MANAGED CARE CONTRACTING & PAYOR SCORECARDS

Transcription

1 April 30, :00 a.m. t 11:00 a.m. Central Time MANAGED CARE CONTRACTING & PAYOR SCORECARDS Mark Blessing Partner BKD, LLP mblessing@bkd.cm Kathy Hughes Senir Client Partner G2N khughes@g2n.rg TO RECEIVE CPE CREDIT Participate in entire webinar Answer plls when they are prvided If yu are viewing this webinar in a grup Cmplete grup attendance frm with Title & date f live webinar Yur cmpany name Yur printed name, signature & address All grup attendance sheets must be submitted t training@bkd.cm within 24 hurs f live webinar Answer plls when they are prvided If all eligibility requirements are met, each participant will be ed their CPE certificates within 15 business days f live webinar 2 1

2 AGENDA Are Yu Being Paid Accrding t Yur Cntracts? Payer Screcards Tips fr Negtiating Managed Care Cntracts Hw Cntracts May Change Due t Health Care Refrm Questins 3 LEARNING GOALS Upn cmpletin f this prgram, participants will be able t Identify key cntrl prcesses & assciated implementatin issues assciated with cntractual allwance management Explain use & implementatin prcess f Payr Screcard methdlgy Identify key appraches t enhancing managed care cntract negtiatins with third-party payrs Discuss ptential effects n managed care cntracting prcess frm key health care refrm initiatives 4 2

3 Are Yu Being Paid Accrding t Yur Cntracts? APPROPRIATE PAYMENTS It s Mre Imprtant Than Ever! It s Nt Just Underpayments Overpayments Denials Late payment impacting aging Slw turn arund n appeals impacting cash flw 6 3

4 APPROPRIATE PAYMENTS Millins f dllars left n the table if nt mnitring 5-10 percent initial underpayments t appeal Why? Limited resurces r systems devted t task Unclear cntract terms Undetected requirements in prvider manuals Cmplicated cntracts that systems can t handle Just plain wrng 7 Surce: Benchmarking Revenue Cycle Perfrmance Results frm the 2013 Natinal Survey f Hspital Revenue Cycle Operatins The Advisry Bard Cmpany APPROPRIATE PAYMENTS Other reasns fr wrng payments Registratin accuracy Lack f clinical dcumentatin in the recrd Lack f charge capture accuracy Chargemaster nt up t date Incrrect cding Incrrect billing 8 4

5 MONITORING AR systems with variance reprting mdule Stand alne systems with interfaces t AR system Sample basis Excel spreadsheets Reprt generatin frm payment psting 9 MONITORING Straight underpayment (wrng per diem, wrng rate) N payment fr implants (RC ) N payment fr specialty drugs (RC 636) Other carve-uts Outlier payments Cntract change-ver perids 10 5

6 Payr Screcards WHY HAVE PAYOR SCORECARDS? Hld Payr Accuntable Benchmark Against Self, Other Payrs r Industry Use in Mnthly r Quarterly Meetings with Payr Cntract Negtiatin Cllect all mney yu deserve under the cntract 12 6

7 ITEMS FOR SCORECARD Days in AR By payr? By prduct? Aging f AR by payr % Payment Variance Cmpared t Revenue First-Pass Reslutin f Claims Denial Rate Initial Final 13 ITEMS FOR SCORECARD Prvider Cllectin Burden ERA d they use them? Standard cdes r they make up their wn? Eligibility Accuracy is their verificatin data base kept up t date? Hw ften d yu verify & infrmatin turns ut t be wrng when claim is filed? Survey scres frm emplyees that wrk with payr 14 7

8 ITEMS FOR SCORECARD Bk f Business Analysis Yur hspital % f their market share Payer % f yur revenue Utilizatin by Payr prduct line Overall Payr prfitability fr yur hspital Administrative Csts 15 Verificatin, Precertificatin, LOS Authrizatins Billing lts f special edits & manual changes? Cst t Cllect hw much d yu spend t cllect $1? ITEMS FOR SCORECARD $ tied up in denials Aging f appeals Late payments Underpayments as % f cases Underpayments as % f net revenue % f bad debt by payr Develp template t use s yu can track against all payrs & share with payr 16 8

9 A FEW OTHER THOUGHTS Even if yu have a mdule in finance system r AR system t track expected payments against actual, yu shuld still test manually t check Set up standing meetings with payrs t review Cntract Language Time limits n retractive determinatins & denials Time limits n recupments r refund requests 17 Tips fr Negtiating Managed Care Cntracts 9

10 BE PREPARED #1 KNOW THYSELF Understand yur reimbursement, cst structure & resultant prfitability at DRG/CPT/CDM cde level (r ther cntract rate setting levels) at service line level at payr level Understand yur strategic directin - what activity is likely t increase & decrease based n ur plans Understand yur market - what activity is likely t increase & decrease based n market changes Understand yur care management abilities what activity is likely t increase & decrease based n care management initiatives 19 BE PREPARED #2 KNOW THY PARTNER Analyze payr screcard infrmatin Analyze histric payr activity & prfitability if pssible at DRG/CPT/CDM cde level at service line level Analyze histric payr reimbursement levels in cmparisn t market Analyze key emplyers cntracted with payr & trend fr payr in yur market Cmpile strategic negtiatin wish-list fr each majr payr based n abve infrmatin & update n regular basis be prepared when pprtunities arise 20 10

11 KNOW WHAT YOU NEED Cncept f Cntract Rate Budget Utilizing histrical data, establish mdel t analyze managed care reimbursement Majr payrs Majr activity (DRGs/CPTs/CDMs etc.) Establish shrt & lng-range strategic gals fr ttal managed care reimbursement levels in cncert with verall budget Utilize mdel t budget needed reimbursement levels by majr payr using key assumptins t achieve shrt & lng-term needed levels Cnsider true net cllectin rates, nt just cntracted rates (i.e., denials, secndary bad debts, etc.) Practively negtiate cntracts t best achieve the required/budgeted reimbursement levels Adjust budget when factrs change New rates fr majr payr Significant activity changes Strategic directin changes 21 NEGOTIATE Cmmunicate identified needs early & ften - cnfidently let them knw exactly what yu need frm this negtiatin Be pen t creative slutins Payrs generally think glbally fr their fee schedule - identifying increases n specific services that are mre imprtant t yu than payer s average prvider will seem less cstly t the payr Payrs are becming mre interested in deeper partnering with prviders in areas ther than reimbursement rates 22 11

12 NEGOTIATE Use the infrmatin yu have gathered t be nimble in the negtiatin - knw what each ffer means t yu quickly Cntract terms are imprtant - include these in negtiatin prcess n regular basis When pssible, respectfully negtiate in an envirnment which includes a credible threat f nt cntinuing the relatinship 23 Hw Cntracts May Change Due t Health Care Refrm 12

13 UNDERSTANDING IMPACT OF MEDICARE T cver the unfunded Medicare liability will require $85.6 trillin, mre than six times the annual utput f the U.S. Ecnmy. Richard Fisher Federal Reserve Bank f Dallas 25 HEALTH CARE REFORM Medicare spending must be slwed Beneficiaries t grw frm 44 millin in 2007 t 77 millin by 2031; due t cuts in refrm bill, trust fund is nw slvent until the year 2029 Medicare budget t grw frm $408.6 billin, 3.1% f GDP t 11% f GDP Hw lng is this sustainable? 26 13

14 WE HAVE SEEN THIS BEFORE THEN - Balanced Budget - HMOs (Health Maintenance Organizatins) - Capitatin - Sustainable Grwth Rates (SGR) NOW - Health Care Refrm - ACOs (Accuntable Care Organizatins) - Bundling - SGR Fix 27 BUILDING BLOCKS FOR PAYMENT REFORM Pay fr Reprting Pay fr Perfrmance Measure Resurce Use Pay fr Value (efficient resurce use & quality) Align financial incentives & new mdels fr care Transparency & public reprting EHR, PHR & interperability between payment & quality data 28 14

15 DEVELOP KEY CARE MANAGEMENT ABILITIES Clinical Care Management Quality & utcmes reprting Patient satisfactin reprting Ppulatin management reprting Management systems EHR? Financial Management 29 Cntract prfitability reprting Reimbursement allcatin issues Cst accunting issues Financial reprting GAAP issues Mnitring liabilities QUESTIONS? 15

16 Thank Yu! Mark Blessing Partner, BKD, LLP Kathy Hughes Senir Client Partner, G2N CONTINUING PROFESSIONAL EDUCATION (CPE) CREDITS BKD, LLP is registered with the Natinal Assciatin f State Bards f Accuntancy (NASBA) as a spnsr f cntinuing prfessinal educatin n the Natinal Registry f CPE Spnsrs. State bards f accuntancy have final authrity n the acceptance f individual curses fr CPE credit. Cmplaints regarding registered spnsrs may be submitted t the Natinal Registry f CPE Spnsrs thrugh its website: The infrmatin in BKD webinars is presented by BKD prfessinals, but applying specific infrmatin t yur situatin requires careful cnsideratin f facts & circumstances. Cnsult yur BKD advisr befre acting n any matters cvered in these webinars

17 CPE CREDIT 1 CPE credit may be awarded upn verificatin f participant attendance Fr questins, cncerns r cmments regarding CPE credit, please the BKD Learning & Develpment Department at training@bkd.cm 33 17