Data Quality:UBO & The Revenue Cycle

TMA Uniform Business OfficeProgram Manager

May 2012

Uniform Business Office (UBO) Organization UBO Cost Recovery Programs MHS Billing Systems MTF Revenue Cycle Data Quality and How it Affects Each Phase of the Revenue

Cycle UBO Success Factors Resources

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Outline

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UBO Organization Chart

TMA CFO

Director, Management Control & Financial

Studies Division

TMA UBOProgram Manager

Service UBO Program Managers

(Army, Navy, Air Force)

ASD (Health Affairs)Director, TMA

Deputy Director, TMA

Intermediate Commands(Army, Navy, Air Force)

MTF UBO

Army, Navy, Air ForceSurgeons General

Army, Navy, Air ForceChief of Staff

Army MEDCOMBUMEDAFMS

Com

mand – C

ontrol - Execution

Policy &

Guidance

Secretary of the Army, Navy, Air Force

UBO Advisory Working Group

Service IM/IT, legal reps & subject matter experts (SME)TMA/IRD, Unified Biostatistical Utility (UBU) Work Group,Defense Health Information Management System (DHIMS), Defense Health Services Systems (DHSS), MEPRS Management Improvement Group (MMIG)

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UBO Cost Recovery Programs

Third Party Collections Program (TPCP)

Medical ServicesAccount (MSA)

Medical AffirmativeClaims (MAC)

Third Party Collections Program- Bill insurers for care provided to eligible DoD beneficiaries

(excludes Active Duty) with other health insurance (excluding Medicare & TRICARE)

Medical Services Account- Includes billing for care provided to eligible patients from

Veterans Affairs/Coast Guard /NOAA/ PHS/Civilian Emergencies/Foreign Military & their Family Members

Medical Affirmative Claims- Bill for care provided to eligible DoD beneficiaries injured

by third parties

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Who Gets Billed Under Which Cost Recovery Program?

Third Party Collections Program (TPCP) - $190.5M (FY 2011)

Medical Services Account (MSA) - $281.2M (FY 2011)

Medical Affirmative Claims (MAC) - $15.1M (FY 2011)

ALL funds collected are retained by your MTF- TPC funds are in addition to the MTFs O&M budget

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FY 2011 Collections by UBO Cost Recovery Program

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Direct Care Third Party Collections Program (TPCP) Inpatient and Outpatient Amounts Billed and Collected

Cumulative Collections ($Millions) through 2nd Qtr 2012

*NOTE: Collected amount includes dollars for healthcare services provided in previous FYs and may exceed current FY billings.

On average, from FY07-FY11, 32% of total MHS uncollected dollars can be attributed to acceptable third party payer denials (co-pay, deductibles, out of network, non-covered benefits).

Data Source: MTF DD Form 2570 submissions to the TMA UBO Metrics Reporting System A/O 30 April 2012

Service Billed Collected Billed Collected Billed Collected Billed Collected Billed Collected

Outpatient

Army 40.40$ 24.70$ 46.70$ 33.60$ 43.50$ 37.10$ 35.70$ 26.30$ 39.50$ 26.80$

Navy 21.70$ 14.20$ 23.10$ 16.80$ 20.70$ 17.80$ 18.90$ 13.60$ 21.40$ 12.10$

Air Force 85.00$ 34.80$ 101.20$ 43.40$ 82.60$ 45.00$ 65.20$ 37.60$ 62.50$ 28.30$

Total 147.10$ 73.70$ 171.00$ 93.80$ 146.80$ 99.90$ 119.80$ 77.50$ 123.40$ 67.20$

Inpatient

Army 29.30$ 12.20$ 27.10$ 14.30$ 21.00$ 10.60$ 25.90$ 11.50$ 18.70$ 10.90$

Navy 11.10$ 3.80$ 7.80$ 3.80$ 7.70$ 3.80$ 8.40$ 3.50$ 10.70$ 3.00$

Air Force 13.40$ 5.20$ 11.00$ 3.50$ 14.30$ 6.20$ 10.60$ 4.60$ 7.40$ 2.70$

Total 53.80$ 21.20$ 45.90$ 21.60$ 43.00$ 20.60$ 44.90$ 19.60$ 36.80$ 16.60$

FY12FY08 FY09 FY10 FY11

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Top Three MTFs by Service for Inpatient TPCP CollectionsCumulative Collections through 2nd Qtr FY2012

Data Source: MTF DD Form 2570 submissions to the TMA UBO Metrics Reporting SystemA/O 30 April 2012

Service FacilityFY2012 Inpatient Collections

Army San Antonio Military Medical Center $3,355,118.77Army Washington D.C. (Walter Reed Army Medical Center) $2,102,469.16Army Ft. Lewis (Madigan Army Medical Center) $1,476,914.96Navy Walter Reed National Military Medical Center $917,678.42Navy NMC Portsmouth (VA) $837,947.81Navy NMC San Diego $512,655.48Air Force Wright Patterson AFB (88th Medical Group) $1,072,235.37Air Force Elmendorf AFB (3rd Medical Group) $353,558.32Air Force Lackland AFB (59th Medical Wing) $350,208.38

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Top Three MTFs by Service for Outpatient TPCP CollectionsCumulative Collections through 2nd Qtr FY2012

Data Source: MTF DD Form 2570 submissions to the TMA UBO Metrics Reporting SystemA/O 30 April 2012

Service FacilityFY2012 Outpatient Collections

Army Ft. Belvoir (Ft. Belvoir Community Hospital) $3,438,505.61

Army Ft. Meade (Kimbrough Ambulatory Care Center) $2,515,146.48Army San Antonio Military Medical Center $1,994,600.91Navy Walter Reed National Military Medical Center $2,674,416.80Navy NH Jacksonville $1,870,815.05Navy NMC Portsmouth (VA) $1,669,560.08Air Force Wright Patterson AFB (88th Medical Group) $2,623,703.47Air Force Elmendorf AFB (3rd Medical Group) $1,771,744.93Air Force Lackland AFB (59th Medical Wing) $1,756,542.57

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Top Ten MTFs for Total TPCP Collections Cumulative Collections through 2nd Qtr FY2012

Data Source: MTF DD Form 2570 submissions to the TMA UBO Metrics Reporting SystemA/O 30April 2012

Service FacilityFY2012 Total Collections

Army San Antonio Military Medical Center $5,349,719.68Air Force Wright Patterson AFB (88th Medical Group) $3,695,938.84Navy Walter Reed National Military Medical Center $3,592,095.22Army Ft. Belvoir (Ft. Belvoir Community Hospital) $3,519,694.41Army Washington D.C. (Walter Reed Army Medical Center) $2,971,031.56Army Ft. Lewis (Madigan Army Medical Center) $2,950,883.01Army Ft. Meade (Kimbrough Ambulatory Care Center) $2,515,146.48Navy NMC Portsmouth (VA) $2,507,507.89Army Ft. Shafter (Tripler Army Medical Center) $2,388,801.13Air Force Elmendorf AFB (3rd Medical Group) $2,125,303.25

Third Party Outpatient Collection System- Government developed system for billing outpatient TPCP

(includes outpatient visits, lab/rad/pharmacy prescriptions) CHCS Medical Services Account (MSA) Module

- Government developed module used for billing TPCP inpatient claims (both institutional & professional charges) & MSA

Relationship to other systems- Provider Specialty Codes and other Provider Data- Collection of other health insurance (OHI) information in

CHCS- Centralized OHI Repository on DEERS- Coding Compliance Editor (CCE)

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MHS Billing Systems

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MSA ClaimsTPCP Inpatient Claims

FinancialPersonnelWorkload

LegendDatabase

Subsystem

Data

Documents

CHCS

DEERS

TPOCS TPCP OP ClaimsMAC Claims

EAS IV

MDR M-2

ADM

WAM PDTS

CCE

AHLTA

Existing MHS Systems

Billing/Collections

Accurate Complete Concise Cost-effective Relevant / Timely / Up-To-Date Presentation Consistent

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Data Quality Characteristics

Visual review for validating and streamlining major clinical business and resource management processes

Data Quality Management Controls are the driving force and conduit for ensuring effective and efficient operations

Results are increased resourcing with reliable outcomes in the form of usable data

Improved patient access, records documentation and coding accuracy

CHCS(Files &Tables)

PatientAccess

PayerEducation

Appeals

Payment Posting

Denial Management

AccountFollow-up

Claims Submissions

Coding

EncounterDocument

PatientRegistrationIns Verify &

Auth

Data Quality Management

CCE TPOCS

ElectronicBilling

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MTF Revenue Cycle

Patient Registration

CHCS(Files &Tables)

PatientAccess

PayerEducation

Appeals

Payment Posting

Denial Management

AccountFollow-upClaims

Submissions

Coding

EncounterDocument

PatientRegistrationIns Verify &

Auth

Data Quality Management

CCE TPOCS

ElectronicBilling

• PATCAT Entry• Collection &

Validation of OHI• DQMC Assessable

Unit 15

Patient Category (PAT) determines the reimbursable rate (if any) for healthcare- Over 300 PATCATs to select from

Challenge of Patients with Multiple PATCATs- Spouse of AD Member who is a Reservist and employed

as a Federal Employee Who is responsible for training/accuracy?

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Importance of Accurate PATCAT Entry

PATCAT course now available via the TMA UBO website http://www.tricare.mil/ocfo/mcfs/ubo/learning_ center/training.

cfm

Training Webinar: How to Assign and Use PATCATs March 13, 2012 @ 0800 March 15, 2012 @ 1400 http://www.tricare.mil/ocfo/mcfs/ubo/learning_center/training.cfm

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Training for Selecting the Correct PATCAT

Use DD Form 2569 to capture OHI information about your patients- All Non-Active Duty Patients required to complete it every

12 months or if data changes- OHI needs to be entered into CHCS PII screen or it

“doesn’t exist” for billing purposes- Direct correlation between presence of a current DD Form

2569 in patient record and rate of TPC billing- Reported monthly in Commander’s DQ Report

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Other Health Insurance (OHI) Information

Encounter Documentation / Coding

CHCS(Files &Tables)

PatientAccess

PayerEducation

Appeals

Payment Posting

Denial Management

AccountFollow-up

Claims Submissions

Coding

EncounterDocument

PatientRegistrationIns Verify &

Auth

Data Quality Management

CCE TPOCS

ElectronicBilling

• Medical Record Availability

• Documentation19

Set of codes unique to CHCS Current business rules preclude TPOCS from receiving ADM

encounters with blank PSCs or PSCs > 900 - (exception of 901 – Physician Assistant)- 702 (Clinical Psychologist) versus 954 (Psychology)

Site visit to large medical center found 20% of PSCs fields were blank- Billable ADM encounter never reach TPOCS

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CHCS Provider Specialty Codes (PSC)

Get your site’s most current CHCS Provider Profile and review the PSC fields for accuracy- No blank fields- Billable providers have PSC under 900 (plus 901 –

Physician Assistant) Determine whose responsible for maintaining the PSC fields

and TRAIN THEM!!! Periodically review the PSC fields to make sure the problem

really has been permanently fixed

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Correcting the CHCS Provider Specialty Codes (PSC)

Every provider who can bill for healthcare services is required to have one

23 May 2007 was the deadline for MHS providers to obtain their own unique NPI Type 1

Are all of your providers NPI Type 1s in CHCS?- No NPI = No Payment from Insurance Companies

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National Provider Identifier (NPI) Type 1

CHCS(Files &Tables)

PatientAccess

PayerEducation

Appeals

Payment Posting

Denial Management

AccountFollow-up

Claims Submissions

Coding

EncounterDocument

PatientRegistrationIns Verify &

Auth

Data Quality Management

CCE TPOCS

ElectronicBilling

• Account Follow-Up

• Payment Posting• Denial

Management

• Insurance Verification• Claim Form Data & Line Item Billing

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Billing/Accounting

What are the Focus Points?- MTF Revenue Cycle

Team Effort (not the just the UBO’s challenge) Staff Education & Training Electronic Interfaces

- Leadership Involvement Stress the need to complete the OHI forms (DD Form 2569s) Brief them on UBO Performance (e.g., OHI Capture, Billings &

Collections for TPCP, MSA & MAC)

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UBO Success Factors

UBO Web Page - http://www.tricare.mil/ocfo/mcfs/ubo/index.cfm

UBO Help Desk Contact Information- ubo.helpdesk@altarum.org- 703-575-5385

Defense Health Information Management System (DHIMS) Web Site - http://dhims.health.mil/

Defense Health Services Systems (DHSS) Web Site- http://www.health.mil/MHSCIO/programs_products/jmis/D

HSS.aspx25

Resources

Questions?

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Questions