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Frequently Asked Questions

What determines my recoveries? 

Case mix, internal processes, ownership of SNFs or HHA’s, and average length of stay are key factors, but we typically see recoveries equaling at least 1% of Medicare inpatient discharges times  an average of $2000 per discharge.

What age of accounts are you reviewing? 

As a result of the MCare efforts with CMS, we can conduct 4-year retrospective review and retroactive reimbursement.

What’s the most recent account that you review?  

Except for Medicare Advantage, we want accounts to be at least 9 months old, so we don’t overlap with any post-acute care provider’s billing. 

What specific transfers are you reviewing? 

02, 03, 04, 05, 06, 50, 51, 61, 62, 63, 64, 65.  (We also obtain 01 for reporting purposes.)

How are you able to get through such a large volume of account reviews for multiple years in such a short period of time? 

Proprietary software with built-in reimbursement formulas and algorithms automatically sorts through assignments to identify claims with potential discharge status code variances.

Do you look for overpayments as well as underpayments?

Yes, but CMS does a great job of identifying overpayments as “take-backs.”   Although it is important from a compliance standpoint to look for both overpayments and underpayments, we have identified less than 100 out of the 3 million-plus accounts we’ve reviewed thus far.  CMS does not edit 04, 50, 51 or 64.  These pay a full DRG regardless of L.O.S. so there is risk that a post acute provider will bill Part A.

How long does it take to see our recoveries start coming in from the initial file given to you?

90 - 120 days from receipt of file.

Are there any hidden or up-front costs? 

No.  All risk is assumed by MCare.

How much effort and time to implement? 

3-4 weeks calendar time, because payer and paperwork are involved, but only 1-3 hours of hospital staff time for DDE logon authorization, approvals, and data file preparation. 

How much involvement for HIM?

We may occasionally require assistance with the name of a post acute care provider in order to properly conduct our research.  This typically would not exceed 25 cases a year.

How much involvement is there for PFS? 

Generally want them aware of program and sometimes rebilling, as well as knowing that payments are coming in on accounts we’re working.

Have you had any experience with my Fiscal Intermediary? 

The geographic diversity of MCare’s client base has enabled the company to establish important relationships with a number of intermediaries, including:

AdminaStar BC of GA Cahaba
Empire FirstCoast Highmark
WPS Noridian Palmetto
Riverbend Trailblazers NGS
Veritus TriSpan NHIC

Where are you finding out what actually happened with a discharge in the post-acute care setting? 

After our software identifies claims with a potential discharge coding discrepancy, our staff then begins to review the claim within the common working file using publicly available information, where through our extensive experience and know-how, we can obtain the required information about 50% of the time. We also follow up with payers and sometimes post-acute care providers by phone to determine what actually happened if the necessary information cannot be acquired otherwise.

Have any of your clients expressed concerns about charging contingency fees on Medicare recoveries? 

The majority of our clients prefer the contingency fee pricing structure because all of the risk is assumed by MCare.  In one or two cases, a client has asked for a “flat fee”, and we have accommodated them, primarily by “backing into” a flat fee that coincides with the contingency fee rate.  It is important to keep in mind that RACs are paid by CMS on a contingency basis.

Can/will you provide some feedback on how we can improve our processes? 

It is very common for hospitals to seek to improve internal processes in hopes of reducing the number and amount of transfer DRG underpayments.  However, this issue is better improved by enhancing communication protocols with post-acute providers.  We have seen many hospitals lower status code variance rates by implementing standard operating communication procedures with their respective post acute care providers.  MCare will be happy to share these observations along with the quantitative data from the results of our review.  The combination of these two approaches will enable you to focus in on the most problematic areas and develop internal communications processes that will help alleviate the problem. In addition, our reports detail why a discharge status code was changed and we expand on that through quarterly reports and benchmarking outlining where the most frequent errors are occurring.   Ultimately, the best solution currently available to the marketplace for the resolution of Transfer DRG underpayments is the implementation of retroactive and recurring review and rebilling of associated discharges. 

What happens after we sign? 

We’ll schedule a 30-minute conference call to go over the implementation details, including DDE authorizations, provider numbers, business associates agreement, data file preparation and transfer, primary client contact, etc.  Then…we’re off and running.

 

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