We help large healthcare systems and individual hospitals thrive under the Outpatient Prospective Payment System. This system has, and will continue to have, enormous financial, clinical, operational, and strategic impact on healthcare providers. Nimitt Consulting creates and implements strategies that help providers maximize their efficiency and reimbursement under this system.
Nimitt Consulting's team of consultants work with organizations to identify clinical, financial, operational, and strategic issues that may be of concern for future compliance risks as well as current revenue opportunities. Strategic alliances with other firms bring expertise in coding, chargemaster reviews, compliance audits, and software support to our clients.
Nimitt Consulting can assist your organization implement key strategies to accommodate APC and OPPS impact. We can also identify long-term business risks and opportunities in clinical, financial, operational and other strategic issue areas.
APC/OPPS Case Study
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Case Study: The CFO of a large hospital system with more than 20 facilities became worried when the system’s Medicare accounts receivables (AR) rose to a staggering 45 percent. With less than 60 days remaining before the close of the fiscal year, the CFO and his managers were concerned that there was not enough internal manpower to resolve all the claims denials and recover the lost revenue. The problems were due to the large number of Medicare changes occurring in a short amount of time; internal software systems and interface issues; and difficulties with the fiscal intermediary’s edits and interpretations of CMS Program Memos. The Nimitt Consulting team was called in to provide education, information, additional staffing and a practical -- yet strategic -- work plan to assist the APC Task Force resolve the problems as quickly as possible. Given the short timetable to resolve the problems, the team focused on unpaid claims involving the largest amount of revenue. The group implemented a “finders and fixers” approach. One group of staff reviewed outpatient claims data reports in order to “find” and flag the major problems. These were passed to a second group to “fix” at the system or hospital level. A final group assessed the process to ensure that the identified problems were actually fixed. Everyone worked extra hours to resolve the unpaid claims problems and, by year’s end, the AR dropped from 45 percent to 27 percent. In another 30 days, the AR was down to 19 percent. By the end of the project, millions of dollars in revenue had been recovered, and a lasting infrastructure created that allowed staff to continue working efficiently and effectively long after the project ended. The CFO considered the project to be a job well done, accomplished because of an effective assessment of the overall problem, identification of key issues, solid teamwork and open communication. |
Key Services
- Facilitating and managing APC revenue cycle groups with a focus on uncovering revenue opportunities and compliance risks
- Tailoring general and specialized APC/OPPS education programs
- Outpatient coding compliance and revenue audits
- Local medical review policy analysis related to drugs and biologicals
- Data analysis and policy development guidance on OPPS issues to government agencies including CMS.
- Preparing financial impact analyses at the hospital and departmental level based on annual payment rate changes
- Pharmacy services billing, reimbursement and compliance risk review
- Drug administration charge, capture and compliance risk review
- Facility Evaluation and Management (E/M) guideline development and audits
- Creating a data and information process map showing the flow of codes and data through the organization before claims are submitted
- Designing outpatient management reports using facility claims data to isolate and minimize compliance risks and revenue opportunities
- Demystifying Medicare’s Outpatient Code Editor (OCE) and the National Correct Coding Initiative (NCCI) edits
- Training on the appropriate use of modifiers and their impact on reimbursement
