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Four Simple Benchmarking Tips to Assess Payments and Billing


The biggest hurdle hospitals face in identifying and quantifying missed reimbursement is limited resources. Hospital finance teams have a wide range of day-to-day responsibilities and many simply don’t have the time or technology needed to analyze the extensive sets of data used for Medicare reimbursement.

While a comprehensive Medicare reimbursement analysis can be difficult to perform, here are a few simple benchmarking tips that can help assess payments and billing to quantify missed reimbursement or savings opportunities:

1. Examine crossover claims

Take a look at Medicaid denials secondary to Medicare. Secondary insurance payments are often overlooked, but significant lost reimbursement may be at stake. Not only could your hospital be losing out on coinsurance and deductible payments, it may be unable to correct and get the bill to Medicaid within timely filing rules. Medicare Bad Debt could also be impacted, as Medicare Administrative Contractors (MACs) require hospitals to bill Medicaid correctly before they’ll allow a Medicare Bad Debt payment.

2. Check SSI percentages

Determine your hospital’s Supplemental Security Income (SSI) percentage relative to the percentage of coinsurance and deductibles that are written off. SSI is a strong indicator for Medicare Bad Debt, as there’s significant overlap between the two populations. In general, the higher SSI percentage, the higher the expected Medicare Bad Debt.

If your SSI is going up, but your bad debts are going down (and neither the state’s approach to payments secondary to Medicare nor your hospital’s policies have changed), it could indicate you’re missing some portion of your Medicare Bad Debt population.

3. Account for every Medicaid-eligible day

Whether you rely on external vendors or your own internal processes, make sure you do a true-up of Medicaid-eligible days for the purpose of calculating Medicare Disproportionate Share. True-ups help hospitals capture all retrospective Medicaid membership changes, as patients can become retroactively eligible or ineligible for Medicaid after hospital stays. They also help hospitals ensure they take advantage of all available retrospective opportunities. The best strategy is to re-investigate your Medicaid-eligible days just prior to any MAC audit of the cost report.

4. Assess your Medicare Advantage patients

Take a look at the number of Medicare Advantage patients you have to make sure all your Medicare Advantage bills are being sent to Medicare Part A for the shadow billing opportunity.

Over time, Medicare Advantage plans change by region and by county. Staying on top of which plans are offered in your area will allow you to better identify those patients at registration. Finding the complete population of Medicare Advantage patients has wide-ranging implications associated with: Indirect and Graduate Medical Education reimbursement (IME/GME), Medicare Advantage Bad Debt reimbursement, CMS compliance guidance, hospice transfers and other cost report and hospital-specific situations.

The next step to maximize reimbursement

While the above actions can help validate whether your hospital’s strategies are maximizing reimbursements, there’s more to be done. Consider having a third party examine your results —whether they come from a vendor or internal sources.

Learn how TransUnion Healthcare can help navigate Medicaid and Medicare reimbursements to ensure your organization gets maximum results.

Do you have questions? Our team is ready to help.