The Conversation – Fall 2014


Readmissions penalties rose as of Oct. 1, 2014

An August 25 story in McKnight’s Long-Term Care News reminded readers that in the third phase of the CMS Hospital Readmissions Reduction Program (HRRP), readmission penalties are rising to 3% of Medicare reimbursements as of October 1. The HRRP, which penalizes hospitals with excessive readmissions for specific diagnostic groups, set a first-year (2013) penalty of 1% maximum reduction of reimbursements. In year two (fiscal year 2014), penalties rose to 2%. This year (FY 2015), the maximum penalty goes up to 3% and expands the conditions for which readmissions can be penalized, now including chronic lung disease and elective hip and knee replacements.

Though the penalties currently affect acute providers only, post-acute providers are clearly a key factor in preventing readmissions. As one industry expert notes, “Although not all hospital readmissions are preventable, many could be avoided with improved post-discharge planning and care coordination.” The growing emphasis on preventing hospital readmissions represents a valuable opportunity for post-acute providers to strengthen collaborations with their acute referral sources to improve care transition processes.

Bundled Medicare payments – a growing reality

“Interest surges in Medicare bundled-payment initiative,” says a July 31 story in Modern Healthcare. According to the article, CMS is set to add about 4,100 providers to about 2,400 “already exploring the possible use of bundled payments for some or all of four dozen medical conditions and procedures, such as diabetes, joint replacements and pacemaker implants.” Providers apply to become candidates and move through a data preparation phase before taking on the model.

With “bundled payments,” health care providers (such as hospitals and physicians) are reimbursed “on the basis of expected costs for clinically-defined episodes of care.” Bundled payments are intended to avoid the extremes of fee-for-service reimbursement (providers paid for each service rendered to a patient – the current norm) and capitation (providers paid a “lump sum” per patient regardless of how many services the patient receives). Bundled payments became part of in the Affordable Care Act as a strategy for reducing health care costs and were launched in January 2013. Read the CMS fact sheet about the program here.

CWF to HETS – still coming!

For several months now, CMS has advised providers about the upcoming termination of Common Working File (CWF) eligibility inquiries, with all Part A providers mandated to move to the HIPAA Eligibility Transaction System (HETS). ABILITY is in continual contact with CMS representatives – rest assured, the move will be coming! CMS is committed to delivering a smooth transition when the switch to HETS actually occurs.

If you are an ABILITY customer using any of these services, you are already ready for the transition:

If you do not have any of these HETS-ready eligibility verification services, take a look at the ABILITY HETS information page and consider the advantages of making the transition today. By implementing improved technology and better workflow, ABILITY customers have gained new efficiencies that quickly impact their bottom line.

More enhancements made to ABILITY | EASE

As part of an ongoing commitment to improving customer experience, ABILITY has released a series of enhancements to the ABILITY | EASE service, based on feedback we solicited from users. A first round of enhancements was released in May. A second release occurred on Oct. 2, with these additional improvements now available to ABILITY | EASE users:

The Claims Correction module can now accommodate a variety of claims editing scenarios, including changes to benefit exhaust and no-pay claims, update claim line items with modifiers, adding and deleting first claim line, changing Type of Bill (TOB) on a Return to Provider (RTP) claim, and more. The enhanced flexibility is designed to help ABILITY | EASE users correct RTP claims and adjust processed claims with the appropriate verification.

The Advanced Management reporting suite has three important enhancements:

    1. Customizable claims reports with more info: Choosing from menu options, you can construct a work list for all claims status: claims follow-up or the latest claims activity on single or multiple sites and NPIs. Every claims status report also includes new data elements:

      •billed and reimbursement amount
      •claim submit date
      •Patient Control Number (PCN)
      •alphanumeric TOBs

    Now you can identify claims aging buckets, potential cost of rejection and denials in AR, amount at risk in ADRs, and collection amount for paid claims or recouped amount by Medicare Administration Contactors (MACs).

    2. Advanced new reports support alphanumeric TOBs that allows for further segmentation once reports are generated. You’ll be able to identify claims with recouped money from MACs, and calculate and report their collection accurately with the itemized TOBs reports.

    3. ABILITY | EASE now features a High Level payment summary report that lists planned and paid EFTs by NPI. You’ll save considerable time with the High Level summary reports, including payment schedules across all your sites – ready to share with your CFO.

If you have questions about these and other improvements in the latest
ABILITY | EASE update, please call Customer Support at 888.460.4310.

We continue to listen to your requests as we further refine all ABILITY services. We appreciate your input to help us produce the highest level of services available within the healthcare industry!

Do you have the latest, free update of the myABILITY platform?

Over 68,000 users are already taking advantage of the new benefits of the myABILITY platform update – available at no cost to you!

    • Single sign-on (no digital certificates)
    • Improved Medicare eligibility display (ability to save filters/preferences)
    • Enhanced user interface
    • Self-administration and configuration of users and user profiles

Not exactly sure what you need to do? Give us a quick call and we will walk you through a few simple steps to get the update, 888.460.4310.

Timely Tips

Learn about the top three new enhancements in myABILITY.

Using the UB04 claim form and doing claims correction in ABILITY | EASE.