Robin Bradbury 800-355-0410 robin@ereso.com Top Ten Questions 1. What are the key measures for the Revenue Cycle? 2. How do you document and share this information with the Revenue Cycle staff? 3. What is our cost to collect a dollar? 4. Do we have expectations and performance standards for our Revenue Cycle staff and do we monitor performance and provide incentives for excellence? 5. How are we managing the patient-responsible dollar? 6. Has a Chargemaster and charge capture review and assessment been performed recently? 7. What are our days in Discharge to Final Bill? 8. Are we getting paid what we should be paid for services performed? 9. Do we have an unpaid claims tracking mechanism? 10. Do revenue cycle stakeholders regularly engage in clearing open items and process improvement meetings? Time and Energy 1
Revenue Cycle 101 When performance is measured, performance improves. Revenue Cycle 102 Objective measures are always better than subjective measures. Question # 1 What are the key measures for the Revenue Cycle? 2
Key Measures Days in Revenue Outstanding Cash Collections Cash as a % of Net Revenue Write-offs as a % of Revenue Aged AR Greater than 90 Days Days in Discharge to Final Bill Up-front Cash Collections Benchmark Data HARA report Geographic region Your facility Free Benchmark Study http://www.ereso.com Sample Information: Facility Bed Size: 122 Average Daily Census: 38 Total Accounts Receivable: $8,000,000 Cash Receipts per Month $900,000 Gross Revenue per Month: $2,000,000 A/R Over 90 Days: $3,500,000 Monthly Cost of BO: $45,000 Write Offs per Month: $150,000 Number of Open Accounts: 19,000 Number of FTE's in BO: 12 Percent A/R in Self Pay: 40% 3
Value Proposition Actual Example Hospital Peer Group Difference Cash Opportunity AR Days Reduction 82 43 39 $1,476,815 Days over 90 Reduction 31.7% 24.4% 7.3% $217,374 DNFB Reduction 24.2 7.2 17.04 Cost to Collect Reduction $ 0.027 $ 0.025 $ 0.002 Bad Debt Write off Reduction 8.9% 2.3% 6.6% Charity Write off Reduction 1.9% 6.9% -5.0% $652,439 $33,356 $855,290 NA Question #2 How do you document and share this information with the Revenue Cycle staff? 4
Primary Communication Methods KPI Dashboard daily, weekly, monthly Key metrics and actual to goal performance posted in Revenue Cycle areas Formal team meetings and huddles (daily, weekly, monthly) Process improvement teams E-mail updates on progress and wins Other? Does consistent communication with employees really matter? Meetings Frequency and Type Do Matter Source: HFMA Strategies for a High Performance Revenue Cycle; Patient Friendly Billing Project 2009 Question #3 What is our cost to collect a dollar? 5
Benchmarks Good comparative measure (common definition) Some times flies under the radar if other metrics are good Important consideration when evaluating investment in resources more cash intake may be worth it National average for hospitals is $.03 per dollar collected Smaller and Critical Access hospitals closer to $.05 to $.10 per dollar collected Question #4 Do we have expectations and performance standards for our Revenue Cycle staff and.. Question #4 (continued) do we monitor performance and provide incentives for excellence? 6
Expectations and Performance Standards Measure metrics and behaviors Front end, middle and back office resources Raise performance level awareness Align goals Creates healthy competition Cream will rise to the top Expectations and Performance Standards Set by function/position and then globally Measure outcomes and behaviors Raise performance level awareness Create healthy competition Incentive plans Align goals Cream will rise to the top Wildly Important Goal 1 Teams need to be engaged in pursuit of the goal Teams should be involved in goal setting based on higher level plan developed Where do you want to go and what do you want to be and how do you want to perform and be recognized in the industry? 1 Drawn from text The 4 Disciplines of Execution by McChesney, Covey and Huling 7
Lead Measures Lead & Lag Measures 1 Those measures that are impacted and measured on a daily basis that impact the Lag Measures Quantity of calls made, quantity of accounts or credits resolved, promises to pay, etc Lag Measures Measures that occur after the fact Gross Days, Cash, Net Days, % of AR > 90 days, etc 1 Drawn from text The 4 Disciplines of Execution by McChesney, Covey and Huling Employee Engagement Q12 Questions from Gallup 1 In the last year, I have had opportunities at work to Learn and Grow. In the last six months, someone at work has talked to me about Progress. I have a Best Friend at work. My associates or fellow employees are Committed to Doing Quality Work. The Mission or Purpose of my company makes me feel my job is important. At work, my Opinions Seem to Count. There is someone at work who encourages my Development. My supervisor, or someone at work, seems to Care About Me as a person. In the last seven days, I have received Recognition or praise for doing good work. At work, I have the Opportunity to Do What I Do Best every day. I have the Materials and Equipment I need to do my work right. I Know What s Expected of me at work. 1 Drawn from Gallup Q12 https://q12.gallup.com/public/en-us/features?ref=homepage#section12q Changing the Paradigm 20 th vs 21 st century Impact of technology tools on performance expectations and standards and outcomes. Example follow-up Many operations across the country still deploy dated AR management techniques Pulling ATBs from PA systems and converting.txt files to Excel or using PA based account ticklers Then there is the painful process of filtering and sorting based on the strategy of the week How many labor hours are involved and how much overlap is there? Are your staff members focusing on the accounts that matter most? Are they able to stratify the accounts based on disposition? These same ATBs are then worked for multiple weeks with no targeted approach other than to filter based on the data elements available Bill date D/C date Account Balance Financial Class 8
Changing the Paradigm 20 th vs 21 st century What if each employee could have a defined workflow engine that was customized to their AR that segmented their accounts based on: Defined rules Real time claim status Focus on claims that require intervention, not those set to pay If you could reduce the number of accounts your staff had to touch by 65%-75% or more each week, would your staff be more effective? Would expectations and work standards change? Would you need the same quality/quantity of employees? Would you obtain different results? Question #5 How are we managing the patient-responsible dollar? The Process.. Registration Patient Data Charges Payer Contract Billing Claim Payment Cash Adjustments Self-Pay Collection Other Payers Cash Bad Debt 9
Common Profile of At Risk Hospital Self-pay A/R accounting for 40% or more of total A/R Ineffective or non-existent pre-registration, insurance verification, eligibility checking, and financial counseling No point of service collection efforts No management of early-out and primary bad debt vendor partners Inconsistent application of bad debt write off and charity policies No or very few tools used to maximize the self-pay portfolio Institute for Health Care Revenue Cycle Research - A Division of Zimmerman, LLC. National Pledge to Reform Uncompensated Care Reform Underway: Adopting Best Practices to Reduce Uncompensated Care and Improve the Patient Experience. a special supplement to PATIENT PAYMENT BLUEPRINT 10
When Respondents Who Had Received Recent Medical Care Learned the Cost of their Treatment 63% don t know the treatment costs until the medical bill arrives; 10% never know the cost. When did you learn what the total cost of the treatment would be, including the amount that the insurance company would pay? Source: Great-West Healthcare 2005 Consumer attitude toward healthcare survey Emergency Room 1/3 of ER patients have no insurance 29% national average collect in ER Discharge collection process Need centralized exit point Joint effort (nursing and registration) Give yourself a chance to collect Potential Affordable Care Act Impacts on Self-Pay, Bad Debt, and Charity Uninsured but eligible patients CMS certified application counselor organizations; employee training In-network vs. out of network coverage ACA regulations cap OOP expense for in-network but not for out of network Benefit/eligibility verification nuances may need more diligence to identify plan details and to ensure that hospital and physicians are in the network for the patient s plan Patient responsibility assume patients won t know their deductible and copayment requirements Unpaid premiums delinquency impact consumers vs. providers; consider starting a reserve fund Charity care analyze early experience and adjust policies accordingly 11
Best Practices? Estimate, Validate, and Advocate Estimate charges, insurance coverage and patient portion (Eligibility and Benefit Verification) Validate demographic, financial, and insurance information (Demographic Data Validation) Advocate for the patient to deal with the obligation (Propensity to Pay) -Cash, Check or Credit Card -Payment plan -Medicaid Eligibility (Payer Search) -Charity Care (Presumptive Charity) -Reschedule? Technology solutions available to support these functions Self Pay Strategy Platform Deliverables Patient Demographic Data and Diagnosis Financial Data Financial Assessment Algorithm Client Specific Payment History Estimated Charges Eligibility Verification Estimated Income Charity Recommendation Maximum Payment Recommendation Payment Propensity Work-Flow Management 12
Results Measurable Results from Presumptive Charity Policy and Self Pay Stratification Reduced placements of self pay accounts to collection agencies by nearly 50% within first six months Increased cash receipts on self pay accounts by over 22% during first 90 days Reduced FTE allocation for follow up on self pay accounts by 25% Reallocated 60% of FTE staff previously assigned to charity application processing Where Are Your Peers Spending Money and Time? Source: HFMA Strategies for a High Performance Revenue Cycle; Patient Friendly Billing Project 2009 Question #6 Has a Chargemaster and charge capture review and assessment been performed recently? 13
Inpatient Treatment Outpatient Treatment EKG EKG DRG Coding APC Coding EKG DRG Payment APC Charge Capture Review Outpatient revenues are significant particularly in rural/community hospitals CMS indicates a 50% underpayment Better performers have these common aspects: Dedicated ownership of process (75%) Supported by technology (47%) Independent reviews (46%) Marshalltown example Effective Charge Capture Review Program Quarterly review of outpatient payments compared to charts Utilize a Nurse Auditor Change processes to capture all charges Retroactively re-bill when appropriate Improve reimbursement 14
Question #7 What are our days in Discharge to Final Bill? Days from Discharge to Final Bill Indicator of effective front end, charge capture and coding process Clients have wide range from 3 25 days Break into parts Sample accounts Determine where the bottlenecks are Doctors sign-off Coding Daily billing Potential Solutions Outsource some of the Coding Use Super Coders on an as needed basis train staff Set goals and expectations Monitor top ten DNFB accounts 15
Question #8 Are we getting paid what we should be paid for services performed? Reimbursement % by Payer EOB review sampling Compare to net revenue calculation Use of software to monitor payment Outside review on contingency fee Payer report cards and payer meetings Most hospitals are leaving 2% to 5% on the table of non-government reimbursement if not using a contract management service Best Practice Payer Collaboration Source: HFMA Strategies for a High Performance Revenue Cycle; Patient Friendly Billing Project 2009 16
Question #9 Do we have an unpaid claims tracking mechanism? Unpaid Claims Tracking Monitoring Trends Improve the front end processes Unpaid claims versus denial tracking Should take a systemic view - unbilled and denials Unpaid Claims Measurement Tool 17
Question #10 Do revenue cycle stakeholders regularly engage in clearing open items and process improvement meetings? Regular Clearing Meetings Collaboration between multiple functions, backgrounds, and skill sets Focus on large dollars use a top ten concept Recurring errors Open communication and no finger pointing May require senior management involvement Next Steps Discuss these questions with Revenue Cycle leader or key stakeholders Perform Benchmark Indicator Analysis (BIA) As a Revenue Cycle team, review the results Set realistic goals and expectations and achieve them 18
Same Services More Dollars Learn from the mistakes of others you can't make them all yourself. E. Roosevelt About re solution Founded in 1998 120 consultants Safety net concept There when you need us. Gone when you don t. Reducing cost to collect through proprietary technology Customized software and services leading to process improvement We increase cash by implementing best practices along with technology when appropriate 57 19
About re solution Services include: -Insourcing -Cash Acceleration -Revenue Cycle Assessments -Training and Mentoring -Interim Management and Staffing Focus on rural and community hospitals Questions? 20
Robin Bradbury 800-355-0410 robin@ereso.com 21