MRS MBAA Master Presentation V9-General

A JH CAPITAL GROUP SUBSIDIARY 1

MBAAMEDICAL BILLING ADVOCATES OF AMERICA

DEDICATED TO TRUE & ACCURATE, FAIR & REASONABLE BILLING


MBAA – An Overview

Snapshot:

• 20 years Patient Advocacy experience

• Market Pioneer

• Recognized market leader in “True, Accurate, Fair and Reasonable”


Leadership

Gayle Sutherland, RN, CPC-H

Director Hospital Compliance

Jeanne Woodward, BSN, RN, CPC

Director Physician Compliance

Teresa Brown, BA, RN, CPC-H

DirectorHospital Accounts

Michael Mann President

Pat PalmerFounder


Financially Stable – Positioned to Grow

TAMPA, FLTwo Site Locations

200 call center seats total

LOS ANGELES, CAJH Capital Group

JACKSONVILLE, FL100 Seat Call CenterLAS VEGAS, NV

100 Seat Call Center

ST.LOUIS, MOCREDIT

CONTROL200 Seat Call Center

VOORHEES, NJ200 Seat Call Center

Non-Traditional Private Equity Group• Based in Calabasas, CA • Certified Minority Owned• Over 1200 Employees• Owns 20 Portfolio

Companies • Healthcare• Specialty Finance• Cyber Security• Real Estate• Government

ROANOKE, VAMBAA

Terry Buske• Sr. Vice President,

Business Development


Would you pay this bill?

What questions would you ask?

Restaurant1 Columbus Circle

New York, NY 10019 102 Tetsuo

Tbl 10/1 Chk 7080 GST 2 Feb28’ 07 7:58 PM

2 Prix Fixe 800.00

20.0000 X 20% Serv. Chrg.

161.00 FOOD/BEVERAGE 800.00 Gratuity/Service

161.00 Tax

67.42 Total Due

1033.42THANK YOU FOR DINING WITH US!!!

A 20% service charge has been applied to the bill. Any distribution of a service charge rests in the restaurant’s sole

discretion


You want the detail

Summary Bill Itemized Bill


UB-04 vs. Itemized

UB-04 Summary Itemized Statement

• Room and Board• Pharmacy• Med-Surg Supplies• IV Solutions• Laboratory• Operating Room• Recovery Room• Emergency Room

• Every single service, item and drug used in a medical procedure and hospital stay

Why would your medical bill be different?


Common Billing Overcharges

• Toothbrush - $1,009.00

• Items like oxygen are included in the room charge but are sometimes billed again separately and individually

• One Aspirin - $180.00 Estimated amount of Non-Compliant and/or Overcharged, Uncaptured &

Up-Coded Health Claim Errors - 2013

What happens when no one is looking?

9

The only way to ensure

compliance is to overlay and compare the Itemized with

the UB04


MBAA’s Billing Compliance Analysis

Compare - Contrast

Based on industry standard coding guidelines including but not limited to:

• Uniform Billing Act• Social Security Act• Code of Federal Regulations• CMS Guidelines

• False Claims Act and the

• AMA Billing and Coding Guidelines

UB-04Itemized

Statement


Compliance Analysis Not Medical Audit


Kaiser Case Study

The Focus of MBAA Reviews:

• Non-Contract Hospital Claims

• Review balances > $50,000

• Finding Average 17% Error Rates

• $8 Million in Savings (12 Months)

Lead, RN Kaiser Foundation

Utilization Management

"A clean claim doesn't equate to a correct

claim."


Kaiser Case Study

Snake Bite Example:

• $950,000 Claim

• Member Plan 80/20

• Hospital offered 2% discount

• Result: True and Accurate = $86,000


Payer

Process Payments

Plan Coverage

Utilization Manageme

nt

Automation

Kaiser Case Study WorkflowBest Practice - Insurance Company Prior to Pay

Pay this Amount

Hospital >$50,000

UB-04Itemized

Statement

EORDetailed Support for

Denial of Non-Compliant Charges

UB04


TPA

Process Payment

s

Confirm Charges

Apply Discount

s

Automation

Workflow - Prior to Pay Best Practice – Self Insured (Company or Union) using TPA

Pay this Amount

Self Insured Organization

>$25,000UB-04

Itemized Statement

EORDetailed Support for

Denial of Non-Compliant Charges

Hospital UB04


Sign Agreement

On-Boarding

Call

Primary POC

Claim Criteria FTP Set Up Drop

Claims

Getting Started

Step 1 – Set-up Step 2 - Onboarding Step 3 – Intake, Support


Minimum Time/Resource Allocation

Monitor FTP 24/7

CoversheetUB-04

Itemized Bill

Questions Answered(1 hour a

Week)

Compliance Analysis

EOR (Explanatio

n of Review)

Five (5) Day Turnaround


MBAA Value Creation

MBAA Performance Standard - Identifying 10-20% Non-Compliant Charges

Current Performance for Kaiser Foundation Northwest - 17%

For every $10M in Claims, MBAA will return $1M - $2M to your bottom line

MBAA retains 25% percent of the SavingsNo Risk – if there is no savings, there is no

cost


Priority / Payoff Matrix

High Payoff / Easy High Payoff / Difficult

Low Payoff / Easy Low Payoff /Difficult

Payoff

High

Low

Resource, Time Allocation Easy Difficult

• Questions?

• Stakeholders?

• Next Steps?


Support Documentatio

n

•Prior to Pay Service Agreement

•ERISA Explanations

•HIPAA Compliant FTP Drop Site

•Drop Site Instructions

•Detailed reports of non-compliant charges

MRS MBAA Master Presentation V9-General

Documents

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