EL PASO COUNTY HOSPITAL POLICY: A-24 DISTRICT POLICY EFFECTIVE DATE: 09/10 LAST REVISION DATE: 10/136 MANAGEMENT ADJUSTMENTS OR PAYMENTS
POLICY
This policy establishes procedures for adjustments and payments associated with patient care or other types of occurrences.
The El Paso County Hospital District’s (EPCHD) policy is to adjust charges or issue a payment on a case-by-case basis based on the outcome of an internal review. A payment or adjustment may be one of the appropriate steps taken to resolve the situation, and is not an admission of liability.
This policy does not apply if the patient is represented by an attorney. (See policy L-4, Lawsuits and Legal Claims).
President and Chief Executive Officer (CEO) has the authority to make exceptions to this policy.
RESPONSIBLE
Board of Managers President and Chief Executive Officer Chief Financial Officer Corporate Controller Patient Financial Services Compliance Office Legal Unit Risk Management Guest Services
POLICY REFERENCES
C-1.4 Patient Satisfaction Committee C-1.9 Claims Management Committee CP-43 Records Retention and Destruction Policy and Schedule L-2 Root Cause Analysis/Sentinel Event P-13 Customer Concerns
DEFINITIONS
Management Adjustment- All or portion of the patient account, co pay, co insurance or deductible for which the patient is not responsible to pay, if applicable.
Complication - any disease or disorder that occurs during the course of (or because of) another disease;
Page 1 of 5 EL PASO COUNTY HOSPITAL POLICY: A-24 DISTRICT POLICY EFFECTIVE DATE: 09/10 LAST REVISION DATE: 10/136 MANAGEMENT ADJUSTMENTS OR PAYMENTS
Never Event - According to the National Quality Forum (NQF), “never events” are errors in medical care that are clearly identifiable, preventable, and serious in their consequences for patients, and that indicate a real problem in the safety and credibility of a healthcare facility.
Unintended Outcome – an unintended act, either of omission or commission or an act that does not achieve its intended outcomes and/or could be perceived to affect the safety or quality of care provided in EPCHD.
PROCEDURE
A. The EPCHD Risk Manager or designee tracks and may review certain Unintended Outcomes (UO) associated with patient care or other types of occurrences.
B. The Legal Unit will be informed of occurrences reviewed by the EPCHD Risk Manager at the Risk Manager’s discretion.
C. Until a determination is made whether the occurrence is an UO, a Complication, or other specific occurrence, the EPCHD Risk Manager will inform the Patient Financial Service (PFS) billing supervisor to:
1. Place the patient billing account on hold.
2. Place a start/stop date for covered charges on the account (date of admission to the date prior to the UO). Charges related to patient care services prior to the UO will be set up to bill for payment from the payor.
D. Members of the Claims Management Committee will meet with the PFS Manager or Supervisor to review and determine the charges to be adjusted, if any.
E. If a Management Adjustment or payment is recommended and the EPCHD Risk Manager has obtained approval from the individuals in section F of this policy, the following process will occur:
1. The EPCHD Risk Manager will notify the PFS Supervisor to release the hold so the account can be billed and processed accordingly. The EPCHD Risk Manager will inform PFS of the type of Unintended Outcome, e.g. Never Event, sentinel event, hospital-acquired condition, quality/service grievance, or other type of occurrence and instruct PFS to move non-covered charges (charges from date of UO to date of discharge) to the Management Adjustment Service Code.
Charges related to additional patient care services due to the UO will be listed on the bill and identified to the payor as non-covered to the payor.
Page 2 of 5 EL PASO COUNTY HOSPITAL POLICY: A-24 DISTRICT POLICY EFFECTIVE DATE: 09/10 LAST REVISION DATE: 10/136 MANAGEMENT ADJUSTMENTS OR PAYMENTS
2. The Management Adjustment/Payment Authorization form will be completed by the EPCHD Risk Manager and signed by those in section F. and forwarded to the PFS Supervisor, who will follow the normal adjudication process.
3. PFS will comply with public and private payor requirements.
4. If the bill was sent to the patient or third party payor prior to the Management Adjustment, the EPCHD Risk Manager will notify the PFS Supervisor for proper handling of the account. The account may be re-billed to appropriately reflect the process outlined in this policy, based on communication and payor regulations.
5. A Management Adjustment or payment does not apply if after the internal investigation, in consultation with the Claims Management Committee members, it is determined that the Management adjustment/payment is not recommended. All charges will be billed according to standard billing processes. The billing that is on hold will be released and the EPCHD Risk Manager may communicate the decision to the patient/family and notify the appropriate individual/department.
F. The EPCHD Risk Manager will obtained approval from the following Claims Management Committee members as follows:
1. From 0 to $ 24,999, in communication with the Compliance Officer and the Corporate Controller;
2. From $25,000 - $99,999, in communication with the Chief Financial Officer (CFO), the Corporate Controller, and the Compliance Officer; or
3. $100,000, in communication with the CEO, the CFO, the Corporate Controller, and the Compliance Officer.
G. If an UO occurs at an EPCHD facility and the patient needs to be transferred to another facility, the following procedures are recommendations on how charges are handled at the second facility:
1. Receiving facility should submit bills to payor for services rendered; 2. EPCHD should submit bills to payor for services rendered; 3. If transfer is not due to patient’s choice, the patient will be encouraged to send related bills for “out-of-pocket” expenses to the EPCHD Risk Manager for review. 4. If transfer is due to patient’s choice, the billing process will be followed based on payor regulations.
H. If EPCHD is treating a patient and a UO is discovered that occurred in a previous facility, the following procedures are recommendations on how the charges can be
Page 3 of 5 EL PASO COUNTY HOSPITAL POLICY: A-24 DISTRICT POLICY EFFECTIVE DATE: 09/10 LAST REVISION DATE: 10/136 MANAGEMENT ADJUSTMENTS OR PAYMENTS
handled:
1. Code the UO as present on admission (POA); 2. EPCHD will bill payer for services; 3. EPCHD notifies the previous facility; or 4. The previous facility should handle on a case-by-case basis with the payor and send an adjusted claim or refund to payor and patient if appropriate.
I. Grievances, refer to policy C-1.4, Patient Satisfaction Committee and P-13, Customer Concerns.
J. Lost property, refer to policy A-7, Management of Personal (Patient) Property. K. The EPCHD Risk Manager will follow the process for completing a Voucher Check Request (VCR) and obtaining a check for an approved payment.
1. The EPCHD Risk Manager may issue the check to the patient/family by hand delivery.
2. In some instances, a copy of the signed check will be forwarded to the Legal Unit.
L. The patient/family may be required to sign an EPCHD Release of Liability as a condition of receiving the adjustment or payment which will be filed in the Risk Management Department.
M. The EPCHD Risk Manager will inform the Claims Management Committee of new requests for Management Adjustments or payments and those that have been approved or denied on a case-by-case basis.
N. All documentation generated by EPCHD Risk Management pursuant to this policy shall be maintained as described in the Records Retention and Destruction Policy and Schedule, CP-43. Records are confidential and subject to the state and federal laws protecting such documents from discovery.
FORMS
Management Adjustment/Payment Authorization 770-026-10 (Rev. 09/13)
Page 4 of 5 EL PASO COUNTY HOSPITAL POLICY: A-24 DISTRICT POLICY EFFECTIVE DATE: 09/10 LAST REVISION DATE: 10/136 MANAGEMENT ADJUSTMENTS OR PAYMENTS
El Paso County Hospital District Date Policy and Procedure Committee Chairperson
President and Chief Executive Officer Date
Board of Managers Chairperson Date
Review/Revision History:
P&P Legal Administrative Board of Committee Review Team Managers 07/10 07/10 09/13 09/10 09/13 09/13 10/13 10/16 09/16
Page 5 of 5