Keeping the Reimbursement Train on Track

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1 EXECUTIVE BRIEFING Keeping the Reimbursement Train on Track By Kelley Blair MA, vice president at Craneware Professional Services and Linda Corley, MBA, CPC, corporate compliance officer, Dell Services Revenue Cycle Solutions The expression may seem trite, but keeping the revenue cycle train on track is nothing to take lightly. The process touches all points of care from the moment the patient walks in the door through final collection of payment and a breakdown at any stage hurts profits. Healthcare executives need to know: 4 Why revenue cycle management is more critical than ever 4 How to tell if the train is off the track 4 How to get started with the chargemaster 4 Where to focus additional improvement efforts Why Revenue Cycle Management is More Critical Than Ever Talk of revenue cycle management picked up in 2000, when Medicare tied outpatient reimbursement to a healthcare provider s correct use of charge codes. Suddenly, complete and compliant charge capture took first priority for many facilities, but progress was often slow. In 2001, 57 percent of hospitals were paid less than the actual cost of caring for their Medicare patients (from the American Hospital Association s May 2003 report, The Case for Hospital Payment Improvement ) % 7.46% 26.87% 40.30% Considering the basis of payment, approximately how much of your revenue is charge-based? g Greater than 50% g 25-50% g 5-25% g Less than 5% Source: Patient Friendly Billing Survey, HFMA, March 2007 Today, The newly adopted Healthcare Patient Protection & Affordable Care Act (public law section ) creates additional challenges that require hospitals to more closely scrutinize their outpatient claims data, which has grown even more complex with this law. Fundamental changes to public law, coupled with enhancements to fraud and abuse statutes, give very little tolerance to errors. Billions of dollars are being spent for additional IRS, HHS and OIG agents to ensure there is a reduction of fraud and abuse dollars as represented by GAO reports. These factors make it more critical than ever that hospitals submit an accurate claim the first time. Not only in order to reduce risks of serious noncompliance When does Chargemaster maintenance cause lost charges? g 0-15% g 16-30% g 30-50% g Over 50% Source: HFMA Insta Poll March % 13% 24% 21% penalties, but also because it is vital that successful hospitals ensure they are receiving optimal appropriate value for the services and supplies associated with patient care. The majority of hospitals are still not collecting all of the revenue they are entitled to. Ninety-two percent of hospitals lost money on outpatient services the fastest growing segment of hospital billable services and medical necessity denials cost some hospitals more dollars than they receive in collections. This adds up to lost revenue contributing to the negative margins experienced by nearly onethird of hospitals.

2 Executive Briefing If indicators show that the revenue cycle train is at least sputtering, if not completely derailed, the first place to start is the chargemaster. A few additional factors keep the focus on revenue cycle management. Medicare charge codes are constantly changing, so the work is never fully done. Also, other payors adoption of similar models has multiplied the opportunity for error. The Healthcare Financial Management Association s (HFMA s) PATIENT FRIENDLY BILLING survey of hospitals reported that 34 percent of respondents received more than 25 percent of their revenue from charge-based or percent-of-charge payment. Most significantly, the recent economic climate has continually decreased capital available to providers, forcing healthcare organizations to look internally to increase cash flow. Like the supply chain, the revenue cycle holds huge opportunities to generate cash. How to Tell if the Train is Off Track Executives can get a quick read on the state of their revenue cycle by tracking several key indicators: 4 Are payors rejecting a high dollar volume of services due to lack of medical necessity? 4 Do a high percentage of claims require billing office intervention to get out the door? 4 Are a high percentage of claims returned by Medicare or other payors for rework? 4 Are a high percentage of claims rejected as duplicates? 4 Are accounts receivable days high compared to national averages or are they growing? 4 Is the billing staff unable to keep up with collections follow-up? Providers that answer yes to any of these questions have opportunities to improve the revenue cycle and, therefore, bring in more cash. Also, low accounts receivable days does not necessarily mean that there are no problems. An organization can process billing quickly, but still not be completely accurate. How to Get Started with the Chargemaster If indicators show that the revenue cycle train is at least sputtering, if not completely derailed, the first place to start is the chargemaster. This is the most important tool to ensure optimum and compliant reimbursement, so if a hospital has resources for just one revenue cycle improvement, this is the one. Why the Chargemaster Matters The chargemaster (Charge Description Master) database holds responsibility for translating services delivered into language both internal staff and outside payors understand. It is the basis for measuring: 4 Revenue performance Did the payors reimburse for the service coded? 4 Costs What services is a department performing and what supplies and pharmaceutical costs are attached to those? 4 Productivity How many of each specific type of service is a department, facility or team performing? When the chargemaster is working correctly, it allows facilities to easily and accurately charge for services provided and offers a consistent way to track and bill for services that are performed identically each time. It also serves as a mechanism for managing revenue and can act as a decision-support tool for the case management and utilization review teams. However, a poorly tended chargemaster process prevents cash from reaching the healthcare provider.

3 Keeping the Reimbursement Train on Track Problems can spring from outdated codes in the database or people not understanding how to correctly use the codes. Any of these factors will result in repeated billing errors, which lead to diminished or eliminated reimbursement dollars. A poll conducted by the HFMA demonstrates how significant an issue this is. One-third of the respondents reported that more than 30 percent of their denials were directly caused by chargemaster issues. Because the chargemaster anchors the entire revenue cycle, improvements at other points will do little to get the train back on course until the processes and data related to the chargemaster are fixed first. Four Guidelines for Good Chargemaster Controls Improving charge capture and reimbursement requires implementing chargemaster management controls. Maintenance must be ongoing, because the chargemaster quickly becomes incomplete, making needed costs unavailable. In these situations, staff uses the incorrect codes and it becomes impossible to receive correct payment. This chain of events shows how quickly the train can be derailed. To ensure they have the right controls in place, providers aiming to improve chargemaster management should follow these four guidelines: 1. Controls are most effective when closest to the transaction Look for points in the process where it makes sense to check accuracy before moving to the next step. 2. A control point is located anywhere the process can break down In addition to getting the right codes into the database, look at how those codes are rolled out to the staff who use them. 3. Design controls that either prevent or detect errors If it is not possible to automatically correct an error, set up a trigger to detect the error for manual intervention. 4. Rank control points based on probability, frequency and materiality of the error If issues exist at multiple points in the process, start with the ones that cause the most lost time and money. 11 Common Gaps in Need of Control Data from a number of healthcare providers shows 11 common control gaps. These are a great starting point for executives seeking quick revenue cycle wins. 1. The chargemaster is not updated for changes to coding rules. Control point: Conduct continuous audits of the chargemaster against rejected charges. Prioritize issues based on financial impact. 2. The chargemaster is missing services. Improving charge capture and reimbursement requires implementing chargemaster management controls.

4 Executive Briefing Even providers with excellent chargemaster controls may see their revenue cycle trains jump off track. Control point: Constantly compare the chargemaster to a best practice database or CPT HCPCS codes available for each department, and review possible omissions with the clinical managers. 3. Medication units of service are incorrect. Control point: Set up a multiplier to automatically convert dispensed units into the correct billable unit, and monitor the multiplier frequently. 4. Pharmacy acquisition costs do not reconcile with revenue. Control point: On a quarterly basis, compare pharmacy purchase history to the chargemaster to make sure all purchased items have codes in the database. 5. Clerical data entry errors exist in the chargemaster. Control point: Implement automated checking of key data elements by comparing them to external sources. 6. There is a significant delay in implementing new charge codes. Control point: Continuously improve the process for adding new codes until it reaches best practice cycle time of two days or less. 7. The clinical staff is disengaged from the chargemaster. Control point: Educate staff on what the chargemaster is and how to use it. Provide access for all clinical staff to view the codes relevant to their areas. 8. The clinical staff is misusing charge codes because they have not been properly educated. Control point: Start with general education about the chargemaster and common codes for each department. Then, establish a process to notify clinical managers of coding changes relevant to their departments. 9. The order entry system does not reflect chargemaster edits. Control point: Have the chargemaster management team get sign off from each department that the clinical system and charge ticket match the chargemaster codes and that their teams have been trained on how to use those codes. 10. Poor documentation is resulting in loss of knowledge. Control point: Keep well-organized and easy-toaccess records of why each decision was made, who was involved in the decision and who was aware of what happened related to charges to create a defensible record of all billing actions. Maintain several years worth of data. 11. The healthcare provider s price for a service falls below cost or fee schedule rates. Control point: Constantly compare pricing information to payors fee schedules to ensure that prices are at or above the reimbursable rate. Where to Focus Additional Improvement Efforts Even providers with excellent chargemaster controls may see their revenue cycle trains jump off track. When this happens and executives ask why claim rejections and denials are growing, they often point to the business office or patient financial services as the culprit. But that is not a fair assessment. The business office does not register, schedule, admit or review medical necessity prior to service. It also rarely manages the chargemaster and does not code or add modifiers. Errors at any of these locations can affect whether a provider receives appropriate reimbursement for the services offered. In addition, the business office is not equipped to make sure, on the back end, that all the information needed has been provided. They will certainly compare diagnosis and procedure information, review the services provided and even check the demographic data to make sure it matches the payor s requirements but that is just a fraction of the factors that influence whether a claim pays, rejects or denies. By the time a claim reaches patient financial services, it has undergone thousands of changes, which need to be managed by the person closest to each of those change transactions.

5 Keeping The ReimbuRsemenT TRain on TRacK 14 Stops on the Revenue Cycle Path To simplify the discussion, it is possible to divide the revenue cycle into 14 steps spread across patient access, medical management and receivables management functions. Patient Access Functions 1. Scheduling 2. Pre-registration and pre-certification 3. Insurance verification 4. Financial counseling 5. Registration and point-of-service (POS) cash collection 6. Medical Management Medical Management Functions 7. Charge capture and entry Receivables Management Functions 8. Medical records and coding 9. Claims submission 10. Third-party follow-up 11. Payment posting 12. Rejection processing 13. Denial and appeal management 14. Contract negotiation and administration To decide where to start, healthcare providers should review each stage and identify strengths and weaknesses. By the time a claim reaches patient fi nancial services, it has undergone thousands of changes, which need to be managed by the person closest to each of those change transactions. 6 MEDICAL MANAGEMENT 7 CHARGE CAPTURE & ENTRy 8 MEDICAL RECORDS & CODING 9 CLAIMS SUBMISSION 10 THIRD PARTy FOLLOW-UP 5 REGISTRATION & POS CASH COLLECTIONS 4 FINANCIAL COUNSELING Revenue Management g Patient Access Functions g Medical Management Functions g Receivables Management Functions 11 PAyMENT POSTING 12 REJECTION PROCESSING 3 INSURANCE VERIFICATION 2 PRE-REG & PRE-CERT 1 SCHEDULING 14 CONTRACT NEGOTIATION/ ADMIN. 13 DENIAL & APPEAL MANAGEMENT

6 Executive Briefing Patients kept in acute care beyond the average length of stay cost hospitals an estimated $50 million a year. Patient Access Full reimbursement starts at first patient contact. A well managed pre-registration and insurance verification process can speed up billing. On the insurance side, all registrars need to understand which data is important to each payor and collect it. This prevents detective work in the billing office. In registration, collaboration between clinical staff, physicians and registrars ensures that the right diagnosis and procedure information get onto the claim. Also, procedures for when to classify patients as inpatient vs. outpatient eliminate denials related to performing services in the wrong setting. Here are some specific strategies that can improve revenue cycle processes in the patient access space: 4 Flowchart how patients enter the system from every access point and identify opportunities for improvement. 4 Move to a point-of-service cash collection model. 4 Perform a monthly admission review. Graph average length of stay compared to payors allowed length of stay to identify areas that might need attention. 4 Involve the case management or utilization review team in determining patient status, inpatient or outpatient. 4 Track all inpatient admissions denied by a payor each month. Some of these might be paid if submitted as an observation stay instead. 4 Establish accountability for Medicare s required Advance Beneficiary Notice (ABN) for outpatients andabn or Health Insurance Notice of Non- Coverage for inpatients. 4 Use compliance software for outpatient diagnosis review, and set clear procedures for following up on issues or questions. 4 Set up financial counseling sessions with all beneficiaries or patients if possible. 4 Review planned observation stays after outpatient or same-day surgeries. These are not covered by Medicare, so observation without some kind of medical complication amounts to providing free bed and breakfast to the patient. Medical Management Because they make decisions about whether to admit patients, keep them for observation or discharge them, the medical management team can affect reimbursement. Patients kept in acute care beyond the average length of stay cost hospitals an estimated $50 million a year. Also, hospitals can be fined or put under a quality improvement agreement if patients are being admitted as inpatients when they do not meet inpatient criteria. Written admissions procedures provided by the medical management team can reduce these risks. The medical management team can also affect medical necessity denials. This used to be an issue with Medicare only, but now all payors are considering medical necessity when they review each charge. Finally, because medical management is such an important component of compliance, the team can create written policies and procedures for key decision points, particularly establishing patient status. This is one of the most problematic areas for providers today. Providers who empower the medical management team to identify strengths and weaknesses, build a plan, work with other departments to implement the plan, and then measure results are seeing strong outcomes. Receivables Management Good receivables management starts with strong chargemaster practices, but a number of other factors influence whether the train stays on track. Education is one. Healthcare providers should be training clinical staff to understand Medicare coverage and coding requirements, in addition to keeping a well-trained charge posting staff. Verifying whether codes are correctly making it to the claim is another. Regular review of the claim form will reveal whether coded HCPCS are dropping to the claim and whether staff is using the most current codes available in the chargemaster. Also, clearly documenting how the system handles soft-coded procedures vs. the hard-coded chargemaster codes helps both clinical employees and the billing team makes the right choices.

7 Keeping the Reimbursement Train on Track Here are some additional specific strategies to improve the receivables management side of the cycle: 4 Conduct small, but regular audits to ensure services are charged correctly. 4 Track edits performed by billing services and send frequent problems back to the clinical staff, so the team can address the root cause and eliminate the error. 4 Capture and review write-off items by line item, department, physician and registrar. Publish the results, communicate them and use them for educational sessions. 4 On the back-end, require manager review before reclassifying items as write-offs or reversing them to the clinical department for further clarification. 4 Report weekly on returned-to-provider claims with reason codes. Itemize the list by biller and payor. 4 Anticipate patient information errors. For example, patients who have been in accidents will not always think to provide their accident insurer as primary insurance. 4 Set up review processes for inconsistent information within a claim form, such as overlapping dates of service or outpatient services delivered within 72 hours of an inpatient admission. 4 Have a very active appeals process. Prioritize efforts based on the dollar value of the denied services. 4 Reinforce the importance of revenue cycle quality with a monthly meeting that reviews strengths, weaknesses and progress on key initiatives. To capture more revenue, healthcare providers also need to look at three additional areas within receivables management: returned-to-provider or denied claims, health information management and staff awareness of Medicare denials. Returned-to-Provider or Denied Claims Resolving returned-to-provider claims eats up valuable time, especially since the codes are often unclear. To speed the process, the billing team should create a resolution manual containing screen prints of returned-to-provider reason codes and instructions on how to resolve each code. To reduce the number of denied or delayed claims, providers can also track claims stuck due to errors in the Medicare processing system and contact the fiscal intermediary or MAC if the dollars become substantial. In addition, a task force should also be responsible to monitor performance by payor, including contract compliance and payment time, and then to address problems. To capture more revenue, healthcare providers also need to look at three additional areas within receivables management: returned-toprovider or denied claims, health information management and staff awareness of Medicare denials.

8 Executive Briefing Keeping the Reimbursement Train on Track In a market where available capital is shrinking, healthcare organizations must look internally to increase cash flow. Health Information Management Written procedures for clinical error review of line items rejected for modifier determination save time. To provide accurate guidance, it is important to get the clinical staff involved in resolving these claims and creating the procedures. Constant tracking can identify problem areas. Providers should track by outpatient area, physician and error message, so the Health Information Management and billing teams can work together to develop action plans that address the root cause. Staff Awareness of Medicare Denials At many healthcare organizations, the business staff will say that they have no, or very few, Medicare denials. Often, this is the result of services being placed in the non-covered column or not being billed at all, instead of a sign of excellent revenue cycle controls. Comparing the total dollar amount of services provided over a month to the total amount collected through patient payments and payor reimbursement gives an accurate picture of the amount of cash lost in the revenue cycle. Conclusion In a market where available capital is shrinking, healthcare organizations must look internally to increase cash flow. Like the supply chain, the revenue cycle holds huge opportunities to generate cash. From the moment the patient walks in the door through final collection of payment for the services delivered to that patient, the revenue cycle process touches all points of care. To start recapturing these funds, healthcare executives need to: 4 Determine whether the train is off the track and identify the problem points 4 Start by cleaning up the chargemaster and implementing controls to ensure that it is well maintained and properly used 4 Assess key stops in patient access, medical management and receivables management to identify and prioritize issues 4 Involve all relevant teams, not just the chargemaster team or the billing office, to improve processes Kelley Blair, MA Kelley Blair is vice president of professional services for Craneware, where she helps hospitals of all sizes better manage revenue cycle strategy projects by providing healthcare operations insights, best practice, performance improvement methods and measurement tools. In addition to more than eleven years of revenue cycle operations management and performance improvement experience, Blair is a certified Six Sigma Black Belt with formal training and experience using Lean and Focus PDCA improvement methodologies in complex integrated health systems. Blair holds a masters degree in Organizational Leadership with a focus on Strategic Management. Linda Corley, MBA, CPC Linda Corley, is corporate compliance officer and learning development leader, Dell Services Revenue Cycle Solutions. She has more than 25 years experience working directly with hospitals and ambulatory surgery centers in the areas of patient financial services, medical records and accounting. In addition to providing associate compliance and HIPAA training, Linda conducts reimbursement and compliance audits for hospitals to improve revenue cycle performance. About Amerinet As a leading national healthcare group purchasing organization, Amerinet strategically partners with acute and alternate care providers to reduce costs and improve quality through its performance solutions. Built on a foundation of data, savings and trust, and supported by a team of clinical and supply chain experts, Amerinet enriches healthcare delivery for its members and the communities they serve. To learn more about the Amerinet difference, visit Amerinet Inc., 2060 Craigshire Road. St. Louis, MO 63146, GC

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