Effective Revenue Cycles Are No Accident

Transcription

1 Effective Revenue Cycles Are No Accident ICAHN Boot Camp October 10, 2014 Jerrie K. Weith, FHFMA, CMPE, CMOM

2 Learning Objectives Characteristics of Best Performers Efficient Encounters = Revenue Cycle Success Measuring Revenue Cycle Performance Identifying Your Opportunities

3 Effective Revenue Cycles Are No Accident Characteristics of Best Performers Technology Staff Payers Process

4 Characteristics of Best Performers Technology Systems HIE

5 Characteristics of Best Performers Technology EHR/PMS communicate Upgraded regularly Continued education

6 Characteristics of Best Performers Staff Right fit Productivity Re-invest Weekly meetings The Why factor

7 Characteristics of Best Performers The lowest level of performance by any employee, allowed to continue without corrective action, becomes the highest level of performance that can be required of any other employee in a similar position with the employer. Reference: Rosemarie Nelson MGMA Healthcare Consultant The ROI of IT: Best Billing Practices

8 Characteristics of Best Performers Payers Set-up Rules Options Changes Reference: AMA 2012 National Health Insurer Report Card

9 Characteristics of Best Performers Process Does it make sense? Uniform Set expectations

10 EFFICIENT ENCOUNTERS = REVENUE CYCLE SUCCESS

11 Efficient Encounters = Revenue Cycle Success Efficient encounters Scheduling Eligibility & benefits verification TOS Claims generation Payment processes Account resolution Collection process

12 Efficient Encounters = Revenue Cycle Success Patient demographics Capture the right information Account review Patient expectations We expect payment at the time of service. Work #, cell phone, Insurance details Guarantor details Ms. Smith, I see you have a past due amount of $ How would you like to take care of that Employer today? We information accept Visa, MasterCard, or do you have an FSA?

13 Efficient Encounters = Revenue Cycle Success Is it worth it? Automate Centralize Payer websites Choose your criteria: Services Payers Everything Use the information obtained! 3 days in advance

14 Efficient Encounters = Revenue Cycle Success Eligibility & benefits verification 51% providers knew what patient owed at TOS 78% patients knew what they owed at TOS It costs between $0.05 and $0.74 to check eligibility How much will your practice benefit to know what your patient owes at the TOS?

15 Efficient Encounters = Revenue Cycle Success Eligibility & benefits verification Faster payments Quicker to collect at TOS than through statement cycle Increase patient satisfaction No one likes a financial surprise after the visit! Increased efficiency Automate through clearinghouse and PMS

16 Efficient Encounters = Revenue Cycle Success Compare coverage to expected treatment & fee schedule Contact patient patient counseling Set alerts in system & schedule Collect at TOS

17 Efficient Encounters = Revenue Cycle Success TOS Confirm information Collect at check-in Collect at check-out How would you like to pay today? We accept Visa, MasterCard, cash and checks.

18 Efficient Encounters = Revenue Cycle Success Reference: InstaMed Trends in Healthcare Payments Annual Report: 2012

19 Efficient Encounters = Revenue Cycle Success TOS Complete record 24 hours Computer Assisted Coding (CAC) Interface charges

20 Efficient Encounters = Revenue Cycle Success Claim generation Charge lag 24 hours (48 hours out of office services) Claim scrubbing Edits Correction Do you update your claim edits on a regular basis?

21 Efficient Encounters = Revenue Cycle Success Utilize a clearinghouse 997 claim rejection report Submit charges within hours 277u claim status report Initial follow-up 24 hours Level 1 rejections

22 Efficient Encounters = Revenue Cycle Success 5% increase over 2 year period 46% 51% Reason payer payments were not received electronically Reference: InstaMed Trends in Healthcare Payments Annual Report: 2012

23 Efficient Encounters = Revenue Cycle Success Payment Processing Contractual Non-contractual Post all zero pays Utilize system automation Reconciliation

24 Efficient Encounters = Revenue Cycle Success Patient Processing Electronic statements Save providers up to 42% compared to paper Make it convenient Only 4% of patients receive medical bills via Estimated $300 billion will be spent by consumers online in % consumers use online bill pay Shorten the cycle Day 0 Day 30 Collection letter Day 60 Day 75 turnover Reference: InstaMed Trends in Healthcare Payments Annual Report: 2012 Reference: Gartner Group, HFMA, and HH&N Research

25 Efficient Encounters = Revenue Cycle Success Account resolution Automate when possible 277/997 reports 24 hours after submission days clearinghouse 31+ days payer website/phone Universal note area Appropriate reports Review notes & tasks Payer High $$$ Down DOS Group by Patient

26 Efficient Encounters = Revenue Cycle Success

27 Efficient Encounters = Revenue Cycle Success 100 claims a day X 20 days a month 2,000 claims 20% denial rate 2,000 claims X 20% = 400 claims 33% of denials are never recovered 400 X 33% = X $ (average reimbursement) = $13,200 monthly Source: The Physician Billing Process: 12 potholes to avoid in the road to getting paid, ed 2, Walker-Keegan, Woodcock, Larch.13

28 Efficient Encounters = Revenue Cycle Success Should it be written off? Contractual versus non-contractual adjustment If Is so, a correction & resubmit! needed? Collect data, follow Should payer it process, be involve appealed? patient & track status

29 Efficient Encounters = Revenue Cycle Success Collection process Automate process Monitor results Write-off at turnover Use specific codes Create reports by code

30 Efficient Encounters = Revenue Cycle Success Where do you go from here? Decide what is right for your practice! Investigate your options Automate when possible Centralize processes Stay up-to-date on new options Partner with your clearinghouse Think outside the box Keep an open mind Reference:

31 Advanced Staff Training Dismissal Process Eligibility Bad Debt Collection Process Cost Estimation TOS Collection Counsel Patient

32 MEASURING REVENUE CYCLE PERFORMANCE

33 Effective Revenue Cycles Are No Accident Measuring Revenue Cycle Performance What s important? Reporting and analysis Tracking and acting

34 Measuring Revenue Cycle Performance What is important? Collections Cash in the door Encounters or FFS Production Units to produce the cash

35 Measuring Revenue Cycle Performance What is important? Collections! A/R Charges, payments, & adjustments Provider Practice Days outstanding Payer mix Collections per RVU Service line Provider

36 Measuring Revenue Cycle Performance What is important? Collections Payments Third party Underpayments Denials and rejections Patient TOS collections Commitment to payment plans

37 Measuring Revenue Cycle Performance What is important? Collections Credit balances Patient Third party Bad debt % bad debt to total revenue Collection agency recovery

38 Measuring Revenue Cycle Performance What is important? Production! CPT/RVU production Location Provider Case mix Location Provider

39 Measuring Revenue Cycle Performance

40 Measuring Revenue Cycle Performance Reporting and analysis Audience Content Presentation method Frequency

41 Measuring Revenue Cycle Performance Reporting and analysis Audience - Providers Short & sweet Personalized Audience - Executive Broader content Presentation method Narrative Columnar Graphical

42 Measuring Revenue Cycle Performance Reporting and analysis Daily Denials and rejections TOS collections Appointments with no charges EFT/ERA reconciliations Weekly Third party underpayments TOS collections

43 Measuring Revenue Cycle Performance Reporting and analysis Monthly Charges/payments/adjustments CPT/RVU utilization Denials and rejections summary Bad debt Credit balances Patient underpayments

44 Measuring Revenue Cycle Performance Reporting and analysis Quarterly Capitation plan performance Payer mix Charges Payments Annually Fee schedule assessment Capitation plan performance Budgeted revenue vs. actual revenue Budget production vs. actual production

45 Measuring Revenue Cycle Performance Tracking and acting KPI Data point or criteria Benchmark Type of KPI Data point to measure results against Internal or external

46 Measuring Revenue Cycle Performance Tracking and acting Why use KPI s? Measure what s important Identify trends Compare progress to expectations Incentivize desired behaviors

47 Measuring Revenue Cycle Performance Tracking and acting Which KPIs do you use? % Co-pays collected vs. total possible co-pays Charge lags Office visits Off-site services Budgeted charges % clean claims Unbilled charges Staff production standards Denials Payer mix

48 Measuring Revenue Cycle Performance Tracking and acting How do you use KPI s? Dashboard Snapshot summary of key results Internal benchmarks» Historical External benchmarks» Marketplace» Industry

49 Measuring Revenue Cycle Performance Tracking and acting Dashboard Decide what s most important Identify the data point to measure Identify the benchmark for comparison Design dashboard to meet your practice s needs Populate dashboard Act on variances to the benchmark

50 Measuring Revenue Cycle Performance Key Indicators Indicator Calculation Significance Frequency Trend Gross Days Receivable Outstanding (DRO) Gross Calculation Ratio Net Collection Ratio % Insurance A/R 90+ Days Total A/R divided by Average Daily Charge Total YTD Payments divided by Total YTD Charges Total YTD Payments divided by Total YTD Charges less YTD Contractual Adjustments Insurance A/R greater than 90 days divided by Total Insurance A/R Indicates how long it takes to convert a claim into cash. Monthly Should be downward trend- Less than 30 Indicates proportion of charges that are converted to cash. Monthly Should be upward trend. Indicates effectiveness of collection efforts on potential dollars, including point of service payments. Monthly Low proportion indicates that accounts are collected effectively. Monthly Should be upward trend. 96% or greater. Should be downward trend- Less than 10%

51 Measuring Revenue Cycle Performance

52 Measuring Revenue Cycle Performance $140, Month Charges Adjustments Payments Feb-12 $ 52, $31, $47, Mar-12 $ 86, $37, $48, Apr-12 $105, $39, $54, May-12 $ 98, $46, $60, Jun-12 $ 96, $36, $47, Jul-12 $ 98, $51, $68, Aug-12 $ 99, $38, $53, Sep-12 $114, $31, $46, Oct-12 $120, $63, $78, Nov-12 $ 85, $41, $55, Dec-12 $ 99, $47, $60, Jan-13 $117, $47, $64, Feb-13 $ 84, $35, $47, $120, $100, $80, $60, $40, $20, $- Analyze charges, adjustments & payments monthly. Correlate with practice/provider production. Charges Adjustments Payments

53 Measuring Revenue Cycle Performance Payment Analysis Payer Name Encounter Chg Amt Count Adj Amt Allowed Amount Fee Schedule Variance Anthem Blue Choice PPO $ $ $ $ $ Anthem Blue Choice PPO $ $ $ $ $ Anthem Blue Choice PPO $ $ $ $ $ Anthem Blue Choice PPO $ $ $ $ $ Anthem Blue Choice PPO $ $ $ $ $ Anthem Blue Choice PPO $ $ $40.00 $ $ Anthem Blue Choice PPO $ $ $40.00 $ $ Anthem Blue Choice PPO $ $ $85.93 $ $ Anthem Blue Choice PPO $ $ $85.93 $ $ Anthem Blue Choice PPO $ $ $20.00 $ $ Anthem Blue Choice PPO $ $ $ $ $ Anthem Blue Choice PPO $ $ $ $ $ Anthem Blue Choice PPO $ $ $ $ $ Anthem Blue Choice PPO $ $ $ $ $ Anthem Blue Choice PPO $ $ $ $ $ Anthem Blue Choice PPO $ $99.07 Compare -$ allowed $ $ Anthem Blue Choice PPO $ $ $85.93 $ $ Anthem Blue Choice PPO $ $99.07 amount -$ not paid $ $ Anthem Blue Choice PPO $ $ $ $ $1.35 amount Anthem Blue Choice PPO $ $ $ $ $ Anthem Blue Choice PPO $ $ $ $ $ Anthem Blue Choice PPO $ $ $ $ $ Anthem Blue Choice PPO $ $ $ $ $0.00

54 Measuring Revenue Cycle Performance Start here tracking results Date of Claim submission to Payer Adjudication Date of Payer Adjudication to Patient Statement/Denial Worked and resubmitted DOS to date of documentation (DOD) Date of Charge Entry to Claim Submission Total Lag Time from DOS to Fully Adjudicated Date of Documentation to date of coding (if not utilizing CAC) Date of Coding to Date of Charge Entry

55 Effective Revenue Cycles Are No Accident What Does an Effective Revenue Cycle Mean? Communication Efficient processes Effective procedures Optimal systems utilization Effective use of resources Attentive management

56 Effective Revenue Cycles Are No Accident Where Are Your Opportunities to Improve Revenue?

57 Effective Revenue Cycles Are No Accident Maximum return on investment in accounts receivables. More Revenue. More Quickly!

58 Anders Health Care Services Anders Health Care Services optimizes staff, resources and revenue for hospitals and physicians by offering solutions and direction to complex practice management issues. We provide an integrated approach from the financial, operational, compliance and strategic perspectives.

59 Anders Health Care Services Jerrie K. Weith, FHFMA, CMPE, CMOM