10/14/2015. Common Issues in Practice Management. Industry Trends. Rebecca Lynn Hanif, CPC,CPCO,CCS, CMUA AHIMA Approved ICD-10-CM/PCS Trainer

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1 Common Issues in Practice Management Rebecca Lynn Hanif, CPC,CPCO,CCS, CMUA AHIMA Approved ICD-10-CM/PCS Trainer cpmresults.com Industry Trends cpmresults.com Patient Responsibility Patients are now responsible for 30 to 35 percent of their healthcare bill Decreased Reimbursement Increased Requirements Higher Deductibles (HAS & HFS) Increased Patient Responsibility Increased Denials Increased Pre-Authorizations 1

2 Patient Responsibility Patient Responsibility Parity Payor Requirements (If you still accept insurance) Mental Health Parity Loopholes - Non-federal government employer that provides self-funded group health plan coverage can opt out In order to keep down costs "medical necessity" reviews have increased to stay in compliance with Mental Health Parity A recent report by Mental Health America ranked Alabama 49th in access to care, which measures access to insurance as well as the available mental health workforce. 20 visits per year for Federal Employees (in approved facilities) 40 visits for substance abuse Medicaid 52 visits per year Providers that accept EAP are few and far between A plan might list that it covers in-patient psychiatric care but doesn't specify the kind of facility Medicare is actually easier in Psychiatry than other specialties 100% of allowable to MD Clinical Psychologist receives 100% of allowable CSW 75% of allowable 2

3 Nickel and Dimed Meaningful Use Requirements Paired down to 9 measures Requirements still require a substantial amount of time -2%+ Physician Quality Reporting System & Value Based Payment At least a -2% penalty but up to -4% ICD-10-CM and DSM 5 Psychiatry s double whammy HIPAA Audits Payor Audits Reimbursement Tactics in the Days of Austerity Part I - Workflow cpmresults.com Front Desk and Authorization Scheduling Rules Do not schedule a patient without collecting insurance information and all other pertinent demographics Front Desk Rules Do not let a patient see the Provider without collecting a copay and calculate the coinsurance based on fee schedules Routinely failing to collect copayments or coinsurance at the time of service violates the anti-kickback statute The physician may waive the copay if an individual determination is made that the patient cannot afford to pay or you have made reasonable collection efforts that have failed. Policies should be in place to define these criteria Private payors consider this a violation of the contract with the physician and can use this as grounds for termination When that patient walks out, the likelihood of collecting that money decreases by 20% No authorization, no visit Authorizations should be received and insurance verified at least 3 days in advance 3

4 Front Desk and Authorization Ask patient to review or verify Demographics Immediately catch data entry errors Acquire additional information: s, Cell numbers, Consents Scan each patient's identification card, insurance card, and required financial documentation upon registration. Educate patients about benefits. If pre-visit verification wasn't performed, take the time at check-in if possible Notifying patients about their financial responsibilities at key opportunities; Create notes, alerts, and special comments within the patient demographics ensures that practice staff (team) are aware of; outstanding balances, bad debt, and/or special concessions. Clinical Workflow Automated patient reminders are worth the investment text, , phone, etc. Now that you have gotten them in the door and they have paid The Provider needs the support of everyone to maintain a good workflow Set a schedule of expectations for the time it should take for a patient to check in all the way to check out Ancillary staff can document the Review of Systems, PFSH Provider Document compliantly because you will be audited (there is no IF) Ask the Provider to jot lists of what can improve his or her workflow Clinical Workflow Sample Cycle of Expectations Wait at check-in 2 minutes Complete check-in 6 minutes Wait in waiting room 14 minutes Move to Provider Office 4 minutes Wait for Provider 5 minutes Interaction with Provider Depends on whether or not you are using time based codes Move to check out 3 minutes Wait a check out 3 minutes Checkout 4 minutes (If the patient needs to request more visits or will need anything before the next visit, checkout needs to know these details and remind the patient at that time. 4

5 Clinical Workflow Assign a Team Lead to hold each group accountable Administrators can t do it all Scheduling Registration Reception Medical Assistants Physicians Coding Data Entry Personal Collections staff Reimbursement Tactics in the Days of Austerity Part II Revenue Cycle cpmresults.com It Takes a Family to Raise a Practice 5

6 Goals for the Revenue Cycle Money Makes the World Go Round (Sadly) Set Clear Financial Expectations with Patients Accelerate Cash Collections -"CASH IS KING" Minimizing Hassles to Improve Patient Satisfaction Reduce patient Bad Debt Decrease Patient and Collection Costs Offer flexible Payment Options Customize Payment Policies based on a Patient's Propensity to Pay Medical Bills. Goals for the Revenue Cycle Money Makes the World Go Round (Sadly) Set Clear Financial Expectations with Patients Accelerate Cash Collections -"CASH IS KING" Minimizing Hassles to Improve Patient Satisfaction Reduce patient Bad Debt Decrease Patient and Collection Costs Offer flexible Payment Options Customize Payment Policies based on a Patient's Propensity to Pay Medical Bills. Medical & Coding Quality of Coding improves with a good clearinghouse CCI edit scrubbers, audit triggers, monitoring, and trending should be available Provide access to specialty-specific billing and coding education Acquire the most updated reference materials Please stop using the 2007 CPT book The LCD from 2003 is expired most likely Revenue Cycle Step Access to Patients and Performance Target Information Documentation of services Physician 100% same day **Complete after each encounter Coding for services Physician/Certified Coder 98% within 24 hours after operative report or chart Verification of all Charting & Coding entered daily Physician 24 hours charge/billing 6

7 Medical & Coding Electronically submit claims 90% claims Monitor Clearinghouse on denials Ensure Corrected Claim is changed in system (Integrity of Records) A detailed Denial Report shall be reviewed on a daily, weekly, monthly and yearly basis. Payment Posting Insurance payments posted to the patient accounts with a turn-around time of 24 hours or less ERA reduces the time spent posting payments giving poster more time to follow up on specific claims Submit secondary claims immediately Reconcile payments daily and do not leave until everything is balanced Payment Posting Revenue Cycle Step Missing encounter report Charge entry/claims processing Access to Patients and Information Department Performance Target Report ran Weekly 24 hours or less, 100% of charge tickets, 98% cleans claims (first run) Charge entry 99% accurate entry of charge verification Claims audit /Coder 100% of charges pass system rules engine Explanation-ofbenefits Outstanding claims research 95% of payments posted within 24 hours of receipt 100% of claims worked every 15 days 7

8 Denial Management Prevent and Manage Denials Monitor Clearinghouse Denials Ensure Corrected Claim is changed in system Working denied claims quickly to provide requested information; Knowing how to appeal denied claims; and Tracking denials to prevent future denials A detailed Denial Report shall be reviewed on a daily, weekly, monthly and yearly basis Denial Management Denial Report by Type Pending Insurance Review Other Insurance Primary Medical Necessity Claim Lacks Information Needed for Adjudication Services not covered (Should have been nipped in the bud by pre-auth/verification team) Denial Management Revenue Cycle Step Rejected claims research Claims denial tracking Appropriate payer payment review Review all Patients Credit Balances Accessto Patients and Information Performance Target Claims worked within 24 hours of receipt 2% or less of total claims denied/monthly report submitted to Management Monthly reporting and follow up within 10 business days Monthly prior to stmt distribution review all accounts with Credit Balance. Issue check where applicable. Apply Interest to Patient Accounts Patient statement Monthly prior to stmt distribution apply interest to accounts based on Clinic's Policy. 100% of patients w/balance receive stmt accordingly: 1st 0 day, 2nd 28 days, 3rd 28 days collection letter, 4 th 28 days demand letter 8

9 Revenue Cycle Step Pre-collections notice processing Access to Patients and Information Collections Performance Target 100% of patients w/outstanding balances days old receive contact regarding their past due account. (2phone calls 5 business days to connect) Pre-collections follow up Pre-collections telephone contact Collections pending list generation Service termination noshow Collections process 100% of patients contacted w/outstanding balances days or older receive contact regarding account. (2 phone calls5 business days to connect) 100% of patients w/outstanding balances 100 days or older MUST be contacted by office prior to submission to collection agency (2 phone calls 5 business days to connect) Submit report to practice monthly Physician Patients are terminated after no-show _# times Outside vendor Monthly submission of 98% of qualifying patients. Physician reviews. Revenue Cycle Step Access to Patients and Information Collections Performance Target End of Day Close Receptionist//Manage ment 100% of money balanced to logs and system by end of day Weekly deposit report Receptionist//Manage ment Submitted to Management Deposit (system to bank) Reconciliation Month End Close & Report Year End Close & Report Management /Management /Management Reconciliation and follow-up within 2 business days of receipt (weekly reconciliation reduces month end closes) Submitted to Management by the 7th of the following month Submitted to Management by the 7th of the following month Tips for Overall Process Improvement cpmresults.com 9

10 You Can t Manage What You Can t Measure You Can t Manage What You Can t Measure Use your tools and reports to monitor for accountability as well as desired outcomes Give specific job responsibilities and create tools that allow you to monitor on an individual basis Utilize them in you evaluation process Give continuous and immediate feedback both positive and negative Retrain where necessary Reward/recognize success Discipline, if needed If the employee has the desire and ability, any failure is on the management Policy and Procedures Appointments How they are made and what is expected at time of visit Co-pay Patients should know that this is expected at time of visit Cancellations There should be a written policy on patient responsibility for cancellations that occur within a minimum time frame Payment Options Cash, check, credit card, practice-funded services, etc. Sliding Scale/ Hardship issues Clear policy on who qualifies for reductions and the process for application Old Balances Clear policy on how old balances are handled prior to visit 10

11 Leadership is Key A leader is one who motivates people to work more effectively together and encourages individuality. Insight Initiative Inspiration Involvement Individuality Style Leadership is Key Leaders know what motivates people. Leaders are able to collaborate with others, work as leaders and also as members of a team. Leaders are confident in their ability to manage and motivate others. A successful leader knows their employees. Communicates expectations clearly and concisely. Is approachable. Shares his/her vision and strategies so team members understand how they fit into the organization and overall blueprint Leadership is Key All the knowledge in the world about the revenue cycle, workflow, and process improvement means nothing in the face of toxic leadership [INSERT YOUR FAVORITE LEADERSHIP QUOTE HERE, PREFERABLY A LEADER THAT WAS NOT A DICTATOR, AND DO YOUR BEST TO EMBODY THAT MOTTO INSTEAD OF READING IT ON A WALL]. 11

12 Questions? Rebecca Hanif, CCS, CPCO, CPC AHIMA Approved ICD-10-CM/PCS Trainer COMPLETE PRACTICE MANAGEMENT t (334) f (334) w cpmresults.com e Rebecca.Hanif@cpmresults.com References ws.com/files/resource-media/pdf/key-metrics-guide-final.pdf 12