Transfer DRGs: Approaches to Revenue Recovery
Under Medicare reimbursement regulations, when certain patients are discharged to post acute care, the discharging hospital is paid at a reduced rate. In some cases, this reduced payment is not justified by the actual post-discharge care. These underpayments are not reflective of coding or billing errors on the part of the provider, but more commonly result from a change in the planned course of treatment subsequent to discharge.
This white paper discusses solutions that allow hospitals to recover the revenue they’ve properly earned when they’ve been underpaid due to the Transfer Rule. Many of the issues and solutions discussed in this white paper also apply to Medicare Advantage transfer claims.
The Value of an Independent Cost Report Review
An accurate and complete Medicare cost report should be a top priority for hospital CFOs and Chief Compliance Officers.
The Medicare cost report continues to play a critical role in the determination of Medicare reimbursement to hospitals and health systems. With the appropriate understanding and review, this report can assist management in future budgeting, decision support and strategic planning.
This white paper discusses the construct of a cost report and how an independent review can lead to revenue opportunities and maintain compliance.
The Value of an Independent IME Review
In 1997, CMS put in place a procedure to pay teaching hospitals for the medical education portion of their reimbursement through a complex system of multiple claim submissions for Medicare Advantage inpatient acute discharges. This system costs hospitals in the US well over $100 million each year through missed payments. The continued year-over-year growth of Medicare Advantage enrollment means that these costs will only increase. Even non-teaching hospitals are at risk due to subsequent regulatory activity. A specialized third party review of a hospital’s billing process can ensure both proper revenue capture and compliant billing while providing a roadmap for process improvement.
This white paper discusses Medicare Advantage enrollment trends, reasons why IME revenue is missed and the benefits of an independent shadow billing review.
Hospital Observation Services
Hospitals are facing several worrisome industry trends such as decreasing inpatient admissions, increasing “observation admissions” and more medical necessity denials resulting in financial challenges.
Many are under pressure to balance inpatient admissions with observation services. A properly deployed observation service has the potential to achieve cost savings for the hospital and improve patient care and satisfaction.
This white paper discusses several approaches to the implementation of observation services and provides best practice advice on optimal approaches for structuring observation services.