The Importance of Patient Access to Revenue Cycle Success

Transcription

1 MOBILE ONE DAY OCTOBER 28, 2014 USA CHILDREN S & WOMEN S HOSPITAL The Importance of Patient Access to Revenue Cycle Success Presented by: Paul Shorrosh, MSW, MBA, CHAM Founder & CEO

2 Session Agenda Challenges driving change Front-end opportunities A Proactive vs Reactive Revenue Cycle WHAT? Clearance, Collections, Conversions WHEN? Ordering>Scheduling>Pre-Reg>Arrival>Registration NAHAM Initiatives: Patient Access KPI s FTE Calculator Pre-Registration Tasks & Tiers Pre-Registration self-assessment Propensity-based Financial Assistance Outsourcing Pre-Registration

3 Target for Change: The Uninsured

4 Uninsured Rates Dropping

5 Uninsured by State

6 Uninsured by Age

7 Rising Under-Insured Health Insurance Status Non-Elderly %* Privately Insured (alone or in combination) 16.1%* Other %* Uninsured Estimated 10% Under- Insured * Health Status, Health Insurance, and Medical Services Utilization: 2010, Current Population Reports, U.S. Census Bureau, Washington, DC, %** Privately Insured (alone or in combination) 33.4%** Other %** AccuReg Uninsured PRO In-House **Congressional Budget Office Under- Insured (unaffordable BAI)

8 Insurance Redistribution AccuReg Confidential

9 AccuReg Confidential

10 AccuReg Confidential Source: HealthPocket.com

11 Provider Sources of Revenue Payer Mix Liability Mix Before ACA After ACA 80% Payer 60% Payer 20 20% Patient Deductibles Co-payments Co-Insurance 40% Patient 20 AccuReg PRO In-House AccuReg Confidential

12 Opportunity: Clearance (Insurance) Scheduling Pre-Reg Reg Service Billing Collections AccuReg Confidential

13 Opportunity: Collection (Patient Liability) 70%* chance to collect from patient pre-service 30%* chance to collect from patient after service Scheduling Pre-Reg Reg Service Billing Collections AccuReg Confidential *According to Academy of Healthcare Revenue and The Advisory Board

14 Opportunity: Conversion (Private Pay) Scheduling Pre-Reg Reg Service Billing Collections AccuReg Confidential

15 Traditional RCM Focus: Billing & Collection Payer Billing & Collections Denials Management Calculating Patient Liability After Payer Reimbursement Outsource Patient Billing & Collections Ordering Scheduling Pre- Registration Registration Service Billing Third Party Collections AccuReg Confidential

16 New RCM Focus: Front End Revenue Cycle Denials Prevention (Automation of Critical FERC Processes: EV, MN, AM, ID, AV, QA) Estimating Payer vs Patient Liability Before Service Assessing Patient Propensity and Ability to Pay Identifying Alternative Payment Sources Collecting Patient Liability Presumptive Charity Ordering Scheduling Pre- Registration Registration Service Billing Third Party Collections AccuReg Confidential

17 Shift the Revenue Cycle to the Front to: Prevent Denials Increase Collections Divert Bad Debt Improve Patient Experience AccuReg Confidential

18 3 Front-End Opportunities: Clearance Identity/Address Verification Eligibility Verification Medical Necessity Prior Authorization Demographics Verification Collection Estimation & Collection Conversion Screen for 3 rd Party Sponsorship Screen for Financing Options Screen for Charity Care AccuReg Confidential

19 Pre-Service Clearance & Collections Shift the revenue cycle to the front? This These This These patients insured has patients is a an require possible out-of-pocket patients have a Prior Medicare a have high Authorization/ABN. estimate a deductible hidden readmission. of coverage. $2,578. plan. DSI Confidential

20 Conversions Prior to Service Reduces Bad Debt Traditional Model Uncompensated Care Pre-Service Model 40% Bad Debt 80% Bad Debt 20 20% Charity Identified Or Qualified 30% Converted to 3 rd Party Coverage or Financial Asst % Charity AccuReg PRO In-House Presumptive Eligibility Financing Loans Discounts Presumptive Charity AccuReg Confidential

21 Conversions Prior to Service Reduces Early Out Costs Traditional Model Pre-Service Model $11.8m Self Pay Accounts Outsourced 20 Agency identified coverage of $1.2m at cost of 15% =$180,000 Qualified Identified $8.2m TRUE Self Pay Outsourced $3.6m Convertible to 3 rd Party Coverage or Financing 20 Front-end identifies coverage of $1.2m at EDI cost of <$5,000 AccuReg PRO In-House Presumptive Eligibility Financing Loans Discounts Self-pay Eligibility Verification AccuReg Confidential

22 Sample PAS Financial Impact 4-hospital health system in Southeast Annual Net Patient Revenue (NPR): $380 Million Self-Pay: 9% Clearance (FE denials 2.5% of NPR) = 9.5M Collections: BAI = $18M uncollected in 2013 (5% of NPR) SP est. 0.5% of NPR = 19M Conversions (est 10% of SP) = 3.4M Total Front-End Revenue Opportunity: $50M or 13% of NPR Cost of solutions: $500k/yr (100:1 ROI)

23 National Association of Healthcare Access Management (NAHAM) Board of Directors Industry Standards Committee Chairman AccuReg Confidential

24 Key Performance Indicators Patient Access Domains NAHAM AccessKeys: 1 Collections 5 2 Conversions 1 3 Patient Experience 2 4 Process Failure/Resolution 5 5 Productivity 7 6 Quality 2 Total Number of KPI's: 22 Industry Standards Committee s Guiding Principles: 1. Simplicity 2. Vision Forward 3. Relevancy to Operational Managers 4. Scalability to all facilities regardless of size or sophistication 5. Focus on measuring outcomes vs activity

25 AccuReg Confidential

26 Process Tiers Tasks Pre-Reg Task AccuReg Confidential NAHAM Pre-Reg Tasks & Tiers TIER ONE: Basic Pre-Reg TIER TWO: Clearance TIER THREE: Collection TIER FOUR: Conversion 1 Review Scheduled Visits 2 Verify Physician Orders 3 Create Accounts in HIS/ADT 4 Assign Medical Record Number 5 Collect Demographics 6 Verify Addresses 7 Verify Employment/Retirement 8 Determine Financial Responsibility 9 Collect Insurance Information 10 Contact Patient 11 Quality Review 12 Insurance and Benefits Verification 13 Medicare Secondary Payer/COB 14 Medical Necessity Screening & ABN 15 Authorization Screening & Obtainment 16 Estimate Patient Liability 17 Collect Patient Liability 18 Screen for Finanical Assistance 19 Arrange Payment Plan 20 Refer to Financial Resources 21 Qualify and Enroll for New Benefits

27 NAHAM s Pre-Registration Tiers Tier 4 Tier 3: Collection Financial Clearance Tier 2: Insurance Clearance Tier 1: Basic Pre-Registration What Tier are you? DSI Confidential

28 Pre-Registration Process Roadmap Required Processes: Work Distribution System, Identity Verification, Address Verification, Quality Assurance, Workflow Tier 2 Clearance Tier 3 Collection Tier 4 Conversion DSI Confidential Tier 1 Basic Pre-Reg

29 Pre-Registration Process Roadmap Required Processes: Automated Eligibility Verification, Medical Necessity Screening, Authorization Management, Workflow Tier 2 Clearance Tier 3 Collection Tier 4 Conversion DSI Confidential Tier 1 Basic Pre-Reg

30 Pre-Registration Process Roadmap Required Processes: Patient Liability Estimation, Payment Processing, Financing Plans, Collections Reporting, Workflow DSI Confidential Tier 1 Basic Pre-Reg Tier 2 Clearance Tier 3 Collection Tier 4 Conversion Essentials for POS Collections: 1. Executive Support 2. Liability Estimations 3. Propensity Scripting 4. Collections Training 5. Reschedule Policy 6. Incentives 7. KPI Visibility & Accountability

31 Pre-Registration Process Roadmap Required Processes: Propensity-based Financial Assistance, 3 rd Party Sponsorship, Charity Screening, Workflow Tier 2 Clearance Tier 3 Collection Tier 4 Conversion DSI Confidential Tier 1 Basic Pre-Reg

32 Major Key: Workflow Technology Automated, Individual, Exception-based & Enforcement-focused Error Warning Policy# returned by payer is different than policy# in Epic. ABN Required. Print form for signature. Eligibility Verification Medical Necessity Warning Error Authorization required. Call Red Flag Alert: SSN was issued after patient birth year. Authorizations Identity Verification Opportunity Estimated amount due is $1,500. Payment Estimation Opportunity %FPL < 100%. Offer 80% discount. Collect $250. Financial Screening Opportunity Charity care candidate. Complete charity care application. Financial Screening AccuReg Confidential

33 Pre-Reg Self Assessment Are you scheduling 40% of expected registrations 2 days prior? Are physicians scheduling 80% of patients electronically? Are you pre-registering 90% of scheduled patients? Do you know what Pre-Reg Tier you are currently operating in? Are 80% of pre-registrations completed per your Tier level? Are front-end denials (1 st pass) reducing by 50%? Do you verify eligibility on all patients including self-pay? Are you estimating and collecting >1% NPR? (copay/ded/co-ins) Are you screening self-pays for charity or 3 rd party coverage? Do you have a propensity-based re-schedule policy? Do you offer propensity-based financial assistance? (discounts, loans, payment plans) DSI Confidential

34 Propensity-based Financial Assistance High Propensity, Low Ability Loan (avg terms) Prompt Pay discount Payment plan Medicaid/Exchange Low Propensity, Low Ability Medicaid/Exchange Presumptive Charity Loan (easy terms) High Propensity, High Ability Make maximum collection effort prior to service Prompt pay discount Low Propensity, High Ability Make maximum collection effort prior to service Reschedule AccuReg Confidential

35 Outsourcing Pre-Registration Less Cost Infrastructure Staffing Technology Less Risk Efficiency Productivity Contingency Model Is it a Core Competency? Typical Daily Productivity and Process Depth: 20 Tier 1 40 Tier 4 AccuReg Confidential In-House Outsourced

36 Process Collect Satisfied Patient Speed Front-End Staff can and will Produce Revenue Cycle Results. Prevent Denials Increase Collections Divert Bad Debt AccuReg Confidential

37 THANK YOU ALABAMA HFMA!! Paul Shorrosh, CEO