Webinar: Next Generation Revenue Cycle

Transcription

1 1 Webinar: Next Generation Revenue Cycle Mark Engelen, Greenway Health Robin Brand, Advisory Board May 7, The Advisory Board Company advisory.com

2 Agenda Welcome Poll 1 Next Generation Revenue Cycle Poll 2 Poll 3 Poll 4 Q&A Greenway Health, LLC. All rights reserved. Confidential and proprietary. Not for distribution except to authorized persons. 2

3 Poll 1 How do you currently manage your billing/revenue cycle operations? In house Outsourced to a dedicated medical billing company Outsourced to your practice management software vendor Greenway Health, LLC. All rights reserved. Confidential and proprietary. Not for distribution except to authorized persons. 3

4 Today s Speaker Robin Brand Senior Consultant, The Advisory Board Company During her six years with The Advisory Board Company, Robin has spent much of her time focused on service line strategy and finance, authoring multiple studies and white papers focused on revenue capture, pricing, patient consumerism and referral capture. As a senior consultant within the Financial Leadership Council, she oversees research examining revenue cycle and margin management, as well as financial performance under risk. Robin holds a Master of Science in international political economy from the London School of Economics, where she focused on international trade and development. She earned her bachelor s degree in political science from the University of North Texas. Prior to joining the Advisory Board, Robin worked in health care policy at the Cato Institute, a Washington, DC based think tank, and served as a domestic policy researcher at the Wall Street Journal. Greenway Health, LLC. All rights reserved. Confidential and proprietary. Not for distribution except to authorized persons. 4

5 Financial Leadership Council Next-Generation Revenue Cycle Prepared for Greenway Health

6 6 Two Forces Transforming the Revenue Cycle 1 2 Shift in Coverage Shift in Risk Increased coverage from public, private health insurance exchanges Rise of high-deductible plans, cost-shifting onto patients under exchanges, through commercial payers challenges collection attempts Total cost of care contracts (shared savings and capitation) reward low-cost, high quality care Revenue cycle must continue to maximize capture while also supporting care management initiatives 2014 The Advisory Board Company advisory.com Source: Financial Leadership Council interviews and analysis

7 Exchange Enrollment Marked by Slow Start 7 7 Cumulative Enrollment in Federal and State Exchanges 3.3M 2.1M 8M Number of enrollees through February K 365K 1.1M 1M October November December December (Pre-Launch Projection) 28% 63% Percentage of Enrollees Ages Percentage Enrolling in Silver Plans Federal Exchanges State Exchanges 2014 The Advisory Board Company advisory.com Source: Kaiser Family Foundation, State Decisions for Creating Health Insurance Exchanges, as of December 11, 2013, available at: Schatz A, Health- Plan Enrollment Surpasses 2.1 Million, Wall Street Journal, Dec 31, 2013, available at: Jost T, Implementing Health Reform: The November Exchange Enrollment Report, Health Affairs Blog, December 11, 2013, available at: healthaffairs.org/blog/; Health Care Advisory Board interviews and analysis.

8 8 Newly-Covered Face Large Obligations on Exchanges Majority of Enrollees Selecting Plans With High Deductibles Health Insurance Exchange Plan Enrollment Percentage of Enrollees Within Each Plan Tier 62% $2,500 Average deductible under silver plans 19% 12% 7% 1% $4,300 Average deductible under bronze plans Bronze Silver Gold Platinum Catastrophic 2014 The Advisory Board Company advisory.com Source: Financial Leadership Council interviews and analyis.

9 9 Trading Price for Volume on the Public Exchanges Reimbursement Information Still Anecdotal, but Rates Not Generous Anticipated Provider Reimbursement Rates for Exchange Plans Catholic Health Initiatives Modest discounts from commercial rates WellPoint Inc. Between Medicare and Medicaid rates Millern Medical Center 1 20% below commercial rates Tenet Healthcare Up to 10% below commercial rates Meyers Health 1 10% above Medicare rates Meriwether Hospital 1 5% below commercial rates ) The Pseudonym. Advisory Board Company advisory.com Source: Mathews AW and Kamp J, Another Big Step in Reshaping HealthCare, Wall Street Journal, February 28, 2013, available at: Health Care Advisory Board interviews and analysis.

10 10 The Future of Employer-Sponsored Insurance? Private Exchanges Poised For Rapid Growth Projected Private Exchange Enrollment 40M 30M 19M 9M 1M Factors Influencing Move to Private Exchange Models Logistical difficulty of benefit renegotiations Internal politics of benefit changes 27% Percentage of consumers receiving employer-sponsored coverage today projected to receive benefits through private exchanges in 2018 Attractiveness of other options 2014 The Advisory Board Company advisory.com Source: Accenture, One-in-Four Consumers Will Receive Employer Health Benefits Through Insurance Exchanges in Five Years, Accenture Research Shows, available at: Health Care Advisory Board interviews and analysis.

11 11 Igniting a Race to the Bottom Exchange Shoppers Trading Premiums for Deductibles Results of Open Enrollment Process % 70% 14% 18% 39% 12% 1 2 PPO HMO High-Deductible Plan 42% Employees on Aon Hewitt health insurance exchanges selecting plans less rich than the previous year Case in Brief: Sears, Darden Restaurants For 2013 open enrollment, self-insured large employers redesigned benefits to reduce health spend through defined contribution model Employers offered employees lump sum credit to choose coverage in Aon Hewitt s online marketplace 1) Preferred provider organization ) The Health Advisory maintenance Board Company organization. advisory.com Source: Mathews AW, To Save, Workers Take On Health-Cost Risk, Wall Street Journal, March 17 th, 2013, available at: Health Care Advisory Board interviews and analysis.

12 2013 The Advisory Board Company 12 Encouraging Patient Frugality High-Deductible Plans on the Rise Increasing High-Deductible Health Plan Enrollment Enrollees with Deductibles of $1,000 or More 25% 18% 7% 10% % Decline in proportion of individuals with a deductible under $ ) From 2012 to Source: Altarum Institute, Altarum Institute Survey of Consumer Health Care Opinions, Fall 2012, available at: Kaiser Family Foundation, "Explaining Health Care Reform: Questions About Health Insurance Exchanges. ; Financial Leadership Council interviews and analysis

13 Likelihood of Payment Drops as Deductibles Rise 13 Increasing Obligations Already Impacting Bad Debt Patient Propensity-to-Pay¹ by Deductible Size 68% 62% 61% 50% 36% $500-$999 $1,000-$2,000 $2,001-$3,500 $3,501-$5,000 $5,001-$6,350 Year Bad Debt as Percentage of Net Patient Revenue Percentage of Patients with Deductibles of $1,000 or more % 7% % 18% 1) Percentage of patients paying any portion of bill The Advisory Board Company advisory.com Source: Financial Leadership Council interviews and analysis.

14 Poll 2 Are you seeing any changes in bad debt or the percentage of total revenue that comes from patient collections at your practice? Yes, we are seeing increases in bad debt Yes, we are seeing increases in patient collections Yes, we are seeing increases in both bad debt and patient collections No, we have seen no change in either No, we are seeing improvements in bad debt Greenway Health, LLC. All rights reserved. Confidential and proprietary. Not for distribution except to authorized persons. 14

15 2013 The Advisory Board Company Risk-Based Payment 15 Embracing New Types of Risk Emerging Payment Models Calling Old Imperatives Into Question Accountable Payment Models Performance Risk Utilization Risk Cost of Care Quality of Care Volume of Care Bundled Pricing Bundled Payments for Care Improvement program Commercial bundled contracts Pay-for-Performance Value-Based Purchasing Readmissions penalties Quality-based commercial contracts Shared Savings Medicare Shared Savings Program Pioneer ACO Program Commercial ACO contracts Source: Financial Leadership Council interviews and analysis.

16 2013 The Advisory Board Company 16 Risk-Based Contracting on the Upswing Twice as Many Providers Have Risk-Based Contracts as in 2011 Percentage of Providers with Risk-Based Contracts in Place Total Cost of Care Bundled Payment Pay-for-Performance Survey 83% 17% 84% 16% 44% 56% 2013 Survey 65% 35% 72% 28% 45% 55% Without Risk-Based Contracts With Risk-Based Contracts The number of providers with total cost of care and with bundled payment contracts has doubled in two years. 1) 2011 question asked as, Have commercial insurers in your market introduced new P4P initiatives in the last 24 months? ; 2013 question asked as, Does your organization currently have any pay-for-performance contracts, besides Medicare s mandatory VBP and readmissions penalties. Source: 2011 and 2013 Accountable Payment Surveys, Financial Leadership Council interviews and analysis.

17 2013 The Advisory Board Company 17 Continuing Investments in the Revenue Cycle Revenue Cycle Challenge Importance Under Risk vs. Fee-For-Service 1 Tracking and reporting quality metrics Tracking utilization of attributed patients Tracking cost of services provided Identifying patients covered under total cost of care contracts at the time of service Coding and clinical documentation Developing financial projections Minimizing cash flow deceleration Identifying and appealing underpayments and denials Equally Important Somewhat More Important Much More Important 1) Based on average ratings from those reporting experience with total cost of care contracts on our 2013 Accountable Payment Survey. Source: 2013 Accountable Payment Survey, Financial Leadership Council interviews and analysis.

18 Poll 3 Does your practice participate in any risk-based contracts/programs today? Yes, we are participating in a risk-based program with a government payer (Medicare/Medicaid) Yes, we are participating in a risk based program with a commercial payer Yes, we are participating in both commercial and government programs No, we are not currently participating in any risk-based contracts or programs. Greenway Health, LLC. All rights reserved. Confidential and proprietary. Not for distribution except to authorized persons. 18

19 2013 The Advisory Board Company 19 Elevating Revenue Cycle Under Reform Eight Strategies for Revenue Cycle Under Reform 1. Maintain focus on high-opportunity cases through the transition 2. Use CDI to support risk segmentation and care management 3. Document to meet quality targets 4. Retool collections to manage larger, more complex obligations 5. Enhance insurance verification processes 6. Expand Medicaid and HIX eligibility screening and enrollment 7. Shift denials focus to root causes rather than appeals 8. Develop disbursement abilities for physicians and external providers Source: Financial Leadership Council interviews and analysis.

20 2013 The Advisory Board Company #1: Maintain focus on high-opportunity cases throughout the transition 20 Risk Elevates Importance of Documentation Goals of CDI Increase as Programs Transition from Fee-for-Service Risk-Based Payment Reasons for CDI Program Fee-for-Service Mitigate postpayment recovery audits Increase revenue capture Capturing quality data Managing highrisk patients Mitigate postpayment recovery audits Increase revenue capture Degree of Risk Source: Financial Leadership Council interviews and analysis.

21 2013 The Advisory Board Company 21 Assessing Current CDI Program Performance 2010 CDI Financial Benchmarking Results * Low Performance n=6 Average Performance n=13 High Performance n=6 Beds per FTE Annual Revenue Impact per FTE $0.3M $0.7M $1.4M Programs Reporting to Finance 33% 46% 83% *Revenue impact reflects the cumulative value of all DRG reassignments associated with CDI interventions over the course of fiscal year Figures do not account for DRG reassignments that would have occurred over the course of a patient s stay independently of CDI queries, nor do they include potential CDI impact on denials or post-payment audit takebacks. Source; Financial Leadership Council interviews and analysis.

22 2013 The Advisory Board Company #2: Use CDI to support risk segmentation and care management 22 From Revenue Capture to Cost Management Incremental Revenue Capture Under Fee-for-Service Patient: J. Smith Date Monday, 5/10 Wednesday, 5/12 DRG Assignment 192 COPD without CC/MCC 191 COPD with CC $1,400 incremental reimbursement impact Elevated Care Management Under Risk Documentation efforts aimed at supporting care management Greater specificity leads to more accurate risk scoring, better care management Friday, 5/14 Monday, 5/ COPD with CC 189 Respiratory Failure $2,200 incremental reimbursement impact $3,600 incremental revenue impact High Risk Medicare Patient Annual Cost: $70,709 Medium Risk Medicare Patient Annual Cost: $20,060 Source: Financial Leadership Council interviews and analysis.

23 2013 The Advisory Board Company #3: Document to meet quality targets 23 Risk Ties Quality to Reimbursement Documentation Necessary to Receive Full Bonus Payout Quality Performance Contingent on Documentation Case Study: Snow ACO² 24 of 33 MSSP¹ quality performance standards focus on preventive health, outcomes, screenings Most include documentation-centered items such as how often physicians report follow-up plans following screening E.g. BMI screening reveals patient is overweight, physician will be required to document follow-up plan % Distinct performance metrics within ACO contract Percentage of bonus based upon performance on each measure 1) Medicare Shared Savings Program. 2) Pseudonym. Source: Financial Leadership Council research and analysis.

24 2013 The Advisory Board Company 26534B #4: Retool Collections to Manage Larger Obligations 24 Rise of Deductibles Complicates Collections Patient Obligation Growing Component of Contracted Rates Increasing High-Deductible Health Plan Enrollment Enrollees with Deductibles of $1,000 or more 25% Sample Contracted Rates for MRI Patient Obligation by Payer and Plan 18% 7% 10% $800 $600 $1,000 $200 $ PPO¹ 1 PPO 2 HDHP² 43% Decline in proportion of individuals with a deductible under $500 Patient Portion Payer Portion Source: Altarum Institute, Altarum Institute Survey of Consumer Health Care Opinions, Fall 2012, available at: Kaiser Family Foundation, "Explaining Health Care Reform: Questions About Health Insurance Exchanges. ; Financial Leadership Council interviews and analysis

25 2013 The Advisory Board Company 26534B 25 Cost-Sharing Varies Under Most Popular Plan Subsidies Add Another Layer of Complexity Different Cost-Sharing Subsidies Within a Silver Tier Plan Income Level % FPL % FPL % FPL >250% FPL Percentage of Total Cost Covered by Cost-Sharing 24% 17% 3% 0% Actuarial Value 94% 87% 73% 70% 60% Percentage of enrollees selecting Silver Tier Plans Source: Financial Leadership Council interviews and analysis.

26 2013 The Advisory Board Company 26 Deriving Patient Estimates From Historical Data Patients Asked to Pay Deposit According to Calculated Averages Rolling Retrospective Charge Review Standardized Down Payment Schedule MRI COPD CHF Procedure/Setting Global Deposit Amount Inpatient Admission $250 Charge Review Period Outpatient Lab $25 Date of Patient Visit MRI $100 CT Scan $100 Case in Brief: Mercy Medical Center 228-bed hospital in Sioux City, Iowa As a bridging strategy, patient access management team reviews top 50 DRGs and APCs by volume to determine average charges Patients shown average charges for previous 90-day period when asked to pay a deposit Source: Financial Leadership Council interviews and analysis.

27 2013 The Advisory Board Company 26534B #5: Enhance Insurance Verification Processes 27 Increasing the Complexity of Enrollment Significant Crossover Expected Between Medicaid, Exchanges Percentage of Future Enrollees with Change in Eligibility Between Medicaid, Exchange 1 8.6% n=19, % 38.4% Plan Benefits Impact of Coverage Transitions Fluctuations in plan design, resulting in variable levels of benefits, premiums, and cost-sharing 26.9% 26.6% 19.9% 6-months 12-months 24-months 1 Change 2 or More Changes Provider Networks Potential disruption of existing provider networks, steering enrollees to new care sites 28 M Adults projected to undergo shift in eligibility across Medicaidexchange market within one year 2 Payment Rate Likely increase in hospital reimbursement with shift from Medicaid to commercial insurance on state exchange 1) Among adults with family incomes below 200 percent of the federal poverty line 2) Using 133% of the federal poverty level as the eligibility threshold Source: Benjamin D. Sommers and Sara Rosenbaum, Issues In Health Reform: How Changes in Eligibility May Move Millions Back and Forth Between Medicaid and Insurance Exchanges, Health Affairs, 30, no.2 (2011): ; Marketing and Planning Leadership Council interviews and analysis.

28 2013 The Advisory Board Company #6: Expand Medicaid and HIX Eligibility Screening and Enrollment 28 Spreading the Word Trinity Health Planning to Educate Patients About Exchanges, Subsidies Building Exchange Awareness Trinity counselors available at hospital to help patients understand eligibility, apply for Medicaid, exchange coverage Computerized enrollment kiosks available to encourage patients to enroll in exchange plans online Community health workers knock on doors, promote coverage at football games, visit laundromat patrons to provide information Awareness Matters for Hospitals There are so many moral and pragmatic reasons why hospitals should be engaged in outreach and [health insurance exchange] education it s a lot like political organizing Tina Weatherwax Grant Director, State Advocacy Case in Brief: Trinity Health 47-hospital health system based in Livonia, Michigan Extending current health insurance awareness and enrollment programs to reach newly-eligible Medicaid and exchange patients Source: Health Care Advisory Board interviews and analysis.

29 2013 The Advisory Board Company 29 Continuing Attempts to Enroll Patients in Medicaid Montefiore s Medicaid Registration Process Emergency Department Financial Impact of Enrollment Medicaid enrollment forms provided to all self-pay patients Reminder letters sent and phone calls made to facilitate enrollment 6,000 Total indigent care enrollment in 2009 Patient Scheduling Weekly reports generated of scheduled self-pay patients Patient Follow-up Patient called and reminded to bring documentation for Medicaid enrollment $1,700 $10.2M Average Medicaid revenue per patient Annual revenue impact of added Medicaid enrollment Scheduled Patients Source: Financial Leadership Council interviews and analysis.

30 2013 The Advisory Board Company 30 New Revenues From Medicaid Enrollment Projected Increases in Patient Revenue From Medicaid Expansion For Three Representative States, By Absolute Extent of Expansion $3.4B Potential Compensation $63M $510M Potential Compensation Potential Compensation Limited Expansion Moderate Expansion Extensive Expansion 1) Calculated based on revenue per enrollee at Montefiore Based on projected eligibility in DE 2) Based on projected eligibility in KY 3) Based on projected eligibility in CA = 50K Patients Source: Advisory Board interviews and analysis; The Center on Budget and Policy Priorities

31 2013 The Advisory Board Company #7: Shift Denials Focus to Root Causes Rather Than Appeals 31 Denials Data Provide Clues On Appropriate Care Managing Medical Necessity Denials at Presbyterian 1 Identify Root Cause 2 Communicate to Clinical Staff 3 Improve Care Management Examine medical necessity denials to determine whether and why the care provided was inappropriate or unsupported Relay key findings from medical necessity review to clinical leaders, care management staff Alter care protocols to optimize utilization and improve care appropriateness Case in Brief: Timmons Health¹ Two-hospital health system in the Southwest Finance using denials data to understand medical necessity, inform future care efforts Findings relayed to clinicians, who then may alter care protocols, revisit utilization assumptions Source: Financial Leadership Council interviews and analysis.

32 2013 The Advisory Board Company #8: Develop Disbursement Abilities for Physicians, External Providers 32 Current Revenue Cycle Centered on AR Traditional Under Risk Disbursement Added to Responsibilities Under Risk-Based Payment Revenue Cycle Focus Billing Collections Managing denials, underpayments Payment to physicians, post-acute care facilities necessary under value-based contracts Source: Financial Leadership Council research and analysis.

33 Poll 4 Does the transition to risk and value based contracts make you more or less likely to consider outsourcing your billing/revenue cycle operations? More likely Somewhat likely Neutral/No Impact Somewhat unlikely More unlikely Greenway Health, LLC. All rights reserved. Confidential and proprietary. Not for distribution except to authorized persons. 33