Practice for CPPM Exam

*Efficiency
Process & doing things right
*Effectiveness
Outcomes & doing the right thing
Accural Accounting
Records revenues when they are earned & expenses when they have been accrued. Provides a more accurate reflection of your current financial situation
Cash Based Accounting
Recognizes revenue only when cash is collected & expenses when cash is paid. Provides a truer reflection of actual cash on hand & requires less reconciliation
Chart of Accounts
Lists all potential accounts for all financial information (income, expenses, assets, liabilities, equities
Income Statement
Records all revenues & expenses associated with the business for a specified time. Summary of a company’s profit or loss during a given period
Balance Sheet
Snapshot of buisness’ financial condition at specific time. Includes values for assets, liabilities & stockholders equity
Cash Flow Statement
Financial statement used to maintain awareness of funds (cash available) to support ongoing business operations
Break Even Point
Point where revenues for services minus all variable expenses = the fixed expenses & add’l revenue will start creating a profit for the business
OSHA
*Procedures for reporting a file
* Evacuatin procedures during emergency
*fire extinguisher locations
* Emergency contacts & info
* Designated meeting location
* Staff assignments & responses
**Revenue Per Visit (RPV) Calculated
Review payor contracts = Toal amount collected ./. total # pt visits
**Days in A/R formula
total A/R ./. (total charges ./. total days in A/R
(i.e. $558039 ./. ($700,00 ./. 60)
Medical Necessity
Most important criteria for E&M
Days in A/R
How long it takes to collect a charge. Good is less than 40 days
**Days in A/R forumula
Total A/R ./. Total charges ./. # of days for charges
Assests =
liabilities & equity
Assests
If assests are higher than liabilites, that’s a good thing
**Net Collection Rate
Total Receipts – Refunds ./. Total Charges – Contractual Adj
Bad Deb Ratios
Total bad debt for period ./. total charges for period
Denials Report & Denials Rate
Total # of denials ./. total claims submitted
*LLC
Limited Liaiblity Company – unlimited owners & limit the am’t of taxes
*Disaster Recovery Planning
Should include prevention, detection & correction
*Pod
Has nurses, exam rooms & physicians offices all located in the same area
*Quantitative Risk Analaysis
Measure of the probabilities of variouus adverse events & the likely extent of the losses if a particular event occurs
EHR Date
1/1/2015 – Providers who have NOT implemented EHR will begin to see a reduction in Medicare payment
Procedure Code Sets
ICD 9 CM Volume II (hospital input charges
HCPCS Level II
CPT
CPT & HCPCS Dates
1/1
ICD 9 Dates
10/1
Bad Debt Ratio
bad debt right offs are adjustments that will result in no collections
Bad Debt Ratio
Total bad debt for period ./. total charges for period
State Prompt Payment Laws
If payments are late by insurance companies
The following will NOT prevent claim denials
Provide medical documentation with an appeal letter to support the service rendered
Productivity Report
Details the volume of procedures being performed by each provider
Denials Report & Denials Rate
Important to cash flow – use weekly to identify denials. Should always stay below 5%
Denials Report & Denials Rate Formula
Total # of denials ./. tot claims submitted
Adjustments to collection
Used for monitoring fluctuations in adjustments
**Adjustment to Collections Ratio Formula
Tot adjustments for period ./. Tot collections for period
Net Collection Rate
Determines how well a business is collecting on eligible revenue. Better to look at net collection rates over a 3-6-9-12 mo period of time
Net Collection Rate Formula
Tot Receipts – Refunds ./. Tot Charges – Contractual Adj
A/R Aging Summary
Used to identify the aging of receivables & if accounts are being collected in a timely manner
**PQRS
Physicain Quality Reporting System = eligible providers are all health care providers, but not out pt surgery center or labs
**PPACA
Pt Protection & Affordable Act = allows sharing of IRS data to identfiy fraudulent providers with tax debts
VOB
Verification of Benefits
ROI
Return on Investment
PECOS
Provider Enrollment, Chain & Ownership System
Medicare EHHR Incentive Program
does NOT include NPs, but does include drs of MD, podiatrists, dentists, psychiatrists
VPN
Virtual Private Network = extremely secure connections between private networks tunneled through the internet
False Claims Act & Qui Tam
Whistle Bloer Act – prohibits any person from knowingly presenting or causing false claims
Rule by All
all physician partners are involved in decision making
**Profit Share Plan
contributions only by the employer; if offered to employer, must be offered to employee
FMLA
Family Medical Leave Act = only applies to employer groups with 50 or more employees & gives up to 12 wks unpaid leave & holds the job
**EDI = Electronic Data Interchange
Current version for HIPPA transactions is X12 Version 5010, NCPDP Version D.0
HIPPA Breach – under 500 pts
report once yearly
HIPPA Breech – over 500 pts
but at least 12 pt addresses out of date, publish a print ad of the breech in nespaper & include the date of the breech & when it was discovered; a brief description of incident ; descriptioin of unsecured PHI involved & suggested steps for individuals to take to protect against problems
HIPPA breech – over 500 pts
must notify local media & notify Secretary of HHS
HIPPA
applies to providers, health plans, clearinghouses, anyone who submits any health info in an electronic manner
Business Associates Agreement
needed when any entity is sharing PHI. NOT used for employees. Also, NOT used for janitors, building maintenance or tax accountants
HIPPA Breech of PHI of 45 records
requires pt notification within 60 days of breech
Offsite biller
Required to log on to remote server that has automatic logoff feature set
Subpoena for medical records
You can send records requested by court order without authorization from pt
Employment Questions OK to ask
worked under different name
ever convicted of crime
if U.S. citizen
education level including degrees & certifications
If relatives employed by organizations
prior employment
Employment Questions NOT ok to ask
age, race, sex, religion, national origin, disability, pregnancy
401K
Employer & employee BOTH contribute
HR forms kept in separate file from employee’s personnel file & in locked location
OSHA compliance
completed FMLA form
Employment eligibilty forms (INSS form 1-9)
Worker’s compenstation
disability forms
**Income Statement Model
this physician compensation model requires allocation of revenue & expenses to each physicain in the practice
Mid Levels
Need Standard of Care agreement if only billing incident to
**SWOT Analysis
Strengths, Weaknesses, Opportunities, Threats
**Anti-Kickback Law
can’t solicit or receive payment for pt referrals
**Compliance Plan
Includes: designate compliance officer
training & education
Written policies for denial mgmt software
Internal auditing
**Stark Law
Prohibits physicians from referring pts to medical facilities in which the physician or member of immediate family has a financial interest
**Stark Law Exceptions
preventive screeing tests, immunications & vaccines
**OSHA
Bloodborne pathogens
Occupationsal exposure determination
Use of universal precatuions
Use of engineering & work practice controls
Use of personal protective equipment
Vaccincation policy for Hep B
Evaluation for use of safer needles & sharps
Post exposure evaluation & follow up
Containment of regulated aste
Communication of hazards to employees
OSHA – types that must be reported
Death
missed days from work
restricted work or job transfer
medical treatment beyond first aid
loss of consciousness
You’re buying aCT scan. What laws to consider?
Stark & AntiKickback
**OIG published resource for AntiKickback Laws
Fraud Alert
QI = Quality Improvement
Routine measurement of performance; QI fixes processes, not people
QA = Quality Assurance
Internal audit of billing procedures to verify compliance with fed & state regulations
QC = Quality Control
a system of technical activities that measures against a criteria or standard (i.e. lab equipment calibrations)
**Plan-Do-Check-Act
A quality cycle & QI method that systematically impacts a process or system
Insurance Reform
* 1/1/15 – pymt reduction for MDs with no EHR
* Medical cost ratio = 85%
* Adult children til age 26 on family policies
* Must provide preventive health
* No annual or lifetime maxiums
* Can’t cancel coverage when beneficiary gets sick
* no prior auth for ER
* restriction on out of pocket maximum, copay & deductibles
* no pre-existing conditions
* 5% increase in mental health services
* employers with 50+ employees are fined for not offering coverage
* employers with <25 ill be offered subsidies
S Corp
limits the # of shareholders, not taxed twice, profit can flow thru to partners equally
Business Relationships
bankers, accountants, attorneys, investment adviosrs
C Corp
most formal; offers stock with or without voting rights & have unlimited shareholder. Provides ownership of business to physicians as they join the practice, but are taxed twice, 1st at the corporate level, then again at the physicain level