Wipfli 0

1. www.wipfli.com 0 Lots of information to share � try for some Q&A at the end, OK to ask questions throughout, and if we run out of time, feel free to email, call, or catch us during the breaks After lunch... Who am I, Tina later Lots of information to share � try for some Q&A at the end, OK to ask questions throughout, and if we run out of time, feel free to email, call, or catch us during the breaks After lunch... Who am I, Tina later

2. Revenue Cycle � Agenda Defining the Revenue Cycle Continuum Today�s Challenges Management Goals and Expected Benefits Opportunities in Key Areas Front End Back End Summary Solution Steps Poll the audience: How many from hospitals? Vs. Physician practices (RHC�s) What role do you play in the RC process (CFO / CEO), Chargemaster analyst?, financial services, Payers? Others??Poll the audience: How many from hospitals? Vs. Physician practices (RHC�s) What role do you play in the RC process (CFO / CEO), Chargemaster analyst?, financial services, Payers? Others??

3. 2 When looking at revenue cycle, we have to look at it as a �flow�, not individual components Different names: operations, front / back end, but if we�re talking about any of these areas, we�re talking about the revenue cycle Revenue cycle process review Operations review Front end vs. back end Where do you see yourself Optimum � All parts understand their role and what others do and work togetherWhen looking at revenue cycle, we have to look at it as a �flow�, not individual components Different names: operations, front / back end, but if we�re talking about any of these areas, we�re talking about the revenue cycle Revenue cycle process review Operations review Front end vs. back end Where do you see yourself Optimum � All parts understand their role and what others do and work together

4. Revenue Cycle Objectives What are we looking for from this process?What are we looking for from this process?

5. Revenue Cycle Objectives To enhance capture and collection of patient billings (efficient, effective, timely, and compliant) To put the patient at the heart of the revenue cycle by providing: Accurate and timely information regarding financial obligations Patient-directed choices regarding flow of financial information To create an integrated approach to revenue integrity with organizationally aligned and common performance goals/metrics To focus on prevention (front-end accuracy versus back-end fixes) To understand the future (e.g., patient-directed choices based on clinical effectiveness and cost) Primary goal of the revenue cycle is to maximize the collection of dollars for service rendered (increase revenue, decrease costs, and improve productivity) Put the patient first; Make them aware of their financial obligation, give them choice, try to streamline the process (web portals to complete registration and history information at home, prior to visit, when they have access to the information Focus on PREVENTION vs. react and fix later Patients are looking for measurable outcomes (quality, cost...) Primary goal of the revenue cycle is to maximize the collection of dollars for service rendered (increase revenue, decrease costs, and improve productivity) Put the patient first; Make them aware of their financial obligation, give them choice, try to streamline the process (web portals to complete registration and history information at home, prior to visit, when they have access to the information Focus on PREVENTION vs. react and fix later Patients are looking for measurable outcomes (quality, cost...)

6. Revenue Cycle � Today�s Challenges Stagnant or decreased wages (economic situation) Patient responsible for more and more of the rising cost of HC Limited budgets (staffing and resources) Rising costs Stagnant or decreased wages (economic situation) Patient responsible for more and more of the rising cost of HC Limited budgets (staffing and resources) Rising costs

7. Average Health Insurance Premiums and Worker Contributions for Family Coverage, 1999-2008 I could stand up here for the next hour and a half and show you statistics and graphs, but I think you have all seen them and no matter how a particular group spins the numbers, we know this stuff from experience (i.e., we see it everyday) Stagnant or decreased wages (economic situation) Responsible for more and more of the rising cost of HC Limited budgets (staffing and resources) Kaiser study 1999 to 2008 inc in family coverage health ins premiums for employer and employee I could stand up here for the next hour and a half and show you statistics and graphs, but I think you have all seen them and no matter how a particular group spins the numbers, we know this stuff from experience (i.e., we see it everyday) Stagnant or decreased wages (economic situation) Responsible for more and more of the rising cost of HC Limited budgets (staffing and resources) Kaiser study 1999 to 2008 inc in family coverage health ins premiums for employer and employee

8. Percentage of Workers Enrolled in High-Deductible Plans, 2008

9. Revenue Cycle � Today�s Challenges Insurance Contracting Is Becoming More Complex: Regional, national, leased, and proprietary networks Continuous discount arrangements Silent PPOs Claims-processing, eligibility, and prior-authorization issues Complex fee schedules Usual and customary charge issues Payment policy issues Unfavorable contract terms that do not protect providers Changing requirements Some of the challenges and potential pitfalls caused when we don�t adequately scrutinize contacts, for complete understanding (need a good health care attorney)Some of the challenges and potential pitfalls caused when we don�t adequately scrutinize contacts, for complete understanding (need a good health care attorney)

10. Revenue Cycle Management � Goals and Expected Benefits

11. Goals and Expected Benefits CMS says 4% of their claims are denied, legitimately, but if even 1% are due to documentation issues or LOS, significant dollars can be lost. We need to streamline the process (efficiency) Payments must be collected at the time of service Get it right the first time (start with registration) Benchmark, so BO isn�t spending valuable time trying to collect on things not collectable (i.e., ins contract prohibits payment)CMS says 4% of their claims are denied, legitimately, but if even 1% are due to documentation issues or LOS, significant dollars can be lost. We need to streamline the process (efficiency) Payments must be collected at the time of service Get it right the first time (start with registration) Benchmark, so BO isn�t spending valuable time trying to collect on things not collectable (i.e., ins contract prohibits payment)

12. 1. Moving back office functions to the front office 2. Shrink work in the back office 3. Capability to discuss �price� with patients We�ve figured out if we do a great job on the front end, the BO job will be more efficient and effective. As consumers pay more, we have to give them more information to partner with themWe�ve figured out if we do a great job on the front end, the BO job will be more efficient and effective. As consumers pay more, we have to give them more information to partner with them

13. Revenue Cycle Opportunities

14. Revenue Cycle Opportunities Registration: Better performing practices focus more of their scarce resources on collecting accurate and timely registration information than in managing the business office operations (specifically the collections aspect of the revenue cycle). The means we have to: train, create scrips, put the right people in this position, design space to make their efforts possible (i.e., confidentiality), hold staff accountable Might require additional staff: Reallocate BO staff to the front? Hire? The means we have to: train, create scrips, put the right people in this position, design space to make their efforts possible (i.e., confidentiality), hold staff accountable Might require additional staff: Reallocate BO staff to the front? Hire?

15. Revenue Cycle Opportunities Registration (continued) Benchmark Opportunities: Percentage of registrations complete: Demographic data completed Insurance benefits verified Financial counselor alerted as defined (defined criteria of self-pay and high coinsurance deductible plan patients) Precertification process completed Work with IT vendor to create �flags� identifying things like when an aurthorization number is missing for a scheduled procedure, or when a key piece of registration information is missing at check in, or that insurance benefits were not verified. �pre-registration� is keyWork with IT vendor to create �flags� identifying things like when an aurthorization number is missing for a scheduled procedure, or when a key piece of registration information is missing at check in, or that insurance benefits were not verified. �pre-registration� is key

16. Revenue Cycle Opportunities Insurance Verification: The insurance verification process is often the first opportunity to identify an at-risk patient: Insurance eligibility verified Coverage determined for service Deductible/co-pays collected Pre registration and ins verification before patient arrives Is an ABN needed? Collections at the time of service Call the patient with their responsibility prior to them arriving (set the expectation) Create firm policies, signage, credit policy brochure, staff who consistently collect from every patient/every timePre registration and ins verification before patient arrives Is an ABN needed? Collections at the time of service Call the patient with their responsibility prior to them arriving (set the expectation) Create firm policies, signage, credit policy brochure, staff who consistently collect from every patient/every time

17. Revenue Cycle Opportunities Insurance Verification (continued) Benchmark Opportunities: Technical denials rate: Number (or percentage) of claims denied due to incorrect insurance or demographic information Clinical denials rate: Number (or percentage) of claims denied due to lack of prior authorization In order to benchmark, must define who is reponsible.In order to benchmark, must define who is reponsible.

18. Revenue Cycle Opportunities Financial Counseling Patient-focused financial counseling includes early identification of at-risk cases for collection. Patients have a right to understand their financial obligation before the service is rendered. Maxim: No surprises� Set the policies for self pay and high deductible � for scheduled procedures, do you collect 50% prior to the procedure? And, define the plan for the remaining? In the clinic setting, PM and E/M and ancillary services often a problem Set the policies for self pay and high deductible � for scheduled procedures, do you collect 50% prior to the procedure? And, define the plan for the remaining? In the clinic setting, PM and E/M and ancillary services often a problem

19. Revenue Cycle Opportunities Financial Counseling (continued) Best Practices: Patient-focused financial counseling (�patient advocate�) is an integral part of patient access. Staff should be well trained to refer potential patients to financial counselors during the registration process (preferably the pre-registration process). Credit card arrangements, electronic funds transfer, and other financial payment options should be creatively deployed (such as longer payment periods with or without interest). Patients qualifying for Medicaid and charity care should be identified in the patient access portion of the revenue cycle. Partner with banks? Identify those who may qualify for charity care of Med Assistance (before the procedure/service, instead of 60 days after, which has already resulted in sig staff time and dollars lost) Partner with banks? Identify those who may qualify for charity care of Med Assistance (before the procedure/service, instead of 60 days after, which has already resulted in sig staff time and dollars lost)

20. Revenue Cycle Opportunities Financial Counseling (continued) Benchmark Opportunities: Days revenue in accounts receivable (self-pay portion) Bad debt write-offs as a percentage of self-pay revenue Percentage of bad debts that could have been classified as charity care Look at the aging of your self pay A/R Do you have the staff to clean it up? Outsource the old? What is the % of bad debt % of self pay? Are you consistent in write off�s? How much could have been charity care? Then, set realistic key performance measures for your organization In recent years, self pay class is the fastest growing class in the A/R portfolio. Do you understand how to assess this up front, or �hope for the best�? Not all self pay are the same, Again, it starts with Registration. Screen patients for government program eligibility, charity program eligibility (sliding scale discounts), payment likelihood (past history; calculate expected collection rate). Need well thought out scripts and the right people Look at the aging of your self pay A/R Do you have the staff to clean it up? Outsource the old? What is the % of bad debt % of self pay? Are you consistent in write off�s? How much could have been charity care? Then, set realistic key performance measures for your organization In recent years, self pay class is the fastest growing class in the A/R portfolio. Do you understand how to assess this up front, or �hope for the best�? Not all self pay are the same, Again, it starts with Registration. Screen patients for government program eligibility, charity program eligibility (sliding scale discounts), payment likelihood (past history; calculate expected collection rate). Need well thought out scripts and the right people

21. Revenue Cycle Opportunities Charge Capture Numerous components of the revenue cycle pertain to charge capture, coding, and documentation. Each serves an important aspect of the revenue cycle. Charge capture is often identified as an area of significant shortcoming in medical practices. Turn over to Tina to talk about charge captureTurn over to Tina to talk about charge capture

22. Revenue Cycle Opportunities Charge Capture (continued) Charging tools (e.g., charge tickets, EMR) are simple and include prompts to providers along with an option to request special coding review (� CR�) as needed.

23. Revenue Cycle Opportunities

24. Revenue Cycle Opportunities

25. Revenue Cycle Opportunities Charge Capture (continued) Benchmarking Opportunities: Coding compared to benchmarks (CMS, internal) Documentation reviews that show consistent improvement Missing charge (entire visit) analysis

26. Revenue Cycle Opportunities Coding Overlooked Opportunities: Capture of new patient visits Consultations Coding based on time Status of three chronic or inactive conditions Preventive medicine and �sick� visit Pre-op consultations in primary care practice (ICD-9 rules) Consult criteria (documented) New/est patient and initial/sub not a factor (except in hosp sub consult) Repeat consultations OK (only criteria are 3 Rs) Family practice request for opinion from IM in same group Time: patient must be present (face to face time in clinic, floor time in hosp) >50% counseling/coordination of care Both times must be documented Pre-op consultations in primary care practice (ICD-9 rules) Consult criteria (documented) New/est patient and initial/sub not a factor (except in hosp sub consult) Repeat consultations OK (only criteria are 3 Rs) Family practice request for opinion from IM in same group Time: patient must be present (face to face time in clinic, floor time in hosp) >50% counseling/coordination of care Both times must be documented

27. Revenue Cycle Opportunities Coding (continued) Overlooked Opportunities: Minor procedures and E/M Ancillary services Venipunctures Physician-performed lab tests Injection/immunization administration Pre-op consultations in primary care practice (ICD-9 rules) Consult criteria (documented) New/est patient and initial/sub not a factor (except in hosp sub consult) Repeat consultations OK (only criteria are 3 Rs) Family practice request for opinion from IM in same group Time: patient must be present (face to face time in clinic, floor time in hosp) >50% counseling/coordination of care Both times must be documented Pre-op consultations in primary care practice (ICD-9 rules) Consult criteria (documented) New/est patient and initial/sub not a factor (except in hosp sub consult) Repeat consultations OK (only criteria are 3 Rs) Family practice request for opinion from IM in same group Time: patient must be present (face to face time in clinic, floor time in hosp) >50% counseling/coordination of care Both times must be documented

28. Revenue Cycle Opportunities Coding (continued) E/M levels of service � key area for concern Often services are underbilled (hospital-owned practices tend to be the most problematic) Wide variation in code usage within a group and specialty Template documentation issues

29. Revenue Cycle Opportunities

30. Sample E/M Analysis

31. Sample E/M Analysis

32. Revenue Cycle Opportunities Coding (continued) Appropriate coding & documentation - critical to revenue cycle management. Effective coder/provider team process (i.e., who does what). Focused reviews � 100% review of patient charts should not occur. (This level of inspection suggests the system is broken on the front end; instead, an effective education and monitoring system should exist.) Coders� roles are that of in-house mentors to provider/nurse teams. Providers receive regular feedback about their coding outcomes (frequency is based on need, not a predetermined timeline).

33. Revenue Cycle Opportunities Coding (continued) Coder/Provider Team Process: The right balance of coding oversight is necessary. Too little: Charge tickets are taken at face value Potential compliance and/or revenue issues Too much: �Production� style or a coder extrapolates codes Most often, creates revenue issues

34. Revenue Cycle Opportunities Coding (continued) Coder/Provider Team Process: The best medical practices focus on: Identifying the right balance, given their practice makeup (specialties, sizes, locations, etc.). Identifying potential problems before they occur (�disease� prevention). Making continual improvements (maintaining well-being).

35. Revenue Cycle Opportunities Coding (continued) Coder/Provider Team Process: Physicians should be responsible for the information on claims. Clinical team (providers & nursing staff) should review all charge tickets before they leave the clinical department for: Completeness Referral and injury information Services Diagnoses Appropriateness Reasonableness of information Content CPT and matching ICD-9 codes Modifiers Other

36. Revenue Cycle Opportunities Coding (continued) Coder/Provider Team Process: In most practices, we advocate that coders: Briefly preview each �charge ticket� for completeness and accuracy (after the clinical check and balance is done). Select unusual or potentially problematic cases to �audit� the documentation. Be available to respond to cases marked by providers �coding review.� But, spend most of their time monitoring coding outcomes and training clinical staff. Coding Educators can be most effective if they are located in the clinical areas.

37. Revenue Cycle Opportunities

38. Revenue Cycle Opportunities

39. Revenue Cycle Opportunities

40. Revenue Cycle Opportunities

41. Revenue Cycle Opportunities Fee Schedule RHCs tend to inconsistently update fees (not an annual process) Fees are typically low and are subjectively set We often hear �we are paid based on costs, so what do fees matter?� Currently working with an RHC whose average CF is $24/RVU (Medicare pays $38) Have you looked at your fee�s � Often historically fees were set based on old methodology (before RVUs) and percentage increases taken each year (i.e., no attention to relevance to other services).Currently working with an RHC whose average CF is $24/RVU (Medicare pays $38) Have you looked at your fee�s � Often historically fees were set based on old methodology (before RVUs) and percentage increases taken each year (i.e., no attention to relevance to other services).

42. Revenue Cycle Opportunities Fees should be strategically developed

43. 42 Revenue Cycle Opportunities This type of fee analysis Uses a consistent, objective approach to establishing and maintaining fees. Optimizes reimbursement. Assesses fees individually and in relation to the entire chargemaster. Provides a defensible methodology. Is market-based. Accurately and fairly reflects the value of each service. Uncovers coding issues (via significant fee aberrations).

44. 43 Revenue Cycle Opportunities Understand your level of competitiveness Decide whether you wish fees to be higher than any payer, or whether you will look to �themes� Be sensitive to your fee history Be sensitive to your market Don't set a fee for 99213 at $150 if the only other primary-care physician around is charging $65. That said, avoid setting fees at all with physicians outside your group. Look at quality data reports from your payers (are your fees in line with your quality)?Look at quality data reports from your payers (are your fees in line with your quality)?

45. 44 Revenue Cycle Opportunities Use a sliding scale percentage markup for purchased goods to create reasonable fees for both high- and low-cost goods. Don�t fall into the trap of updating fees for only your common services (e.g., key surgeries and E/Ms, but skipping imaging this year). Be cautious of the 80/20 rule. 80% of the codes might be appropriately priced, but the remaining 20% can still have a significant impact. Hospitals (#1)Hospitals (#1)

46. 45 Revenue Cycle Opportunities Assess fees annually (or more often for purchased goods) Round fees to the nearest dollar For fees that are significantly too high or low, consider your options Making the full change all at once (consider a �hold harmless� approach for visible or repeating services) Changing them over time (e.g., develop a cap and floor, then change them again in X months)

47. Revenue Cycle Opportunities

48. Revenue Cycle Opportunities Back End � Billing The business office represents the last opportunity for charges to be modified/corrected. While this remains an important task at every practice, revenue cycle management must recognize the importance of obtaining correct information as early as possible in the revenue cycle.

49. Revenue Cycle Opportunities Back End � Billing (continued) Best Practice: Issues with the business office often highlight the importance of improvement efforts on the front-end aspects of the revenue cycle. We suggest an integrated, cross-functional Revenue Cycle Team with significant business office representation to help design the standard work and processes for patient access-related activities. NOT fix it on the back-endNOT fix it on the back-end

50. Revenue Cycle Opportunities Back Office � Billing (continued) Benchmark Opportunities: There should be meaningful metrics established for the revenue cycle for process improvement monitoring purposes: A/R days Total cash collections Denial rate Bad debt rate Charity care rate Payment verification

51. Revenue Cycle Opportunities Back Office � Collections & Denials Management: The collections function goal is to secure the greatest amount of reimbursement possible. Typically, this is only accomplished through persistence and proper alignment of goals.

52. Revenue Cycle Opportunities Back Office � Collections & Denials Management (continued): Denials management is a key element of the revenue cycle. A recent study identified 77% of the errors leading to denials were associated with front-end deficiencies. Eligibility accounted for 25% of denials Demographic information accounted for 33% of denials Authorizations accounted for 19% of denials in the survey Have you set up consistent denials codes across ALL payers? (denials prevention)? Have you set up consistent denials codes across ALL payers? (denials prevention)?

53. Revenue Cycle Opportunities Back End � Collections & Denials Management (continued) Best Practices: Tracking denials to identify sources (root cause analysis) and acting upon the trends Employing Revenue Cycle Team to develop sustainable solutions Have you tracked denials to ensure staff are focusing efforts on denials that can be won? Every denial should be a learning tool Make a spreadsheet and track payer specific denials.Have you tracked denials to ensure staff are focusing efforts on denials that can be won? Every denial should be a learning tool Make a spreadsheet and track payer specific denials.

54. Revenue Cycle Opportunities Back End � Collections & Denials Management (continued) Sample key performance indicators: These indicators are �hospital�, no information is available for physician clinics. s this the right list for your organization? For example, the first one may be only 10-25% currently in some offices. And, the percentages associated with the performance indicators must be appropriate for your organizationThese indicators are �hospital�, no information is available for physician clinics. s this the right list for your organization? For example, the first one may be only 10-25% currently in some offices. And, the percentages associated with the performance indicators must be appropriate for your organization

55. Revenue Cycle Summary � Solution Steps

56. Revenue Cycle Summary Solution Steps Perform an initial revenue cycle assessment: Identify key tasks for the entire revenue cycle Identify non-value-added processes or activities Design workflows to streamline current processes and empower employees to be accountable for their part in reaching organizational goals. Reorganize front-end and business office functions (potentially including a new organizational structure) to increase accountability and manager effectiveness.

57. Revenue Cycle Summary Solution Steps Revise policies and procedures and job descriptions to ensure organization-wide consistency. Implement a cross-functional Revenue Cycle Team to enhance quality improvement efforts. Establish performance metrics for the revenue cycle department based on the quality of work and effectiveness of effort. Determine if additional technology is needed to support desired state processes.

58. Revenue Cycle Summary Solution Steps Ask your team these questions: Are we monitoring E/M utilization, by physician, at least annually? If so, do we provide feedback to the providers (good and bad)? Do we update our charge tickets and documentation templates at least annually and do we look at the actual design of the tools? Do we conduct regular documentation reviews to look for revenue opportunities or compliance concerns? (By the way, do we have a compliance plan??) Do we regularly conduct educational sessions for physicians and billing staff?

59. Revenue Cycle Summary Solution Steps If the answer to any of these questions is �no,� your response should be �Why not?� If the answer to any of these questions is �yes,� your response should be �What were the findings, and what was the result?�

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