IMA PPT Template EXPERIENCE VALUE RESULTS Grooming a Top Notch Patient Access Professional Brought to you by Agenda Introduction Examples Compliance Overview Training and Education Performance Manag.
VALUE EXPERIENCE RESULTS Grooming a Top Notch Patient Access Professional Brought to you by Agenda ♦ Introduction ♦ Examples ♦ Compliance Overview ♦ Training and Education ♦ Performance Management Brought to you by Introduction Patient Access Associates perform a diverse and complex range of tasks during the registration process: ♦Data Collection ♦Insurance, Benefit Verification ♦Identification of Pt Financial Liability, POS Collections ♦Securing required signatures ♦Acquisition of Referrals and Pre Certification Embedded within the daily functions of an Access Associate are laws and regulations applicable to their day-to-day job responsibilities Brought to you by Today’s Discussion ♦ Identify violations that could lead to legal liability for the organization and employee ♦ Provide an understanding of the laws and regulations that impact Patient Access Services ♦ Learn techniques to incorporate a full realm of compliance training into existing education plans Brought to you by HIPAA Enforcement Examples ♦ Following investigation by the U.S Dept of Health and Human Services, office for Civil Rights, the University of California at LA settles potential violation of HIPAA for $865,000 – Complaint alleged that two UCLAH employees looked at electronic health records repeatedly without permission Upon further investigation, it was reported between 2005 -2008 numerous employees looked at the EMR of patients without valid reason Brought to you by HIPAA Enforcement Examples ♦ In 2009, Mass General lost PHI on over 192 patients – consisting of patient schedules with names, MRN’s billing information, diagnoses, procedures – An employee, while commuting, left the documentation on a subway train The documents were never found – $1M settlement Brought to you by Penalty and Action Plan ♦ Covered entities are responsible for actions of their employees ♦ Penalties in the amount of $1.8M were incurred between the two facilities ♦ Corrective action plan established – Privacy and Security Policies and Procedures – Regular and robust training – Independent monitor to assess compliance Brought to you by Recovery Audit Contractor ♦ Three year demonstration – pilot (2005 through 2008) – Identified $1.03 billion of improper Medicare payments – $900 million in overpayments returned to Medicare Trust Fund ♦ 40 percent of overpayments due to medically unnecessary services (65 percent for services provided in an inappropriate setting) ♦ percent due to insufficient documentation ♦ 35 percent connected to incorrect coding ♦ 17 percent – other category Brought to you by RAC Exposure (*Evaluation of the 3-year demonstration) Improper payments due to: ♦ Medically Unnecessary Services ♦ Services provided in an inappropriate setting ♦ Incorrect coding ♦ Improper documentation ♦ Other Brought to you by Patient Access Link ♦ Medical Necessity – Critical function in all access areas to: – Prevent improper Medicare payments – Ensure provider can pursue payment from beneficiaries ♦ Advance Beneficiary Notice (ABN) – Failure to issue an ABN can lead to financial losses to an organization due to inability to bill for services denied by Medicare as medically unnecessary ♦ Medicare Secondary Payer Questionnaire (MSPQ)– Since 1980, the MSP provisions have protected Medicare funds by ensuring that Medicare does not pay for services and items that certain health insurance or coverage has primary responsibilities for paying Brought to you by 10 Patient Self Determination Act Advance Directive means a written instruction, such as a living will or durable power of attorney for health care, relating to the provision of health care when the individual is incapacitated Organization’s Responsibility: ♦Provide written information regarding Advance Directives ♦Document in Medical Record ♦Educate patients, employees and community Brought to you by 35 Policies and Procedures Primary Related ♦ Medical Necessity ABN ♦ EMTALA ♦ Medicare Secondary Payer Questionnaire ♦ Patient Identification ♦ Emergency Department Registration ♦ Orders for Outpatient Testing ♦ Advance Directive ♦ Registration of Family and Friends ♦ Patient Rights and Responsibilities ♦ ♦ ♦ ♦ ♦ ♦ 36 Guarantor Policy Performance Management Performance Improvement Plan Registration Quality Assurance Insured Self Pay Policy Patient Search, Name Standard Brought to you by Competency Competency: ♦ Quality of being adequately or well qualified ♦ Ability of an individual to perform a job properly ♦ Set of defined behaviors that provide a structured guide enabling the identification, evaluation and development of the behaviors in individual employees ♦ Combination of knowledge, skills, and behavior used to improve performance Brought to you by 37 Performance Management Brought to you by 38 Performance Measurement ♦ Demonstration of Competency ♦ Ongoing Evaluation – QA Monitoring – MSP Audits – Medical Necessity Compliance – Vendor Reports – ‘Rounding’ with Reason ♦ Performance Management – Behavioral Based – Addresses Confidentiality and Security Brought to you by 39 Method of Evaluation ♦ Pre- and Post- Test ♦ Return Demo ♦ Direct Observation ♦ Verbal Affirmation – Sign Off Brought to you by 40 Employee Responsibilities ♦ ♦ ♦ ♦ ♦ ♦ Timely completion of mandatory training and education modules Perform Medical Necessity check for outpatient procedures every time Issue ABN when indicated Accurate and complete documentation on MSPQ Understand the importance of completion of MSPQ Collaboration with Case Managers and other clinicians to ensure level of care orders are in place ♦ Consistent review of outpatient orders and appropriate follow up for incomplete, illegible orders ♦ Utilize solid interview techniques, adapt scripting Brought to you by 41 Individual and Department Key Performance Indicators Individual KPI MSPQ audit MED Necessity ABN audit Documentation Audits a Consents b Place of Service Order Department KPI MSPQ audit ABN Audit Technical Denials Brought to you by 42 Performance Management Key Behaviors to ensure compliance: ♦ Adheres to the Health System’s Code of Conduct ♦ Remains up to date and compliant with all Federal, State and Local laws, Joint Commission standards or regulatory requirements which apply to assigned area of responsibility ♦ Ensures confidentiality of all customers/patients/residents information and that information is only available to those who have a business reason to know ♦ Accepts responsibility for one’s actions and decisions ♦ Builds trust and maintains consistency through words and actions Brought to you by 43 Improvement Needed Behaviors ♦ Fails to follow laws, regulations or Health System policies consistently ♦ Demonstrated by: – Sub par auditing results – Less that 100% MSP completion – Failure to check Medical Necessity or issue an ABN 100% of time Brought to you by 44 Access Leadership Responsibilities ♦ Develop policies ♦ Communicate, Communicate, Communicate! – Disseminate Information to staff ♦ Measure Results – Improved Performance – Reduction in Denials ♦ Audit – Round – Individual and Department Performance ♦ Review results with staff, coach, and mentor ♦ Report results to Sr Leadership Brought to you by 45 Training Tool Kit ♦ ♦ ♦ ♦ ♦ ♦ ♦ Department Orientation Check List Training Module Documentation Competency Validation, Inventory, and Tracking Sheet Performance Management Evaluation Criteria Applicable Policies and Procedures Trainer Evaluation Sign In Sheet Brought to you by 46 Benefits of an Effective Training Program Employee Organization ♦ Employee Satisfaction ♦ Professionalism ♦ Professional Development ♦ Financial Security – Reduced denials – Less turnover – No penalties ♦ Builds credibility ♦ Employer Satisfaction ♦ Improved Outcomes Patient ♦ Patient Satisfaction ♦ Safety and Quality ♦ Positive Outcomes ♦ Dignity and respect Brought to you by 47 Unintentional Consequences – failure to comply ♦ Incorrect data validation – risk of privacy breach Ask Don’t Tell Campaign ♦ Medical Necessity Checks on limited number of procedures ♦ Physician Selection errors - *Safety and Privacy ♦ Incorrect Guarantor listing ♦ Opt Out Vulnerability - *Safety Brought to you by 48 Unintentional Consequences – failure to comply ♦ Incorrect data validation – risk of privacy breach Ask Don’t Tell Campaign ♦ Medical Necessity Checks on limited number of procedures ♦ Physician Selection errors - *Safety and Privacy ♦ Incorrect Guarantor listing ♦ Opt Out Vulnerability - *Safety Brought to you by 49 ... you by 17 Patient Access Orientation Training Plan Week Monday Tuesday Wednesday Thursday Dept Orientation Patient Access Overview – Scope of Responsibility Data Collection Insurance – Patient. .. Liability ♦ Returned overpayments to Medicare Trust Fund Brought to you by 13 Patient Access Leadership Responsibilities Patient Access is at the forefront and recognized as a vital component of the... system Brought to you by 18 Patient Access New Orientation Training Plan Week Monday Tuesday Physician Outpatient Order Registration Documentation Wednesday Thursday Friday Inpatient Registration Emergency