Consultants can tell you a lot about how to work with Medicare's outpatient prospective payment system.
But wouldn't you rather hear what two hospital accountants have actually tried in response to the PPS?
Dennis Fuller and Wendy Resnick of seven-hospital Shands HealthCare, Gainesville, Fla., have been knee-deep in the morass of outpatient PPS codes and regulations since well before the system's Aug. 1, 2000, implementation.
Fuller, reimbursement and tax director, and Resnick, an executive accounting assistant, will present "Year No. 1 Outpatient PPS Implementation: Lessons from a Provider" from 10: 30 a.m. to 12: 30 p.m., Wednesday, June 20. They'll draw on the experiences they have gained in managing the PPS for hospitals ranging from a giant teaching hospital, 558-bed Shands at the University of Florida, also in Gainesville, to a small rural facility, 16-bed Shands at Live Oak (Fla.).
Fuller says the presentation should resonate with hospital business managers "because it's from people in the trenches, not consultants. Maybe (the audience) can see, `By golly, these people can do it. Why can't we do it?' "
The outpatient PPS forced Shands to make a huge change in its approach to billing changes. "I think for the first time, it's been critical to have your clinical people looking at reimbursements," Resnick says.
That task has been made more difficult by the steady stream of refinements HCFA has made to the system. "We don't have time as providers to disseminate this information to probably all of the people who should get it," Resnick says. "The silver lining in the clouds is that this has captured their attention probably more than ever before on how they can help with the revenue stream."
One revelation of the new system is the lax coding that was practiced on emergency-room visits. "If you have a minor surgical procedure, we had a tendency to code that as (just) an ER visit," Fuller says. "But if there are procedures taking place, you could get reimbursements for those, and we weren't capturing that in the past."
The outpatient PPS has been an eye-opener for fiscal intermediaries, too. "I don't think they were prepared for the changes software-wise, and they certainly weren't prepared staffing-wise to educate the providers," Resnick says.
An approach Shands used that could help other providers is to gather clinical, operations, compliance, finance and patient services employees in a room to painstakingly review individual claims, Fuller says. "As boring as this may sound, we looked at how claims were actually processed, and we looked at what we were paid with how we used to be paid," he says.
Fuller took some of what he learned from those claims reviews back to the Medicare Technical Advisory Group that meets periodically in HCFA's Baltimore office.