POST ACA REVENUE CYCLE TRANSFORMATION

Transcription

1 POST ACA REVENUE CYCLE TRANSFORMATION

2 Agenda Intro Revenue cycle features ACA impact areas What did we expect? UDS and PMG data analytics Top to-do items Summary

3 ICD 10 Update* Encounters with DOS post 10/1/2015 need to use ICD 10 Codes Largest change in coding in 20+ years Potential of significant cash flow issues Daily update suggested from billing - # Denials Significantly more time needed to fight denials * Caresource Medicaid (OH) paid 29,674 FQHC claims & 11 ICD10 denials. Medicare Intermediary in OH paid 2,340+ ICD 10 claims

4 Revenue Cycle Features Demographics Manage Denials Charge Entry Unpaids & Appeals Transmit Claims Patient Statements Post Payments General Management Close & Reporting ALL MISSION CRITICAL ACTIVITIES PRE- AND POST-ACA!!

5 What did we expect? Decrease in self-pay volume Increase in Medicaid enrollees Medicaid represents 64.3% (2013) & 66.9% (2014) of total payments Elevated blended encounter rate CHCs make more money Expanded healthcare exchanges RCM/Billing staff feeling more burdened Over-burdened outcome: Elevated AR Lower performance around KPI

6 UDS Data - Insurance & Visits CY13 vs. CY14 Mix of insured vs. uninsured Uninsured decrease, -7% (7.6M to 6.4M) Insured increase, +7% (14.1M to 16.5M) Patient visit volume Increase, +5.3% (+21.7M to 22.9M) **Possible $100+ per visit swing from slide patient vs. Medicaid Source: Geiger Gibson & RCHN Community Health Foundation Research Collaborative; Policy Research Brief # 42

7 UDS Data - Insurance & Visits Source: Geiger Gibson & RCHN Community Health Foundation Research Collaborative; Policy Research Brief # 42

8 UDS Data - Growth in Patients Source: Geiger Gibson & RCHN Community Health Foundation Research Collaborative; Policy Research Brief # 42

9 UDS Data - Insured vs. Uninsured Delta Source: Geiger Gibson & RCHN Community Health Foundation Research Collaborative; Policy Research Brief # 42

10 UDS Data National National Charges 2012 National Payments 10% 27% 13% 47% medicaid medicare public private self pay 4% 12% 10% 64% medicaid medicare public private self pay 4% 9% Source:

11 UDS Data AK AK Charges 2012 AK Payments 10% 26% 34% medicaid medicare public private self pay 26% 51% medicaid medicare public private self pay 26% 13% 1% 1% 12% Source:

12 UDS Data 2014 National 2014 National Charges 2014 National Payments 10% 26% 13% 47% medicaid medicare public private self pay 4% 12% 10% 64% medicaid medicare public private self pay 4% 10% Source:

13 UDS Data 2014 AK AK 2014 Charges AK 2014 Payments 11% 28% 34% medicaid medicare public private self pay 26% 51% medicaid medicare public private self pay 24% 13% 1% 1% 11% Source:

14 UDS Data Thoughts I Trends Less self pay in 2014, should continue in 2015 More insurance visits higher reimbursement per encounter Splintering of payer mix - Credentialing/enrollment needs Additional patient visits in 2014, right size billing staff Increase in self pay/slide payment per encounter

15 UDS Data Thoughts II AK Expanded Medicaid effect for FQHCs 20 states, no state expansion program 28% still uninsured (indefinite?) Data integrity, suspect Sustainable trend? Premium payments continued? Source: Geiger Gibson & RCHN Community Health Foundation Research Collaborative; Policy Research Brief # 42

16 Blended Encounter Rate - What is it? Average payment per visit/encounter How to calculate: Total Payments Total Visits* = Blended Encounter Rate vs. (different than knowing) Medicaid or Medicare Rate.

17 Blended Encounter Rate 2012 UDS Data.. Pre-ACA Average payment per visit/encounter How to calculate: National, ALL CHC UDS data 2012 National UDS 5 Line 34 (Grand Total Visits) 83,766,153* 2012 National UDS 9D Line 14 B Collection $9,024,236,793* 2012 National Blended Encounter Rate: $107.73/visit* Alaska Only 2012 AK UDS 5 Line 34 (Grand Total Visits) 515,046** 2012 AK UDS 9D Line 14 Collection $80,042,598** 2012 AK Blended Encounter Rate: $155.41/visit** * **

18 Blended Encounter Rate 2014 UDS Data: Post-ACA Average payment per visit/encounter How to calculate: National, ALL CHC UDS data 2014 National UDS 5 Line 34 (Grand Total Visits) 90,379,441* 2014 National UDS 9D Line 14 B Collection $11,416,470,097* 2014 National Blended Encounter Rate: $126.32/visit* Alaska Only 2014 AK UDS 5 Line 34 (Grand Total Visits) 537,310** 2014 AK UDS 9D Line 14 Collection $97,682,138** 2014 AK Blended Encounter Rate: $181.79/visit** * **

19 Blended Encounter Rate: Post-ACA Average payment per visit/encounter Average AK community health center reimbursement per encounter 2012 $ $ $

20 UDS Data: Payer Mix Shift 2013

21 UDS Data: Payer Mix Shift 2014 Uninsured Delta: -7.57% (Decrease) Medicaid Delta: +8.16% (Increase) CHiP Delta: -.17% (Decrease)

22 Post-ACA RCM Focus Item #1 Billing 101 RCM = Revenue Cycle Management Get paid as much as able on first claim submission Clean Claim Get paid as much as you are able (legally entitled) when you can, so you can give it away when you want to RCM Expert??? CFO Billing Manager Outside Firm

23 Post ACA RCM Focus Item #2 RCM Benchmarking Expense as percent of payments: < 9% Cost per claim: < $8 Electronic claim transmission: 90%+ Clearinghouse utilization: Yes Certified staff: At least one RVU/Medicare based charges: Yes < 30 DAR ICD 10 denials reported and fixed AR over 90 Days, < 20% Net AR: As close to $0 as possible

24 Post-ACA RCM Focus Item #3 Enrollment Medicaid encounter rate rocks Took ACA $ or not get patients enrolled Expand Medicaid patient base Teach all staff to recognize opportunity to enroll Volunteer staff focus on outreach Room on CHC website explaining: Plan options with benefit detail in plain language Open enrollment deadlines

25 Post-ACA RCM Focus Item #4 Better Front Desk Battle is won or lost at the front desk. Eligibility check every patient every time Check every patient every time 15-20% of ACA beneficiaries, no premium paid TOS payment SFS Slide deductibles and copayments No insurance verified pay cash (NO EXCEPTION) Start Triangle of Communication with regular meetings RCM (Billing) to Front Desk to Providers

26 Post ACA CHC Focus Item #5 Maximize Performance Share understandable data Picture worth a 1,000 words Again, Triangle of Communication Who are in-house experts & accountable?? Target charges/payments. CFO Acceptable denials Billing Manager System optimization IT Lead Provider productivity Medical Director (other?)

27 Post ACA CHC Focus Item #5 Data Example

28 Summary USE RCM Data Analytics Look for trends ICD 10 Review and plan of attack Regular and persistent review Defined/Targeted performance expectations Control what is controllable Hold people accountable