Revenue Cycle Maximization

Transcription

1 Revenue Cycle Maximization Revenue Cycle Maximization Presented by: Peter Bowhall CEO Andrea Neace ClaimRemedi, Inc. Santa Rosa, CA

2 FQHC Revenue Cycle At its core is the Claim Revenue Cycle Maximizing claim revenue Accelerating claim revenue Managing the process

3 Claim Revenue Cycle The complete Claim Revenue Cycle process involves: Staff clinical, front desk, billing office EMR/PM systems Clearinghouse/EDI Services

4 Survey- Question Survey Question: Do you know what percentage of your claims are denied?

5 Survey- Response Do you know what % of your claims are denied? Survey said: 24% = 1%-10% denial rate 28% = 11%-30% denial rate 6% = 30%-50% denial rate 42% = don t know

6 Rejection/Denial Statistics 20%-30% of claims are rejected or denied on first submission 33% of denials are not recovered (The Physician Billing Process) Initial claim cost = $5-$7 versus $25-$30 to rework a rejected/denied claim

7 Payment Statistics Payers report the incorrect contracted payment rate on 12%-21% of claims 20% of claims are underpaid Underpayment equates to 7% of net revenue

8 What s Ahead 5010 (January 2012) ICD10 (October 2013) Physician Quality Reporting Initiative PQRI (2015)

9 Claim Lifecycle Management Eligibility Claim Submission Claim Scrubbing & On-line Editing Claim Tracking - Management by Exception ERA Processing Analytics Denial Management, Benchmarking, Dashboards

10 Eligibility Verification One of two ways to reduce first pass rejections Eligibility is one of the most common causes for claim rejections Study 8% of total claims submitted rejected due to eligibility issues

11 Eligibility Verification Is the patient covered? Does the patient have other insurance? Do we have the correct registration info? What are the maximum allowable visits? What is the patient s share of cost? The first step in the claim revenue life cycle.

12 Eligibility Statistics 79% of practices check patient eligibility. 24% check patient eligibility every visit (MGMA-Larson Allen LLP). Best performers check eligibility: For all patients Every patient visit Using EDI technology

13 Best Performers Lower A/R days and shorter collection cycle. Other things they have in common: They do more analysis than others They have more support staff per provider They utilize more technology services

14 Claims Scrubbing The second way to reduce first pass rejections Identify & correct errors before claims are sent to payers Reverse engineer ERAs to identify payer specific edits

15 Scrubber Rules Engine Why reverse engineer ERAs to identify payer specific edits? Edits vary significantly by payer Many payers do not use industry wide standards Many payers use undisclosed proprietary edits We do not release what we do and do not edit.

16 Claim Management Track and monitor the status of all claims after they have been forwarded to payers. Manage by exception those claims that are: Rejected, pended or denied claims requiring rework or follow-up Missing in action payer lost or never received claim

17 Claim Management

18 Claim Management

19 Claim Management Proof of timely filing: Claims that never make it into adjudication Payers want to see the acknowledgment they sent you not your record of when you sent claims

20 Revenue Cycle Management You can t manage what you don t measure. Claim Revenue Cycle Management consists of: Managing denials Comparing payer reimbursements with contracted amounts

21 Analytics If you are getting 835s (ERAs) & 277s, you have all the data you need. Data is not information. You have to torture it before it becomes useful. (MGMA conference) Analytics tools are often underused. Enables you to manage the claim process instead of letting the claim process manage you.

22 Denial Management Managing denials with technology instead of manual processes can significantly lower your A/R days no matter how good your manual processes are. Identify reasons for denials Implement staff training at the source Reduce denials Fix process instead of fixing individual claims Measure effectiveness of denial management

23 Denial Management

24 Denial Management

25 Denial Management Track denials by payer, procedure, provider, location and user. Identify who or what is causing denials front desk, back office, etc. Identify problem payers & their requirements Drill down to claim detail

26 Payment Monitoring Track actual allowed amounts by procedure, modifier & payer: Ensure payments are in line with your contracts Identify underpayments Those who monitor allowed amounts will find incorrect payments from payers.

27 Payment Monitoring

28 Underpayments How do payers underpay: Payer errors Partially paid claims Downcoding

29 Payment Monitoring

30 Payer Comparisons Compare payers by: Reimbursement allowed amounts by procedure & modifier Denials Days to pay

31 Days to Pay Days to Pay

32 Payment Monitoring

33 How Do You Compare How do you compare with other provider organizations? How do you stack up? By specialty, zip code, state & payer Allowed amounts by procedure, modifier & payer Denials What percentile do you fall into?

34 How Do You Compare

35 Questions? Questions?