In this episode, Michelle Keller-Eiler, Manager in the Revenue Cycle team at BESLER walks through the essentials of Transfer DRG revenue recovery for Medicare Advantage discharges.
Michael Passanante: Hi, I’m Mike Passanante, the host of the Hospital Finance Podcast. Welcome back. Today, I’m going to be talking with Michelle Keller-Eiler who’s a manager in our Revenue Cycle team here at Besler Consulting.
Michelle’s going to talk to us about Transfer DRG for Medicare Advantage discharges. Welcome to the show, Michelle.
Michelle Keller-Eiler: Thank you.
Michael: So let’s dive right in. With the growth in Medicare Advantage populations, can acute hospitals recover Transfer DRG underpayments from the Medicare Advantage plans?
Michelle: Technically, yes. However, under payment recovery from Medicare Advantage plans differs from traditional Medicare.
Many Medicare Advantage plans pay based on DRG which is required for the review. It is important to understand your Medicare Advantage penetration using publicly available data for your area as well as specific hospital statistics to ensure your efforts will pay off.
Michael: So how is the recovery effort different from the traditional Medicare recovery process?
Michelle: Unfortunately, without the availability of a Common Working File for Medicare Advantage, the process is very manual. There is much more direct contact with the payers and post-acute care providers involved. Ultimately, there are many more touches on each account to confirm if the planned post-acute care was actually received.
Michael: So I understand providers have four years to recover Medicare underpayments. Does that same timeline apply to Medicare Advantage?
Michelle: Unfortunately, most plans do not allow a four year look-back. However, we have discovered some plans which do allow this with the use of Medicare language allowing a claim reopening based on good cause.
In most cases, the timely filing limits are very specific to the plan and the provider. Providers must be aware of the specific limits when embarking on a Medicare Advantage transfer review. You want to refer to your contract for further details and use your findings for future contract negotiations.
On average, when we perform the review, we’re doing a one-year retro look-back.
Michael: Are there any other concerns with regards to contracts?
Michelle: The first step is to confirm that the reimbursement is based on Medicare DRG. And then you want to look and see what percentage of the DRG so you can correctly calculated your expected additional reimbursement. Some plans will pay it 100%, others are set at 95%, 105%. It does vary based on the contract.
You also want to look for any specific carve-outs that are relevant to the post-acute care role.
Michael: Talk us through what’s required to start this type of review.
Michelle: First, the facility will have to have a data file that includes all Medicare Advantage discharges with relevant patient data for the appropriate time period. Additional information required in the file would be the DRG, the length of the stay, the insurance plan and ID number, the discharge status and, if available, the plan post-acute care provider.
The reviewer will also need to identify which accounts are impacted by the rule. This is based on a few factors. First again, the plan details as we mentioned to make sure that it pays based on the DRG, the DRG, the length of stay and the discharge status.
Once the impacted accounts are identified, the validation process can begin. Identifying the impacted accounts is a key step prior to beginning the validation as only those accounts that qualify should be reviewed.
Michael: Who needs to be involved with the review?
Michelle: It depends on if the review is to be handled internally or if it’s going to be outsourced to an external partner.
Michelle: If the review is handled internally, multiple departments will need to be coordinated to ensure accurate and compliant completion of the review. It certainly takes a team-centric approach with a project manager overseeing the many moving parts.
It will start with IT or finance who will need to run a data file with the required elements; a contract manager or Medicare Advantage manager familiar with the contracts will need to identify which plans should be included and the timely filing requirements for each; HIM or case management will need to identify the plan post-acute care provider if that information is not available in your data pool; the staff members need it to validate the post-acute care;
A clinical team member will need to review for medical relatedness for home health claims. The appropriate staff member will need to update the discharge status for claims identified as needing correction; a billing team member to appropriately submit the corrected claims with any requirements from the plan; a follow-up staff member will be needed to appeal any incorrect processing of the corrected claims; and of course a member of management to determine how to handle the documentation of each corrected claim in the event there is an audit.
So that’s very team-centric for internal reviews.
If you’re going to outsource the review to an external partner, the vendor requirements for the engagement will be outlined with the client. Generally speaking, the data file will still be required. So that will involve IT or finance.
Post-acute care provider information will be needed. If it’s not included in the file, access will need to be granted or HIM involvement will be required.
Depending on the contract, billing and follow-up can be done by the vendor or the facility. If the facility choses to re-bill, then that would require their billing staff involvement.
It’s important to identify a liaison that will be working with the external partner to manage through the issues that surface. You want to keep a guage on what’s being worked on and what’s approved. Most of the time, this is done on a contingency basis on recoveries collected. Remember, compliance is still key.
Michael: What’s involved in resubmitting a corrected claims? Is it the same as submitting an adjusted claim for Medicare?
Michelle: There are many steps involved with submitting the corrected claims to the Medicare Advantage plan. It’s not the same as submitting to Medicare. You want to identify the correct address before resubmitting the hard copy corrected claim or you need to know if it has to be sent electronically. You want to identify if there are specific requirements to submit the corrected claim to the payer. Sometimes, they require a claim form, a cover sheet or almost like an appeal letter.
You do also want to identify the appeals process and that appeal’s address in the event that you need to go to that route. You want to contact your provider representative for special reprocessing unit procedures. Occasionally, if you’ve appealed a claim and it’s still denied incorrectly, you can go through that special reprocessing unit for payment.
Again, you need to refer to your contract terms for process and procedures. You may need to have a different process for different plans. Unfortunately, there’s no one-size-fits-all with these.
Michael: This is a pretty intense process. How time consuming is it?
Michelle: Unfortunately, the process is very manual and very time-consuming. Compliance and adherence to regulations is critical. The validation process for each claim involves multiple touches and multiple calls. It’s not a simple calculation determine if a claim has been financially impacted by the transfer rule.
And there can be a lot of wasted follow-up work unless the review is properly focused on the real opportunities. Without the Common Working File, FISS or another single system to compare against, submit and follow up on claims, significant resources are needed. Contacting multiple payers each with their own requirements, timely filling guidelines, appeal timeframes and issues with resubmission all takes time and a knowledgeable person.
Once a corrected claim is submitted, additional time is needed to follow up as there are instances in which the claim is not reprocessed correctly. For example, a duplicate claim denial will need appropriate follow-up and resubmission as required by the plan. This sometimes involves multiple phone calls, sending appeals, completing additional worksheets, cover sheets. And all of these need to be submitted to the correct address for the plan.
Ultimately, the time and effort spent is rewarded with the appropriate recovery for the underpayment.
Michael: So one final question for you, Michelle. Are there any post-review items that hospitals should be considering?
Michelle: You spend a lot of time looking at your managed care contracts in this. So when you’re reviewing your contracts early on in the process, you may find key items that should be renegotiated during the new contract renewal.
As a result of the review, there may also be unexpected issues identified. For example, since length of stay is an element that needs to be evaluated to ensure the claim needs further review, you may find that a particular DRG has a consistently longer length of stay than the geometric mean length of stay.
Another example could be nursing home patients that come to your facility frequently and return to the nursing home as long-term care residents not under skilled care. And they are assigned a skilled care discharge status which is not consistently incorrect. You could help identify those patients and monitor them moving forward.
By working through the validation process, re-billing or follow-up process, areas of improvement may be noted by the team. These process improvements should be implemented in the next batch of data.
Speaking of the team, during the review, there’s a lot of team work involved to ensure accurate and compliant results. It’s important to recognize the team-building that occurred during the process as everyone is working together.
Michael: That’s great information, Michelle. Thanks for spending some time with us today.
Michelle: Thank you!
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