The New Vision of Health Care Revenue Transformation

Transcription

1 The New Vision of Health Care Revenue Transformation Chuck Lund Mid Atlantic Health Services Financial & Employee Transformation Solution Leader (571)

2 How would you rate your own revenue cycle? Some of the world s most skilled, most caring and most efficient healthcare providers are at best mediocre managers of their own revenue cycle. The only constant, in fact, is that the average hospital sacrifices between one and three percent of its revenues to poor revenuecycle management. Health systems generally build such losses into their operatingcost models. Instead of working to minimize revenue-based losses, they opted to forecast them. However, competition is up, profits are down, slack payeroversight is out and hyper-vigilant cost-management is in.

3 How would you rate your own revenue cycle? Most at-risk are health systems with: relatively high managed care revenue component, yet minimal patient access, payment compliance or denial management provisions in place. The decentralized structure of most providers is not conducive to improving revenue cycle management or increasing its related accountabilities. Revenue cycle functions are scattered (no mega-process view exists), Clinical leadership is not in tune with the roles and responsibilities associated with revenue cycle management.

4 Clearly, the revenue cycle isn t a department; its collaboration of interdisciplinary processes and systems Front End Middle Back End Portfolio Maximization Patient Access Redesign Denial Management Charge Capture And Pricing Clinical Integration Documentation and Coding Billing Process Redesign Cash Collections and Reimbursement Service Line Growth Capacity Management Referral Management Scheduling Pre-registration Insurance Verification and Eligibility Point-of-Service Collections Registration Points Call Center Technology and Outsourcing Prior Balance Adjudication Case Management Physician Alignment Denials and Appeals Tracking Appeals Process Contract Management Services Referrals and Authorizations Electronic Charge Capture/ Reconciliation Market-based Pricing / Fee Screen Review Operational Pricing Strategic Pricing Standardization of Charge Description Master Managed Care Pricing and Contracting Medical Management Infrastructure Service Line Redesign Physician Alignment Bed Management Resource Management DNFB* Reduction CDMP** Outpatient Documentation APC Process Improvement HIPAA Medical Records Redesign Late Charge Analysis EDI Editing and Billing DNFB Reduction* Electronic Billing Validation Cash Acceleration Denial Management Self-Pay Collections Third Party Follow-Up Software Medicare Bad Debt Recovery Electronic Remittance Payment Posting Agency Management Cost Report Analysis Rate Modeling Underpayment/ Zero Payment Reviews Disproportionate Share Review Contract Management Services Medicare Account Reconciliation Technology Enablement Organizational Alignment Change Management

5 The New Vision of Health Care Revenue Transformation Culture & Values Organization Needs & Requirements People Process Technology Infrastructure Competencies & Skills

6 provides the necessary infrastructure to support sustained results. Front End Middle Back End Standardized and Integrated Processes Leveraged Technology Knowledge Sharing System-wide Performance Monitoring Economies of Scale Change Management Deploys standardized, leading practice operating models Leverages legacy systems and existing infrastructure Defines performance expectations and productivity metrics Utilizes exception reporting for performance management and timely issue resolution Creates management and executive level performance monitoring tools and tracking reports Integrates responsibility for achievement of financial results across the enterprise Instills accountability through ongoing corporate-wide performance tracking and reporting Aligns specialized revenue cycle resources to ensure knowledge transfer, implementation and change management Focuses on increasing cash and net revenue 10% - 15% Increase in Cash Flow Enhanced morale Sustainable Results 1% - 3% Increase in Net Revenue Improved Margins

7 Where incremental dollars generally come from Typical Composite P&L Opportunity 1% to to 3% of of Net Revenue Denial Avoidance & Management (60%) Patient Payment Strategy (20%) 3 rd rd Party Payment Compliance (10%) Vendor Contract Coordination (5%) Revenue Mgmt Initiatives (5%) Enhanced authorization & certification Concurrent utilization review Complete and timely service documentation Improved registration data quality Point of service (POS) collection programs Enhanced patient payment alternatives Accelerate patient notification and follow-up process Alternative resourcing strategies Automated contract management tool Simplified contract terms Specialized collection follow-up resources for payment variances Technology enabled tools to assist registrars in correct identification/compliance of insurance plan. Broad based evaluation of contract terms associated with third party services Enhanced management and performance evaluation Coordinated RFP process to assure optimum pricing and service levels Charge definition and capture Documentation and coding improvements Cost report improvements

8 Revenue-optimization barriers are often woven into the complex fabric of staff and job functions Lack of requisite skills, and insufficient remedial training; A percent annual staff-turnover rate; Business applications that are outdated, inaccessible, non-existent or incompatible; Inappropriate compensation structure; Ineffective organization structures.

9 Revenue transformation organizational models: provide for interdisciplinary revenue cycle management. Component Executive Executive Steering Steering Committee Committee Primary Responsibility Establishes Establishes priorities, priorities, approves approves action action plans plans and and performance performance measures, measures, approves approves resources, resources, monitors monitors progress, progress, reports reports plans plans and and progress progress Investment Weekly Weekly meeting-30 meeting-30 Days Days Regular Regular meetings meetings throughout throughout Outside Outside assignments assignments Revenue Revenue Cycle Cycle Work Work Group Group Propose Propose priorities, priorities, prepare prepare and and implement implement work work plans, plans, define define and and prepare prepare deliverables, deliverables, manage manage resources, resources, facilitate facilitate implementation implementation and and monitor monitor and and report report on on progress progress Full Full time time facilitator, facilitator, project project leaders leaders and and staff staff On-going On-going time time commitment commitment from from revenue revenue cycle cycle managers managers Resource teams: Resource teams: Collections Collections Registration Registration IS IS HIM HIM CRM CRM Assembled Assembled to to man man specific specific initiatives initiatives requiring requiring significant significant resources resources over over substantial substantial blocks blocks of of time time Need for incremental investment in Need for incremental investment in people, space, equipment and/or people, space, equipment and/or external external resources resources likely likely for for specific specific initiatives. Immediate action on initiatives. Immediate action on Backlogs. Backlogs. Page 9

10 Integrated Revenue Transformation Technology Implement Bolt-on Technology Optimize Core and Bolt-on Systems Patient Access Revenue Cycle Strategies Organization Alignment and Change Management Denial Mgmt Work Flow Technologies Charge Capture Clinical Integration Document & Coding Billing Process Cash Collection Payor Provider Consumer Bolt-On Applications Current & Future Core Applications Scheduling Patient Mgmt Clinical Mgmt Patient Acct Accts Receivable Revenue Cycle Technology Infrastructure Patient Mgmt System Integration Repositories Clinical Systems Patient Financial Executive & Management Decision Support Contract Mgt Exec Info System Enterprise Reporting Trend Analyses Financial Reports Productivity Reports econnectivity to External Communities Tech. Suppliers Financial Institution Collection Agency

11 Integrated revenue transformation utilizes tools to establish accountability, and sustain the improvements Dashboard Reports Senior Management Weekly/Monthly Trends Performance Measurement Reports Education & Training Management and Staff Ongoing Department Managers Daily/Weekly Continuous Improvement Process Work Queue Reports Staff Daily

12 Integrated Patient Access Model Defined guidelines and workflow tools for consistency in data capture, financial screening, admission and discharge planning Access to accurate payor requirements and criteria Pre-service activities performed simultaneously to include preregistration, insurance verification and patient financial education On-line/real time referrals, insurance verification, preauthorization, address checking and credit scoring Knowledgeable staff regarding medical necessity, level of care and ABN requirements Delay/deny policy for non-covered, non-emergent cases

13 Integrated Patient Access Model Self pay portions identified and collected prior to or at time of service Patient history reviewed for financial counseling needs Standardized performance measures are in place for each level and function Quality assurance monitoring program Workflow integration, on-going communication and collaboration between Patient Access and Clinical Care Management Reduced patient wait times and interaction with registration personnel

14 Patient Access Management Reports Patient Access Reporting Tool Worklists Access Resource Productivity Point of Service Collections Quality Assurance Monitoring Key Performance Indicator Scorecard Key Performance Metrics Target Pre-Admission of Scheduled of Non-Emergent, Scheduled Cases > 95% Insurance Verified Prior to or Within 24 Hours of Admit/Service 100% Maximum Registration Error Rate < 2% Patient Financial Education to Required Cases 95% Collections at Time of Service > 80% Patient Waiting Time (Under 10 Minutes) 90% Customer Service Survey Rating of Good to Excellent > 80%

15 Integrated Service Documentation Model Timely and accurate documentation of procedures and diagnosis in patient medical record Updated Charge Description Master (CDM) for additions and changes to HCPCS, CPT and Revenue codes Records of discharged/departed patients are available to Health Information Management (HIM) within 24 hours A first in, first out workload distribution is in place supplemented by prioritizing high dollar accounts during backlog periods

16 Integrated Service Documentation Model Clinical reports are electronically available to coders 95% of coder s productive time is spent on coding and abstracting; analysis and chart completion are performed by noncoders Reconciliation efforts are completed daily with an escalation process for missing records Documentation issues are trended and addressed concurrently Transcription turnaround time complements timely coding Standardized performance measures are in place for each level and function within HIM

17 Service Documentation Management Reports Daily Discharged Patients Unbilled Detailed Worklists by Patient Type Unbilled Inventory (by Age Category & Patient Type) Coder Productivity Unbilled Inventory Past Bill Hold Incomplete Records Release of Information/Records Requests Key Performance Metrics Target Gross Days Revenue in Discharged, Not Final Billed Accounts 4 Percent of Records Received within 24 Hours of Discharge 100% Average Days from Discharge to Coding 2-5 Inpatient Cases Coded per Day Outpatient Surgery Cases Coded per Day Emergency Room Cases Coded per Day 125 Average Turnaround Days for Release of Information 3-5

18 Integrated Third Party Payor Billing Model Maximum utilization of payor specific edits and correct coding edits Claim edit bill holds cleared within one day Properly identified covered and non-covered charges Corrective action and resolution of identified billing errors Standardized, automated initial, secondary and tertiary billing processes Standard and timely process for obtaining attachments required by payors

19 Integrated Third Party Payor Billing Model Documentation on payor contracts terms and conditions, and payor regulations is consistently updated and available for staff use Contract management software utilized to net A/R down to contracted amounts Accountability for key performance metrics Ongoing training and education to staff on billing regulations Communication of data collection, charge capture and medical records issues

20 3 rd Party Payor Billing Management Reports Discharged, Not Final Billed Accounts Bill Editor Claims Hold Claims Errors Summaries (by Payor and Error Code) Electronic Billing Transmission Outstanding Billing Attachment Requests Biller Productivity Key Performance M etrics Target Bill H old/suspense D ays 4 D ays From D ischarge to C laim s Filed D ate - Inpatient < 5 D ays From D ischarge to C laim s Filed D ate - O utpatient 3-5 C laim s H eld in Editor > 1 D ay 0 Paper Claims Processed Per Day Electronic Claims Processed Per Day Billing Error R ate < 2%

21 Integrated Follow-up/Collections Model Full utilization of automated collector workfiles, based on payor specific follow-up criteria and timeframes On-line/real time insurance follow-up statusing Documentation of all insurance and responsible party interaction in the system in standardized note formats Tracking of documentation / medical record requests Daily monitoring of cash collections Electronic payment and remittance posting Continuous monitoring of payments received against payor contract terms

22 Integrated Follow-up/Collections Model Ready access to all EOB, remittance and patient payment documentation Timely compliance with credit balance resolution and reporting Timely response to telephone and correspondence inquiries Integrated denial recovery activities Monitoring write-offs and maintaining appropriate authorization levels for write-offs Established policies and procedures for assigning, canceling and returning agency placed accounts Auditing of outsource and bad debt collection vendor activities Accountability for key performance metrics

23 Follow-up/Collection Management Reports Collections Follow-up Worklists (Staff and Mgmt) Collector Productivity Document Requests Listing Aged Trial Balance (Detail and Summary) Cumulative Cash Collections Key Performance Indicator Scorecard Executive Level Dashboards K ey Perform ance M etrics T arget N et D ays R evenue in A ccounts R eceivable < 55 Percent of A ccounts A ged > 90 D ays Past D ischarge < 20% Bad D ebt as Percent of G ross R evenue < 2% M anual C ontacts per D ay A utom ated C ontacts per D ay N et C o llectio n P ercen tag e 100% C redit Balance Percentage of G ross R eceivables < 2% C ollection A gency R ecoveries vs. W rite-offs 18% - 20% Sm all Balance O utsourcing 60% - 75% Early O ut O utsourcing > 25%

24 Integrated Denial Management Model Defined roles, responsibilities and organizational structure for denial management Consistent process for registration results Integrated technology between clinical and revenue cycle process areas Referral management, insurance verification, pre-certification and authorization protocols Access to accurate payor requirements and criteria Knowledgeable staff regarding medical necessity Accurate diagnosis and procedure coding Standardized denial classifications and definitions

25 Integrated Denial Management Model Accurate and up-to-date denial tracking and reporting Concurrent management of inpatient denials Policies and procedures for concurrent and retrospective denial processing Active physician advisor Standard protocols for appeals processing Payor specific initiatives for high volume payors Consistent monitoring of write-offs and revenue loss due to avoidable denials Accountability for key performance metrics

26 Integrated Denial Management Management Reports Denial Tracking Database Denial Management Worklists Denial Management Resource Productivity Summary Denial Activity by Major Payor Summary Denial Activity by Reason Code Denial Overturn Rate Adjustment Transaction Report Key Performance Metrics Target Denial Write-Offs as Percent of Net Revenue < 1% Denied Claims as Percent of Claims Billed 2% - 5% Denials - Access Related 6% - 10% Percent of Denials Reversed > 90%

27 Integration factors for other key revenue cycle components Charge Description Master (CDM) Charge line items in CDM for all services/procedures performed Accurate HCPCS, CPT-4, Revenue codes and OPPS applicable revisions Consistent and ongoing maintenance (simplified CDM, reduced duplication, deletion of outdated codes) Enhanced net revenue through optimization of procedure pricing Charge Capture Formal charge reconciliation process implemented with appropriate departmental monitoring and reporting Charges are entered into billing system within 24 hours of service Formal late charge policy including departmental compliance monitoring and reporting Clinical Documentation DRG assignments and case mix index that accurately reflect patient severity Appropriate hospital and physician profiling and performance outcomes data Reduced regulatory exposure due to complete and consistent documentation and coding practices Defined, measured and reported system financial measures, case mix, clinical quality outcome measures, and patient and provider satisfaction with care

28 Integration factors for other key revenue cycle components Medical Records Coding All inpatient and outpatient services/procedures are accurately coded for billing Accurate data related to the Outpatient Prospective Payment System (OPPS) Managed Care Contracting Defined and structured underpayment recovery program Competitive, market-based payor contracts Cost Report Focused reviews to confirm accuracy of Medicare payment rates and cost reimbursement areas of the report Proper matching of Medicare cost and charges with total costs and charges Appropriate cost report filing methodologies applied

29 The path from here to there Tighter accountability Create systems using a revenue cycle operating model (RCOM). Put a senior executive in charge of delivering results, e.g., a chief revenue cycle officer. Implement performance-based management information tools. Insist on board-level sponsorship. Reduced variability Implement common infrastructure and management. Automate consistent work flow and approvals. Monitor registration quality address variances that result in technical denials. Proactively challenge payment denials. Utilize bolt-on applications to leverage technology enablers. Monitor and measure progress associated with back-end operations.

30 The path from here to there Better information management Aggressively maintain charge data master, master patient index, contract master and insurance master files across the IDN. Assure adequate and complete documentation to support reimbursement. Leverage knowledge, insight and clinical results when scheduling, authorizing and certifying procedures. More comprehensive (end-to-end) integration Assume primary accountability for the revenue cycle. Launch and manage an ongoing revenue optimization analysis program. Concentrate on strategic functions and optimize entire schedule-topayment Cycle. Maintain and enforce common policies and controls across the IDN. Implement Web-enabled technology and automate workflow and approvals. Leverage partner relationships and align incentives.