Problem:
Medicare Advantage shadow billing represents a strong reason for providers to have knowledgeable people, iron clad processes and properly working technology in place. Hospitals are under increased pressure to make sure that they identify and re-coup money that is rightfully theirs while balancing the challenges of dealing with a myriad of compliance issues.
Solution:
The following are some insights to aide in maximizing efforts and reimbursement:
1. A comprehensive understanding and reconciliation to the PS&R report (both Report type 110 and 118) will ensure that the MAC has captured the correct claims.
2. The function of shadow billing should occur within a reasonable time frame and not allow too much time to pass by when performing retrospective reviews. Timely filing is non-negotiable in this case.
3. Conduct on-going reviews to ensure that you are capturing and shadow billing all MA patients you treat through automation and tracking (not just for Inpatient acute patients but also for other related patient settings including Psych and Rehab units).
4. Based on the results of your reviews, you may need to tighten existing internal processes and controls and create new ones as needed based on the results of your review. Include team members that are familiar with the impact to reimbursement when it comes to patient days and what is captured on the cost report.
Finally, stay in touch with your peers and industry experts and continually look in areas where you didn’t look before (i.e., misclassified MA patients continue to be an area of opportunity as well as non-traditional aged MA beneficiaries) to capture shadow bills.
Potential Gain:
Providers should not lose sight of the requirement to shadow bill! In fact, because of declining reimbursement, even more focus should be given to niche areas to help make up potential deficits – simply missing 1% – 2% of these claims can result in significant lost revenues!
Providers are successfully capturing between 92% – 99% of the claims that should be shadow billed. This appears to be a strong success rate, but even a small percentage increase to your IME/ GME can increase payments by $250,000 to $750,000 annually.
Mario Feher, Director
IMA Consulting
mfeher@ima-consulting.com
215-514-0951
