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Profile of Success: CHRISTUS Health

Transfer DRG Reimbursement Recovery Program Puts Dollars Back in the Door

Organizational Overview
CHRISTUS Health, headquartered in Dallas, TX, is a not-for-profit health system consisting of 40 hospitals, inpatient and long-term care facilities as well as dozens of clinics, physician offices and other health care services in Texas, Arkansas, Louisiana, Oklahoma, Utah and Mexico. The system employs more than 25,000 associates, with 8,000 physicians on facility medical staffs. It is listed among the top ten Catholic health systems in the U.S., and its 16 acute care hospitals have a combined total of 4,848 beds and 59,338 FY 08 Medicare inpatient discharges.

CHRISTUS Health, like numerous other organizations, realized that Transfer DRG discharges represented the potential for discharge coding errors—not because of anything done erroneously by its facilities’ staffs, but rather because of what actually happened or didn’t happen to patients after their discharge from CHRISTUS’s acute care facilities to a post-acute care provider (e.g., SNF, HHA). Given the nature of CMS’s regulations governing Transfer DRG payments, such coding errors could have resulted in both overpayments as well as underpayments to their hospitals. With CMS already editing for overpayments, the real opportunity resided in those discharges that might have resulted in an underpayment. Based on the volume of applicable discharges, the underpayment potential was estimated to be at least $0.5M for a single year, with that number increasing several-fold if the system could somehow “look back” several years in its review to identify any coding errors.

The challenge lay in finding the resources to efficiently and effectively review over 150,000 Medicare IP discharges alone for the previous four years, as well as selected other discharges (rehab, Medicare managed care, and TriCare). With over half of those discharges having a Transfer DRG, a retrospective review would first require determining which accounts actually had a Transfer DRG, and then doing an account by account review of those TDRGs to see if there was any potential for over- or underpayments. Following that determination, each status code variance would have to be updated and resubmitted to the applicable fiscal intermediary (FI) for a corrected payment, whether positive or negative.

CHRISTUS decided, after looking at its own internal resources, to outsource the task to MCare Solutions, Inc. Julie Holly, Director of Reimbursement for CHRISTUS, said, “After looking at several companies, we chose MCare because of their long-standing experience in this area, their technology for analyzing accounts, and their willingness to actually do the rebilling for us instead of asking our own staff to perform that task. Plus, they had great references and an obviously high level of expertise in Transfer DRGs.”

Using MCare’s file specifications for relevant accounts, CHRISTUS prepared and submitted a file of accounts going back several years for MCare to review. MCare’s first step in its analysis process was running the files through MCare’s proprietary software analyzer, which contains reimbursement formulas and payment-related algorithms corresponding to CMS regulations. This step pared down the initial assignment of accounts to those warranting further review to determine potential coding variances. MCare’s staff then followed up on each account’s history, as well as contacted post-acute care providers and the FI’s when necessary to determine what actually happened with the patient and/or provider after discharge from the CHRISTUS acute care facility. When it was determined that an error in payment had been made, whether an overpayment or an underpayment, the MCare staff made the appropriate change in the discharge status code via the Direct Data Entry (DDE) system, and resubmitted it to the FI for a corrected payment. Detailed results were documented at the patient level and conveyed by MCare to CHRISTUS for its records.

Thus far, the retro review of approximately 90,000 accounts initially assigned for the period 10/1/05-12/31/06 from all the CHRISTUS facilities participating in the program has resulted in the identification and collection of over $1.33M in underpayments. It also resulted in the identification and correction of 5 accounts totaling a little over $9,000 in overpayments. These recovered payments (and corrected overpayments) were realized within six months from the time the program first started. Additional recoveries continue through the review of other CHRISTUS accounts assigned on a recurring basis to MCare for follow-up and recovery, as well as from the review of even older accounts.

Of accounts assigned and reviewed to date, 25% had an associated TDRG, of which 19% warranted follow-up to determine the accuracy of prior payments. Of the total accounts assigned, 0.9% have resulted in additional incremental payments, at an average of $2,302 each. “These results are well within the range of our expectations, based on what MCare had projected, and we couldn’t be more pleased with MCare’s efforts, organization, and results,” concluded Ms. Holly.