The Power of Revenue Management

The Power of Revenue Management Presented By Judy Capko Capko & Company www.capko.com The Power of Revenue Management 6/13/07 1

About the Speaker The Power of Revenue Management 6/13/07 2

The Speaker: Judy Capko A healthcare consultant and author of the run away topselling book Secrets of the Best-Run Practices. More than 20 years experience as a practice administrator and consultant. Emphasis on building patient-centered strategies, maximizing resources, and improving operational and financial performance. Hundreds of physicians and administrators have benefited from her advice and innovative, energetic approach to organizational management and strategic planning. National recognition in her field, working with both small and large practices, as well as major academic faculty practices from coast to coast. Popular speaker for major healthcare conferences such as MGMA, national specialty associations, healthcare systems, regional medical societies and healthcare executive summits. The Power of Revenue Management 6/13/07 3

Course Objectives Discuss key components of the financial mindset Review essential processes to get paid for what YOU do! Learn how to analyze collection performance Discover the importance of data to guide decision-making The Power of Revenue Management 6/13/07 4

The Revenue Chain Everybody Has A Role Patient Scheduler Receptionist Clinical Staff Physician Cashier Insurance Biller Collector Manager The Power of Revenue Management 6/13/07 5

Financial Mindset Capturing Charges Revenue Recovery Profitability The Power of Revenue Management 6/13/07 6

Financial Mindset Step 1 Financial Mindset Step I: Capturing Charges 1. Contracting & Eligibility 2. Coding and Documentation 3. Charge Reporting The Power of Revenue Management 6/13/07 7

Contracting Issues Who Will You Contract With? Is this a major player? Is the contracting agent solvent? Will you lose market share if you don t sign on? Are the Terms Acceptable? Educating Staff! The Power of Revenue Management 6/13/07 8

Practical Contracting Issues Reviewing Relevant Documents Credential and grievance QA & UM Are the Terms Reasonable? Coverage expectations Charge submission and payment timing In and out clauses Any Deal Busters? The Power of Revenue Management 6/13/07 9

Patient Registration Respect it! Patient s First Financial Document Is the form user friendly? Does it ask for essential information? Is it reviewed when it is completed? Legibility, accuracy, missing information Is it updated annually? The Patient Encounter Is information verified at each visit? The Power of Revenue Management 6/13/07 10

Front End Pre-Authorization Are Your Processes Well Defined? Who obtains it? Is there consistent documentation? Do they know the requirements? Are there check points? Is there accountability? The Power of Revenue Management 6/13/07 11

Accurate Coding of Services Is Charge Documentation Effective? Office charge ticket Hospital charge card Do all Caregivers take Responsibility? Is There a Resident Coding Expert on Staff? The Power of Revenue Management 6/13/07 12

Financial Mindset Step 2 Financial Mindset Step 2: Revenue Recovery 1. Claims Submission and Patient Billing 2. Reimbursement Management 3. Collection Management The Power of Revenue Management 6/13/07 13

Timely Charge Submission Charge Entry Office: 1 2 Days In Patient: 2 5 Days Billing Submission Office: 3 4 Days In Patient: 3 10 Days Surgery: 3 14 Days Why not raise the bar? The Power of Revenue Management 6/13/07 14

Monitoring Charge Reporting Performing an Audit Appointment record Chart notes Charge slip Patient ledger Explanation of benefits Are charges missed? Is coding accurate? How costly are your errors? *Cost to rework a claim = $22 *Source: Univ. of Utah Medical Group, Ingenix Conference 2004 The Power of Revenue Management 6/13/07 15

Coding Patterns The Bell Curve Comparative 4000 3500 3000 2500 2000 Established Patient 1500 1000 500 0 99212 99213 99214 99215 The Power of Revenue Management 6/13/07 16

Billing & Collection Procedures Financial Policies Are they in writing? Are they adhered to? Are the payment policies posted and/or available for patients? Collection Activities Third party (such as Transworld Systems) Non-covered services Patient responsibility Monitoring QC / backlog The Power of Revenue Management 6/13/07 17

Comparing Practice to National Benchmarks Maintow n Urology Percentage Collection Comparisons 70.00% 60.00% 50.00% 40.00% 30.00% 20.00% 10.00% 0.00% Dec-04 Aug-05 MGMA NAHC %Collections The Power of Revenue Management 6/13/07 18

Revenue Management Benchmarks Best Practices: Will vary by specialty Months in A/R = 1.5 to 2 Total A/R = less than two times monthly charges Aged A/R 90+ days = less than 20% of total Collection ratio = 95% of *adjusted charges *Adjusted charges refers to charges minus contractual adjustments The Power of Revenue Management 6/13/07 19

Practice Productivity ABC FAMILY CARE 2003 135,000 115,000 95,000 CHARGES 75,000 RECEIPTS ADJUSTMENTS 55,000 35,000 15,000 JAN FEB MAR APR MAY JUNE JULY AUG SEPT OCT NOV DEC The Power of Revenue Management 6/13/07 20

Spot Red Flags Dr. Nice Guy Monthly Activity $140,000 $120,000 $100,000 $80,000 $60,000 Charge Receipts Adjust $40,000 $20,000 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov The Power of Revenue Management 6/13/07 21

Dig Deeper Spike in adjustments Stockpiling adjustments Bad debt write offs Improper write offs Embezzlement Decline in receipts Poor payer performance Claims rejection Delayed payment posting Embezzlement The Power of Revenue Management 6/13/07 22

Analyze Patient Collections Over the counter (OTC) payments Co pays Old balances Patient responsibility Deductibles Non-covered charges The Power of Revenue Management 6/13/07 23

Establish OTC Collection Goals OTC Payments Average daily OTC collections Payment as % of patient s balance % of patients that paid the visit co-pay Historical performance $406 12% 55% 30 days target 50% 80% 60 day target 70% 100% 90 day target 90% 100% The Power of Revenue Management 6/13/07 24

Patient Payments Your patient statement Is it patient-friendly? Easy to understand Cycle billing Account follow-up Dunning messages Who does what and when? The Power of Revenue Management 6/13/07 25

Insurance Reimbursement Analysis Scrutinize EOBs Proper Payment Reasons for payment denial major carriers Collection Rates by Individual Payer/Provider Payment timing trends Contractual & bad debt write-offs Aging by Payer Class The Power of Revenue Management 6/13/07 26

120 Days Aged Payer Mix MEDICARE HMO 73% 9% 7% 11% PPO OTHER The Power of Revenue Management 6/13/07 27

Comparing Adjustments By Payer / By Doctor 40 35 30 25 20 Dr. A Dr. B Dr. C 15 10 Red Flags: Aetna Blue X Cigna Medicare 1) Cigna adjustments higher 2) Dr. B adjustments higher than Dr. A / C Why? The Power of Revenue Management 6/13/07 28

Compare Average Reimbursement Top 7-10 Codes / Top 5 Payers (by utilization) CPT Codes 99203 99204 99205 99212 99213 99214 99214 *Hassle factor Bl X Aetna Cigna ABC PPO Medicare *Assign 1 point for each hassle factor for a maximum of 5 points. The higher the points, the poorer the performance. Zero is best! The Power of Revenue Management 6/13/07 29

The Hassle Factor Examine the Indicators Requires repeated requests for referral or authorization Slow down in claims processing Delay or errors in payment Patients and/or employees complain about the insurance company / the plan Provider relations support is sub-standard The Power of Revenue Management 6/13/07 30

The Patient & Finances Communication Financial policies Patient responsibility Staff responsibility Patient statements Your Role as Patient Advocate The Patient s Role as Your Advocate The Power of Revenue Management 6/13/07 31

Tips On Billing Cycle Management Cycle billing Better work flow Better cash flow Dunning messages Prompt action & accountability Keep your word Make sure they keep their word The Power of Revenue Management 6/13/07 32

Staff - Physician Team Understanding THEIR Role Knowledge of Financial Policies Supporting Financial Policies Continued Education Staying Current Communication Accountability The Power of Revenue Management 6/13/07 33

Financial Mindset Step 3 Financial Mindset Step 3: Profitability 1. Cost Containment 2. Operational Efficiency 3. Customer Service The Power of Revenue Management 6/13/07 34

Making Data Driven Decisions Examining Historical Patterns & Shifts Patient and payer mix Provider performance Payer performance Practice Composition Has it changed and if so, why? Can we influence it do we want to? Profitability Productivity and overhead The Power of Revenue Management 6/13/07 35

Family Practice Benchmarks Description *National Benchmark Your Practice Variance Action Plan Gross Charges $543,157 Adjustments 163,941 = 29.7% Receipts $433,383 Operating Expense $248,834 57.4% Net Profit $186,797 = 42.8% Total A/R $71,411 *NAHC Statistics Family Practice N=411 The Power of Revenue Management 6/13/07 36

Productivity Factors Effective Scheduling Realistic templates Room utilization Monitor and manage Cancellations and no shows Two a day: $100 ea. X 192 d = $38,000 a year Take control Time out of Office The Power of Revenue Management 6/13/07 37

Operational Efficiency Staff Training Tools Accountability Turnover Automation Facility The Power of Revenue Management 6/13/07 38

Step Cautiously Into The Future Build and Strengthen Relationships Payers, referral sources, patients Stay Current With Market Trends Monitor Business Performance Invest in Automation Develop a Strategic Plan Set and achieve performance goals Live your mission The Power of Revenue Management 6/13/07 39

Q&A Judy.Capko@transworldsystems.com The Power of Revenue Management 6/13/07 40

The Power of Revenue Management Presented By Judy Capko Capko & Company www.capko.com The Power of Revenue Management 6/13/07 41