THE JOYS OF REVENUE CYCLE MANAGEMENT & MEDICAL BILLING

Transcription

1 THE JOYS OF REVENUE CYCLE MANAGEMENT & MEDICAL BILLING 1

2 A RAPIDLY CHANGING ENVIRONMENT RAC Audits Insurance Overpayments (take backs) PPACA ICD-10 PQRS, MU Penalties LIMITED TOOLS, LIMITED PERFORMANCE Canned reports provide no business intelligence PM treats medical AR no differently than conventional AR Limited oversight on write-offs No industry standards for label engineering NEW RESOURCES REQUIRED Data Engineers/Architects RCM Business Analysts Management of Pay for Performance: ACO, CIN, PHO CPMA S Medical CPA s 2

3 PRACTICE LEAK DEFINED The MGMA asserts that 3% of all revenue loss is unavoidable due to patient debt, pre-authorization/certification issues and eligibility mishaps. BLACK HOLE CLAIMS TM... claims inappropriately written or adjusted off, an unworked denial, or an active claim not addressed for four weeks or more. AGING PATIENT RESPONSIBILITY CLEAN CLAIM CLEAN CLAIM CLEAN CLAIM TIMELY FILING LOSS How close is your collections ratio to the industry standard, optimal benchmark? 3

4 WHAT THE EXPERTS ARE SAYING 4

5 DATA DRIVEN DECISIONS Medical practices are swimming in data. Data flows into medical practices daily from practice management (PM) systems, electronic medical record (EMR) systems, accounting systems and many other sources. Too many practices extract only the bare minimum of data required to file claims and meet reporting obligations, without recognizing the value in the flood of data that passes through the practice. Better Data Better Decisions : Using Business Intelligence in a Medical Practice by Moore, Nate and Reimers, Mona 5

6 BUSINESS INTELLIGENCE DEFINED Business intelligence (BI) is the set of techniques utilized for the transformation of raw data into meaningful and useful information for business analysis purposes. BI technologies are capable of handling large amounts of unstructured data to help identify, develop and otherwise create new strategic business opportunities. The goal of BI is to allow for the easy interpretation of these large volumes of data. Identifying new opportunities and implementing an effective strategy based on insights can provide businesses with a competitive market advantage and long-term stability. Quality data leads to insight, insight leads to decisions. DATA.DRIVEN.DECISIONS. 6

7 POOR DATA QUALITY The amount indicated is associated with an exception report for eclinicalworks. It demonstrates a perfect example of the impact of poor quality data. This number should be close to zero, and its important to note that we did not add color for effect. 7

8 PRACTICE LEAK MEASURES Custom Measures AR is the commonly accepted standard measure for RCM health, however it is a woefully inadequate metric of performance and practice health. Static 120+ Active Claim, Adjudicated (CO45), balance remains 120 days since Date of Service Timely Filing_Check Not Adjudicated, Active Claim >90 days since Date of Service. May or may not have been filed, no CO45 Under Pay Inactive claim (zero balance) Payment < threshold % of Medicare Allowable Zero Pay Inactive Claim Charge equals adjustment MEASURES SUMMARY Type Count Calculated Value Estimated Loss Static ,808 $159,370 Timely Filing Check ,864 $8,653 ZeroPay ,947 $22,628 UnderPay ,295 n/a * UnderPay ,650 n/a * * MGMA estimate 2% loss on allowed amount Jan 1-Dec31, 2014 UnderPay based on allowable amount, most orgs do not have up to date fee schedules in system. 8

9 WORKCASE EXAMPLES 9

10 WORKCASE EXAMPLE: eclinicalworks Negative balance 10

11 WORKCASE EXAMPLE: Timely Filing Check, Subsequent Systematic Follow Up 11

12 Zero Pay: UnderPay, Adjustment Labels The description of this adjustment transaction is adjustment. Lacks specificity and therefore makes the true root cause impossible to track. Practice was paid $.13 on an $80.00 charge. 12

13 EMR Systems Experience 13

14 Insurance Contract Management Most medical practices today do not have the time or the expertise to identify and initiate the needed changes to their practice in order to capitalize on these opportunities. A great place to start, though, is in the area of Insurance Contract Management 14

15 Gerald P. Giglia, CPA: Biography Practicing Accountant for 31 years as a partner in a large regional CPA firm Managing Partner of a 75 year old CPA firm Consulting with medical practices for over 20 years Has been a Member of the following groups: Medical Group Management Association (MGMA) Healthcare Financial Management Association (HFMA) Health Care Advisors Association (HCAA) Founding Board Member of a children s hospital Currently serves on a number of local non-profit boards 15

16 Insurance Contract Management 9 Steps to Improve Insurance Contract Management 1 2 Review and understand your contracts and the different products within the contracts. Assure payments agree to the contracts. 3 Allocate overhead to all CPT codes / procedures. 4 Profit centers by codes and insurance products. 5 Collect performance data on each insurance company and products. 6 Develop quality care measurements and cost control measurements. 7 Understand each insurance's renewal policies and procedures. 8 Develop a negotiating strategy by insurance. 9 Develop a relationship with your contract representative. 16

17 Insurance Contract Management: Total RVU s 17

18 Insurance Contract Management: Cost & Collections, per RVU 18

19 Insurance Contract Management: Cost Per Procedure As compared to Practice Fee Schedule # CPT Proc Short Name Units Charges 2011 RVU Cost Per RVU Cost Per Procedure Practice Fee Schedule MRI, LOWER EXTR , , OFFICE/OUTPATIE , OFFICE/OUTPATIE , MRI, UPPER EXTR , , ARTHRP KNE COND , , , OFFICE/OUTPATIE , ARTHRS KNE SURG , , ARTHRS KNE SYNV , , SHOULDER SCOPE, , , ARTHRS KNE SURG , , OFFICE/OUTPATIE , ARTHROCNTS ASPI , SHOULDER SCOPE, , , , ARTHRP ACETBLR/ , , , TX INTER/PR/SUB , , , RADIO EXAM, KNE , INITIAL HOSPITA , ARTHRS KNE SYNV , , ARTHRS SHO SURG , , OPTX FEM FX PRO , , , ARTHRP KNE COND , , , SHOULDER SCOPE, , , G0289 CHONDROPLASTY , RMVL IMPLT DP , , NEURP&/TRPOS ME 87 93, ,

20 Insurance Contract Management: Profitability By Procedure PPO # CPT Proc Short Name Units Cost Per Procedure Total Cost Proposed PPO Total PPO Fee Profit (Loss) MRI, LOWER EXTR , , (9,596.40) OFFICE/OUTPATIE , , , OFFICE/OUTPATIE , , , MRI, UPPER EXTR , , (4,187.05) ARTHRP KNE COND 14 1, , , , , OFFICE/OUTPATIE , , , ARTHRS KNE SURG , , , ARTHRS KNE SYNV , , , SHOULDER SCOPE, , , , ARTHRS KNE SURG , , , OFFICE/OUTPATIE , , ARTHROCNTS ASPI , , SHOULDER SCOPE, 13 1, , , , , ARTHRP ACETBLR/ 4 1, , , , TX INTER/PR/SUB 5 1, , , , RADIO EXAM, KNE , , (1,318.68) INITIAL HOSPITA , , ARTHRS KNE SYNV , , , ARTHRS SHO SURG , , OPTX FEM FX PRO 1 1, , , , ARTHRP KNE COND 6 1, , , , SHOULDER SCOPE, , , G0289 CHONDROPLASTY , , RMVL IMPLT DP , , NEURP&/TRPOS ME , ,

21 Insurance Contract Management: Insurance Performance Metrics Volume (Charges) Gross Collection % Net Collection % Contract to Medicare A/R Ratio A/R Age Total Points Average Points Overall Ranking Overall United (tie) Medicare BCBS Tricare Humana (tie) Aetna Cigna

22 BEST PRACTICES WHY THEY MATTER REVENUE LOSS POOR OR INCORRECT BILLING AND CODING PROCESSES RESULT DIRECTLY IN REVENUE LOSS, TO THE TUNE OF 15-25% OF ALL PRACTICE INCOME. THAT S $150,000-$250,000 OF EVERY 1 MILLION DOLLARS GENERATED BY A PRACTICE. THINK IN TERMS OF HOW THOSE RESOURCES COULD BE APPLIED ACROSS THE ENTIRE PRACTICE AND THE IMPACT IS CLEAR COMPLIANCE IF YOU ARE NOT COMPLYING WITH ACCEPTED BUNDLING AND CODING STANDARDS, YOUR PRACTICE IS AT RISK IF AUDITED. ON THAT NOTE, FLORIDA HAS INTRODUCED ITS OWN STATEWIDE COMPLIANCE DIVISION, INCREASING THE FREQUENCY AND LIKELIHOOD OF INDIVIDUAL PRACTICES BEING AUDITED PATIENT CARE HOW YOUR PRACTICE BILLS & CODES DIRECTLY IMPACTS THE LEVEL, ACCURACY AND QUALITY OF CARE THAT YOUR PATIENTS RECEIVE. PATIENTS ARE THE SINGLE MOST IMPORTANT ELEMENT OF ANY PRACTICE, AND ANYTHING THAT GETS IN THE WAY OF HOW THEY ARE CARED FOR JEOPARDIZES THE ENTIRE PRACTICE PATIENT SATISFACTION WHEN YOU DON T BILL PROPERLY YOUR PATIENTS KNOW IT. WHEN THEIR TIME AND ENERGY AND FRUSTRATION IS INVESTED IN CORRECTING BILLING ERRORS MADE BY YOUR PRACTICE THEY ARE LESS LIKELY TO RETURN FOR CARE STAFFING THE PROCESS OF BILLING AND CODING IS COMPLEX, AND IF NOT MANAGED WELL THE IMPACT ON STAFF MORALE, TURNOVER, AND OVERALL EFFICIENCY IS IMMEASURABLE. MISTAKES NEED TO BE CORRECTED, AND CORRECTING MISTAKES TAKES TIME, TIME THAT COULD LIKELY BE BETTER SPENT CONCENTRATING ON PATIENT CARE AND SATISFACTION 22

23 THE SOLUTION Finding problems is one thing, solving them is quite another. Upon completion of the Proof Module Analysis, you ll want to move forward with the solution itself, MedCo Data s Revenue Shield System. It s a phased approach, designed for a straightforward purpose; the optimization of revenue capture and the realization of increased cash flow. REHABILITATION A deep dive into your current processes designed to uncover and then resolve upstream issues CORE ESSENTIALS Process creation and implementation, staff training & optimization followed by structured follow-up. MAINTENANCE Peace of mind through the Expert monitoring of your Billing universe. Secures the Ongoing preservation and Growth of your revenue. REHABILITATION ROOT ANALYSIS RAPID FIX TARGET CAPACITY CORE ESSENTIALS FUNDAMENTAL TRAINING FOUNDATION CHECK MAINTENANCE DATA.DRIVEN.DECISIONS. SENTINEL SIGN CPS TRACKER CLAIM VELOCITY SECURITY COMPLIANCE MEANINGFUL VISUALS 23

24 About MedCo Data Services Include MedCo Data is the single source provider for all healthcare and practice-based technology. Taking a consultative approach, we fashion customized solutions that drive efficiencies and lower operational costs. Our core philosophy is simple, and it centers on the notion that doctors and medical professionals should have the comfort of knowing that they can concentrate on patient care first and always. MedCo Data has the expertise, insight and experience to make your practice more efficient and profitable. Revenue Cycle Management Services -Revenue Shield System -ICD-10 Consulting Proactive Technology Management Services -Single Point Technology Management Network Infrastructure Services -Network Assessments & Security -Desktop/Laptop/Tablet provisioning -Server provisioning and Hosting -Application Development EHR/EMR Consulting Services -EMR Implementation Training -Meaningful Use Consulting -EMR Consulting -Workflow Centric Suite Website Services -Digital Marketing Strategies -Search Engine Optimization -Online Reputation Management -Social Media Management -Website Hosting -Website Design 24