Transcript Setting Your Organization Up for Success

SETTING YOUR ORGANIZATION UP FOR
SUCCESS: UNDERSTANDING THE COMPLEXITIES
OF THE REVENUE CYCLE
Kentucky Primary Care Association, 2016 Fall Conference
Thursday, November 10, 2016
9:00am – 10:15am
The following information was used as visual aid during a
presentation/training session led by a BKD, LLP advisor. This content was
not designed to be utilized without the verbal portion of the presentation.
Accordingly, information included on these slides, in some cases, are only
partial lists of requirements, recommendations, etc. and should not be
considered comprehensive. These materials are being issued with the
understanding they must not be considered legal advice.
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CONTAINING COSTS
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The Revenue Cycle
THE REVENUE CYCLE
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Charge structure
Patient scheduling
Patient registration
Pre-appointment activities
Patient flow
Charge capture & entry
Third-party billing
Denial management
Patient collections
DO ALL OF THE PIECES FIT?
KEY PIECES OF THE REVENUE CYCLE PUZZLE
Patient
Scheduling
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Validate patient
demographic data
Utilize automation/
technology to verify
insurance coverage
in advance of visit
Set payment
expectations
Notify patients of
required
documentation
needed at
appointment
Patient
Check-In/Out,
Appointment
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Re-confirm
registration/
insurance
information
Collect copay
Collect outstanding
balance
Schedule follow-up
appointment
Correct
documentation;
coding & charge
capture
PostPatient Visit
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Charge
reconciliation to
services rendered
Clear &
understandable
statements
Claims scrubber
process (PMS
and/or
clearinghouse)
Manage claims
rejections & denials
A/R follow-up
Collections process
RESOURCES
CHARGE STRUCTURE
Health Centers:
• PIN 2014-02
 Sliding fee discount
schedule
 Fee schedule
1. Services
2. Reasonable costs
3. Local prevailing rates
 Other provisions to
consider
BILLING & COLLECTIONS
• Health Center programs must:
 Maintain adequate cash flow to support
operations
 Maximize revenue from non-Federal sources
 Have systems in place to maximize collections &
reimbursement for its costs in providing health
services, including written billing, credit &
collection policies & procedures. (Section
330(k)(3)(F) & (G) of the PHS Act)
BILLING & COLLECTIONS, CONT.
• Revenue maximization requires:
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An adequate & competitive fee schedule
A corresponding schedule of discounts
Prompt & accurate billing of third-party payers
Billing of patients in accordance with the schedule
of discounts
 Timely follow-up on all uncollected amounts
BILLING & COLLECTIONS, CONT.
• Process necessary to ensure that federal grant
resources address true financial access barriers to
the maximum degree possible
• Health Centers are expected to utilize information to
monitor performance compared to internal &
external benchmarks, as well as for tracking trends
Patient Collections
TIME OF SERVICE (TOS) COLLECTIONS
• Best opportunity to collect
• Educate patients regarding payment for
services
 Financial policy
• Co-pay
• Self-pay
• Prompt pay options
• Past due accounts
PATIENT COLLECTIONS
• Set the tone
 Expectations consistently
communicated by all
personnel
• Initial telephone contact & front desk staff
• Providers & clinical staff
• Administration
 Accountability
• Measuring & reporting cash collections
PATIENT COLLECTIONS, CONT.
• Patient consequences
 Make money owed an issue – past balances are
not ignored
• Payment plans
• Collection agency
• Attorney
• Staff consequences
INTERNAL CONTROLS
• Does cash received & cash posted balance
daily?
• What happens to overpayments?
• Is every patient payment posted immediately?
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End of day reconciling forms
System generated receipt
Ability to post adjustments
Statements generated
PATIENT COLLECTIONS, CONT.
• After the visit
 Accuracy
 Understandable statements
 Speed
 Follow-up
PATIENT COLLECTIONS, CONT.
• In-house collection efforts
 Daily productivity target per FTE
 45 to 70 accounts worked
 Can use 70 contacts per FTE per day as a
reasonable expectation
 On average it takes 2.5 contacts to achieve account
resolution
Impact of Clinical Processes
IMPACT OF CLINICAL PROCESSES ON REVENUE
• Scheduling
 Highly restricted patient types & times
 Acute patient/same day scheduling process
 Volume
• Charge tickets/Electronic Health Record (EHR)
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Accuracy & completeness
Timeliness of completion
Off-site services rendered
Legibility (if by paper)
Provider signature/esignature
IMPACT OF CLINICAL PROCESSES ON REVENUE,
CONT.
• Coding
 Fear of over-coding
 Under-coding to “help” the
patient
• Patient flow
 Taking patients back before
front office processes are completed
 Directing patients to check-out process
IMPACT OF CLINICAL PROCESSES ON REVENUE,
CONT.
• Additional issues to consider
 Advance Beneficiary Notices (ABNs)
 Staff & provider buy-in to collections process
Benchmarking for Improved
Performance
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KEY PERFORMANCE INDICATORS (KPIs)
• Recall the key components of the revenue
cycle
 Begins with appointment scheduling & ends with
payment resulting in $0 balance due
• How do I know if we are doing a good job?
You’ve done well
this week, Bob.
Stand by the
machine & press
the button.
KPIs, CONT.
• Monitoring tools/dashboards
 Monitored & reported to executive management monthly
 Feedback provided to staff
 Visualization is often beneficial
TRAINING PROGRAM
 Comprehensive training
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Practice management system is just a component
On-the-Job (OTJ) training should be a part, not the entirety
Effective trainer
Written training materials
Dedicated time
Competency assessments
POLICIES & PROCEDURES
 Written, compliance-driven policies & procedures
• Undocumented = leaves room for interpretation
• Detailed guidance in procedure format
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Billing third-party payers
Credit balances
Insurance follow-up
Small balance adjustments
Budget plans
Bad address
Patient correspondence
TECHNOLOGY IMPACT ON THE REVENUE
CYCLE
• Most practices only use 50% of their practice
management system’s capabilities – what
percentage does your organization utilize?
 Incorporate more automation versus utilizing
manual staff hours
TECHNOLOGY IMPACT ON THE REVENUE
CYCLE, CONT.
Multiple channels for patient communication
Automated Phone Systems
Appointment reminder calls, answering services
Kiosks
Automated patient (self-service) check-in, complete forms, review of
HIPAA documentation, access to information & educational materials
regarding health conditions, treatments, medications or preventative
care
Web-based Tools, On-Line Portal Options
Allow patients to communicate with providers & other
clinicians, review test results, update demographic
information, make payments, schedule appointments,
request medication refills and referrals
BILLING PRACTICES
• Is your organization receiving Medicare payments
from Medicare Part A & Part B?
• Have you recently reviewed services based on payer
coverage or payment changes?
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Initial Preventive Physical Exam (IPPE)
Annual Wellness Visit (AWV)
Diabetes Self-Management Training (DSMT)
Telehealth
Medicare Advantage
• Is your PMS/EHR updated with the most current CPT
& ICD-10 codes?
BILLING PRACTICES, CONT.
 Billing requirements for
RHC/FQHC services
 Non-billable services
• Nurse-only visits
• Revenue codes
 Define FQHC services
• Encounter understanding
 Non-FQHC services
• Laboratory services
• Technical component
MISSING REVENUE
• Missing Charge Rate: < 1%
 < 1% of charges missed on audit (quarterly) of
encounter form (paper or electronic health record
equivalent) to charges entered
 Processes in place to ensure all encounter forms
are entered into the practice management system
 Processes in place to ensure no missed offsite
visits
ACCOUNTS RECEIVABLE MANAGEMENT
• Who is managing your A/R?
• What information do they provide?
• What changes have they implemented within the last
60 days?
KPIs
• Average days in accounts receivable (A/R)
 Annual revenue divided by 365 days = average daily
revenue
 Current accounts receivables divided by average daily
revenue = average days in A/R
• Multi-specialty, All Practices:
 Better performers: 28.45*
 Others: 42.32*
• Primary Care, Single Specialty:
 Better performers: 23.54*
 Others: 39.56*
* Source: MGMA Performance & Practices of Successful Medical Groups, 2015 Report based on 2014 data
KPIs, CONT.
METRIC
MULTI-SPECIALTY,
ALL PRACTICES
PRIMARY CARE,
SINGLE SPECIALTY
Better performers:
13.76%*
12.20%*
Others:
33.78%*
34.88%*
Better performers:
99.30%*
98.62%*
Others:
96.39%*
96.50%*
Better performers:
54.94%*
62.73%*
Others:
49.32%*
53.72%*
Percent of total A/R over 90 days old
Adjusted fee-for-service (FFS) collections
Gross FFS collections
* Source: MGMA Performance & Practices of Successful Medical Groups, 2015 Report based on 2014 data
KPIs, CONT.
• Percent of claims billed electronically
 Best practice & average: 95%*
• Days to charge entry
 Best practice & average: Same day or 24 hours
• Days to claim submission
 Best practice & average: 2 days
* Source: MGMA Performance & Practices of Successful Medical Groups, 2015 Report based on 2014 data (Multispecialty, All Practices)
KPIs, CONT.
• Measure performance to determine success
• Set goals for financial performance
related to the revenue cycle
• Various performance indicators
ACCOUNTS RECEIVABLE FOLLOW-UP
• What is your denial rate? How does it relate
to the industry benchmark?
• What happens when a claim is not paid?
• How many outstanding claims do you have?
• What guidance is provided to staff on
prioritization of claims?
ACCOUNTS RECEIVABLE FOLLOW-UP, CONT.
• Claims denial rate
 Target = < 5% of total claims
• Better performers: 4.90%*
 Reduce re-work & get paid
faster
 Improve cash flow
* Source: MGMA Performance & Practices of Successful Medical Groups, 2015 Report based on 2014 data
ACCOUNTS RECEIVABLE FOLLOW-UP, CONT.
• Staff productivity indicators
 Outstanding claim follow-up
• Approximately 800 – 1,000 claims per month
ACCOUNTS RECEIVABLE FOLLOW-UP, CONT.
• Quick follow-up on non-payment
 Tighten statement cycles
 Example:
Days from Initial Statement
Billing Cycle
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Initial statement
30 days
2nd statement
45 days
1st pre-collect
60 days
2nd pre-collect
75 days
Refer to agency
Common Billing Issues to Avoid
COMMON BILLING ISSUES
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Failure to verify insurance
Incorrect patient information
Upcoding (downcoding)
Unbundling (bundling)
Documentation not supporting code(s)
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Lack of documentation
Lack of medical necessity
Incorrect modifier usage
Wrong diagnosis or procedure code
• Duplicate claims
BILLING & CODING COMMON SENSE
• If it wasn’t documented, it wasn’t done.
• If it wasn’t done, it can’t be billed.
• If the service isn’t necessary, it shouldn’t be
provided.
• If you weren’t there, your name shouldn’t
appear in the medical record or on the claim.
Medicare Regulations: Living in the
Present & Planning for the Future
Bob, do you have time for an audit?
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COMPLIANCE CONSIDERATIONS
• Changes in regulations & evolution of
technology
 ICD-10
 FQHC Medicare PPS Rule
 Chronic Care Management (CCM)
 Advance Care Planning (ACP)
 Practice Management System (PMS)
COMPLIANCE CONSIDERATIONS, CONT.
 Medicare Access and CHIP Reauthorization Act of 2015
(MACRA)
• Physician Quality Reporting System (PQRS)
• Medicare & Medicaid Electronic Health Record (EHR)
Meaningful Use incentive programs
• Social Security Number Removal Initiative
 E-consults
 Telehealth
• Is your organization prepared?
THE MANY LAYERS OF AUDIT AGENCIES
Office of Inspector General (OIG)
Health Care Fraud Prevention &
Enforcement Action Team (HEAT)
Unified Program Integrity
Contractor (UPICs)
Medicare & Medicaid Recovery Audit
Contractors (RACs)
Comprehensive Error
Rate Testing Program
(CERT)
Supplemental Medical
Review Contractors
(SMRCs)
QUESTIONS
910 E. St. Louis St.
Springfield, MO 65801-1190
Office: 417.865.8701
Fax: 417.865.0682
www.bkd.com
you
Monique D.Thank
Funkenbusch,
CPC
Managing Consultant
[email protected]
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Disclosure
Information contained in this presentation is informational only
& is not intended to instruct providers on how to use, or bill for
health care procedures. Providers should consult with their
respective insurers, including Medicare fiscal intermediaries &
carriers, for specific information on proper coding & billing for
health care procedures. Additional information may be
available from physician specialty societies & hospital
associations. Information contained in this presentation is not
intended to cover all situations or all payers' rules & policies.
Reimbursement laws, regulations, rules & policies are subject to
change.
The information in BKD sessions is presented by BKD
professionals for informational purposes only. Applying specific
information to your situation requires careful consideration of
facts & circumstances. Consult your BKD advisor before acting
on any matters covered herein or in these seminars.
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