Revenue Cycle Management: It Takes a Village. Problem Statement

Transcription

1 Revenue Cycle Management: It Takes a Village AHRA 38 th Annual Meeting August 24, 2010 Patricia R. Blank, Executive Vice President, InSight Imaging Nancy Walker, Executive Director, RCM, Insight Imaging Statement In December of 2007, the financial leaders of InSight Imaging became acutely aware of the need to address the Revenue Cycle process. On the heels of the Deficit Reduction Act of 2005 and its direct effect on declining revenue and cash flow, it became imperative that we fine tune every process and effectively bill and collect for what we do! INSIGHT RETAIL IMAGING AT A GLANCE As of 1/01/2008 Retail Imaging Centers (13 States) Number of Annual Procedures.836K Total Annual Charges $469M Number of Imaging Center Employees..... > 1200 Number of Centralized Billing Offices... 3 Number of Billing Employees... >250

2 Revenue Cycle Assessment 32% of AR was aged past 120 days Days Sales Outstanding (DSO) stood at 62 days Receipts for services less than 90 days were at 78% First Level Claim Denials were at 17% For every dollar of patient owed fees, $.25 was being written off Analysis Grid Metrics InSight December 2007 AR>120 days 32% 13% DSO Industry Standard Denial Rate 17% 12.8% Receipts % for transactions less than 90 days 78% Not known Revenue Cycle Goals

3 The Plan. Develop a solution that incorporates technology and the creation of new roles and accountability within the revenue cycle Imaging Centers Billing Implement Change Management across 1200 employees Our Revenue Cycle Dissected Revenue Cycle Assessment: Imaging Facility Centric 75% of the Revenue Cycle tasks and roles were owned by the retail imaging center Of the 17% total first level denials, 15% could be traced back to errors at registration $20M+ needed to be collected from patients at time of service Contract Rates were not available, allowing for proper patient collections

4 Schedule Management and Insurance Verification Scheduling did not gather insurance information. That role was assigned to the patient confirmation team. Patient confirmation was only being performed on MRI and CT scans. Therefore, insurance verifiers needed to call patient or referring physician office to get insurance information. Many verifications were not able to be accomplished. Change scheduling procedure to include data entry of insurance carrier and patient insurance ID # Create a process, via automated interface with eligibility vendor, to initiate an eligibility check at time of scheduling. This check, if successful, would insert or update the patient demographics and decrease verifier work load. Patient Registration 4% of our charges were denied for coverage. Only MR and CT were insurance verified. Lag between scheduling event and date of service created ineligible encounters. 7% of our charges were denied due to data entry errors. Most denials were due to transpositions in the patient ID, subscriber ID, plan, and group number Use eligibility engine to run 100% of patient encounters at time of service via integrated interface between RIS and Check in functions. If insurance showed ineligible, convert patient to self pay. Insert or update these key fields from the 271 message received via the eligibility engine interface. Patient Collections During patient confirmation, we had been unable to give instructions as to patient owed responsibility. Without clear instructions, patients were not prepared to pay. We did not know how to factor remaining deductibles or co insurance because we did not know contract allowed amount. We collected estimated patient responsibility BEFORE the exam was completed. This left open balances on patient accounts and patient responsibility for additional procedures, or supplies were never considered. Bring back, via the plan benefit interface, the remaining deductible amount as well as % co insurance. Program a contract module that could discern contract allowed for each CPT or HCPC and integrate this information and the calculation into patient invoicing and super bill. Change the workflow. Technologist MUST complete exam in RIS immediately and no money is to be collected until after Tech completion. Create a checkout role.

5 Technologist Exam Performance and Completion Exams were authorized for a specific CPT code. The CPT performed was not an exact match due to radiologist protocols, patient intolerance, etc. The technologist assumed we could get the a retro authorization. Technologists were not amending studies to include performed adjunctive procedures and supplies. (i.e. MR Arthrogram, no joint injection, no fluoro guidance, no supplies) Workflow change. If for any reason the CPT needed to be changed, the insurance company or RBM was notified and an authorization change was requested prior to performing the new study. If we could not reach the appropriate party to facilitate change, we would proceed with new study, as not to inconvenience patient. Program an associated charges logic into the RIS. Display all associated codes and default all must have codes to mark as complete and all might have codes to be available for technologist selection. Charge Creation Transactions that were in an incomplete state and did not meet the criteria for a clean claim were advancing to billing nightly resulting in claim lag and denied claims. Accountability for end of day processes and quality of work was poorly defined. There was no ability to sequester incomplete or incorrect transactions. Program a wizard that would only allow clean claims to advance into the billing process. Program a work screen that captures incomplete or incorrect transactions. Make center manager accountable for monitoring and fixing transactions. Revenue Cycle Assessment: Billing and Collections Centric Costs to collect each dollar were double the industry standard Claims that did not pass EDI edits where not worked consistently For every dollar of denials, we were writing off $.30 No Short Pay analysis Collector process and strategies nonexistent

6 Coding Even though Insight had purchased the A Life Coding tool, almost 100% were being reviewed Down coding was rampant in low tech modalities. Focus on creating business rules that would allow transactions to pass edits. Target 80% of transactions to go green. Create business rules for x ray abstraction. Work with radiologists on what MUST be in report to support specific CPT codes Audit and Claims Submission 100% of claims were compared to patient packets to screen for accuracy. No tracking of denials. No accountability or process for monitoring EDI queues. Aged accounts never making it through clearing house to payer. Make the center accountable for data integrity. Capitalize on eligibility interface to make audit an unnecessary process. Rely on interface to insert or update the correct patient demographics Identify the genesis of claims denials via tracking and metric development. Create an EDI specific role. Create a process to insure that claims do not hang or reject. Collections and AR Follow-up Payment posters accepted the EOB amount as contract rate. No short pay analysis could be performed except on an audit basis. No timely notification to payers of short pay condition. Collectors worked AR from paper Aged Trial Balance report. Unclear as to which collector was working what. No set process for dealing with patient balances. Develop and load contracts into a module that would write the contract allowed amount into the payment posting and collections screens. Create a short pay mail merge function that would create a payer letter, at time of payment posting, for any short paid claim. Develop a tool that can drive collector process by creating collector work lists, based on management strategies Create a procedure that included routine statements and implement telecollector technology.

7 Fast Forward 2 ½ Years>>>> 20 21

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11 Analysis Grid Metrics InSight December 2007 InSight June 2010 Industry AR>120 days 32% 9% 13% DSO Denial Rate 17% 5.5% 12.8% Receipts % for transactions less than 90 days 78% 86% Not known Thank you!