Top Five Best Practices for Optimal Revenue Cycle Management

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1 WHITE PAPER: Top Five Best Practices for Optimal Revenue Cycle Management 1 I Top Five Best Practices for Optimal Revenue Cycle Management

2 Did you know? The right revenue cycle partner can help your practice capture 15% more revenue. Most medical practices today are barely getting by financially. Declining reimbursement from government and private payors, along with increasing operating expenses associated with new mandates such as Meaningful Use and ICD-10, are causing many practices to lose profitability and sometimes see their own salaries decrease as well. Collecting every last dollar earned is critical to their future survival and success. The days of ineffective billing practices are long gone. Simply put: Every dollar counts. Yet, according to statistics from the Medical Group Management Association (MGMA), most practices leave up to 30% of their potential revenue on the table every year. 1 That 30% can be the difference between staying open and independent, or having to shut down your practice. The causes of billing inefficiencies are well known. Yet, due to resource constraints, ineffective business processes, a lack of sophisticated automation, or lack of effectively trained staff, most practices can t seem to overcome these hurdles. In order to survive and thrive, however, you must overcome these hurdles and begin closing the gap between revenue earned and revenue collected. This whitepaper details the top five best practices you can utilize to ensure that your practice collects every dollar earned and will help you to optimize every area of revenue cycle management for your practice. 1. Keep Your Schedule Full and Productive The increasingly powerful force wave of consumerism in healthcare is requiring providers to rethink their business models and develop a different type of relationship with patients and members - the ultimate consumers of their services. Historically, the purchasing and financial decisions in healthcare were made at the wholesale level, with arrangements between the payors, providers, and the employer. Unlike any other consumer market in the United States, where the power of the consumer is visible, the consumer in healthcare was glaringly absent. Today, that trend is shifting: the clout of the consumer in healthcare is 1 5 tips to improve your medical practice s billing and collections, MGMA In Practice Blog, Oct 2010, 2 I Top Five Best Practices for Optimal Revenue Cycle Management

3 growing, as patients become more involved in their healthcare decisions. The following healthcare changes are driving this new consumer-driven model: Know who s doing the work Is the RCM partner you are working with outsourcing some or all of the collections process? Having one partner that is doing all the work ensures a consistent and predictable outcome. High Deductible Health Plans (HDHP). Individuals face increased deductibles for their healthcare consumption and now have skin in the game. Plans today have an average deductible of $1,000. This is encouraging many individuals to begin demanding improved price visibility and quality metrics to help assist in the decision-making process of where and when to seek services. With consumers shouldering more of the financial burden, services such as decision support, advocacy, and other ancillary services have become a market standard. Insurance Exchanges. With the exponential increase in healthcare costs, employers are beginning to opt into insurance exchange markets to get out of the business of plan design - and increasingly out of the business of paying. Payors must shift their focus away from strictly selling services to the employer to a strategy that reaches and meets consumer demands. New Reimbursement Models. Whether it be the Readmission Reduction Program, Bundled Payments, Value-Based Purchasing, or the ACO model, providers are not only being held responsible for the quality of care they are providing, but must also bear more of the financial risk of consumer decisionmaking. These forces mean that today more than ever, your practice needs to make it easy and intuitive for patients to understand the value of your services, to schedule appointments easily and efficiently, and to ensure that scheduled appointments are kept. The efficiencies in scheduling create a full, productive schedule that benefits both your practice and your patients. Setting the Appointment: Your First Opportunity to Make a Good Impression There are few industries today that make it so difficult and inconvenient for their customers to access them as some medical practices. Traditionally patients call the practice during business hours to try and schedule an appointment. However, they may face many frustrating obstacles to this simple task: If they call during business hours, they may be put on hold (maybe multiple times); if they call during lunch hours they might reach a recording. Once they get through and actually schedule an appointment, it can be a trial and error process that may take 5-10 minutes to find a day and time that works. Patients hate it. The staff hates it. It is process that should have been changed long ago. 3 I Top Five Best Practices for Optimal Revenue Cycle Management

4 Helpful Hint Not all cloud services are automatically HIPAA compliant. If you are using a cloud provider, request a copy of their HIPAA compliance program documents, and also request that they sign a Business Associate Agreement. If they cannot produce them, or they are reluctant to execute a BAA, you have a major problem. Leveraging today s technology, patients can access tools online to schedule an appointment when it is convenient for them. Patients will appreciate the convenience, and staff will appreciate the reduction in inefficient phone scheduling. Online 24/7 scheduling allows patients to set appointments when and where it is most convenient for the them. Online scheduling also allows your practice to easily capture key communication information through the process, such as patient and phone contacts. In addition, you can engage your patients at a more meaningful level by using patient contact information for important follow-up information such as vaccinations, practice updates, and more. Finally, online scheduling drives patients to your website, where they can find additional, in-depth information on practitioner expertise, services provided, directions and other valuable resources. Making Sure the Appointments Happen Once patients have scheduled an appointment, getting them to keep the appointment is the next step. According to MGMA statistics, there is a 5-7% no-show rate for the average practice. Time is money for physicians. A missed appointment is a lost revenue opportunity. With online scheduling, your practice can leverage powerful interactive tools to ensure that patients keep their appointments. When the patient schedules an appointment online, they can simply click on a link to update their personal calendars with the appointment information. In addition, practices can establish automated and interactive reminder messages through automated phone calls, s, and text messages. These automated reminders cut down on missed appointments and benefit both patients and the providers. 2. Collect the Patient s Responsibility of the Service Patient responsibility is increasing year after year it is now at nearly 25% of the value of the total bill. 2 Practices need to develop a core competency in collecting the patient portion. The insurance payment alone is unlikely to cover the full cost of the service provided. The patient portion is often the source of profit in a visit, yet practices generally only collect on 50% of what they are owed from patients. 3 2 New AMA Study: Patients Responsible for Nearly One-Quarter of the Medical Bill, June 2013, 3 The next wave of change for US health care payments, McKinsey Quarterly, May I Top Five Best Practices for Optimal Revenue Cycle Management

5 Understanding patient responsibility and having the skills to collect co-pays, co-insurance and deductibles during the visit are critical given the challenges of collecting after the fact. In order to do this, however, the practice needs to have the information on patient responsibility and past due balances close at hand. Automate Patient Eligibility More than 25% of payor denials occur because patients are not eligible for benefits. 4 An insurance card is not an ID card; it functions like a credit card proof of an ability to pay for the service to be provided. No other business says to a customer, Oh, we have your card on file and we will just assume it to still be good. Not likely. Every time you buy something with your credit card, you have to produce the card to prove that it is still in good standing. Your practice should be no different. Seeing a patient without confirming his/her insurance information is taking a huge risk on never receiving payment. Patient s coverage can change from visit to visit. Ensuring active coverage is essential in preventing eligibility and coordination of benefit denials and identifying accurate co-pay and deductible amounts. The problem is that checking eligibility either through the web or online is cumbersome and time consuming. It can also be expensive if your practice is paying for each transaction through a traditional practice management system or clearinghouse. Implementing a modern revenue cycle system will enable your practice to automate this process - ensuring patient eligibility and enabling early collection of patient responsibility. You can enable automated 270/271 responses, access real-time verification, and create flags and alerts to identify demographic capture errors in scheduling process. Automated identification of patient responsibilities will vary from payor to payor but will likely communicate innetwork co-pay, out of network responsibility, and deductible used to date. This information is critical in estimating costs for services, as well as the outstanding balance for your patients. Patients need to understand their payment responsibility upfront before the service is provided. By leveraging software tools to verify a patient s insurance coverage upfront, communicate the estimated cost for services, inform the patient of their obligation, and help them understand the terms and timing of their payment, you can eliminate payment confusion and improve patient payment outcomes. 4 AMA, Follow That Claim, 5 I Top Five Best Practices for Optimal Revenue Cycle Management

6 Institute Patient Friendly Statements In today s healthcare market, there is a fine line between sufficiently informing patients of their responsibilities regarding balances not collected at time of service and overwhelming them. Enhancing your billing statement s functionality, design, and delivery method will increase the speed in your patient receipts. Patient friendly statements are clear, with legible fonts that highlight pertinent sections of the statement, such as account information, guarantor, amount due, due date and remittance address. In addition, your statement should be concise and correct in terms of services rendered and balance due. Finally, your practice should provide the ability for online as well as offline payment. Online Bill Payment Make it Easy for Patients to Pay Think of your experience today as a consumer. How do you pay your bills? The majority of consumers today are strongly encouraged to pay their bills electronically and most do so willingly. It is more convenient for the patient and much more cost effective for the practice, since paper checks and trips to the bank are reduced. Making it easy for patients to pay is vital in creating a patient positive experience and collecting the ever-growing amount owed by patients. Setting up an online payment portal will also enable automated withdrawals and payment plans. It s fast, easier for patients, reduces payment procrastination, eliminates manual processing of deposits, and eliminates late fees and overdrafts. In summary, by automating the entire billing process from eligibility to patient payment, your practice can significantly increase timely, accurate collection on the patient portion owed for your services, while at the same time reducing any confusion for the patient in terms of their responsibility. 3. Eliminate Denials Historically, practices have focused on billing claims and kept their fingers crossed. This leads to delay in payments, increased bad debt, and additional expense. Practices today need to find an efficient way to manage denial volume and successfully appeal claims for adjudication. Top focus should be on denial prevention. The best way to do this is by utilizing an automated claims/scrubber rules engine at the time of charge entry. Two primary reasons a claim doesn t result in a payment are as follows: Either the claim is not received by the payor, or the payor denies payment due to a 6 I Top Five Best Practices for Optimal Revenue Cycle Management

7 Did you know? According to the MGMA, 65% of denials are never appealed. A true RCM partner will help you adjudicate denials - regardless of the dollar amount. defect in the claim, whether incomplete or incorrect demographic data, or lack of documentation supporting the services billed. When a claim is denied, it is often far too costly and time consuming for a practice to do the necessary follow up and appeals to ultimately secure payment. In fact, 65% of denials are never even appealed. 5 The work has been done and a service provided but an administrative error dooms the provider to non-payment. A medical claim is simply data I saw this patient (patient demographics), on this day (DOS encounter data), they have this problem (coding), I did this for them (coding) and they have this insurance (insurance data). Get those five pieces of data right and you will get paid; get any of them wrong or miss any data elements and getting paid is a long, hard trek. Sounds simple, right? It is conceptually. But actually getting all the data elements complete and accurate in a busy practice environment in an area with the potential for frequent staff turnover can be a challenge. Add to that the constantly changing requirements of your payor mix, state requirements, and changing reimbursement methods, and the process gets far more complicated. This is where a good claims editing system comes in, as a tool or set of tools that can be deployed to ensure process rigor and data integrity. Here are some common data errors that can result in a denied claim and loss of payment: Assignment: Accept assignment box checked inappropriately Authorization: Claim form did not list the mandatory authorization number or referral form is missing Invalid CPT code Contract number: Subscriber s contract number missing or invalid Dates: Missing or incorrect dates, such as admission and discharge dates, duplicate dates of service for same procedure code, or dates of first symptom Diagnosis: Diagnosis code missing or invalid Group number: Missing group number on claim form ID number: Physician s national provider identification (NPI) number missing on claim form Insurance information: Subscriber s name, gender, Social Security number, group, and/or plan number missing or invalid Modifiers: Missing modifiers on procedure that requires one Patient information: Patient s gender missing or invalid, patient s address invalid, birth date missing Place: Place of service incorrect or inconsistent with service provided 5 Insurance denials: Is your practice to blame? MGMA In Practice Blog, Dec 2011, 7 I Top Five Best Practices for Optimal Revenue Cycle Management

8 Provider: Provider (physician) information missing or incorrect (for example, NPI) Referral: Referring physician s name and/or NPI missing on claim form Service type: Type of service listed incorrectly on claim form Partner for Success The right RCM partner wil help you streamline workflow, decrease denials, and increase revenue. Asking the right questions will be the key to finding your ideal match. Smart claims editing enables your practice to apply pre-adjudication edits to the claims specific to your practice, payor mix, and state giving you the chance to identify and correct the error before the claim is submitted. Unfortunately, these tools are not available in traditional practice management systems (PMS). In fact, most PMS are dumb data input systems accepting whatever data is put in regardless of whether it is accurate or even complete. This leads to dirty data and ultimately to lost cash as claims go out the door only to be denied payment. Faced with constantly changing regulatory guidelines, including ICD-10, a state-of-the-art claims editing tool ensures that your organization reduces claims denials while optimizing quick and accurate reimbursements. The payors all have automated systems that analyze claims to flag errors and trigger denials. Providers need the same set of tools to keep up and maintain reimbursement. Savvy practices will look beyond their PMS vendor and bring in a revenue cycle partner that offers state-of-the-art claims editing technology, as well as experienced billing experts, to help them improve clean claim rates and reduce denials. That is the type of purpose-built RCM system MDeverywhere has built from the ground up. 4. Enforce Your Payor Contracts You are getting your bills out the door clean and complete and collecting the full patient portion. How are you making sure that the payors are paying you what they are contractually obligated to pay? Even when a claim is paid, it is sometimes not paid correctly. And when there is a mistake in payment, it is often to the benefit of the insurance company. According to the AMA, up to 10% of claims are not paid correctly. 6 And commercial payors on average underpay on 7% of their claim adjudication. This can add up to 6 AMA, National Health Insurer Report Card, , news/ national-health-insurance-report-card 8 I Top Five Best Practices for Optimal Revenue Cycle Management

9 significant revenue loss for your practice. But most practices are simply so pleased to be paid at all that they don t bother to appeal these underpayments. That is even if they have the ability to flag them. A contract is the written agreement that defines the terms by which providers offer services to members and the method by which you will be reimbursed for those services. Sounds simple in theory, but the contracts are complicated and vary state to state. Understanding them is critical. For example, your organization bills Payor A $100,000 per month for services rendered. However, Payor A consistently under pays on your contract by 10% or $10,000 each month on your top CPTs. This means your organization is losing upwards of $120,000 per year in underpayments. This unfortunately is not an unusual scenario. Surely you would notice that amount of money missing. Not necessarily. The problem is the underpayments are spread across hundreds of patient records, which means the amount per patient is small and easily overlooked. This is further compounded when you factor in that Payor A is only one of a 100 payors you work with on a daily basis. Identifying underpayments and then adjudicating them with each of your payors can be a daunting process. In fact, it is estimated that the average medical practice loses as much as 11% of its revenue due to underpayments each year. Monitoring and appealing expected payments doesn t have to be overly complicated or expensive if you have the right resource or partner working on your behalf. The revenue generated from the underpayments will more than cover the cost and result in a significant gain overall. The right system will allow your practice to create a system knowledge repository on fee schedules and reimbursement rules for your key payors, create system flags and alerts to identify underpayments for every line item, and create individual appeals with a given payor to set precedent, following with bulk appeals if necessary. 5. Don t Just Survive Thrive Through Proactive Training and Tools How do we survive and even thrive through the new transitions in healthcare laws specifically ICD-10? Start by not underestimating the degree of change 9 I Top Five Best Practices for Optimal Revenue Cycle Management

10 Helpful Hint Not all RCM services are created equal. It is important to understand what parts of the revenue cycle a company really takes on before you sign up and what the real costs are for those services. required. Don t skimp on training. This will require a significant investment in time and money, but the payoff is immense. Doctors will not be able to learn about new laws and regulations on the fly. Coders will need to be re-certified. AR and billing personnel will need to understand the new coding schema to manage the follow-up processes. Have your documentation procedures assessed to make sure that they are adequate for the increased specificity of ICD-10. Talk to staff early about their willingness and ability to make this transition. Proactive training is key to thriving in the current healthcare environment. The best option for many practices may be to engage with a revenue cycle partner that has already made the investment in the tools, systems, and training and can provide a turnkey training solution for a practice. In this way, practices can leverage the resources and capabilities of a trusted, stable partner that has significant expertise, technical know-how and capital required, and is focused on ensuring your practice s financial success. Your practices can also leverage the benefits of operational scale, technical expertise and capital investment of a business partner. The right partner can help a practice continue to thrive through this key healthcare transition. By working with a company that is wholly focused on business operations and revenue cycle optimization, your practice can maintain control over all clinical decisions and not just survive but thrive as an independent practice. Conclusion Today more than ever, medical practices must embrace best practices in revenue cycle management in order to stay profitable and thrive in their business. This includes the following: 1. Embrace patient engagement and the role they have as a consumer in the healthcare market and build systems that allow them to utilize tools that empower them and ultimately keep your schedule full and productive 2. Surround front office staff with tools and technology to streamline the patient experience and reduce claim defects, increasing the collections on payor responsibility 3. Eliminate denials with smart data and process control systems at the frontend 4. Enforce payor obligations according to contract requirements 10 I Top Five Best Practices for Optimal Revenue Cycle Management

11 5. Thrive through change with proactive tools, systems, and training A staggering 30% of revenue is left behind every year through eligibility denials, coding errors, unpaid patient balances, lack of follow up and underpayments. That is what is creating the vicious cycle that exists in many practices today. Practices simply don t have the money to invest in the sort of sophisticated systems that offer real-time automated eligibility, robust coding rules, patient collection tools so they lose more money every year putting them even further behind the technology curve. Practices need to break out of this cycle by not trying do it all on their own, or by choosing an expensive traditional outsourcing model. The best approach is to find a partner whose interest is in alignment with your goals one who will help you to optimize every area of revenue cycle management for your practice. It could be the difference between having to close your doors or thriving in a everchanging healthcare environment. By following the best practices outlined in this whitepaper, you can move beyond the quick fix mentality and finally get on top of your practice, with systems in place that will help you optimize every area of revenue cycle management. About MDeverywhere Contact Us! 230 Third Ave. Waltham, MA (631) option 4 MDeverywhere offers a leading revenue cycle management (RCM) and electronic medical record (EMR) solution including credentialing services for physicians. Our unique RCM solution includes purpose-built, cloud-based practice management software, coding rules engines, contract monitoring tools and full-scope claims management and back-office services. A fully integrated, user friendly, Meaningful Use Stage 2 certified EMR ensures our clients will be fully compliant with regulations. Our single source solution is proven to streamline workflow, decrease denials and increase revenue. As an NCQA Certified CVO, we assist clients in taking control of the credentialing processes through delegation. MDeverywhere was founded in 1995 and currently serves over 7,000 physicians nationwide. Our clients include solo practices, group practices, large faculty practices, and hospitals in over 40 different specialties. For more information, go to 11 I Top Five Best Practices for Optimal Revenue Cycle Management

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