hfma georgia chapter november 10, 2011. contracting and payment approaches payment methodologies ...
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RCM Challenges in Healthcare Reform
hfma Georgia ChapterNovember 10, 2011
Contracting and Payment Approaches Payment Methodologies Integrating Clinical and Financial Aspects of the
ACO New Revenue Cycle Requirements Basic Revenue Cycle Challenges and Solutions Advanced Revenue Cycle Challenges and
Solutions A Practical Health System Discussion Guide
Presentation Outline
Tier 1: Fee-For-Service and the World we have lived in for the past 20 years Approach
Tier 2: The Near Term changes of Procedure and Episode of Care Bundling, and Combined P4P with Physicians and Hospitals Approach
Tier 3: Managing an Accountable Care Organization Approach
The Three Tiers of Payment Approaches
Hospitals Separate and Physicians Separate
CMS maintains Part A and Part B
APCs, DRGs, Fee Schedules, UBs and HCFAs
Payers/Providers negotiate the methodologies
%Charges, DRG Case Rates, Procedures, Per Diems, Fee
Schedules, % Medicare, etc.
Administrative and Clinical Utilization Review
Denials, Underpays, Disputes, etc.
Tier 1: Fee-For-Service
Physicians and Hospitals Combined Services All-Inclusive Procedures and Services Procedure Specific or Episode of Care
Single Site (Acute Care) or Multiple Site (IP,OP, Office, Rehab, Home Care)
Performance Payments Severity Adjusted EBM Guidelines Across Continuum Contracting and Claims Adjudication
Tier 2: Bundling and Value-Based Contracting
Integrated Physician/Hospital Organization Responsible for Identified Populations Direct Contracting with Buyers Accept Risk for Defined Patient Services Have an Information Platform to Measure Clinical
Performance and Perform Financial Transactions Act like a Payer?
Tier 3: Health Systems as Accountable Care
Organizations
A Common Platform for All
Manage Scenarios Simultaneously
80% Tier 1, 15% Tier 2, 5% Tier 3
Combined Performance Reporting
CMS and Payer Tier Profiles
MC & PFS Desktop Simplification
Physician/Hospital Care Coordination
Enrollment and Payment Functionality
A Combined Solution for All Three Tiers
Patient-Centered Medical Home Payment
Primary Care Driven Front End of Acute Services
Bundled Procedure Payment
High Cost Services – CABG, Joints, Backs, etc.
Bundled Episodes of Care Payment
Tied to Patient Condition and Time Related
Performance Based Payment
EBM Based, Severity Adjusted, Outcome Based
Partial and Total Capitation Payment
Population and Condition Driven
New & Expanded Payment Models
Clinical Service Line Alignment Clinical Pathway Development Benchmarking Complex Procedures Benchmarking Episodes of Care Modeling Episodes and Procedures Creating Bundled/Performance Contracts Adjudicating Bundled Claims Reporting/Managing Utilization
ACO Integration Roadmap
Utilization Reporting Across Continuum Health System and Payer Driven IP, OP, Physician, Ancillary Providers
Data Aggregation in Multiple Delivery Sites Clinical Data from Physicians, Rehab, and Home Care Financial Data Across the Continuum
Revenue Cycle Calculations & Transactions Contracting, Claims Management, Adjudication
Patient/Payer Membership Management
Expanded RCM Requirements
Create and Model Bundled Contracts Develop and Manage Combined Charge
Masters and Fee Schedules Aggregate Bundled Claims and Payments Calculate Performance Payments Provide Timely, Accurate and Transparent
Clinical and Financial Reporting
Basic Revenue Cycle Challenges
Patient Enrollment and Eligibility Contract Modeling across Continuum Maintenance of Multiple CDM/Fee Schedules Case Management/Referral Services Claim Re-Pricing/Clearing/Payment Dispute Resolution/Collections Risk Sharing, Gain Sharing, Treasury
Services
ACO-Like Revenue Cycle Challenges
Bundled Payment Capabilities Contract Modeling and Management
Integration of Fee Schedules and CD
Patient Eligibility for Bundled Programs Performance-based Payment Capabilities
Clinical/Severity-based Calculations
Financial/Spend-based Calculations
Integrated Reporting Capabilities Robust Utilization and Financial Reports
The Basic Solution
Claims Management, Clearing, Posting Enrollment and Provider Rostering Case/Referral/Utilization Management Dispute and Collections Management Provider Credentialing ACO Patient Self-Service Portal Treasury Services Multi-Level Reporting – Financial/Clinical
The ACO-Like Solution
Board Of Directors Senior Leadership Team (C-Suite) Clinical and Financial Department Managers The Revenue Cycle Team Leaders All Revenue Cycle Personnel
An Organizational Discussion
Answer All of our Facilities All Active Medical
Staff Contracted
Ancillary Physicians and
Extenders Facilities (Rehab, ASC,
etc) Home Care, Hospice
RCM Solution Provider
Demographics TINS and Sites Facility Identifiers CMS Information RCM IT
Information Clearinghouse Info
Who is in Our Integrated ACO?
Answer Cardiovascular Orthopedic/Joints Spine Surgery Stage 2 Cancer
RCM Solution Physician Roster Sites of Service Services
Benchmarks Model Claims Contract Terms Fee Schedules,
Codes
Which Service Lines are in the ACO?
Answer The Hospital
Employees Aetna Fully Insured United ASO
Employers Tri-Care
RCM Solution Contract Terms Payment Method Enrollment
Database Patient
Demographics Patient Benefits
Who are the Covered Enrollees?
Answer PCMH – Primary
Care Episode of Care Medicare SS Blue Cross
Performance based grouper outcome
RCM Solution Charge Coding Calculation Engine Contractual
Discounts Payment Posting Performance
Measures Distributions
What Payment Models Included?
Answer Will vary by Payer Likely % Medicare Performance-
based Individual Provider
Whatever we can
RCM Solution CDM & Fee Schedules
By Provider, By Contract Grouper and EBM
performance calculator
Medicare Values for all ACO Providers
What Rates will ACO Charge?
Answer Across Care
Continuum Primary Care Specialty Care/OP Acute Care/IP Sub-Acute Home Care/Follow up
RCM Solution Capture Claim
Activity Report Care
Variance from Benchmarks
Facilitate interfaces to Providers in ACO
How Will ACO Monitor Performance?
Answer Receive Claims
from Providers and Facilities
Send Claims or Claim Summaries to Payers
Receive Payments from Payers
RCM Solution Bundled Claims
Scrubbing Bundled Claims
Clearing Calculation Engine
Performance-based Payment Posting Variances
How Will the ACO Handle Claims?
Answer From the Claims
Data From Payer Data From Clinical Data
RCM Solution Standard Reports
from ACO RCM Database
Payer Report Validation
External Data Imports
Ad Hoc Reporting
How Will The ACO Prepare Reports?
Answer We will for the
Transactions side The Medical Staff
will run the care delivery management
RCM Solution Implement a
Platform that will manage these transactions
Who Will Manage the ACO?
Be Sure that the Revenue Cycle Team is an Integral Part of the Health System discussions about Integrated Care In a nice way, remind leadership that this Reform is
Revenue Cycle Management reform Take an Inventory of your Hospital Patient
Accounting, Contract Management, and RCM reporting capabilities
Identify the likely Providers (Physicians and other facilities) that will be a part of your Integrated Network
Talk with your big Payers about their Interests Monitor CMS ACO Progress
So Then, How to Start – Part 1
Identify missing parts in existing RCM IT infrastructure These will likely be in complex contract management, cost
reporting, CDM and Fee Structure Management, etc. Research opportunities with existing RCM IT
vendors Do they have platforms to integrate the new RCM
functionalities for providers across the care continuum? What are their plans?
Explore the Market for New or Added Solutions Look for platforms that accommodate the entire continuum Remember the new requirements – enrollment, bundled
modeling, bundled claim adjudication, treasury, etc.
How to Start – Part 2
Present your researched RCM Functionality Plan to the Health System Integrated Care Leadership Group
Incorporate the Clinical Benchmarks, EBM Standards, and Services (CMS ACO, Cardiovascular, Ortho, etc.) under consideration by the Clinical Leadership
Determine what Services and Payment Models are being considered by your major Payers
Using your new processes, Model the potential arrangements that are being discussed by the ICLG
Bring the Information back to the Leaders for Discussion
Sign a Contract & Manage the Transactions
How to Start – Part 3
The Shift from FFS will likely be gradual and incremental
There is sufficient time to design your plans But, it will take time culturally and operationally. Clinical Change Management will require
consensus building and professional compromise Revenue Cycle Change Management will require
operational retooling, distributed accountability, and technical upgrades to maintain a shared RCM Platform
The Market Winners will be Ready for the Change
Summary
