exported for analysis. Analysis can be performed on contracts under negotiation by comparing the proposed terms against the current terms, displaying the impact based on the remits received. Each remit is assigned a current contract parent and a Proforma contract, then settled side by side to see how the proposed terms will impact reimbursement. This will provide the hospital a basis for counter proposal to ensure revenue is not negatively impacted with a new contract.

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ParaRev Data Maintenance

Posted on by EM Squared
RevTeg
Revenue Integrity

With all of the constant changes to coding and billing requirements, many organizations are overwhelmed with maintaining billing systems. Annual pricing updates are also a challenge for many facilities. ParaRev has the capability to assist the hospital in the implementation of updated CPT®/HCPCS codes and prices through ParaRev’s Data Maintenance Services which allows your hospital to maintain ongoing updates to your change master through remote access.

Hospital resources are finite, and with the constantly evolving environment of healthcare, codes and billing requirements can be hard to manage.  ParaRev’s Data team serves as a relief valve to ensure that the changes we are proposing our implemented in a timely and accurate fashion.

ParaRev can produce a custom upload file or ParaRev will process the price change manually and/or scripting changes directly into the billing system utilizing a secured remote connection.

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Lab PAMA

Posted on by EM Squared
RevTeg
Revenue Integrity

ParaRev’s Lab PAMA Reporting Service offers an efficient and accurate method to meet a new Medicare reporting requirement due from certain hospitals in the first quarter of 2022. The reporting is extremely burdensome and labor-intensive, and penalties are high for failure to report timely, complete, and accurate data.  Many hospitals are required to report, for the first time, “private payor” lab payment rates in detail during the first quarter of 2022. Medicare will use this data to set the Clinical Lab Fee Schedule rates for 2023-2025. 

ParaRev’s Lab PAMA reporting service uses electronic claim and remittance files to efficiently prepare copious amounts of payment data into a consolidated spreadsheet that can be used to confidently report private payor lab payment rates to Medicare. Reports are due in the first quarter of 2022 for a six-month period in which payments were made (Jan-June 2019) by private payors for each laboratory service CPT® code.

Our powerful web-based platform efficiently matches line item payment data from electronic remittances to claims submitted to commercial payors on the 14x TOB. ParaRev’s technology and expertise produces a detailed, comprehensive spreadsheet which supplies verifiable data organized in a manner that is easily adapted for submission on a consolidated report to Medicare.

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Claim Review

Posted on by EM Squared
RevTeg
Revenue Integrity

ParaRev will review detailed itemized and UB04 outpatient claims to identify missing charges, compliance problems, and billing issues. The review will be completed by a certified coder with extensive experience in all areas of coding and auditing.

From the review, we will identify charge process capture issues, coding and compliance errors, billing errors, and identify documentation and system issues. We will then:

  • Provide detailed and summary reports identifying ParaRev recommendations and impact on reimbursement
  • Provide supporting authoritative references to support ParaRev recommendations
  • Review our findings and provide education in a meeting with the opportunity for the client to ask questions, provide comments and discuss recommendations
  • Analyze reimbursement impact
  • Provide ongoing support regarding coding/billing questions through our PDE software

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Charge Master Review

Posted on by EM Squared
RevTeg
Revenue Integrity

With the emergence of codes as the basis for almost all forms of reimbursement, charge master coding and maintenance has become a daily chore. Ensure your hospital’s Charge Master is up-to-date and compliant by having ParaRev identify and correct errors, compliance issues and missing charges.

The ParaRev HIM Staff will review Medicare, Medicaid and Workers Comp code changes on a monthly basis and update the charge master where required, any changes which impact the charge creation and capture process will be reviewed in the monthly RMC.

The ParaRev Charge Master Review deliverables include: Checking invalid HCPCS/CPT® and Revenue Codes, checking line items for charge compliance and modifiers, checking valid code assignment, checking pricing internally and against fee schedules and pricing data, reporting and implementing updates. The desk review can be expanded with an “on-site review” to meet with each of the Revenue Department Managers and complemented with a “Claim Review” and on-site visit.

One of the main goals of the program is to empower and unleash the entrepreneurial forces contained within each Department Manager. Managers are encouraged to update codes, prices and add services throughout the month, Managers are often frustrated by the slow pace of the current charge maintenance process. ParaRev’s services ensure that everyone is involved in the charge master maintenance process.

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Purchase Item Master Review

Posted on by EM Squared
RevTeg
Revenue Integrity

Many health care organizations experience difficulties capturing and billing supply charges due to inconsistencies between the purchase item master (PIM) and the Charge Description Master (CDM) billing system. Many times these systems are not linked; and therefore become unsynchronized resulting in lost revenue and other compliance concerns. ParaRev’s Purchase Item Master Review brings together the coding and financial analytic components of our services to create a link and a process to appropriately maintain the purchase item master (PIM) and Charge Description Master (CDM) systems simultaneously.

Determining which supply items are billable and maintaining consistency between the Purchase Item Master (PIM) and the Charge Description Master (CDM) can become a daunting task for revenue cycle and materials management personnel. 

The goal of the PIM review is to identify all billable items contained within the PIM and reconcile the PIM by line item to the CDM. The review also analyzes the HCPCS and revenue codes for the PIM/CDM items, to ensure compliant and appropriate supply billing practices.

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Pharmacy Pricing Analysis

Posted on by EM Squared
RevTeg
Revenue Integrity

Hospitals are moving towards standardizing pharmacy pricing across all departments and services, thus improving compliance issues associated with inconsistent charging practices.

Although no standard methodology exists, it is ParaRev’s opinion that when creating pharmacy pricing methodologies, the following must be considered:

•  Self-Administered Drugs (SAD) should have lower markups to comply with Medicare billing standards

•  Pricing should be developed using a nationally recognized cost basis or actual acquisition cost

•  Fixed Add-On and Minimum Charges should be utilized to compensate for any use of additional departmental resources for handling or compounding the medication

The ParaRev Pharmacy Pricing Process assists facilities in creating a rational, cost-based pharmacy markup that remains sensitive to self-administered drugs and uses a nationally recognized cost basis. The project focuses on reducing self-administered drugs while increasing injectable items to meet the revenue goals of the organization.

The ParaRev Pharmacy Pricing Process deliverables include a proposed markup, gross and net revenue projections, an item-specific detailed spreadsheet proposed changes, and a full write-up of techniques and findings.

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