SETTING YOUR ORGANIZATION UP FOR SUCCESS: UNDERSTANDING THE COMPLEXITIES OF THE REVENUE CYCLE

Transcription

1

2 SETTING YOUR ORGANIZATION UP FOR SUCCESS: UNDERSTANDING THE COMPLEXITIES OF THE REVENUE CYCLE Kentucky Primary Care Association, 2016 Fall Conference Thursday, November 10, :00am 10:15am

3 The following information was used as visual aid during a presentation/training session led by a BKD, LLP advisor. This content was not designed to be utilized without the verbal portion of the presentation. Accordingly, information included on these slides, in some cases, are only partial lists of requirements, recommendations, etc. and should not be considered comprehensive. These materials are being issued with the understanding they must not be considered legal advice. 3//

4 4// CONTAINING COSTS

5 The Revenue Cycle

6 THE REVENUE CYCLE Charge structure Patient scheduling Patient registration Pre-appointment activities Patient flow Charge capture & entry Third-party billing Denial management Patient collections

7 DO ALL OF THE PIECES FIT?

8 KEY PIECES OF THE REVENUE CYCLE PUZZLE Patient Scheduling Validate patient demographic data Utilize automation/ technology to verify insurance coverage in advance of visit Set payment expectations Notify patients of required documentation needed at appointment Patient Check-In/Out, Appointment Re-confirm registration/ insurance information Collect copay Collect outstanding balance Schedule follow-up appointment Correct documentation; coding & charge capture Post- Patient Visit Charge reconciliation to services rendered Clear & understandable statements Claims scrubber process (PMS and/or clearinghouse) Manage claims rejections & denials A/R follow-up Collections process

9 RESOURCES

10 CHARGE STRUCTURE Health Centers: PIN Sliding fee discount schedule Fee schedule 1. Services 2. Reasonable costs 3. Local prevailing rates Other provisions to consider

11 BILLING & COLLECTIONS Health Center programs must: Maintain adequate cash flow to support operations Maximize revenue from non-federal sources Have systems in place to maximize collections & reimbursement for its costs in providing health services, including written billing, credit & collection policies & procedures. (Section 330(k)(3)(F) & (G) of the PHS Act)

12 BILLING & COLLECTIONS, CONT. Revenue maximization requires: An adequate & competitive fee schedule A corresponding schedule of discounts Prompt & accurate billing of third-party payers Billing of patients in accordance with the schedule of discounts Timely follow-up on all uncollected amounts

13 BILLING & COLLECTIONS, CONT. Process necessary to ensure that federal grant resources address true financial access barriers to the maximum degree possible Health Centers are expected to utilize information to monitor performance compared to internal & external benchmarks, as well as for tracking trends

14 Patient Collections

15 TIME OF SERVICE (TOS) COLLECTIONS Best opportunity to collect Educate patients regarding payment for services Financial policy Co-pay Self-pay Prompt pay options Past due accounts

16 PATIENT COLLECTIONS Set the tone Expectations consistently communicated by all personnel Initial telephone contact & front desk staff Providers & clinical staff Administration Accountability Measuring & reporting cash collections

17 PATIENT COLLECTIONS, CONT. Patient consequences Make money owed an issue past balances are not ignored Payment plans Collection agency Attorney Staff consequences

18 INTERNAL CONTROLS Does cash received & cash posted balance daily? What happens to overpayments? Is every patient payment posted immediately? End of day reconciling forms System generated receipt Ability to post adjustments Statements generated

19 PATIENT COLLECTIONS, CONT. After the visit Accuracy Understandable statements Speed Follow-up

20 PATIENT COLLECTIONS, CONT. In-house collection efforts Daily productivity target per FTE 45 to 70 accounts worked Can use 70 contacts per FTE per day as a reasonable expectation On average it takes 2.5 contacts to achieve account resolution

21 Impact of Clinical Processes

22 IMPACT OF CLINICAL PROCESSES ON REVENUE Scheduling Highly restricted patient types & times Acute patient/same day scheduling process Volume Charge tickets/electronic Health Record (EHR) Accuracy & completeness Timeliness of completion Off-site services rendered Legibility (if by paper) Provider signature/esignature

23 IMPACT OF CLINICAL PROCESSES ON REVENUE, CONT. Coding Fear of over-coding Under-coding to help the patient Patient flow Taking patients back before front office processes are completed Directing patients to check-out process

24 IMPACT OF CLINICAL PROCESSES ON REVENUE, CONT. Additional issues to consider Advance Beneficiary Notices (ABNs) Staff & provider buy-in to collections process

25 Benchmarking for Improved Performance 25 //

26 KEY PERFORMANCE INDICATORS (KPIs) Recall the key components of the revenue cycle Begins with appointment scheduling & ends with payment resulting in $0 balance due How do I know if we are doing a good job? You ve done well this week, Bob. Stand by the machine & press the button.

27 KPIs, CONT. Monitoring tools/dashboards Monitored & reported to executive management monthly Feedback provided to staff Visualization is often beneficial

28

29 TRAINING PROGRAM Comprehensive training Practice management system is just a component On-the-Job (OTJ) training should be a part, not the entirety Effective trainer Written training materials Dedicated time Competency assessments 29 //

30 POLICIES & PROCEDURES Written, compliance-driven policies & procedures Undocumented = leaves room for interpretation Detailed guidance in procedure format Billing third-party payers Credit balances Insurance follow-up Small balance adjustments Budget plans Bad address Patient correspondence 30 //

31 TECHNOLOGY IMPACT ON THE REVENUE CYCLE Most practices only use 50% of their practice management system s capabilities what percentage does your organization utilize? Incorporate more automation versus utilizing manual staff hours

32 TECHNOLOGY IMPACT ON THE REVENUE CYCLE, CONT. Multiple channels for patient communication Automated Phone Systems Appointment reminder calls, answering services Kiosks Automated patient (self-service) check-in, complete forms, review of HIPAA documentation, access to information & educational materials regarding health conditions, treatments, medications or preventative care Web-based Tools, On-Line Portal Options Allow patients to communicate with providers & other clinicians, review test results, update demographic information, make payments, schedule appointments, request medication refills and referrals

33 BILLING PRACTICES Is your organization receiving Medicare payments from Medicare Part A & Part B? Have you recently reviewed services based on payer coverage or payment changes? Initial Preventive Physical Exam (IPPE) Annual Wellness Visit (AWV) Diabetes Self-Management Training (DSMT) Telehealth Medicare Advantage Is your PMS/EHR updated with the most current CPT & ICD-10 codes?

34 BILLING PRACTICES, CONT. Billing requirements for RHC/FQHC services Revenue codes Define FQHC services Encounter understanding Non-billable services Nurse-only visits Non-FQHC services Laboratory services Technical component

35 MISSING REVENUE Missing Charge Rate: < 1% < 1% of charges missed on audit (quarterly) of encounter form (paper or electronic health record equivalent) to charges entered Processes in place to ensure all encounter forms are entered into the practice management system Processes in place to ensure no missed offsite visits

36 ACCOUNTS RECEIVABLE MANAGEMENT Who is managing your A/R? What information do they provide? What changes have they implemented within the last 60 days?

37 KPIs Average days in accounts receivable (A/R) Annual revenue divided by 365 days = average daily revenue Current accounts receivables divided by average daily revenue = average days in A/R Multi-specialty, All Practices: Better performers: 28.45* Others: 42.32* Primary Care, Single Specialty: Better performers: 23.54* Others: 39.56* * Source: MGMA Performance & Practices of Successful Medical Groups, 2015 Report based on 2014 data

38 KPIs, CONT. METRIC Percent of total A/R over 90 days old MULTI-SPECIALTY, ALL PRACTICES PRIMARY CARE, SINGLE SPECIALTY Better performers: 13.76%* 12.20%* Others: 33.78%* 34.88%* Adjusted fee-for-service (FFS) collections Better performers: 99.30%* 98.62%* Others: 96.39%* 96.50%* Gross FFS collections Better performers: 54.94%* 62.73%* Others: 49.32%* 53.72%* * Source: MGMA Performance & Practices of Successful Medical Groups, 2015 Report based on 2014 data

39 KPIs, CONT. Percent of claims billed electronically Best practice & average: 95%* Days to charge entry Best practice & average: Same day or 24 hours Days to claim submission Best practice & average: 2 days * Source: MGMA Performance & Practices of Successful Medical Groups, 2015 Report based on 2014 data (Multispecialty, All Practices)

40 KPIs, CONT. Measure performance to determine success Set goals for financial performance related to the revenue cycle Various performance indicators

41 ACCOUNTS RECEIVABLE FOLLOW-UP What is your denial rate? How does it relate to the industry benchmark? What happens when a claim is not paid? How many outstanding claims do you have? What guidance is provided to staff on prioritization of claims?

42 ACCOUNTS RECEIVABLE FOLLOW-UP, CONT. Claims denial rate Target = < 5% of total claims Better performers: 4.90%* Reduce re-work & get paid faster Improve cash flow * Source: MGMA Performance & Practices of Successful Medical Groups, 2015 Report based on 2014 data

43 ACCOUNTS RECEIVABLE FOLLOW-UP, CONT. Staff productivity indicators Outstanding claim follow-up Approximately 800 1,000 claims per month

44 ACCOUNTS RECEIVABLE FOLLOW-UP, CONT. Quick follow-up on non-payment Tighten statement cycles Example: Days from Initial Statement Billing Cycle Initial statement 30 days 2nd statement 45 days 1st pre-collect 60 days 2nd pre-collect 75 days Refer to agency

45 Common Billing Issues to Avoid

46 COMMON BILLING ISSUES Failure to verify insurance Incorrect patient information Upcoding (downcoding) Unbundling (bundling) Documentation not supporting code(s) Lack of documentation Lack of medical necessity Incorrect modifier usage Wrong diagnosis or procedure code Duplicate claims

47 BILLING & CODING COMMON SENSE If it wasn t documented, it wasn t done. If it wasn t done, it can t be billed. If the service isn t necessary, it shouldn t be provided. If you weren t there, your name shouldn t appear in the medical record or on the claim.

48 Medicare Regulations: Living in the Present & Planning for the Future

49 49 // Bob, do you have time for an audit?

50 COMPLIANCE CONSIDERATIONS Changes in regulations & evolution of technology ICD-10 FQHC Medicare PPS Rule Chronic Care Management (CCM) Advance Care Planning (ACP) Practice Management System (PMS)

51 COMPLIANCE CONSIDERATIONS, CONT. Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) Physician Quality Reporting System (PQRS) Medicare & Medicaid Electronic Health Record (EHR) Meaningful Use incentive programs Social Security Number Removal Initiative E-consults Telehealth Is your organization prepared?

52 THE MANY LAYERS OF AUDIT AGENCIES Office of Inspector General (OIG) Health Care Fraud Prevention & Enforcement Action Team (HEAT) Unified Program Integrity Contractor (UPICs) Medicare & Medicaid Recovery Audit Contractors (RACs) Comprehensive Error Rate Testing Program (CERT) Supplemental Medical Review Contractors (SMRCs)

53 QUESTIONS

54 910 E. St. Louis St. Springfield, MO Office: Fax: you Monique D.Thank Funkenbusch, CPC Managing Consultant 54 // experience momentum

55 Disclosure Information contained in this presentation is informational only & is not intended to instruct providers on how to use, or bill for health care procedures. Providers should consult with their respective insurers, including Medicare fiscal intermediaries & carriers, for specific information on proper coding & billing for health care procedures. Additional information may be available from physician specialty societies & hospital associations. Information contained in this presentation is not intended to cover all situations or all payers' rules & policies. Reimbursement laws, regulations, rules & policies are subject to change. The information in BKD sessions is presented by BKD professionals for informational purposes only. Applying specific information to your situation requires careful consideration of facts & circumstances. Consult your BKD advisor before acting on any matters covered herein or in these seminars. 55 //

56