transforming the business of transplantation


The financial complexities in transplant billing and reimbursement create multiple challenges to optimize a program’s bottom line. From knowing how to effectively contract for services, to accurately tracking organ acquisition expenses, to knowing how, when and what to bill for the various payors across all phases of care, it’s not uncommon for programs to have opportunities for significant financial improvement. TMG offers a full line of comprehensive Financial Reviews and Analysis to evaluate a transplant program’s financial health.

Medicare Cost Report Review

To remain financially viable and compete in today’s market, a transplant program must appropriately account for all allowable expenses in the Medicare Cost Report (MCR). Transplant programs face the unique challenge of creating and maintaining effective systems needed to accurately track those expenses. TMG provides a thorough analysis of our client’s reporting systems and recommendations to ensure compliance with Medicare cost reporting regulations through improved registration, billing and collection processes. The end result is a step-by-step implementation guide to optimize allowable Medicare cost reporting opportunities and insure reporting compliance. TMG’s reviews encompass all areas relating to Medicare cost reporting:

  • Review and Analysis of Recently Filed MCR
  • Comprehensive Analysis of Claimable Transplant Recipient and Donor Costs
  • Review of Direct and Indirect Expenses and Cost Allocation Statistics
  • Creation of MCR Pro-Forma with Recommended Revisions
  • Standard Acquisition Charge Recommendations
  • Overview of Areas of Opportunity and Areas of Audit Risk
  • Recommendations for Billing System Modifications
  • Process Overview for Filing Amended cost report and appeals

Physician Compensation & Productivity

Physician compensation has become a topic of interest as the national trend continues for more physician practices to become either affiliated or owned by health systems. CMS is proposing adding HCPCS modifiers to report on the 1500 and the UB-04 if the hospital is billing for provider-based outpatient departments as this leads to higher payment rates by CMS.

The current trend is for health systems to move towards using the Relative Value Units (RVUs), which are a measure of value used in the United States Medicare reimbursement formula for physician services. This payment model provides compensation to physicians based on work RVU (wRVU) productivity. However, many of these RVU models have flaws and according to the February 12, 2014 publication by The Advisory Board Company Medical Group Practice Strategy Council, there are three ways hospitals are working around the flaws in RVU-based payments:

  1. Institution of a group-wide withhold;
  2. Alter per-RVU conversion rates; or
  3. Create artificial RVUs

TMG has the expertise to custom design RVU models to document physician work effort that is not captured in a patient billing wRVU model by combining non-billable RVUs with the existing billable RVUs. This new customized hybrid model can be created to capture the entire academic, clinical and relationship building work effort that each physician is providing and your transplant center is already funding.

Managed Care Contracts & Claims Reviews

Transplant programs can have a portfolio of managed-care and commercial contracts that assure patient volume. However, unless the program is able to effectively operationalize these contracts, the potential to not capture all the revenue that is contractually allowable is significant. As most managed care payors contract with transplant centers based on a carve-out rate, transplant centers must have the facilities and infrastructure in place to meet the demands of carve-out contracting, build market share, maintain quality clinical outcomes and optimize contribution to margin. TMG offers a comprehensive review that includes:

  • Analysis of current Commercial Contracts and Billing Compliance
  • Review of Global and Facility Accounts for Payment Accuracy
  • Analysis of Carve-Out Requirements and Language
  • Comparative Analysis of Reimbursement against Local/National Reimbursement
  • Evaluation of Volume and Outcome Requirements for Participation in National Transplant Networks

Additional Finance Consulting Services

  • Transplant Billing and Collections Effectiveness Review
  • Profit and Loss Analysis
  • Revenue Management
  • Cost Reduction Strategies
  • Market Share Analysis and Growth Strategies
  • Transplant Program Feasibility & Start Up