|
|
Revenue Enhancement Project
Posted: 8/2/2004
Objectives:
- To identify Medicare Members that should have been classified as institutionalized and develop documentation in regards to their status.
- Submit such documentation for recovery retroactive payments.
- Train the staff how to utilize this process in maintaining these procedures on an ongoing basis.
Methods:
- We need to develop a clear, concise definition of "institutionalized" individual. Such "institutional" facilities can be obtained from the NY State Department of Health, Division of Aging, Social Security Office, Medicaid Office, and/or the NRSG Homes, Retirement and Life Care Community. Once facilities are identified and verified as "institutional", we generate reports listing potential institutional members for the last three years. The outcome will be used to identify common trends for institutionalized members as well as track down potential institutionalized individuals.
UB92 Claims Information:
- Members with claims identified based on the place of service
- If they were discharged to Skilled Nursing Facility or other facility
- Look for DRG's (Drug Related Group) which may indicate to an institution
- Claims showing a discharge and re-admission date on the same day (i.e., transfers)
HCFA-1500 Claims Information:
- Identify CPT-4 codes; physician visits, physical medicine and rehabilitation codes, and psychiatric therapeutic codes
- Member claims identified by CPT-4 codes, within the place of service
- Member claims identified by CPT-4 codes, other than those identified from the above report, within the place of service.
|
|
|
