Transcript
A JH CAPITAL GROUP SUBSIDIARY 1
MBAAMEDICAL BILLING ADVOCATES OF AMERICA
DEDICATED TO TRUE & ACCURATE, FAIR & REASONABLE BILLING
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MBAA – An Overview
Snapshot:
• 20 years Patient Advocacy experience
• Market Pioneer
• Recognized market leader in “True, Accurate, Fair and Reasonable”
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Leadership
Gayle Sutherland, RN, CPC-H
Director Hospital Compliance
Jeanne Woodward, BSN, RN, CPC
Director Physician Compliance
Teresa Brown, BA, RN, CPC-H
DirectorHospital Accounts
Michael Mann President
Pat PalmerFounder
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Financially Stable – Positioned to Grow
TAMPA, FLTwo Site Locations
200 call center seats total
LOS ANGELES, CAJH Capital Group
JACKSONVILLE, FL100 Seat Call CenterLAS VEGAS, NV
100 Seat Call Center
ST.LOUIS, MOCREDIT
CONTROL200 Seat Call Center
VOORHEES, NJ200 Seat Call Center
Non-Traditional Private Equity Group• Based in Calabasas, CA • Certified Minority Owned• Over 1200 Employees• Owns 20 Portfolio
Companies • Healthcare• Specialty Finance• Cyber Security• Real Estate• Government
ROANOKE, VAMBAA
Terry Buske• Sr. Vice President,
Business Development
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Would you pay this bill?
What questions would you ask?
Restaurant1 Columbus Circle
New York, NY 10019 102 Tetsuo
Tbl 10/1 Chk 7080 GST 2 Feb28’ 07 7:58 PM
2 Prix Fixe 800.00
20.0000 X 20% Serv. Chrg.
161.00 FOOD/BEVERAGE 800.00 Gratuity/Service
161.00 Tax
67.42 Total Due
1033.42THANK YOU FOR DINING WITH US!!!
A 20% service charge has been applied to the bill. Any distribution of a service charge rests in the restaurant’s sole
discretion
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You want the detail
Summary Bill Itemized Bill
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UB-04 vs. Itemized
UB-04 Summary Itemized Statement
• Room and Board• Pharmacy• Med-Surg Supplies• IV Solutions• Laboratory• Operating Room• Recovery Room• Emergency Room
• Every single service, item and drug used in a medical procedure and hospital stay
Why would your medical bill be different?
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Common Billing Overcharges
• Toothbrush - $1,009.00
• Items like oxygen are included in the room charge but are sometimes billed again separately and individually
• One Aspirin - $180.00 Estimated amount of Non-Compliant and/or Overcharged, Uncaptured &
Up-Coded Health Claim Errors - 2013
What happens when no one is looking?
9
The only way to ensure
compliance is to overlay and compare the Itemized with
the UB04
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MBAA’s Billing Compliance Analysis
Compare - Contrast
Based on industry standard coding guidelines including but not limited to:
• Uniform Billing Act• Social Security Act• Code of Federal Regulations• CMS Guidelines
• False Claims Act and the
• AMA Billing and Coding Guidelines
UB-04Itemized
Statement
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Compliance Analysis Not Medical Audit
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Kaiser Case Study
The Focus of MBAA Reviews:
• Non-Contract Hospital Claims
• Review balances > $50,000
• Finding Average 17% Error Rates
• $8 Million in Savings (12 Months)
Lead, RN Kaiser Foundation
Utilization Management
"A clean claim doesn't equate to a correct
claim."
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Kaiser Case Study
Snake Bite Example:
• $950,000 Claim
• Member Plan 80/20
• Hospital offered 2% discount
• Result: True and Accurate = $86,000
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Payer
Process Payments
Plan Coverage
Utilization Manageme
nt
Automation
Kaiser Case Study WorkflowBest Practice - Insurance Company Prior to Pay
Pay this Amount
Hospital >$50,000
UB-04Itemized
Statement
EORDetailed Support for
Denial of Non-Compliant Charges
UB04
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TPA
Process Payment
s
Confirm Charges
Apply Discount
s
Automation
Workflow - Prior to Pay Best Practice – Self Insured (Company or Union) using TPA
Pay this Amount
Self Insured Organization
>$25,000UB-04
Itemized Statement
EORDetailed Support for
Denial of Non-Compliant Charges
Hospital UB04
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Sign Agreement
On-Boarding
Call
Primary POC
Claim Criteria FTP Set Up Drop
Claims
Getting Started
Step 1 – Set-up Step 2 - Onboarding Step 3 – Intake, Support
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Minimum Time/Resource Allocation
Monitor FTP 24/7
CoversheetUB-04
Itemized Bill
Questions Answered(1 hour a
Week)
Compliance Analysis
EOR (Explanatio
n of Review)
Five (5) Day Turnaround
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MBAA Value Creation
MBAA Performance Standard - Identifying 10-20% Non-Compliant Charges
Current Performance for Kaiser Foundation Northwest - 17%
For every $10M in Claims, MBAA will return $1M - $2M to your bottom line
MBAA retains 25% percent of the SavingsNo Risk – if there is no savings, there is no
cost
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Priority / Payoff Matrix
High Payoff / Easy High Payoff / Difficult
Low Payoff / Easy Low Payoff /Difficult
Payoff
High
Low
Resource, Time Allocation Easy Difficult
• Questions?
• Stakeholders?
• Next Steps?
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Support Documentatio
n
•Prior to Pay Service Agreement
•ERISA Explanations
•HIPAA Compliant FTP Drop Site
•Drop Site Instructions
•Detailed reports of non-compliant charges
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