Explore "tpa" with insightful episodes like "Episode 38 - Obesity and What it Means for Plan Sponsors", "#36(TPA3) Eva Aschauer, Head of ESG: "Ich sehe einen Trend zur freiwilligen Nachhaltigkeitsberichterstattung"", "Thanksgiving Travel - Emily Nipps Tampa International Airport", "Josh Gillin - Tampa Airport Job Fair" and "Episode 75 - Climate â rational action, and affordability" from podcasts like ""HR Benecast", "Der Österreichische Nachhaltigkeitspodcast", "Beyond the News WFLA Interviews", "Beyond the News WFLA Interviews" and "Croydon Constitutionalists Podcast"" and more!
Nearly half of working Americans have obesity, raising the risk of Type 2 diabetes, heart disease and stroke. Hear from George Huntley, founding member and CEO of the Diabetes Leadership Council, about the importance of addressing obesity and the role it plays in employee retention. He'll share successful treatment options and the direct and indirect benefits for plan sponsors and their participants.
War in Europe, continuing supply chain and logistics challenges, climate change, economic pressures, an absentee trade agenda from the Biden Administration, and more are making it difficult to be optimistic about anything—let alone rice—an export-dependent crop. USA Rice’s Sarah Moran and Peter Bachmann, who tag-team international issues for the industry, join Michael and Lesley to share their outlook on trouble spots and opportunities.
To help Ukraine, consider these charities, rated A- or higher in efficacy by CharityWatch.org:
Catholic Relief Services
Doctors Without Borders USA
Mercy Corp
Samaritan’s Purse
Team Rubicon
Hosted by:
Michael Klein and Lesley Dixon
Business owners and employees leave money on the table year after year by not having the right retirement plan in place. In this episode, Karen talks with the Mobile, Alabama employer, employee, and personal retirement plan TPA specialist Crystal Sears of Azalea Administration. Crystal explains all the options employers and employees now have with 401(k) and other retirement plans and how to get started saving for your future. Plus, learn why setting up an employee plan is one of the best ways to hire, motivate, and keep your best team members and top producers.
{Editor's Note: this is a rebroadcast of a past episode. Karen is taking the week off the show to spend time with her family for the Fourth of July holiday.}
Learn more about Crystal Sears and Azalea Administration.
Key Takeaways:
1. A 401(k) plan is it's a way to save money, but you're saving it for yourself.
2. Employee retirement plans for your help you find, motivate and keep your best employees.
3. Hire a qualified third-party administrator to set up and manage your company's retirement plans.
4. Cheap index funds won't cost you a lot of money, but they won't make you any money either.
5. Start the retirement plan process with your CPA, Accounting Department, or your HR department.
6. Find the right TPA specialist to administer your retirement plans.
Learn More About Karen Simmons & CFO Consulting
Karen C. Simmons, P.C.
CFO Consulting Services
In recent newsletters, we’ve outlined some scenarios where drugs used on inpatients receive extra payment in addition to the MS-DRG reimbursement. Two examples are for hemophilia factors and drugs designated for 2-3 years of new technology add-on payments.
However, some drugs receive separate payment because the inpatient claim is coded differently and results in a higher-reimbursed MS-DRG. Let’s look at the scenario when tPA is administered to a stroke patient in the Emergency Department and then the patient is admitted.
Although the tPA may be administered in the ED when the patient still has a status of outpatient, when the patient is admitted, all the outpatient charges must be combined and reflected on a single, inpatient claim (Three Day Payment Window). However, when we look at the MS-DRG reimbursement structure, we see that the cost of TPA is accounted for through the inpatient payment system (IPPS).
The MS-DRG payment is calculated as the relative weight of the MS-DRG x hospital blended rate. Relative weights and hospital-specific rates are recalculated annually. The hospital blended rate is based upon many factors including urban vs. rural location, wage variations, teaching hospitals, and the disproportionate share of financially indigent patients. The actual payment for the same MS-DRG will vary between facilities based upon these and other variables (e.g. readmission rates).
Let’s look at our scenario of tPA administration in the ED with subsequent inpatient admission. The DRG listing for stroke for FY2021 is MS-DRGs 061-066.
Available in Table 5 of the FY2021 IPPS Rule are the relative weights for each MS-DRG:
A full list of DRGs is available at: https://www.cms.gov/icd10m/version39-fullcode-cms/fullcode_cms/P0002.html
In our example, let’s take a hospital whose blended base rate is $7,626.99 and compare the compensation for MS-DRG 63 vs. MS-DRG 66.
MS-DRG 63 (no complications; received tPA) = $7626.99 x 1.7099 = $13,041.39
MS-DRG 66 (no complications; no tPA) = $7626.99 x 0.7109 = $5,422.03
The payment difference is around $7600+
The revenue reflected in a higher payment due to a different MS-DRG may be difficult to correlate with the direct expense incurred by pharmacy for the tPA since the difference in reimbursement will not be itemized on the Remittance Advice (RA) returned from the payer.
Since these are inpatient claims, the individual HCPCS code for tPA will not be listed. Instead, HIM coders would put these ICD-10-PCS codes on the inpatient claim to identify those patients who received the thrombolytic so that a different MS-DRG will be reimbursed.
1. Pharmacy and Finance should determine which drugs may result in higher MS-DRG patients when administered to inpatients.
2. Education should be provided to HIM coders as to where documentation for these drugs may be located in the patient’s medical record (e.g. Emergency Department record, Radiology notes, Medication Administration Record).
3. When drugs result in additional inpatient reimbursement based upon a higher relative weight for the MS-DRG, Pharmacy and Finance should incorporate the additional revenue into financial calculations when evaluating drug costs. As the reimbursement for the tPA will not be itemized on the Remittance Advice (RA), a separate financial calculation should be developed correlating the drug cost for the tPA and the additional revenue received.
Drugs continue to enter the market at a fast rate with a heavy price tag. This is complimented with lightning speed information flow directly to providers and patients creating a quick uptake in the utilization. “Time is money”. This phrase has stood the test of time and is more important to consider in the evaluation of the pharmacy revenue cycle.
CMS provides temporary or transitional pass-through payment for certain drugs, biologicals and radiopharmaceuticals as indicated in the Social Security Act Section 1833(t)(6). For the purposes of pass-through, radiopharmaceuticals are included as “drugs”.
The following outlines at high level some of the key elements to transitional pass-through payment. This is not all inclusive and should refer back to the act for more details.
An application must be submitted to CMS for approval of pass-through status
Service is provided in a covered hospital outpatient department
Service provided is not comparable to another group clinically and with respect to the use of resources to another category
Drug is “new” and whose cost is not insignificant in relation to the associated OPPs payment for the procedure
Pass-through payment will be made for at least 2 years, but not more than 3 years
Pass-through payment applications are accepted on a quarterly basis and will expire quarterly to grant pass-through payment for as close to 3 years as possible (previously expiration occurred annually)
Pass-through drugs are assigned a status indicator of “G” in Addenda A and B
Payment is based on the ASP methodology and may use a basis of ASP, WAC, or AWP depending on data availability
Pass-through status often creates confusion around biosimilars as this language has changed throughout the last five years. In CY2016 and 2017, biosimilars were included in their reference product HCPCS assignment and not subject to pass-through status. Upon the finalizing CY2018 Hospital Outpatient Prospective Payment, biosimilars were granted a separate HCPCS code and became eligible for pass-through status. Thus, each new biosimilar that enters the market regardless if it is not the first biosimilar in the category will be assigned a unique HCPCS code and is eligible to receive pass-through payment.
Pharmacy teams should monitor for new and expiring drugs with pass-through status. Pass-through status may aid in a formulary decision when assessing financial impact taking special consideration for biosimilars.
Revenue integrity teams should monitor for new and expiring drugs with pass-through status and the associated change in status indicator. In select 340B eligible organizations, this change will drive changes in billing modifiers. (To be discussed in more detail in future article)
An important element in the American Heart Association’s, “Get with the Guidelines-Stroke“ is that tPA should be administered within 4.5 hours of the first sign of stroke to dissolve the blood clot, restore blood flow to the impacted area of the brain and reduce disability.
“Drip and ship” means that front-line, community hospitals quickly administer tPA to people suffering an ischemic stroke, and then immediately transport them to a comprehensive stroke center.
The front-line community hospital typically treats the patient in the Emergency Department, administers tPA and prepares the patient for transport. The community hospital will bill an outpatient ED claim including the HCPCS code for the tPA (J2997- Injection, alteplase recombinant, 1 mg), CPT codes for the administration of the bolus/infusion of the tPA and any additional services provided prior to transfer.
The receiving hospital will admit the patient and assume responsibility for the patient’s care.
Upon discharge, the hospital will bill the admission on an inpatient claim.
In addition to services provided while an inpatient, the receiving hospital should also add ICD-10-CM code Z92.82 (Status post administration of tPA (rtPA) in a different facility within the last 24 hours prior to admission to current facility) as a secondary diagnosis. Including this code on the inpatient claim increases the reimbursement for the admission (in addition to the DRG payment). CMS coding guidance indicates that this code should be added even if the patient is still receiving the tPA at the time they are admitted to the receiving facility.
Due to the specificity of the code, we recommend the transfer record be included in the medical record of the inpatient admission and that it is review to ensure that the documentation details that the patient received the tPA within 24 hours of admission.
It may be difficult to identify these patients since the tPA was not administered at the receiving facility, and therefore J2997 would not be listed on the account. One approach is to review all inpatient discharges with a Point of Origin Code = 4 (Transfer from a hospital (different facility); Inpatient-The patient was admitted to this facility as a hospital transfer from an acute care facility where he or she was an inpatient or outpatient) that also have an ICD-10-CM diagnosis code of Stroke. Point of Origin codes are a required data field on the UB-04 or 837I (electronic equivalent of UB-04).
1. Revenue Cycle and HIM should develop a process to identify inpatient stroke patients who received tPA and another acute-care facility prior to transfer. One approach is to review all claims with a Point of Origin Code = 4, and a ICD-10-CM Diagnosis code of Stroke.
2. HIM Coders should review the transfer record to ensure that there is documentation that the patient received tPA at the originating facility and add ICD-10-CM code Z92.82 as a secondary diagnosis which results in additional reimbursement.
Included in the discussion is understanding the fundamentals of plan design and how the discrimination testing works in a 401(k). Important information for employers that have a 401(k) plan already or considering starting a new plan for their company. Join Rob Masson and Mark Massey of SMA Services, Inc in the final part of our retirement 101 series.
Expert discussion covering things you need to know about 401(k) plan fees if you are sponsoring a plan for your employees. Why having an understanding of how fees work is critical if you are an employer and an explanation of the four main categories of fees that are in a 401(k)? Join our experts Mark Massey and Rob Masson of SMA Services for Part 1 of our Retirement Series.
In this episode of Inside the Plan with the 401(k) Brothers, Bill Bush and Andy Bush, advisors at Horizon Financial Group, talk with Melissa Terito, CPA, Partner and Third-Party Administrator at Sentinel Pension about some frequently asked questions that plan sponsors have been reaching out to her with.
Episode Highlights:
referrals?
mean that everyone becomes 100% vested in the plan?
3 Key Points:
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