We appreciate the opportunity to present Healthcare Consulting Services, LLC’s (HCS) listing of available services in the APC arena. We have been actively involved with a number of hospitals and believe we are the best option for assistance in this area. The following list describes the services available from HCS.

The key to successful APC implementation and maintenance is the initial and ongoing education of all levels of staff. Training will be necessary for a wide range of personnel including your Board and Senior Management throughout your Billing and Coding Staff.

HCS offers many options of training programs including:

The chargemaster is the key to appropriate reimbursement as well as proper compliance with HCFA regulations. Service departments of the Hospital will need to review and update their chargemaster on a regular basis to ensure that procedures are assigned proper CPT/HCPCS codes for appropriate reimbursement under APCs. In addition to our hospital-wide education, we also provide the Hospital with extensive department-specific education.

For each department included in our chargemaster engagement, we will discuss the billing and coding issues being attested and will work to help ensure that each department is billing its outpatient services in compliance with Medicare guidelines. The primary goal of our analysis is to educate and assist the Hospital in assigning the correct HCPCS codes to its chargemaster.

HCS can perform a comprehensive chargemaster analysis for the Hospital. We "kick-off" our chargemaster engagements with a hospital-wide seminar that is focused on Medicare regulations for billing compliance. In this meeting, we build a framework for the staff that stresses their role as invaluable members of the compliance "safety net."

Proper coding and documentation have always been important, but have become even more so with the APC system implementation. Hospitals must analyze their claims to ensure they have appropriate supporting documentation (authorized practitioner’s order, medical report and billing forms) for the services performed and reported for payment. Further examination of each claim to ensure that appropriate ICD-9, HCPCS/CPT-4, and UB-92 (revenue) codes have been assigned and are in accordance with HCFA and Fiscal Intermediary/Carrier coverage requirements (e.g., LMRPs) will be necessary.

Failure to accomplish the aforementioned properly can result in rejected claims, reduced reimbursement, and various fraud and abuse issues. HCS has personnel trained and experienced available to assist you with these procedures.

There will be many operational challenges facing the billing office personnel with the APC reimbursement system. Among the challenges that are magnified by the APC payment system are resolving billing errors, adjusting late charges, correcting and rebilling rejected claims, resolving over and under payments, implementing and utilizing an effective pre-bill edit process and adjudicating claims.

All of these issues will require the billing staff to effectively communicate with the Hospital information systems, ancillary departments, reimbursement staff and medical records. Developing communication tools and procedures for resolving these issues must be designed prior to the onset of the APC system in order to significantly decrease duplication of errors and delays in claim payments.

HCS can assist in these reviews and help determine the quality of billing procedures, the existence of efficient editing functions and compliant billing practices, the resolution of late charges and rejected claims and the existence of effective patient communication.

Documentation and billing for all services performed by the Hospital outpatient staff will be a key component in accurate reimbursement under the APC payment system. Outpatient documentation requirements will significantly increase with the APC reimbursement system making it more important than ever to ensure that all medically necessary services are accurately documented on the UB-92 claim form as well as in the patient medical record.

HCS can assist the Hospital in performing these documentation reviews on an initial as well as an ongoing basis.

Much like DRG reimbursement, APCs and their respective co-payments will be Hospital-specific. In addition, HCFA will allow a portion of the co-payment to be waived.

HCS can provide your Hospital with your specific APC reimbursement per APC and help to determine what your Hospital-specific co-payments will be. We can also help to determine the impact of reducing the co-payment for particular APCs.

Once the Hospital has a system in place to process APCs, it will be necessary to review claims periodically to ensure that the reimbursement received is proper. This review of claims should begin with the documentation in the patient file and end with the final payment. HCS can assist Hospital personnel with these reviews or provide resources for outsourcing with little or no assistance from Hospital personnel.

Knowing your Medicare contractual write-off has become increasingly difficult and yet is more important than ever as reimbursement shrinks and bottom lines become smaller, HCS can assist the Hospital in preparation of your budget or on an annual or ongoing basis to prepare monthly contractuals under APC reimbursement.

As with many other areas, the Hospital’s manuals become more important with the implementation of APC reimbursement. As the system is developed and refined many changes will be made and announced by HCFA and manuals will need to be constantly updated. In addition, as each update is released many Hospital personnel will be affected and will need to be informed on a timely basis.

HCS is available to assist the Hospital in assessing its present status related to Medicare manuals and applicable regulation publications and keeping the Hospital informed of changes and updates that need to be reflected in the manuals. In addition, assistance is available in training key Hospital personnel in pertinent areas of the manuals and other applicable regulations.

With the implementation of the DRG system in 1983, many Hospitals felt it necessary to add an employee to coordinate the various aspects of the new reimbursement system. The outpatient APC system will most likely require Hospitals to do the same. This person will be responsible for training, keeping current with regulation changes, analyzing coinsurance rates and communicating updates throughout the various affected departments of your Hospital.

HCS can assist by providing these services for your facility through an outsourcing arrangement thereby eliminating the need for a full-time FTE.

The implementation of APCs will most likely reduce the Hospital’s reimbursement, necessitating Hospital management to closely monitor margins by procedure or product line.

HCS can assist the Hospital in implementing a resource-based procedural cost model and developing cost at the chargemaster level. Procedural cost can then be utilized to review direct and indirect cost by APC, DRG or product line.

With any new reimbursement program, it is financially beneficial to establish the "industry norm" as a basis of comparison for your facility. There are several benchmarks that hospitals can use to determine their utilization of resources as compared to industry norms by APC.

Utilizing the APC impact report, we can develop an analysis of your facilities consumption of resources by APC and impact on reimbursement. By reviewing the claims that group to the high loss APCs, we can help identify utilization trends that may be abnormal.

Working with your utilization review committee and physicians, we can help establish benchmarks for your Hospital to help review utilization behavior.

There has recently been increased emphasis on criteria for determining an entity’s provider-based vs. freestanding status. All new acquisitions will require HCFA/Fiscal Intermediary review. In addition, existing facilities that wish to become provider-based will also need HCFA approval. Care should be taken to review reimbursement via APCs versus the current fee schedules to determine whether provider-based status is preferable.

HCS can assist with this analysis to compare reimbursement via APCs to those under the current free-standing fee schedule as well as in the completion of the Provider-based Facility Questionnaire required by HCFA to obtain approval.

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