Last year we had an article here talking about reasons to consider assisted living. It was more about the needs for assisted living and the potential emotions associated with it by the residents.

Sophia Playing the Harp
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This time around we’re going to address issues around assisted living centers that most people don’t know, things that may help you decide if it’s the place you want to put your loved one into. After having to go through the process with my own mother I’m sharing some of what I’ve learned.

1. Assisted living organizations don’t take insurance

Assisted living isn’t a senior care center. The idea is for it to be a place for those of a certain age who can pretty much take care of themselves but might need some minor assistance. Many of them might be older, but that doesn’t necessarily mean they’re not pretty healthy.

Because of this, insurance isn’t going to cover any of the bills; at least not those generated by the assisted living center. They will help coordinate visiting nurse services if requested by a physician, which will be covered by those of Medicare age. Otherwise, it’s going to be totally out of pocket at this level.

2. How much money you have to spend monthly

Believe it or not, this is the 2nd most important thing to know, even moreso than what the monthly rates are. Many of these facilities are going to want to set up automatic withdrawal, which means you need to make sure the resident has the funds to last them for a long time. The income level is going to need to be somewhat significant; don’t even think about looking into assisted living if you can’t spend at least $4,000 a month. This isn’t all “fee” though; I’ll be addressing more below.

3. How much monthly rates are

This is actually the 3rd most important thing to know. Assisted living fees are different across the country and even across your own area. I live in the Syracuse NY area and fees run from between $2,300 and $4,800 a month.

As you can imagine, the least expensive fees are probably in large facilities in urban areas, and the most expensive fees will be in very nice settings with a bit more exclusivity. But wait; there’s more.

These facilities will have rooms of different sizes, from studios to 2-bedroom “suites”. Don’t think apartment sizes for these prices; they’re probably less than half the size of a traditional 2-bedroom apartment.

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One that I looked at had what they called a studio apartment which was 100 square feet; that’s the size of a small home office. It didn’t include cable or phone, but it did include heat, and since older people are always cold this might not be a bad feature. Meals and activities will be included in the fees, along with some limited travel and transportation to doctor’s appointments or to the store if you request a small refrigerator in the room.

The more you can spend, the nicer a place you can get, but you’re going to want the resident to have enough spending money to enjoy themselves.

4. How nice are the facilities

Once again this is based on location and price, but even pricey assisted living centers might not be all that nice. There was one assisted living facility that was very spacious and well laid out. It had multiple sitting rooms and game rooms, and even an exclusive room where there was a piano and extra large TV for movie night.

The big spaces can be really nice. Other spaces might seem a bit oppressive. Some residents might end up having to share a room, just like in a hospital, and that’s not always a pleasant experience. Also, some facilities aren’t as clean as you’d hope they would be, especially if they have a lot of residents. Unfortunately, most of the people working in these larger places don’t make a lot of money, so it’s hard keeping quality help.

5. What recreational opportunities do they have?

Sitting Room
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You like to know that your family member will be mentally and physically engaged instead of having to sit around watching TV. Most of these facilities will offer games, dances, sing alongs and movies, but the larger the places are, the less likely they’ll be in making sure everyone participates as often as you’d hope. Smaller facilities have employees that get to know the residents pretty well, and in those cases the residents will be encouraged to participate in these things more often. By the way, this one comes from talking to residents of different facilities and their experiences.

6. What are the meals like?

Some assisted living facilities have almost world class chefs and fancy meals and desserts. Some will have standard comfort food, while others might have sandwiches and one daily special for lunch or dinner. No one will starve, but the food might not be all that flavorful since dietary concerns become the norm.

Also… well, this one’s not quite fair, but it was an observation I had at one facility. There was a large dining room and I was there during lunch. Half the tables had residents who were still in their night clothes or robes, and sitting at tables either ignoring each other or just looking… old. A few tables had great engagement and laughter, but strangely enough those tables were all male. I’m not sure what that says overall but I have to admit that it gave me pause, thinking that my mother might be at a table where no one was talking or showing any life.

7. Are there hidden fees?

This one is the most important thing you have to find out about. Many facilities will offer different levels of care based on tier pricing, in which case you know what’s going on up front. One of the facilities I looked at gave us a price list of extras, and some of them seemed a bit outrageous. Since they determine which extras your family member might need to receive, it’s possible that your monthly bill could end up being as much as 300% higher than the actual monthly rate… being automatically withdrawn without your prior approval. That will eat up savings pretty quickly.

Truthfully, it was this last one that convinced my wife and I to move my mother into the house with us. It’s turned out to be the smartest move, and we can make sure that her money is safe and that she’s well taken care of.

Most people will have to think about assisted living at some point in their life. I hope this has been helpful.
 

Just like almost all businesses large enough to have employees pay someone to audit their businesses, hospitals sometimes need to, or should have, someone come in to audit their receivables process. It can involve looking at the charge master or how charges are captured, or a host of other things. This article is specifically going to talk about the billing process because it’s one of the most critical parts of the hospitals financial health.

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In general terms, we start talking about receivables when the billing process begins and it’s time to try to collect payment on the charges submitted by departments within the hospital. A review of receivables usually means looking at the billing process because it can be unwieldy and complicated… or has been made to be so over time. Depending on the depth a hospital is looking for, a review can take a week, or it can take a month or more.

Below is a portion of a paper I wrote for a magazine years ago on what it take in doing a billing review:

“If I were going to go in and do a billing review, I’d ask for some things up front. One would be an age trial balance, which would then allow me to look at both new and old accounts and give me an opportunity to look at why older accounts weren’t being paid. I’d then want to review one of these accounts on their system, or in their billing records, and of course review any notes they had on these outstanding claims. You can learn a lot by reviewing as few as 25 to 50 claims; that’s how insurance companies do it when they come in to review claims specifically for them.

I’d ask for a copy of billing and collection procedures, if they had any. I’m someone who believes that no department can be run properly without having a lot of their processes down on paper.

I’d ask for EOBs (explanation of benefits, also known as vouchers) for a one or two month period. This would allow me to scope out accounts that look problematic so I could determine whether it’s procedural or something out of the control of the facility… which eventually means it’s procedural. I’d be checking to see how long it took to post payments and allowances, if they posted the correct allowances (also known as adjustments), and how long it took to bill either secondary insurance or the patient.

I’d also be looking at denials, and I’d probably take one full month for their top 3 or 4 insurance companies and see what the denials were, and what their frequency was. Denials aren’t always billing’s fault, but sometimes they are if they’re not being worked properly. Sometimes this leads to looking at the medical records for some of these patients because sometimes I’ve seen billers taking it upon themselves to change codes just to get bills paid; that’s a major definition of fraud.

I’d also want to interview some of the billing personnel. If it’s a small group, I’d want to talk to everyone independently, and if it’s large, then I’d like to talk to a random number of them, without the supervisor or manager around. That would give me a chance to ask them specific questions on how they do their work, and each person would be asked the same questions, to find out if everyone handles claims the same way, or if each person does their own thing.”

That’s the basic process in doing a full review of a hospital’s billing department. The one thing I like to make clear is that this isn’t a witch hunt. The idea isn’t to determine if management is deficient or to get anyone into trouble. After all, those people need to be there to handle things when the reviewer leaves. Any report will detail the findings and hopefully make recommendations that can be implemented to get things working properly. I say that because years ago when I was a director and we had a review, every recommendation was “put more people on…”; that wasn’t helpful one bit.

There you go; that’s the entire process. How does your facility handle things like this? If you have any comments or questions, please post them below.
 

Every person who works with hospital bills know something about revenue codes. Some folks have at least a basic concept of what revenue codes are supposed to be, that’s about as far as it goes. Scarier yet, some people have only heard the term. It would seem that it’s time someone addressed revenue codes in more detail, yet in simpler terms.

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Revenue codes are used to classify what you’re billing for. They’re used for variety of reasons including:

* Type of room a patient may be in

* Type of services that are being performed

* Type of service that might be performed

* Type of supplies or pharmaceuticals that might be given to a patient

Using Incorrect Codes

Because they’re complex, we sometimes make errors when using revenue goes. Sometimes incorrect revenue codes are used because of the perception of what’s being performed versus what is actually going on. For example, revenue 510, which stands for clinic, is quite often used for services provided in a hospital setting because no one is quite sure how else to use it.

Many times it’s questionable whether the services being performed should be charged or not, but each facility has to determine that. Evaluation and management codes that are performed in different areas of the hospital (ex: pain management, maternity) are quite often coated with a 510.

Many insurance companies won’t cover these services because they’re being billed with service type 131 (outpatient hospital setting). Others have recommended that revenue code 761, treatment room, would be better to use in these instances, as it’s more accurate than 510. The facility should review whether or not they should be billing for these types of services since most of the time they’re performed by nursing personnel.

Procedure Codes

There are revenue codes that need procedures codes, some that don’t, and some that might or might not need them. Revenue codes from 00X to 24X don’t require procedure codes because they denote room charges. Revenue codes after that concerning procedures always need a revenue code (ex: 300 to 319, 320 to 359 for radiology related services).

Supply revenue codes (27X) may or may not need them, but supplies are a different sort of animal. Some insurance companies such as Medicare may reimburse separately for certain supplies that are coded with a HCPCS code (codes beginning with a letter, followed by 4 numbers). Some revenue codes aren’t reimbursable by insurances such as Medicare unless the facility has a specific provider number for them, such as for revenue code 274 (prosthetics and orthotics). In this instance, the hospital has to have what’s known as a DMEPOS number, which allows them to sell durable medical equipment. Any supply that could be considered as take-home, revenue code 273, will probably not be covered by many insurance companies.

There is a debate as to whether it’s legitimate or not to classify these items under revenue code 271, nonsterile supply, in order to capture costs. Those in favor of it say that hospitals should be allowed to show these costs since they’re not going to be reimbursed for them anyway. Those against it feel that it’s an attempt to get around the billing regulations that say it’s a noncovered hospital item (I’m with this group); in essence it could constitute fraud. Finance administrators need to make the decision on which way they go and have it documented. I always recommend to err on the side of caution.

Some procedure codes can be classified with many different revenue codes. Endoscopic surgical procedures are one example. They can be billed using revenue code 360, 361, 450, 490 and 750. It depends upon location as to whether your facility bills one way because of contractual obligations or another way for classification purposes.

The flipside of the above is that there are certain revenue codes that should not be coded with specific types of procedure codes. For instance, there are many interventional radiology services that radiology departments have coded with procedure codes under their revenue codes, when they belong under surgical codes instead. What should be coded is the radiology component of the surgical service instead. Hospitals are either undercharging or possibly looking like they’re double billing for services provided.

There are times when you might expect to see a specific revenue codes when another one is used. For instance, if revenue code 370 (anesthesia) is used, many insurance companies expect to see a 710 (recovery room) revenue code with it. Certain procedures, such as cardiac catheterizations and certain CAT scans, are expected to have pharmaceutical and/or radiopharmaceutical charges along with them. They may not change the reimbursement a facility route will receive, but not having them could definitely delay payment.

Professional Fee Codes

Finally, there are certain revenue codes that most insurance companies don’t expect to see from hospitals, although your facility may have specific reasons for using them. The 96X to 98X range is for professional fees, and 99X are patient convenience items. Sometimes hospitals are responsible for billing professional fees along with the hospital bill. Some hospitals charge patients for convenience items that they know insurance companies won’t pay for, but don’t separate it from other accounts receivable items. Most hospitals usually charge for some of these items in a different way or don’t charge for them at all.

This is just a quick look at some of the issues concerning revenue codes. Most of the time revenue codes are easy to deal with. Sometimes they can be very complicated. It’s best to know what you’re up against so you can start a plan of action and documentation to protect your facility.
 

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