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Understanding RBRVS

Understanding RBRVS. What is RBRVS (Resource Based Relative Value Scale) RBRVS to Discover & Set Fees RBRVS to Choose Procedure Code. What is RBRVS?. It is how 3 rd parties pay RVU x CF = Payment. What is RBRVS?. RVU = Relative Value Unit All procedures assigned “ relative value ”

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Understanding RBRVS

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  1. Understanding RBRVS • What is RBRVS (Resource Based Relative Value Scale) • RBRVS to Discover & Set Fees • RBRVS to Choose Procedure Code

  2. What is RBRVS? • It is how 3rd parties pay RVU x CF = Payment

  3. What is RBRVS? • RVU = Relative Value Unit • All procedures assigned “relative value” • Based on resources needed to deliver procedure • 3 types of resources

  4. What is RBRVS? • 3 types resources: • Physician Work (PW) • Practice Expense (PE) • Malpractice (MP)

  5. What is RBRVS? • Each type resource assigned a “relative value”

  6. What is RBRVS? • PW RVU • PE RVU • MP RVU

  7. What is RBRVS? • 3 resources totaled = • PW RVU + PE RVU + MP RVU = Total RVU

  8. What is RBRVS? • 8000 CPT codes • 8000 (total) RVUs • = Relative Value Scale, ie • Resource-Based Relative Value Scale (RBRVS)

  9. Examples of RVUs • RVU range 0 to 470.33 • RVU of 0?

  10. Things Assigned “0” RVU • Category 3 CPT 0207T (evacuation meib gland) (Lipiflow) • S codes (HCPCS Level 2) S0620 (exam + ref, routine, new) (TOS handout) • After hours office visits 99050 • Routine Exam • “Dump” codes 92499 (unlisted ophthal service/proced)

  11. Examples of RVUs • RVU of 470.33? • CPT 37227 Revascularization of femoral artery (for occlusive disease) • X 34.023 = $16,002 (2013)

  12. Examples of RVUs • Eye Codes (2013) • 92004 = 4.45(x 34.023 = $151.40) • 92015 = 0.58 ($19.73) • 65600 = 12.07 ($410.66) (tattoo) • 92950 = 9.05 ($307.91)

  13. Facility vs. Non-Facility RVU • Facility RVU < Non-facility RVU, ie • Provider: Facility $$ < Non-facility $$ • Facility: Facility & provider split pay

  14. Facility vs. Non Facility Non-Facility: • Physician office • Patient home • Freestanding imaging center • Independent pathology lab

  15. Facility vs. Non Facility Facility: • Hospital • Ambulatory surgical center (ASC) • Skilled nursing facility (SNF)

  16. GPCI Geographic Practice Cost Index • Alters RVU for local economy Separate GPCI for each economic area • (PW x GPCI) + (PE x GPCI) + (MP x GPCI) = total RVU (for specific area)

  17. GPCI Geographic Practice Cost Index • Medicare – Uses GPCI • Non-Medicare – May or may not use

  18. What is RBRVS? RVU xCF= Payment

  19. Conversion Factor • Converts RVU to payment • 3rd parties choose CF • Usually one CF, sometimes more • 2013 Medicare CF 34.023

  20. Yearly RVU & CF Change

  21. Yearly RVU Change • RVU data updated yearly; Up & down • GPCIs may change

  22. Adopt RVU Change • Medicare January 1 Adopts new RVUs & GPCIs

  23. Adopt RVU Change • Non-Medicare Anytime Year of RVU Any year GPCI Used or not

  24. Adopt RVU Change • Non-Medicare 10 sets RVUs in past 5 years

  25. Yearly CF Change • Medicare CF changes Jan 1: budget neutrality Published Nov 1 Fed. Register

  26. Yearly CF Change • Non-Medicare Pick their CF: market forces Often higher than Medicare Occurs anytime

  27. Examples RVU x CF = Payment

  28. Examples 92004 Medicare 2013 4.45x34.023 =$151.40

  29. Examples 92015 Medicare 2013 0.58x34.023=$19.73

  30. Examples 65600 Medicare 2013 12.07x34.023=$410.66

  31. Examples 92950 Medicare 2013 9.05x34.023=$307.91

  32. Understanding RBRVS • What is RBRVS • RBRVS to Discover & Set Fees • RBRVS to Choose Code

  33. Set Medical Fees • Obtain pay schedule, all contracted plans • Or calculate with RVU x CF = Payment • Identify highest payer • Set office fees above highest plan RVU x CF = Office Fee

  34. Set Medical Fees • Choose your CF • Twice-yearly re-assess • Fees accurate, reasonable • Not good when insurance pays your charge

  35. Set Medical Fees • Medical fees already determined • Insurance defines value

  36. Set Routine Fees • Market-driven • Routine service unrelated to Medical • Routine fees unrelated to Medical • RBRVS unrelated

  37. Control Accounts Receivable GOAL Collect all patient portion on day of service

  38. Control Accounts Receivable 3 Parts A. Prepare Payment Schedules B. Verify Insurance C. Day of Service – Collect Patient Portion

  39. Control Accounts Receivable A. Prepare Payment Schedules Spreadsheet, common codes (40) Columns 1st – U&C 2nd – Insurance Maximum Allowed 3rd – Write Off 4th - Insurance Due 5th - Patient Due (spreadsheet example)

  40. Control Accounts Receivable file://localhost/Users/alanhomestead/Documents/My Documents B 3-8-13/Adventures 11-3-12/1 AccuFee/2013/AccuFee 2013 Files XLSX/1 AccuFee 2013 15.4.xlsx

  41. Control Accounts Receivable A. Prepare Payment Schedules One spreadsheet per insurance (8 - 10) If more than one plan, One spreadsheet per plan (1 – 2)

  42. Control Accounts Receivable B. Verify insurance Before patient arrival Beginning of month, employer paid premium? Ask Deductible, Co-Pay, Co-Insurance %

  43. Control Accounts Receivable B. Verify insurance Co-Pay, Co-Insurance may vary with office call surgery test specialty

  44. Control Accounts Receivable B. Verify insurance Deductible Amount Amount not met

  45. Control Accounts Receivable B. Verify insurance Medicare – application allowing access to Medicare claim and eligibility information. Deductible balance If Medicare Advantage (can see pending claims)

  46. Control Accounts Receivable B. Verify insurance Medicare, claim & eligibility information Noridian – Endeavor: online (Jursdctn F-WA,OR,ID,MT,ND,SD,WY,AK,UT,AZ,CA,HI,NV) Novitas – IVR: Interactive Voice Response 855-252-8782 (Jursdctn L-DE,NJ,PA,MD,DC, Arlington & Fairfax county, city of Alexandria) Palmetto – OPS: Online Provider Services, or IVR (Jursdctn 11/M-WV,VA,NC,SC)

  47. Control Accounts Receivable B. Verify insurance Medicare, claim & eligibility information CGS – CSI: (online) Claim Status Inquiry, or IVR (Jursdctn 15-OH,KY) WPS – C-SNAP: (online) CMS Secure Net Access Portal, or IVR (Jursdctn 8-IN,MI)

  48. Control Accounts Receivable C. Day of Service – Collect Patient Portion Deductible – found before patient arrive Co-Pay – found on insurance card Co-Insurance - found on spreadsheet at check- out

  49. Control Accounts Receivable C. Day of Service Write off un-collectable A/R very accurate

  50. Control Accounts Receivable C. Day of Service Patient portion of A/R = small fraction of monthly production

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