The Future Vision of Access Management: Turning the Revenue Cycle Upside Down!

Transcription

1 The Future Vision of Access Management: Turning the Revenue Cycle Upside Down! Matt Haynes Administrative Director, Central Business Office Services Baptist Hospitals of South East Texas Hans P. Morefield Senior Vice President, Strategic Partners SCI Solutions Julie Waddell Vice President, Revenue Cycle Solutions Strategy MedAssets

2 The Future Vision of Access Management: Turning the Revenue Cycle Upside Down! OVERVIEW With the increasing pressures affecting the financial forecast of healthcare providers, processes and procedures must be tightened up earlier in the revenue cycle to secure payment, reduce denials and bad debts, as well as decrease days in accounts receivable. You will learn how providers have analyzed the issues, identified the opportunities and implemented technology to operate in a production environment to obtain financial securitization and decrease, if not eliminate, errors on the back end. LEARNING OBJECTIVES This session will identify areas in the revenue cycle front end when opportunities exist and realize best practices that can be initiated to improve operations. Participants will learn how one organization applied innovative processes and tools to the front end of the revenue cycle to avoid denials and improve POS collections. FACULTY Matt Haynes Administrative Director, Central Business Office Services Baptist Hospitals of South East Texas Matt has over 25 years of revenue cycle experience. Currently, he serves as the Administrative Director of Business Office Operations for Baptist Hospitals of South East Texas, which includes the Direction Central Business Office operations for 5 facilities. Prior to joining Baptist Hospitals, Matt held corporate and regional positions for several large investor owned hospital companies including Community Hospital Corporation, Triad Hospitals and HCA. Hans P. Morefield Senior Vice President, Strategic Partners SCI Solutions As Senior Vice President of Strategic Partners, Hans Morefield is responsible for managing SCI's relationships with strategic partners, developing special business relationships, and shaping the company's business strategy and long term product plan. SCI Solutions serves over 350 hospitals with the industry s most advanced,

3 web based patient access applications for health systems covering online orders, enterprise scheduling, self scheduling, front end revenue cycle management, appointment reminders and patient arrival. Prior to joining SCI Solutions, Hans was a Senior Manager with Cap Gemini Ernst & Young, where he focused on strategic information systems planning and the design, selection, and implementation of enterprise patient systems. His clients included many of the nation's largest healthcare organizations. Prior to Ernst & Young, Hans managed project implementations and participated in product development for Healthcare Data Exchange (HDX), the EDI subsidiary of Shared Medical Systems (SMS). He is a graduate and trustee of Kalamazoo College in Kalamazoo, Michigan. Julie Waddell Vice President, Revenue Cycle Solutions Strategy MedAssets Julie has more than 23 years experience in healthcare revenue cycle operations in both the not for profit and investor owned sectors working for organizations such as Triad Hospitals and HCA, the Healthcare Company. As VP, Revenue Cycle Solutions Strategy, Julie helps to define client solutions by interfacing with customers and prospects and interpreting the customer s needs. Julie previously held the role of CarePricer Product Owner where she was responsible for the development and growth of the Web based tool that produces Patient Friendly Estimates. Julie has been published in HFM, AHIMA Journal and Frontiers of Health Services Management. She is a member of HFMA and a frequent speaker at national healthcare association events. INTENDED AUDIENCE Revenue cycle leaders, PFS and patient access directors, managed care directors, reimbursement directors and other healthcare leaders responsible for quality and process improvements INSTRUCTIONS FOR OBTAINING CONTINUING EDUCATION CREDIT To be eligible for CE NASBA credit: Attendees must be badge scanned for attendance and submit a completed evaluation form for this session Attendees should contact Dayna Baskerville (dbaskerville@medassets.com) to obtain their Certificate of Completion.

4 The Future Vision of Access Management: Turning the Revenue Cycle Upside Down! Hans Morefield Julie Waddell Matt Haynes SVP, Strategic Partners SCI Solutions VP, Revenue Cycle Solution Strategy MedAssets CBO Director Baptist Hospitals of SE Texas CONFIDENTIAL PROPERTY OF MEDASSETS. MedAssets is a registered trademark of MedAssets, Inc. Copyright MedAssets, All rights reserved. Overview Industry topography Moving from the back end to the front end Breaking it down Obtaining an order Scheduling Pre registration Financial Clearance Registration & discharge Success: Baptist Hospitals of SE Texas Recommendations 2 1

5 Industry Topography Percent of data needed for billing originating at registration 70% National average registration error rate 46% Percent of denials that could be prevented at registration > 50% Greater Geate population o of uninsured/underinsured sued/u de sued Higher deductibles, co pays, and co insurance Healthcare Informatics Research Series Data Patient Access Resource Center - NAHAM - Modern Healthcare - HCPro Quarterly benchmarking report 12/08 3 Industry Trends Insurance fraud and identity theft Verification and validationinin scheduling, pre registration registration and registration Managing new financial risks Financial securitization in pre service Transparency Pii Pricing and quality Staffing / Training Disparate systems and fractured lines of authority 4 2

6 Issues Impacting Operations and Reimbursement Payor delay payment tactics Lack of eligibility ibilit and benefit information Increased delays for medical necessity audits, reductions in reimbursement Increased administrative requirements to ensure timely and adequate reimbursement Complexity and rate of change has acceleratedfor compliance and regulatory requirements of government and managed care payors Limited timeframe to appeal ondenials denials, respond to audits 5 Best Practice Revenue Cycle Model Scheduling Progressive Model Obtain order / schedule patient Demographic, financial and clinical data capture Insurance eligibility/benefit verification Authorization & referral management Patient financial education and counseling Patient liability management Comprehensive registration Limited Financial Counseling Charge capture Charge capture Medical Records completion Claim scrubbing, edit resolution and claim submission Follow up, transaction posting Arrival account activation Coding Charge entry edits Charge capture Billing Transaction posting Revenue Optimization Margin Optimization 3

7 Patient Access Activities Scheduling Patient Estimates Appropriate Orders Address Verification Charity/Medicaid/ Medical Necessity / Alternative Payment ABN Sources Eligibility & Benefits Propensity to Pay / Verification cato Credit Scoring Authorization POS Payment processing Quality Assurance 7 Moving to the Progressive Model 4

8 Physician Orders The First Opportunity The process for most hospital services starts with a MD s order The order from the referring physician defines: Who is the patient What service do they need Why do they need it CHALLENGE: Ordering process mostly manual Paper based orders creates own set of issues Move to automate process has been growing 9 Physician Orders and the Revenue Cycle Order process defines Who, What, Why Revenue cycle opportunities : Detailed patient information including demographics and insurance If authorization or pre certification is required If medically necessary based on What (CPT4 code) & Why (ICD9 code) Medical necessity is the biggest revenue cycle opportunity at the very start of the healthcare process 10 5

9 Scheduling Scheduling kicks off the hospital s internal revenue cycle processes Allows for: Detailed patient data collection, especially if patient calls/is called Opportunity for the scheduler to refine data collection by asking additional questions, including revenue cycle questions For that insurance plan, I need a group number Is the patient the subscriber? No, then who s the subscriber? If you don t have insurance, then I need you to answer Ideally, the scheduler can do more than just collect information 11 Scheduling, Pre Registration Ideally, a scheduler can: Verify a patient s eligibility Warn that an authorization is required, and collect auth number Validate medical necessity Schedule the patient for financial counseling Discuss a patient s potential liability Pre register the patient If this is all done and satisfied, the patient is ready for their clinical encounter 12 6

10 Scheduling to Financial Clearance however, this can t always be completed by the scheduler Potential reasons why this may not get done: Too long a scheduling call Patient is not on the phone MD s office doesn t have authorization yet Scheduling system doesn t talk to ADT system Schedulers not a part of revenue cycle team Disparate or insufficient technology Financial Clearance finishes the process before arrival 13 Financial Clearance Defining Financial Clearance: Eligibility verification Benefit information Referral, authorization, certification Estimate of out of pocket liability Pre service payment or appropriate arrangements Identifying alternative payment sources Financial clearance may be performed pre service, registration, discharge Best Practice: Ensure all tasks are completed for all patients every time. 14 7

11 Financial Clearance Challenges 1. Multiple points of entry 2. Staff training (or lack there of) 3. Different patient types require different financial clearance tasks 4. Disparate systems that don t talk to one another 5. No contiguous work flow 6. Silos within organization 15 Registration & Discharge Ideally, most financial clearance tasks should take place in the pre service areas Opportunities exist when the patient presents and up to discharge Challenges: Direct admits Emergency Department Walk ins Non patient services (specimen sample) 16 8

12 One Organization s Training Program: Defining your role Personal responsibility Teamwork Customer Service Regulations JCAHO HIPAA Keys to Compliance EMTALA Medicare Compliance and LMRP Forms Patient Access Directives Financial Clearance Methods Discussion Point Components of Verification Insurance Quick References Insurances Government Payors HIC Number Suffixes Railroad Retirements Beneficiary Number Prefixes TRICARE Other Federal, State and County Programs Commercial Insurance Required Information for Approvals Financial Counseling Timing Credit Checks Financial Counseling 6 hours Shdli Scheduling Pre Registration Walk Ins Unscheduled Non ED Quality Control System Overview Data Validation UB04 Activity 17 Success! Baptist Hospitals of SE Texas 9

13 Baptist Hospitals of SE Texas is located in Beaumont Texas. The Central Business Office supports 4 acute care facilities, 1 LTAC, 1 Cancer Treatment Center and a mid sized group of multi specialty physicians. The CBO provides centralized Scheduling, registration, insurance verification, billing, collection, cash posting, contract management and coding and other support services for our member facilities. The CBO employees 60 employees using a model that includes Centralized and decentralized services based on the location of the client. 19 Moving the Back Office Functions To the Front The perfect storm was brewing among the facilities serviced by the CBO, in fact the main facility which hosts the CBO has been devastated by the two most recent Hurricanes Rita and Ike. It goes without saying we truly had a disaster to overcome. Top Operational Challenges: Fragmented processes related to scheduling, order capture, insurance verification, authorizations, medical necessity checks, point of service collections

14 WHERE DO YOU EVEN BEGIN!!!!! In re defining the front end role we set out to utilize the best practices among hospitals in all areas of the revenue cycle. Automated and detailed Eligibility Detailed authorizations obtained prior to service. Automated physician order system Pricing Transparency including a Patient Portion Estimator Optimization of Point of Service Collections Partnerships with the industry leaders in technology 21 The Before and After Where were we? Where did we want to be? Lost orders, Order facilitator technology that included Scheduling delays, Inadequate medical necessity checks resulting in denials and potential compliance issues Minimal use of Electronic eligibility. No estimation tool to accurately determine patient portions No confidence in estimating and collecting patient portions resulting in after the fact collection efforts Poor patient/physician satisfaction medical necessity checks Integrated and on demand eligibility vastly improving timing and accuracy of verification and pre registration. Patient Portion Estimator technology that utilizes actual managed care contract terms/hospital chargemaster to determine patient amount due. Improved patient through put, increased productivity, Decreased cost to collect Improved Physician and Patient satisfaction 22 11

15 What Were Our Main Benefits to Re defining the Front End Process Setting the community standard Allowed us to engage our physicians in a powerful process change Increased adherence to regulatory compliance standards Improved poedpatient t satisfaction satsacto Improved financial outcomes 23 Affecting Change Decreased lost orders Previously received around 120calls a week indicating that we lost the order. We rarely receive this call 5 times in a month now Increased efficiencies and less time on phone Previously faxed orders may not have been worked for a couple of days. Now worked immediately. Orders are kept organized in a work queue and resulted quickly. Orders are complete and electronically signed Patient Safety issues are satisfied Complete tracking and visibility of orders Internet based product (no dependence on system integration) The number of orders waiting to be worked decreased from around 150 a day to 15 a day

16 Affecting Change Improved medical necessity review Decreased scheduled medical necessity denials from around 240 a month to a current average of 5. Annual Reduction of $1.2M in medical necessity denials Authorization ti Leveraged technology to alert services requiring authorization Registration accuracy Better information with order process improved registration accuracy. Improved Registration accuracy from 82% to 95% Patient estimates More accurate information about services being scheduled allows creation of more accurate out of pocket liability estimates. Increased annual POS collections by $1.8M 25 Recommendations Analyze errors and denials from billing system Identify patient types, services, location, time, physician to determine if there is a trend Categorize opportunities from highest to lowest impact and from greatest to least effort to implement change Start with highest impact, least effort Continuously measure everything 26 13

17 Contact Information Matt Haynes, Administrative Director CBO, Baptist Hospitals of SE TX (409) Hans Morefield, Sr. VP Strategic Partners, SCI Solutions (914) Julie Waddell, VP Revenue Cycle Solutions Strategy, MedAssets (972)