Oct. 8, 2019 – The MPF Revenue Cycle team had a very adventurous visit planned for me when I arrived at Rady Children’s Business Center (Copley). The moment I walked into the dining rooms, I felt like I was finally on my first Hawaiian vacation!
I learned so much from my travel guide about the incredibly detailed, complex and important work that the five teams within MPF Revenue Cycle complete every day. Director Tami Krumheuer leads the five teams, which are headed by Melissa Thomas, Manager of patient financial services; Helen Ramirez, Edwina Solomon and Carmen Rodriguez, managers of professional billing and coding for different specialty areas; and Sheryl Mojica, manager, PFS — customer service and payment applications. Teaming up with these six inspiring leaders are 97 staff members who support 553 providers in 35 unique medical specialties. In FY19, this team processed 718,369 claims and collected $2.2 million over the target goal! Very impressive!
To help me understand how the revenue cycle works, I was challenged to an “Amazing Race”-style journey around different “islands,” which each represented a step in a successful billing process. As background for my race, I was told providers had billed codes on a surgical case that triggered an Epic audit. The audit suggested that the services might be considered bundled (and therefore not paid by insurance). It was up to me to sort everything out — with a little help from my MPF revenue cycle friends, of course. This was a very creative way to learn about such a complicated process. As a former provider and electrophysiologist, I was well aware of this issue with bundled payments and was often frustrated as to why I couldn’t bill for all the care that I appropriately provided.
The “islands” I visited on my Epic journey (get it?) represented teams in key areas such as billing and collections, division support, and payment application. Each destination also had its own unique “geographical features,” which I explored to gain deeper insights into team responsibilities.
On to the race! First, I stopped at Charge Review Coral Reef, where I learned that charges entered into Epic go through a series of rules and edit checks to ensure billing accuracy. If issues with the charges are identified, they are routed to the charge review work queue for analysis. To solve my “Amazing Race” case, I had to head to Coder’s Paradise to have a coder review the medical record and determine what treatment the patient received and if the code selected was the most appropriate one to represent that treatment. After this, the claim could be resubmitted, but I then received a surprise inspection and another Epic warning that there was a fee not associated with a Current Procedural Terminology (CPT) code! I needed some assistance, so I headed to the Pricing Pineapple Fields of Big Kahuna Specialists Island for advice. Here, team members compared the code to our fee schedule of CPT codes for procedures and services. If the code isn’t on our schedule, steps are taken to determine our pricing, and the new code gets added to the Epic fee schedule. From here, I cleared all errors and the accurate code was posted to the account. But I wasn’t off the hook just yet. The claim was stopped because it required an authorization that was missing. I was sent to Claims Edit Sandy Beach Island to solve the issue. Onward!
Once there, I learned that when we post charges to the account, any information that is missing or inaccurate is flagged, which is important so that we can submit the cleanest possible claim to the payor and minimize payment delays. Just when I thought I was in the clear on my exit from Sandy Beach Island, I ran into a squall: the billing provider was not credentialed with the health plan! To avoid more rough seas, I headed back to Big Kahuna Specialists Island and took shelter in the Credentialing Discovery Cove. Because the billing provider wasn’t credentialed, we had to add them to our group. The team starts the Medi-Cal enrollment process as soon as possible because it can take three to four months for Medi-Cal to process the application. Once approved, the provider is linked and the claims are once again released. I survived the storm and was ready to submit to the health plan! For a little relaxation, I sailed around the island to Claims Castaway Bay.
In this bay, I was filled in on how the team generates a daily electronic claim file in Epic that is submitted to our clearinghouse, which reviews all claims to identify additional details that might result in payor rejection. Then, the claims are either sent back to Claim Edit Sandy Beach Island for review and corrections, or, if it is a “clean claim,” it goes to the payor for processing. The claim is then documented in the shipping log so that billing and collections representatives are aware that it made it successfully to Remittance Treasure Island for payment, or alternatively, if the payor rejected the claim. Once again, I thought I was in the clear! But, think again … the shipping log showed that it has been 30 days since I submitted my clean claim and I had not received a payment or denial. I received word that my claim was last seen at No Response Mystery Island.
I sailed over to the island and contacted the health plan and the state. Both told me that my claim was denied for coordination of benefits. Another barrier! I discovered that it was routed to Hospital billing, which caused a delay. I then had to send what I learned to Remittance Treasure Island to request the remittance from the Hospital team while I followed up and headed back to Denial Shipwreck Island to track down the primary payor. Here, I had to write an appeal to the payor to explain the bundling and medical necessity, and to make the case that the services should be separately reimbursed and paid. I must have written a good letter, because my claim was overturned and successfully paid! Time to make harbor on Remittance Treasure Island and celebrate my success.
The adventure was almost over, but first, there was some follow-up necessary. Back on Remittance Treasure Island, I learned that payors send payments straight to our bank with an explanation of benefits which contains a detailed breakdown of how the payor judged each service. The file is loaded into Epic and processed to match clean payments to charge lines. If there are any mismatches, the file will error for a payment application representative to manually review and ensure proper distribution of payments to the correct charge line. If not electronic, it has to be manually loaded into Epic. In this case, the system issued an alert that the claim was underpaid based on our contract with the health plan. For some help, I went to the experts at Big Kahuna Specialists Island and looked for the Underpayment Volcano. In situations of underpayment, the team works with the payor on resolving the issue at a macro level, as well as on submitting appeals for additional reimbursement on individual claims, as outlined in our contract. To make the payment whole, there was still a 20 percent coinsurance due from the patient, and the family requested to set up a payment plan.
On to Payment Plan Hope Island to set this up! Payment plans can be established as monthly installments until the amount due is satisfied. After time passed, the payment plan was fulfilled, but, there was an undistributed claim on the patient’s account — they overpaid! Off I went to Hula Refund Island to determine that it was truly an overpayment, and processed the refund. With a new zero balance, I was off to the finish line at Tiki Trainer Landing to collect my reward: full payment of my claim!
Wow! What a whirlwind. We finished my visit with some well-earned (by everyone!) breakfast burritos and tropical fruit. I also received a plaque commemorating my journey and a box full of San Diego suggestions for restaurants, beaches and other hot spots. My family will love that. It truly takes a village to offer our patient families a great experience from start to finish, and we could not do that without the diligence of this team. Thank you all so much!