Avoid costly mistakes with Medicare registrations
Prevent penalties for noncompliance
Years ago, when patients came in with Medicare coverage, registration staff were "ecstatic," recalls Robin Teneyck, director of patient access for Sound Shore Health System in New Rochelle, NY.
"All they needed to worry about was whether the effective date of coverage preceded the date of service under Part A for inpatient and Part B for outpatient," she says. Teneyck says that today, her patient access staff must do the following things:
Verify if the patient has Medicare or Medicare HMO coverage, by checking the eligibility response.
Cross-reference another table if the eligibility comes up as Medicare HMO, to determine which Medicare HMO.
Call the Medicare HMO to determine if pre-certification is required.
Verify recent care with the patient or family, to try to establish the extent of available coverage, such as the available number of inpatient days and whether any deductible under Part A or B is due.
Verify with the patient or family that there is no other coverage, through the patient's or spouse's possible employment.
Explain coverage limitations to patients, such as inpatient deductible being due again if the patient has not been hospitalized in more than 60 days, if physical therapy is due to a car accident in which no-fault insurance is primary, or how group coverage is primary to Medicare.
When a Medicare patient is under age 65, and has been found eligible for Medicare due to a permanent disability, determine whether the patient may still be within a 30-month period of eligibility for group coverage through him- or herself or spouse since the condition was diagnosed. "This would be primary to Medicare for end-stage renal disease," says Teneyck.
Complete the Medicare Secondary Payer Questionnaire for every visit by a patient with Medicare coverage.
Heavy toll on staff
Teneyck says that compliance with federal regulations takes a "heavy toll" on patient access staff. "Registration takes so long today because of all the documentation that has to be secured from patients, acknowledging their rights are being protected," says Teneyck.
Teneyck says that this documentation includes consent of treatment, patients' rights, patient privacy, the Important Message from Medicare, medical necessity, Medicare Secondary Payer Questionnaire, release of information, assignment of benefits, and guarantor responsibility.
"Another form ascertains the transaction took place in a language understood by the patient," adds Teneyck.
Penalties for noncompliance could include take-backs on future reimbursements, or ultimately, forfeiture of approved provider status, warns Teneyck.
"It is best to look upon regulations as a road-map to quality care," she says. "Using the example of the Medicare Secondary Payer Questionnaire, it is in everyone's best interest to bill the proper payer from the start. This includes complying with eligibility, referral, and authorization rules."
To ensure timely payment by Medicare, registrars need to immediately input physician information, the diagnosis and the tests ordered, says Joy Wright, a patient registration supervisor at Lodi (OH) Community Hospital.
However, staff must sometimes call or fax the order to the physician's office for an additional diagnosis, says Wright. "If the physician's office is closed, the patient is required to sign the ABN [Advance Beneficiary Notice]," says Wright. "The patient may not understand the choices, or they don't have the testing completed."
Teneyck ensures that staff immediately input physician information, diagnosis, and tests ordered to safeguard proper and timely payment by Medicare, spot-checking the registrars' work throughout the day. She also updates and monitors a daily report of the next day's scheduled services, listing accounts missing the physician's name, diagnosis, tests, and/or payer information.
"There is computer software to automate monitoring of quality improvement processes by not allowing progress to the next screen unless selected parameters are met," notes Teneyck.
An ABN must be collected from patients, adds Teneyck, detailing their awareness that a service to be provided is not medically necessary. "Staff need to explain to the patient that under the circumstances, the patient is expected to pre-pay for the service or postpone the care," she says.
Teneyck says that she has found that the best approach is to address this at the time of service. "If the doctor's office calls for the appointment, you can complete the medical necessary check and ask any additional question you need to complete the check," she says.
If the patient calls for the appointment, Teneyck says that staff usually have enough time prior to the appointment to call the physician to make sure the diagnosis is correct. "If the services are not covered, we call the patient at home to alert them before they come in and give them the option of paying or cancelling," she adds.
If the patient shows up without an appointment and without the medical necessity check being completed, staff call the physician while the patient is present, says Teneyck. If the physician is not there, staff speak with the physician on duty to ensure it is not an emergency and the test can wait, she explains.
"If it's not an emergency, we give the patient the option of paying for the test, cancelling or rescheduling," says Teneyck. "We notify the physician's office of any canceled appointments."
[For more information, contact:
Robin Teneyck, Director of Patient Access, Sound Shore Health System, New Rochelle, NY. Phone: (914) 365-3745.
Joy Wright, Patient Registration Supervisor, Lodi (OH) Community Hospital. Phone: (330) 948-5526. E-mail: email@example.com.]