Leveraging Predictive Analytic and Artificial Intelligence Technology for Financial and Clinical Performance Matt Seefeld CEO & Co-Founder mseefeld@interpointpartners.com www.interpointpartners.com (404)446-0051 HFMA Fall Institute 2011
Agenda Purpose of Leveraging Predictive models and Artificial Intelligence Root Cause Analysis Defining Predictive Analytics Case Studies Revenue Modeling and Resulting Net Revenue Impact Financial Reserve Process Example Analytic Models Revenue Cycle Reserve & Hindsight Health Reform Marketing and Strategy Payor Mix Clinical Analytics Defining Artificial Intelligence Technology and Example Models Example Data Systems to Integrate with and Data Points to Extract from 2 Leveraging Predictive Analytic and Artificial intelligence Technology for Financial and Clinical Performance Nov 10, 2011 Confidential
Why Use Predictive Models and Artificial Intelligence Analysis? Today s rapidly changing healthcare landscape is forcing providers to look at IT solutions that drive advanced planning and understanding to make informed decisions. High demand for understanding how today s decision can impact future financial outcomes Rapid growth in digital data capture systems and the ability to link these systems to a centralize data warehouse creates unparalleled analysis flexibility Protecting every dollar in good revenue is imperative for long term financial viability Positive clinical outcomes will require the ability to look at decisions and outcomes in new and dynamic ways (especially to change Physician behavior) Lack of time to data mine and try to figure out why things are happening Go beyond Dashboards and Scorecards that tell you things are good vs. bad but don t tell you the why Bottom line is advanced technology models and root cause analysis engines can help your organization make informed business decisions. 3 Leveraging Predictive Analytic and Artificial intelligence Technology for Financial and Clinical Performance Nov 10, 2011 Confidential
Advanced Technology with Predictive Analytics / Forecasting Predicative Analytic models when built on a scalable and dynamic technology platform can pull data from an existing data warehouse or consolidate data from multiple stand alone systems. What are some key components to consider in the design of a Predictive Analytic technology: Allows the user to interact with the data points to generate what if scenarios Shows a trend line of historical data points compared to the future based on informed decision making Ability to drill down into the data (e.g. Inpatients, Medicare, Admit from ER) Ability to data cube to look at different dimensions (e.g. by payor, service, department) Identify the rate of change over time (e.g. at what rate is Medicare denials improving) Provide flexibility with setting time periods (e.g. Q3 compared to last Q3) Allows the user to apply various mathematical algorithms to assist in understanding the past, since the end user is likely to be more familiar with the current data These models will allow your team to Forecast future financial, operational and clinical impacts based on your knowledge today and using the appropriate historical data set. 4 Leveraging Predictive Analytic and Artificial intelligence Technology for Financial and Clinical Performance Nov 10, 2011 Confidential
The Old Way of Predicting Using Excel to run models time consuming and not flexible and have to be manually updated to change views (e.g. what if we wanted to look at Anthem Blue Cross for Neurology Inpatients admitted from the Emergency Department?) 5 Leveraging Predictive Analytic and Artificial intelligence Technology for Financial and Clinical Performance Nov 10, 2011 Confidential
A New Way of Predicting Using a dynamic and scalable technology to develop predictive models allows the user to run scenarios instantly saving time and improving insight into data that will help the decision making process. 6 Leveraging Predictive Analytic and Artificial intelligence Technology for Financial and Clinical Performance Nov 10, 2011 Confidential
The Old Way of Predicting the Reserve Process Using Excel to run reserve and liquidation models time consuming and not flexible and have to be manually updated each month or quarter depending on how often your organization updates the reserve process. Ability to change views would take too much time in Excel or Access (e.g. what if we wanted to look at Aetna insurance plans bad debt write-offs for Inpatient, Cardiology patients?). Reserve Modeling Payor Hindsight A/R Balance % Contractural % Bad Debt % Charity % Denied Current A/R Balance Est Contr. Allowance Est Bad Debt Est Charity Est Denials Blue Cross (4) $25,110,902 52.9% 1.2% 0.6% 0.6% $25,379,117 $13,276,134 $301,331 $150,665 $143,132 Champus (7) $5,120,274 74.8% 0.1% 0.1% 1.4% $4,987,949 $3,830,989 $7,168 $6,144 $71,172 Commercial/Managed Care (3) $32,115,744 37.3% 2.3% 1.2% 3.5% $32,100,192 $11,969,538 $738,662 $378,966 $1,124,051 Medicaid (2) $27,682,736 67.6% 0.8% 2.5% 0.1% $13,528,779 $18,724,603 $210,389 $692,068 $19,378 Medicare (1) $51,204,201 67.4% 0.1% 0.3% 1.4% $55,591,557 $34,521,872 $46,084 $143,372 $721,979 Self Pay (5) $37,715,282 0.0% 14.0% 15.2% 0.4% $46,140,949 $0 $5,280,140 $5,744,037 $147,090 Workers Comp (8) $2,029,889 50.7% 0.1% 0.0% 0.0% $1,567,858 $1,028,342 $1,624 $0 $406 Total $180,979,029 $179,296,401 $83,351,478 $6,585,397 $7,115,253 $2,227,208 The old way of reserving usually results in a time consuming process where you can only look at one view limiting flexibility and often times accuracy. 7 Leveraging Predictive Analytic and Artificial intelligence Technology for Financial and Clinical Performance Nov 10, 2011 Confidential
Defining the Variables Impacting the Reserve Process The changing healthcare landscape, specifically patient mix and payor behavior is putting tremendous pressure on Finance departments to have more dynamic ability to reserve appropriately: Rising uninsured and utilization of Emergency Services as their primary care medium Increase insurance premium cost being shifted to the patients (e.g. rising bad debt on commercially insured patients) Retrospective reviews (RACs) and other means of payors to delay payment, partially or completely deny services after they have occurred Appropriate classification of transaction codes so you have a complete and accurate liquidation of Gross Revenue Improving process at your hospitals are showing financial dividends much quicker than prior years (e.g. ABN processing, Medical Necessity screening, POS collections) Maintaining an accurate Contract Management system The bottom line is all these changes have a dramatic impact on predicting how much of each gross revenue dollar needs to be reserved for non cash write-offs. 8 Leveraging Predictive Analytic and Artificial intelligence Technology for Financial and Clinical Performance Nov 10, 2011 Confidential
A New Way of Managing the Reserve Process Dynamic reserve models (A) provide the insight to make more informed decisions on what you should reserve for each deduction to revenue. The ability to interact with your schedule (B) allows you to forecast beyond historical performance. Bullet 1 A B 9 Leveraging Predictive Analytic and Artificial intelligence Technology for Financial and Clinical Performance Nov 10, 2011 Confidential
A New Way of Managing the Reserve Process Using a dynamic and scalable technology to develop predictive reserve models allows the user to run scenarios instantly saving time and improving insight into data that will help the decision making process on how to reserve A/R appropriately. Be able to look back at Revenue liquidation for any period of time (e.g. 6, 9, 12 months) and segment the deductions to revenue for cash and adjustments Go beyond Financial Class views and be able to drill into specific insurance plans along with being able to set filters on other dimensions (e.g. patient types, services) Understand how well you are tracking to your expected reserve schedule from your prior analysis (e.g. Self Pay A/R is reserved for bad debt at150 days at 100% but your trend shows you will be at 100% bad debt write-off at day 120) Be able to save, share and collaborate within your technology medium with other key finance personnel for planning and executing the reserve process Be able to interact with the reserve model so you can change the projected reserve percents and see what the new reserve amount on current A/R should be These dynamic models allows your team to interact and forecast future financial reserve requirements and quickly adapt when required based on your knowledge today and using the appropriate historical data set. 10 Leveraging Predictive Analytic and Artificial intelligence Technology for Financial and Clinical Performance Nov 10, 2011 Confidential
Revenue Cycle Analytics What is the impact of changes in Payor Mix? What if we see a 5% increase in Medicaid volume? What if we see a10% increase in Medicare volume? What is the impact of changes in Cash Factor/Reimbursement? What if BCBS lowers it s fee schedule by 10% What if BCBS lowers it s fees on Procedure X? What if all payors lower fees on Procedure X? What is the impact of reducing denials by 10%? What is the impact of reducing bad debt by 15%? What is the impact of reducing A/R over 90 by 10%? What is the impact of reducing DNFB over 4 days by 20%? Other? 11 Leveraging Predictive Analytic and Artificial intelligence Technology for Financial and Clinical Performance Nov 10, 2011 Confidential
Reserve and Liquidation Analytics What is the impact of changes in Patient Type? What if we see a 10% in Emergency Room Self Pay Volume? What if we see a 15% increase in patient liability collections for elective same day surgeries at the point of service? What is the impact of claims for UHC being paid on average 10 days quicker? What if a group of Physicians are doing procedures that are being denied by Medicare? What is the impact if financial counselors are securing more charity care patients? What is the trending of my contractual allowance percents for iplan B01 zero balance accounts for the last 3 months? How about 6 months? What should I reserve for denials for medical necessity if I improve my level of care screening in the Emergency department? Other? 12 Leveraging Predictive Analytic and Artificial intelligence Technology for Financial and Clinical Performance Nov 10, 2011 Confidential
Health Reform Analytics What will be the impact of pending health reform proposals? What is the impact of an increase in government sponsored plans? Assume % of uninsured s move to government plan Assume % of commercially insured s move government plan Assume combination of both What will be the impact if Medicare moves to Value-Based Purchasing? What will be the potential impact of bundled payments? What will be the impact of reductions in certain DRGs? Other? 13 Leveraging Predictive Analytic and Artificial intelligence Technology for Financial and Clinical Performance Nov 10, 2011 Confidential
Marketing & Strategy Analytics Where are our patients coming from? Which communities have the preferred patient mix? What if we increase our volume from preferred communities by 10%? What service lines generate the highest revenue? Which communities should we target our marketing? Which services should be marketed in those communities? Should we build more Medical/Surgical Beds? What is the P&L impact of closing the Neurosurgery service line? Other? 14 Leveraging Predictive Analytic and Artificial intelligence Technology for Financial and Clinical Performance Nov 10, 2011 Confidential
Payor Mix Analytics Changes in the local market place What is the financial impact of a local employer closing? What service lines will see less volume because of the closing? What if Company X reduces their workforce by 10%? What if Company Y increases workforce by 10% What if self-pay increases by 10% due to rise in unemployment? Changes in the State Budget What is the impact of proposed changes to certain insurance plans? What if there is an increase in Medicaid numbers? What if Medicaid reduces reimbursement? What will be impact of an increase in Medicare beneficiaries due to Baby Boomers? What if more retirement communities are developed? Other? 15 Leveraging Predictive Analytic and Artificial intelligence Technology for Financial and Clinical Performance Nov 10, 2011 Confidential
Clinical Analytics What is the impact of Bystolic vs. Lisinopril in treating blood pressure reduction in males over 40 with benign hypertension? What is my RAC audit risk if my chest pain inpatients admitted from the Emergency room that stay less than 24 hours increases from 20% to 30%? If my medical necessity denial overturn rate increases 10% over the next quarter what is the net revenue impact? If I reduce my length of stay by.25 for top 3 DRGs when compared to the GMLOS for Cardiology patients how much bed capacity will be opened? Will it impact my off service placement rate? Other? 16 Leveraging Predictive Analytic and Artificial intelligence Technology for Financial and Clinical Performance Nov 10, 2011 Confidential
Advanced Technology with Artificial Intelligence Artificial Intelligence technology models will bring the answers root cause to the pressing questions you are faced with the constantly changing face of healthcare. These models are designed to run on their own and alert you to the key reasons on why your financial, operational, and clinical landscape is changing. What are some key components to consider in the design of a Artificial Intelligence Technology: Design models that have a direct impact to financial performance or clinical quality (e.g. changes in outstanding receivable; changes in length of stay; changes in payor mix) Implement automated alerts sent to PDAs and email when your landscape is changing in a negative or positive manner Stratify the variables that are driving the highest change for the areas you build Artificial Intelligence models around (e.g. AR is increasing Medicare IP over 90 days increasing) Build templates that help with the design of action plans based on what the models are telling your organization (e.g. reduction strategy for denials; improvement of cash factor) 17 Leveraging Predictive Analytic and Artificial intelligence Technology for Financial and Clinical Performance Nov 10, 2011 Confidential
Artificial Intelligence Root Cause Models Artificial Intelligence models should be aimed at identifying the variables that impact financial, operational or clinical efficiency and performance. Why are my A/R days and A/R over 90 levels increasing for commercial payors? Has my denial rate increased? Is my billing lag (discharge to claim submit date) increasing? Is my average days to pay increasing? Why is my length of stay going up? What are the top 3 DRGs, Physicians and Medical Services that are increasing the length of stay over CMS benchmark? Why is my cash flow over the last quarter down 6% compared to goal? Is my self pay revenue increasing? What are the top 3 services? Am I writing off more commercially insurance patient liability to bad debt? If so what payors? Why are my denial overturns declining? What are the top 3 denial codes driving the reduction in overturns? Is the volume of denials increasing causing workflow issue? 18 Leveraging Predictive Analytic and Artificial intelligence Technology for Financial and Clinical Performance Nov 10, 2011 Confidential
What Types of Data Sources to Extract from? Some critical data systems that will help improve financial performance, clinical quality, operations and overall strategic decision making for both predictive analytic and artificial intelligence technology models. Patient Accounting Cost Accounting Labor Management Non Labor Supply Chain Clinical Documentation Electronic Health Record Bed Management Standard Data Sets (835/837, 270/271) CPOE Decision Support Physician Practice Management 19 Leveraging Predictive Analytic and Artificial intelligence Technology for Financial and Clinical Performance Nov 10, 2011 Confidential
What Types of Data Dimensions should be Extracted Whether you are pulling from a centralized data warehouse or pulling from multiple disparate data sources it is imperative to think through what data fields will drive the most value. It is not recommended to pull every data point as that adds unneeded complexity and could cause confusion and impact user adoption. Some examples: Medical Service Patient Type Financial Class Department / Location Attending Physician DRG Diagnosis Codes Procedure Codes Insurance Plans Admit Source Patient Zip Code / City Admit & Discharge Nurse Stations Discharge Disposition Present on Admission Facility Code Supply Item Supply Cost Units Transaction Codes GL Code Charge Code Revenue Code Chief Complaint / Admit Diagnosis Total Charges Total Insurance Payments Total Patient Payments Total Adjustments Admit & Discharge Date & Time 20 Leveraging Predictive Analytic and Artificial intelligence Technology for Financial and Clinical Performance Nov 10, 2011 Confidential
Value Proposition of Leveraging Advanced Technology Building these interactive and automated technology models will help drive performance, awareness and accountability across your organization. Some key areas of immediate value: Improve Cash Flow Reduce accounts receivable Improve net revenue Increase gross revenue Improved Reserve Prediction Reduce bad debt expense Maximize outsourcing vendor commissions Protect every dollar of good revenue Decrease in FTE expense by automation Improve quality of care Reduce variation in Physician practice patterns Target marketing 21 Leveraging Predictive Analytic and Artificial intelligence Technology for Financial and Clinical Performance Nov 10, 2011 Confidential
Business Areas that Utilize these Models to Drive Performance Many business segments within your organization will utilize these interactive tools: Patient Access Patient Accounting HIMS Marketing Case Management Nursing Strategy and Operations Decision Support Procurement Labor Management 22 Leveraging Predictive Analytic and Artificial intelligence Technology for Financial and Clinical Performance Nov 10, 2011 Confidential
Questions? Matt Seefeld mseefeld@interpointpartners.com (404)446-0051 www.interpointpartners.com 23 Leveraging Predictive Analytic and Artificial intelligence Technology for Financial and Clinical Performance Nov 10, 2011 Confidential