Finance

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

Regulatory Compliance

The ever-growing and changing regulatory requirements placed upon transplant programs today creates an environment where programs have to understand the full impact of all decisions, both clinical and business related.  TMG consultants have worked with many adult and pediatric transplant programs on regulatory compliance with CMS and OPTN/UNOS. Our experience in this area includes:

• CMS Recertification & F-QAPI Survey Readiness

• Ongoing Compliance with the CMS CoPs

• CMS Mitigating Factors Application Guidance and Assistance

• CMS Systems Improvement Agreement (SIA) Fulfillment

• OPTN/UNOS Compliance for Onsite Reviews and Data Reporting

• OPTN/UNOS Membership and Professional Standards Committee Reviews

Quality & Peer Reviews

Modern transplant programs are not only stewards for a scarce resource, but also must perform in a highly competitive and complex regulatory environment.  Regulatory agencies have taken a heightened interest in transplant patient outcomes and the day-to-day operation of transplant programs. It is imperative that an organization be effectively designed to implement and maintain an efficient, regulatory compliance transplant program that produces quality patient outcomes.

TMG provides Quality Reviews and Peer Reviews, both preemptively for programs potentially facing non-compliance with CMS and/or UNOS, and for programs required to do so as part of a Systems Improvement Agreement (SIA) with CMS.  Our services include:

• Transplant QAPI Program Analysis

• Transplant QAPI Program Implementation

• Preemptive Multidisciplinary Independent Peer Review

• SIA Fulfillment of Independent Peer Review

• SIA Fulfillment of Onsite Quality Consultant

Organizational Effectiveness

As transplant programs compete for market share, it is necessary to regularly assess current internal and external factors to keep a competitive edge. Although some transplant benchmarking and best practice studies exist, TMG offers customized benchmarking and business planning based on similarly sized and structured transplant programs across the country. In order to grow and evolve, programs need to analyze the critical components and measurements of success in multiple areas. As transplant professionals and consultants we’ve created and observed a myriad of approaches to structuring and maintaining a successful transplant program. Our comprehensive Organizational Effectiveness Reviews focus on the effectiveness of an organization and practical strategic opportunities in the following areas:

• Leadership and Staffing for Clinical and Business Operations

• Transplant Organizational Structure and Support Services within the Health System

• Workflow Processes for Recipients and Living Donors across all Phases of Care

• Quality Assessment and Performance Improvement (QAPI) Plan and Initiatives

• Regulatory Compliance

• Data and Systems Management

• Market Share and Growth Potential

• Strategic Planning

Program Feasibility & Start Up

The clinical and administrative complexities of transplantation can be overwhelming to a hospital considering the start-up of a transplant program. As such, our first step in providing a Transplant Feasibility Study is education. We empower a hospital with the necessary knowledge to make an informed and calculated decision. Along with the education, we conduct a comprehensive evaluation and analysis of the following to create a robust financial pro-forma of projected volumes and required resources:

• Demographics and Incidence of End State Organ Disease of the Potential Patient Base

• Current Transplant Competition in the Market and Organ Availability

• Contractual Relationships necessary to Initiate and Sustain a Transplant Program

• Certificate of Need Assistance

• Facilities and Staffing Infrastructure Requirements

• Regulatory Requirements

• Transplant Critical Success Factors

For transplant programs in the beginning phases of implementation or restructuring, TMG offers the following program support and consulting services:

• OPTN/UNOS Application

• Recruitment of Physician and Administrative Leaders

• Interim Leadership Placement

• Staff Training

• Workflow Development

• QAPI Program Development

• Medicare Cost Report and Transplant Billing Readiness and Training

• CMS Certification Readiness

• Managed Care Contracting