SSMcElyea-Vironet
Guest
Background:
3-day payment window started 7/1/2012. My management has failed in getting a system together to make this work for our organization. I was not made aware that this rule applied to us until I was on medical leave and wasn't coming back until 8/1/2012. It was left on me to figure this out and it should have been on management and higher ups! Nonetheless, we have a team working together to get money refunded and claims reprocessed with a PD modifier. It's the pay and chase method. We have no other choice. We hold claims for 3 days but we can not get to those at all so it's a pointless effort. In fact, everything we've read on WPS and CMS seems to contradict itself. We interpreted this as best as we could but only to find we missed a few things. Our hospital is not on the same system as we are. This process would be so much easier if we were. Our clinics are uncooperative in getting charges done within the 48hr rule to even get to look at these claims. We are over extended as it is with a short staff to deal with this magnitude of a work load. 3-day payment window is all OT work for us but it's not consistently worked daily like it needs to be. We find our billing office is doing the work of the hospital when we shouldn't. They make us go into their system to find these patient admissions and that is only able to be done once a week currently. Remember, we're short staffed. I don't even think the charges I gave the hospital to fix on their claims are even being done. This is where we're confused the most. We bill the PD modifier on radiology and we know we'll get the PC back regardless. How does this even work on the office related items? UAs, injections, lab tests, etc? Do we still bill this out with a PD on our claims? Or do we give these to the hospital to bill out on their UB-04 forms? We're so lost and we're sinking deeper and deeper into a sink-hole. At first, we weren't even including E&M codes because I was told we weren't. Yet, we find information that says they are included? So now we're scrambling to go back to 7/1/2012 to find all those that we've missed.
Please note that we have a running spreadsheet starting on 7/1/2012 to current listing all Medicare (including advantage plans) inpatient stays, admission date, 3 days listed for the window, our accounts number(s) for that patient in our system, all DOSs listed, related and unrelated procedures listed on each DOS, refund information if one was done, etc... We're covering our rears in case of an audit with Medicare. I have no clue if the hospital is doing their part but from what I've learned, they aren't complying.
We need help and WPS doesn't have a single one person to go to for help and we've reached out to our partnering hospital (network we're a part of but not owned by or we wouldn't even be in this mess) and the rule doesn't apply to them so they haven't really researched it themselves so they are NO help. We've researched online and that's where the confusion begins and ends. I doubt there is a list of outpatient related services....right?
IS THERE ANYONE OUT THERE EXPERIENCING THIS 3-DAY PAYMENT WINDOW RULE WHO HAVE ACTUALLY BEEN ABLE TO MAKE THIS WORK FOR THEM AND HAVE A BETTER UNDERSTANDING?! HELP!!!!!
I'm grasping at straws it seems...help!
3-day payment window started 7/1/2012. My management has failed in getting a system together to make this work for our organization. I was not made aware that this rule applied to us until I was on medical leave and wasn't coming back until 8/1/2012. It was left on me to figure this out and it should have been on management and higher ups! Nonetheless, we have a team working together to get money refunded and claims reprocessed with a PD modifier. It's the pay and chase method. We have no other choice. We hold claims for 3 days but we can not get to those at all so it's a pointless effort. In fact, everything we've read on WPS and CMS seems to contradict itself. We interpreted this as best as we could but only to find we missed a few things. Our hospital is not on the same system as we are. This process would be so much easier if we were. Our clinics are uncooperative in getting charges done within the 48hr rule to even get to look at these claims. We are over extended as it is with a short staff to deal with this magnitude of a work load. 3-day payment window is all OT work for us but it's not consistently worked daily like it needs to be. We find our billing office is doing the work of the hospital when we shouldn't. They make us go into their system to find these patient admissions and that is only able to be done once a week currently. Remember, we're short staffed. I don't even think the charges I gave the hospital to fix on their claims are even being done. This is where we're confused the most. We bill the PD modifier on radiology and we know we'll get the PC back regardless. How does this even work on the office related items? UAs, injections, lab tests, etc? Do we still bill this out with a PD on our claims? Or do we give these to the hospital to bill out on their UB-04 forms? We're so lost and we're sinking deeper and deeper into a sink-hole. At first, we weren't even including E&M codes because I was told we weren't. Yet, we find information that says they are included? So now we're scrambling to go back to 7/1/2012 to find all those that we've missed.
Please note that we have a running spreadsheet starting on 7/1/2012 to current listing all Medicare (including advantage plans) inpatient stays, admission date, 3 days listed for the window, our accounts number(s) for that patient in our system, all DOSs listed, related and unrelated procedures listed on each DOS, refund information if one was done, etc... We're covering our rears in case of an audit with Medicare. I have no clue if the hospital is doing their part but from what I've learned, they aren't complying.
We need help and WPS doesn't have a single one person to go to for help and we've reached out to our partnering hospital (network we're a part of but not owned by or we wouldn't even be in this mess) and the rule doesn't apply to them so they haven't really researched it themselves so they are NO help. We've researched online and that's where the confusion begins and ends. I doubt there is a list of outpatient related services....right?
IS THERE ANYONE OUT THERE EXPERIENCING THIS 3-DAY PAYMENT WINDOW RULE WHO HAVE ACTUALLY BEEN ABLE TO MAKE THIS WORK FOR THEM AND HAVE A BETTER UNDERSTANDING?! HELP!!!!!
I'm grasping at straws it seems...help!