revenue strategies in rural health clinics-making the most...
TRANSCRIPT
Revenue Strategies in Rural
Health Clinics- Making the Most
of Your Resources and Time
Deborah HolzmarkSenior Manager
Physician Services Consulting Group Dixon Hughes PLLC
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Agenda• Why is it getting so hard?
• Making the Most if It – Patient Collections and Time of Service Collections
– Managed Care Contracts
– Provider Production and Compensation
– Coding– Coding
– Technology
– Work Flow
• Motivation Guidance
• Questions to ask….
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Why?
• Market Consolidation
– Fewer payors = less competition
– Lowering of the reimbursement bar
• Managed Care Maturation
– Added complexities– Added complexities
– Medicare Advantage Plans
• Reimbursement Deterioration
– Changing edits
– Lower flat reimbursements
• Limited revenue enhancement opportunities
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35%
40%
30%
35%
40%
45%
All small firms (3-199
workers)
All firms
Percent of insured workers with a
deductible of $1,000 or more for single
coverage
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16%
21%
10%12%
18%
22%
6%8% 9%
13%
0%
5%
10%
15%
20%
25%
2006 2007 2008 2009
All large firms (200 or more
workers)
Uncollected Patient Balances• Why are all these dollars being written off?
(by each physician)
– Uncollected Copays
– Uncollected Coinsurance
– Deductibles for surgeries
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– Deductibles for surgeries
– No Coverage
– ER call cases
– Timely Filing
– No Authorization
– Many $$$ were from patients WITH insurance
Unexpected Adjustments
$40,000
$50,000
$60,000
$70,000 $66,175
Unexpected Adjustment Comparison Source : January - June 2009 Billing Manager Report
Adds up to an estimated $100,000 in lost revenue over one year
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$-
$10,000
$20,000
$30,000
$40,000
Timely Filing Uncollectible Deceased/no
est.
Small Debt No Auth. BC Indigent Provider Not
Cred.
$22,453
$7,871$6,194 $6,000 $3,149 $2,924
Time of Service Collections
• Why is this so important to track?
– Medical Bills – bottom of the priority list
• Folks will first pay the essentials
– “Wealth Without Risk” by Charles Givens
• Page 21-22 – don’t pay your medical bills – interest free
– Patients feel it is a RIGHT not a privilege
– Consumer Driven HealthCare
– We enable this behavior
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Time of Service Collections
• Most practice AR is patient responsibility =
about 50% over 120 days and older
– Old payment plans
– No statement accounts
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– No statement accounts
– The “black hole”
• The longer it ages…the less likely we will ever
collect
• The “best” collect payment at time of service
75%-90% of the time…
Real Time Claim Adjudication
• Just imagine…
– Adjudicating a claim at the time of service
– Handing the patient their EOB at check out
– Collecting their responsibility– Collecting their responsibility
– Never shows up on the AR
– No letters or phone calls
– No statements
– Patients & Staff are happier
Trend your TOS Efforts
$100,000
$110,000
$120,000
$130,000
Comparison Time of Service CollectionsSource: PM Reports
$40,000
$50,000
$60,000
$70,000
$80,000
$90,000
$100,000
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
Prior Period 2007 Current Period 2008 Linear (Current Period 2008)
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Claims Management Benchmarks
Submission
• Daily
• Electronically at least 90%
• Charge Entry –
Lag Times
• Charge Entry –Submission < 72 hours
• Service to Charge Entry < 48 hours
Denials
• < 5% on 1st
submission
• Appeals Filed within 5 days of posting
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Claims
Management
The Physician Billing Process: 12 Potholes to Avoid in the Road to Getting Paid 2009 Edition Walker, Woodcock, Larch & MGMA Best Practice Survey 2008
Claims Management Benchmarks
Scrubbing
• All Claims
• Verify Eligibility 90%
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QA Audit
• 5% per team member per month
Missing Charge Audit
• 10% of claims per month
Claims
Management
AR Aging
• AR Aging Buckets – look at by Payor
– What does it tell you?
• If your dollars are aging in a consistent manner comparable to peers
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comparable to peers
– What impacts this number?
• System aging parameters
• Collections Activities
• Bad Debt
• Payor Delays
• Appeals
AR Aging
71%
53%
72%
50%60%70%80%
Benchmark Comparison A/R AgingSource: PM Reports & MGMA Better Performers Survey 2008
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12%5% 3% 7%
33%
6% 5% 3%7% 5% 4%
13%
0%10%20%30%40%50%
0-30 31-60 61-90 91-120 120+
Benchmark Aug 2006 April 2008
Managed Care Contracts
• Many practices sign what
comes across the desk
• Most do not renegotiate
annually – and this hurts us ALL annually – and this hurts us ALL
• Large majority do not have fee schedules
loaded – how plans make millions…..
• You would be surprised at how many practices
have charges below fee schedules…
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Payor Report Card
Gross Collections Adjusted Collections AR Days AR 120+
% Payor Mix
Current
% Payor Mix
Prior
Period
Hassle
Factor
(A-F)
Payer 1 38% 115% 42 10% 17% 12% C
Payer 2 36% 69% 79 35% 1% 1% D
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Payer 2 36% 69% 79 35% 1% 1% D
Payer 3 29% 97% 56 22% 2% 3% D
Payer 4 51% 85% 51 18% 13% 17% C
Payer 5 32% 84% 40 9% 3% 3% C
Payer 6 18% 105% 63 8% 61% 61% B
Production and Compensation
• Perception and Reality
– I am working harder than I did last year! Benchmark Comparison
Net Charges Per Physician
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$4,261,499
$5,477,642
$4,277,944
$-
$1,000,000
$2,000,000
$3,000,000
$4,000,000
$5,000,000
$6,000,000
MGMA Estimated Total 2008 Annualized 2009
Production and Compensation
• Scheduling – Have their been changes in scheduling templates?
– Has EMR implementation impacted scheduling?
– How long until the next available appointment for a new – How long until the next available appointment for a new
patient?
– How long until the next available appointment for an
existing patient?
– What are the parameters for closing to new patients?
– How do you deal with urgent needs?
– What are the hours of availability?
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Production and Compensation
• Incentive aligned?
– Equal shares
– “eat what you kill”
– Modified “eat what you kill” – Modified “eat what you kill”
– Straight production/RVU/other methods
• The changing model- lifestyle over income
• Compensation and part time physicians
• Compensation and nearing retirement physicians
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Coding
• Since 1996 Centers for Medicare & Medicaid
Services (CMS) has implemented several
initiatives to prevent improper payments
before the claim is processed. The overall goal before the claim is processed. The overall goal
of CMS’ claim review programs are to reduce
payment error by identifying and addressing
billing error concerning coverage and coding
made by providers
• This is just the beginning…
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Coding
• May 2008 Medicare FFS Payments Report-
Shows that 3.7% of Medicare dollars paid did
not comply with one or more Medicare not comply with one or more Medicare
coverage, coding, billing or payment rules.
This equates to $10.2 billion in Medicare
overpayments and underpayments annually
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Coding
• The old and new faces of government audits:
• RAC- Recovery Audit Contractors
• CERT- Comprehensive Error Rate Testing
• Carrier/FI- Medical Records Reviews • Carrier/FI- Medical Records Reviews
• Pre-Payment Reviews- National Correct
Coding Initiatives, Medically Unlikely Events
• MICs- Medicaid Integrity Contractors
• Private Payors- Fraud and Abuse Units
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Coding
• Moving from reactive to proactive
– Your risks have increased significantly!
– Internal data audits
– Internal documentation audits – Internal documentation audits
– Internal billing audits
– Strong billing policies and procedures
– Peer review and response to offenses
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Coding
• Medicare CERT appeals
– The never ending history
– LCD issues
– Medical Necessity trumps all – Medical Necessity trumps all
– Where oh where are the records?
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Technology
• EMR and the stimulus package
– Costs versus benefits
– “meaningful use”
– True process change versus EMR dump – True process change versus EMR dump
– The real costs associated with EMR
– Moving rapidly into the second phase of utilization
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Technology
• PM Systems
– Reporting capabilities
– Reporting expertise
– Can you truly manage without data? – Can you truly manage without data?
– The Training Soapbox
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Workflow
• The copier story
• The long long walk • The long long walk
• The segregated pods
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Workflow
• The big opportunities, can you find them?
– Live the experience!
– Moving resources to the patient – pushing not
pulling pulling
– Touching things once
– Everything at my fingertips
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Motivation Guidance
• Incentive Plans
– Statistics?
– Who is included?
– How much $?– How much $?
– How often?
– Other ideas?
– The best things in life are….
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Questions to Ask….
• What are your “unexpected adjustments” and what would they represent if you could turn them into $$
• What are your most common denials? Do you know your denial rate?
• Can you verify eligibility electronically?• Can you verify eligibility electronically?
• Are your fee schedules loaded?
• How much are you collecting at TOS?
• Is your financial policy clear and provided to the patient?
• How do you handle discounted/free services? Is it consistent?
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Questions to Ask….
• Ask your staff – “How do you know if you are doing a
‘good job’?”
• How much are you recovering from your collection
agency?
• What are the most common reasons you turn things • What are the most common reasons you turn things
over to collections?
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Questions to Ask…
• Where is production today compared to this time
last year? Do I understand what is
positively/negatively impacting this?
• What is my biggest risk in a coding audit? Do my
providers really understand the rules?
• What is the best way I am using technology?
• What is my biggest challenge in technology?
• When was the last time my staff had training on the
PM system?
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Questions to Ask…
• Does our floorplan and workflow
support/improve patient satisfaction?
– Provider satisfaction?
– Limit the steps patients make? – Limit the steps patients make?
– Limit the steps staff makes?
– Provide privacy?
– Make the staff and providers more efficient?
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Questions?
Deborah Holzmark, RN, MBA, CPHQ,
MCS-P, CMPE MCS-P, CMPE
828.775.3687
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