Leading a High Functioning Financial Team

Transcription

1 Leading a High Functioning Financial Team 2014 CPCA BILLING MANAGERS AND CFO CONFERENCE SHERRY CALDWELL, CHIEF FINANCIAL OFFICER ANNE FRUNK, REVENUE CYCLE MANAGER SHASTA COMMUNITY HEALTH CENTER MICHELE LAMBERT, CHIEF FINANCIAL OFFICER MICHELLE MONROE, REVENUE CYCLE DIRECTOR VISTA COMMUNITY CLINIC Billing Manager and CFO Relationship Team building blocks CFO & Responsibility Patient Revenue/Patient A/R = high risk area for compliance CFO UDS, OSHPD, Financial Statements CFO Certifies and asserts billing is done accurately to a variety of agencies Team approach 2 heads are better than 1! How to keep your CFO out of your Practice Management System!! The Revenue Cycle 1

2 #1 Revenue Maximization Where are we leaving money on the table? What role does Billing have in ensuring that the Health Center gets paid for every visit? How is the Billing office ensuring that Registration is doing their Job? Managed Care, HEDIS, Quality Incentives, Meaningful Use How do we know all services are being coded? #2 Is it the people or is it the system? How do we find the root cause of an issue? How do we fix it? How do we train on it? Who is responsible to monitor it? Is communication maximized between all members of your team? #3 There isn t enough time in the day! How do we ensure that work only gets done once? How do we set the right priorities in and out of department? 2

3 #4 How do we ensure that we are compliant? Coding / Claims Demographics (UDS, OSHPD) Contractual Payments FQHC / Sliding Fee Scale regulations Regulatory Reporting Program Eligibility Policies & Procedures IS YOUR DATA RELIABLE??! #5 We work in a constantly changing environment Culture of Continuous Improvement Shifting Payer Mix System Upgrades Staff Turnover Health Center Growth Expansion New Lines of Services Changing requirements (PCMH, MU, Compliance, etc ) Communication Avoid blind spots The single biggest problem in communication is the illusion it has taken place. George Bernard Shaw 3

4 Communication Avoid blind spots Open Lines of Communication What do CFO s need from their Billing Managers? What do Billing Managers need from their CFO? Are you both on the same page? Set goals together Plan how do we get there? Keep everyone involved in the know Agree on a time frame Communication Avoid blind spots Who works in the Billing Department? Scheduler, Check in, MA, Nurse, Clinician, Scribe, Referral Coordinator, HIS, Check out Billing Department = processing charges, coding, payment posting, denials, A/R, statements Communication Avoid blind spots Build bridges between departments Billing Manager attends outside department meetings i.e., Check in, Nurses, Clinicians, Operations Level of respect for the Billing department 4

5 Do you have a Data Integrity Plan? Building scorecards that have a positive impact to the bottom line Key Performance Measures Check in process = verify eligibility, income documentation, UDS Days in A/R Unbilled encounters = Gap between date of service and date billed Percentage of Denials = Tracking denials by reason codes, payer, financial class Coding Compliance = do charges meet medical necessity Sharpen the saw Do you have a training program? Check in Software, financial programs, verifying and understanding eligibility, UDS requirements, income verification, etc. Clinical Protocols, documentation supports charges, medical necessity, completed orders without charges, etc. Managed Care 5

6 Managed Care Tips Review your contracts to ensure you are receiving proper payments, i.e. specialists. Hardcode your modifiers and limit variations of NDCs. Build your reason code library to work for you. Work your denials you may discover a systematic issue i.e., FQHC Medi/Medi s, simultaneous billing issues. RECOMMENDATIONS TO ADDRESS THE ISSUES #1 Revenue Maximization Know what the opportunities are: Changes to regulations Health Plan Contracting Front desk collections Timely A/R follow up Clean Claim Management The person doing the work knows what isn t being paid! Billing Manager should know the system well enough to do regular spot checks on claims/denials What is your system capable of telling you? RECOMMENDATIONS TO ADDRESS THE ISSUES #1 Revenue Maximization Training Correct Payer Slide Program HEDIS, Quality Incentives, Meaningful Use Charge capture Denials Management Program Need easy access to reports in order to truly maximize revenue 6

7 Revenue Maximization Managed Care Wrap capture Insurance Portfolio with Wrap Data Filters: Start Date End Date Date of Service Range 1/1/2013 1/11/2013 Insurance Location (Facility) Insurance Visits (FFS/CAP) FFS Payments Wrap Visits Wrap Payments Molina MediCal Managed Care Grapevine 91 $3,295, $81, Horne Street 8 $325, $8, North River Road 61 $1,790, $51, Pier View Way 20 $654, $16, VTB Family Medicine 43 $1,269, $43, VTB Pediatrics 224 $7,285, $191, VTB Womens Center Main 52 $2,124, $48, Molina MediCal Managed Care - Total 499 $16,746, $441, Overall - Total 499 $16,746, $441, Revenue Maximization Quality/PCMH Measure Tracking NCQA (PCMH) - Problem List Compliance (2B1) Filter(s): Claim(s) not deleted, Claim(s) not voided Start Date of Service: Jan 1, 2013 End Date of Service: Jan 31, 2013 Location 2B1-2 Count (Medical Patients) 2B1 Count (Problem List) 2B1 Percent (Problem List) Grapevine 2, % Horne Street % North River Road % Pediatric- Other % Pier View Way 1, % VTB Dental % VTB Family Medicine 2, % VTB Pediatrics 2, % VTB Womens Center Main 1, % Overall - Total 10,484 3, % May 8, :08:58 PM Revenue Maximization Missed Opportunities Analysis Table 6B: Quality of Care Indicators (Section C) Filter(s): Claim(s) not deleted, Claim(s) not voided Date of Service Range: Jan 1, 2013 through Mar 31, 2014 Special Population: Universal (All Patients) Section C: Childhood Immunizations Childhood Immunization Total Number of patients with 3rd Number Charts Sampled or EHR Number of Patients Immunized (c) birthday during measurement year total (b) (a) Children who have received age appropriate vaccines who had their 3rd birthday during measurement year (on or prior to 31 December) Overall - Total May 8, :15:16 PM 7

8 Insurance Class Enc's Visits Visits % Claims Paid Claims Charges Chg/Claim Ins Pmts Pat Pmts Total Pmts Pmt/Claim Pmt/Paid Claim Total Adj Net A/R (#) Net A/R (Amt) Net A/R % Coll Rate Child Health Plus % $ 144,687 $ 228 $ 18,967 $ 83 $ 19,050 $ 30 $ 59 $ 134, $ 4, % 69.0% Commercial 28 2, % 2,641 2,206 $ 736,453 $ 279 $ 163,269 $ 22,506 $ 185,775 $ 70 $ 84 $ 392, $ 95, % 51.0% Commercial HMO % $ 29,004 $ 259 $ 9,742 $ 3,036 $ 12,778 $ 114 $ 105 $ 15, $ 3, % 72.8% Exchange % $ 12,695 $ 249 $ 2,746 $ 484 $ 3,230 $ 63 $ 154 $ 3, $ 2, % 46.9% Family Health Plus % $ 221,262 $ 241 $ 35,238 $ 1,032 $ 36,270 $ 39 $ 74 $ 173, $ 17, % 61.5% Medicaid 32 2, % 2,885 2,584 $ 708,926 $ 246 $ 318,829 $ 1,896 $ 320,725 $ 111 $ 124 $ 111,559 1,945 $ 345, % 40.2% Medicaid HMO 113 9, % 9,948 5,172 $ 2,816,091 $ 283 $ 456,986 $ 1,589 $ 458,575 $ 46 $ 89 $ 2,106, $ 211, % 67.9% Medicare 19 2, % 2,334 1,980 $ 522,090 $ 224 $ 191,854 $ 3,404 $ 195,258 $ 84 $ 99 $ 129, $ 29, % 72.2% Medicare HMO % $ 109,860 $ 240 $ 20,979 $ 803 $ 21,782 $ 48 $ 84 $ 75, $ 10, % 57.3% Self Pay 47 6, % 6,709 1 $ 1,577,696 $ 235 $ 109 $ 124,515 $ 124,624 $ 19 $ 19 $ 1,212,889 5,001 $ 444, % 34.5% Wrap Around/STPP % 10,035 9,162 $ 1,979,900 $ 197 $ 997,796 $ - $ 997,796 $ 99 $ 109 $ 832, $ 149, % 86.9% JAN - Total , % 36,726 21,129 $ 8,858,664 $ 241 $ 2,216,515 $ 159,348 $ 2,375,863 $ 65 $ 106 $ 5,186,466 9,568 $ 1,313, % 64.7% 5/15/2014 Revenue Maximization Root Cause Analysis A/R Aging ($) Billed No Sort Selected (A) No Denial Record (B) A1 (Claim denied charges.) (B) CDR04 (Elig- Incorrect Payor Attached) (B) CO109 (Claim not covered by this payer/contr...) (B) CO11 (The diagnosis is inconsistent with th...) (B) CO119 (Benefit maximum for this time period...) (B) CO125 (At least 1 Remark Code must be provided) (B) CO152 (Payment adjusted because the payer de...) (B) CO16 (Insurance not primary payor) (B) CO170 (Payment is denied when performed/bill...) (B) CO177 (Payment denied because the patient ha...) (B) CO22 (Payment adjusted because this care ma...) (B) CO24 (Insurance is not primary payor) (B) CO31 (Patient cannot be identified as insured) (B) CO40 (Charges do not meet qual for emerg/urg) (B) CO45 (Charges exceed your contracted/ legis...) (B) CO47 (This (these) diagnosis(es) is (are) n...) (B) CO58 (Payment adjusted because treatment wa...) (B) CO61 (Charges adjusted as penalty for failu...) (B) CO94 (Processed in Excess of charges.) (B) CO96 (Non-covered charge(s).) (B) CO97 (Payment is included in the allowance...) (B) COA1 (Claim Denied Charges.) (B) COB22 (Contractual Obligations-This payment is) (B) COB4 (Tmely Filling Reduction) (B) OA24 (Payment for charges adjusted. Charges...) (B) PR142 (Claim adjusted by the monthly Medicai...) (B) PR167 (This (these) diagnosis(es) is (are) n...) (B) PR26 (Expenses incurred prior to coverage.) Total Total Complete Financial Summary w/ Net Receivables Filter(s): Date of Service Range: Jan 1, 2014 through Jan 31, 2014 Billable Status(es): Billable A/R Excluded Claim Status(es): None - Do NOT Exclude Status(es) May 8, :51:02 PM RECOMMENDATIONS TO ADDRESS THE ISSUES #2 Is it the people or is it the system? How do you find the root cause of an issue? You need to know what you are looking for! Who manages Patient Management system? Do you or your staff know the integration between PM and EHR? How do you fix it? Who is responsible in your organization for putting action to your findings? How do you train on it? Someone needs to be responsible! Who is responsible to monitor it? 8

9 RECOMMENDATIONS TO ADDRESS THE ISSUES #3 There isn t enough time in the day! How do we ensure that works only gets done once? Reporting Clear understanding of who is doing what! Reports as Communication Audits The Billing Office finds an error who fixes it? Our Solution How do we set the right priorities in and out of department? Available resources RECOMMENDATIONS TO ADDRESS THE ISSUES #4 Billing s role in Compliance WHAT WE VE DONE Encounter Audits Registration Coding (Medical Necessity) Claims Payments Demographics Audit Correct Payer, Correct Slide, Correct Co Pay Collection RECOMMENDATIONS TO ADDRESS THE ISSUES #4 Billing s role in Compliance FQHC / Sliding Fee Scale regulations We are the guardians to ensure that Operations is following the regulations Program Eligibility Hold your billing staff accountable from knowing their payers Empower your staff to ask questions Policies & Procedures Set standardization throughout your organization 9

10 #5 A constantly changing environment Management must set the culture that we can always do better!... while being mindful to communicate that staff is doing a good job Shifting payer mix it all comes back to knowing the payers! Who knows them? Must prepare, test, and train for all system upgrades! Don t forget about your billing staff s involvement #5 A constantly changing environment Even with all our best efforts, staff leave Can be an opportunity to shift existing staff into the position they are best suited for Can be an opportunity to re align roles within the department Always an opportunity to bring new skill sets in Health Center Growth/Change Finance/Billing must have a seat at the table in all expansion talks for the beginning! LET S PLAY A GAME 10

11 LET S PLAY A GAME Fake it til you make it! KEEPING STAFF MOTIVATED Know what your staff is motivated by! Usually it is not money KEEPING STAFF MOTIVATED Long term staff engagement and recognition These people are your history book! Expect this is the way we ve always done it and break the pattern!! People want to be challenged and use their brains!! Find a way to use their knowledge Let them mentor new staff in the department Ask for their advice make a concerted effort to use them as the expert. Can lead to their further development. 11

12 KEEPING STAFF MOTIVATED Know what you know and know what you don t know! Encourage your people to do the same People work best when they are not afraid to fail Management that s us! must be a resource for them Be comfortable admitting that you don t know the answer and be willing to find it out for them! Address any issues they bring forth one way or another. Lack of response is discouraging, de motivating, and can quickly undo progress. KEEPING STAFF MOTIVATED Ideal face to face communication How productive are weekly meetings when you set the agenda? Let them talk!... And let them provide the solution. KEEPING STAFF MOTIVATED Remaining calm in the fire All management must be committed to not over react Fires become controlled burns! Staff must know that they will not get in trouble for identifying issues How do you let them know that you are all in this together? 12

13 Thank you 13