Q. Is there an easy way to make sure that our payer contracts give us our maximum reimbursement?

A. Yes! Most Hospital's contracting process is dysfunctional. Key points for contracting are seldom tracked or made available to the hospital's contracting department to maximize reimbursement. All efforts to maintain and update a hospital's chargemaster are in vain if the contracts do not reflect these on-going changes. Most contracts are for multi-year periods locking in mistakes that can cost the hospital millions in lost revenue. This is one of the most often overlooked sections of revenue capture by hospitals today!

Q. Is there a simple way for us to insure that requests for changes to the chargemaster are completed?

A. Many hospitals overlook a simple process that is already in place to solve on-going maintenance of their chargemaster. The process is an efficient and systematic way to document requests for changes that also identifies all the necessary "tacking" components. This process should be the starting point of a comprehensive charge master consulting project; however, it is overlooked by most consulting firms.

Q. Our hospital always seems to be playing "catch-up" in identifying and resolving problems. It seems that most of the time problems are found after they are discovered by accident.

A. The lack of accurate monitoring methods not only results in revenue loss but also can result in compliance problems. In addition, not posting proper charges for services guarantees that payers will have the opportunity to reimburse hospitals less in the future. On a daily basis, changes take place that impact revenue capture; often, these changes go completely unnoticed by staff.

Q. Is bigger always better regarding the number of consultants sent to complete a project?

A. No. More often than not a large number of consultants results in a higher cost to the hospital. Also, a greater number of consultants may actually reflect less expertise and the use of the project as a training site by the consulting company. How many consultants does it take to screw in a light bulb?

Q. How can we be sure we are not missing revenue and critical issues with all of the on-going changes in health care today?

A. What the hospital does not know "does" and will hurt it. This does happen on a daily basis at most hospitals. Major decisions are made by staff members without any clear checks or balances being in place. Only a very few of these are ever discovered and these come to light only after an incident has occurred. Change is inevitable and the only process is to monitor for change at the highest level. However, once established, this is an easy process for the hospital. If charge capture is the goal, front to back integration and monitoring must be established.

Q. Is it important that we know how our charges for services were arrived at? At times it seems that our charges have no rhyme or reason.

A. Hospitals should be able to defend their cost based upon their usual and customary pricing methodology (ie, MMC has found a simple sterile disposable towel listed at $2,000.00 in a hospital chargemaster).

Q. When a hospital is selected for review by the RACs (Recovery Audit contactors) what is the time period they are selecting (claims) for the review?

A. CMS noted that for FY 2007 the RACs reviewed claims that were originally paid between 2002 and 2006. During CY 2007 RAC's identified and corrected $371 Million Dollars of improper payments. 96% reflected over payments and 4% were underpayments.
Note: None of the RACs had experience identifying underpayments before the RAC program.

Q. From a consulting standpoint, what are the lessons learned from the RAC audits?

A. Because RACs are paid on a contingency fee basis, they established their claims review strategies to focus on high dollar improper payments i.e. inpatient hospital claims that give them the highest return. Most hospitals have a poor methodology for defending their charges for inpatient claims. Many hospitals have little to no audit process in place for the inpatient side of services. Facilities should maximize their processes to insure that accurate billing and documentation is in place to validate services. Most hospitals see the “big picture” of their over-all operations however they seldom make sure that all of the dots are connected to ensure accurate reimbursement.