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Pricing Structures and Strategies for the 21st Century

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Pricing Structures and Strategies for the 21st Century

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    1. Pricing Structures and Strategies for the 21st Century

    2. MODELS FOR PRICING

    3. PRICING BELIEFS Dartboard Cost-based Market-driven Relative Value Blended Approach State Specific

    4. RECOMMENDED MATERIALS

    5. DETERMINE THE FOLLOWING Current Fee Volume For Top 75 CPT Codes Relative Value Complexity and time involved in performing procedure RBRVS Physician work + practice expense + liability insurance x conversion factor

    6. BENEFITS Provides a quick analysis of current fees May find inconsistencies after review

    7. ANOTHER MODEL FOR PRICING Determine single or multiple conversion factor Identify CPT codes by section List current fee and frequency Identify total non-facility RVU Select top 10 to 15 CPT codes by highest frequency for each CPT section

    8. DETERMINE CONVERSION FACTOR Gross Conversion Factor Average based on your current fee Frequency-Adjusted Conversion Factor More weight to your most frequently performed procedures

    9. CONVERSION FACTOR

    10. DETERMINING FEES

    11. RBRVS FREQUENCY BASED

    12. DETERMING FEES

    13. PACKAGING Bringing Clients In To The Practice Determine needs of companies Determine if services are a loss leader Advertise, Advertise, Advertise

    14. Steps to Start Monitoring Create a spreadsheet listing: Top 25-50 CPT codes utilized Your current charge for corresponding code Contract amount by payer. Create a contract sheet listing: All contracts List if discounted by percentage or fee schedule.

    15. Steps to Start Monitoring Create a drug/supply listing: Top 25-50 drugs/supplies with fee utilized Copies of invoices for drugs/supplies listing your cost to provide to payers when challenging Create a payer file Keep an eye open! Track inappropriate reductions Notate payers specific inappropriate reductions

    16. QUESTIONS Are all the billed services represented? Reimbursement correct/appropriate? Is payment within an acceptable timeframe? Can I appeal this particular denial, payer bundling issue, and/or reimbursement error? Other questions…..?

    17. ARE ALL SERVICES REPRESENTED? Compare the claim with the system information Request itemization if necessary Create or follow the internal protocol for handling a claim without all services represented

    18. APPEAL Apply proper documentation, coding, and billing guidelines (AMA, Contracts, State Guidelines) Gather sources to support appeal Follow internal protocol for re-submission of claim, as applicable

    19. COMMUNICATION Know your payers Don’t hesitate to contact payers Develop a relationship with payers

    20. APPEAL LETTERS Have standard letters on file Tracking system for appeals Share knowledge during staff meetings

    21. ACTIVE INVOLVEMENT Informs management of potential contract renegotiations Better informed employees Improvement on the bottom line

    22. Revenue Management/Capture Strategies Superbill/Chargeticket/Encounter Form Evaluation/Management Guidelines Chargemaster Revisions and Updates Internal/External Training of Staff Electronic Medical Records

    23. Revenue Management/Capture Strategies Superbills/Chargetickets/Encounter Forms Delete Omitted Codes Add Twin Codes Devise a logic and flow Add New Codes Consider Diagnosis codes on Back of form Train and follow-up

    24. Revenue Management/Capture Strategies Evaluation and Management Guidelines 1995 Guidelines 1997 Guidelines Which do you use?

    25. Revenue Management/Capture Strategies 1995 E/M Guidelines Overview Exam Body areas/Organ Systems Comprehensive Exam Need Policy and Procedure

    26. Revenue Management/Capture Strategies 1997 E/M Guidelines Overview Exam Bullet Point System Clear documentation requirements Difficult to understand

    27. Revenue Management/Capture Strategies Chargemaster Revisions and Updates Must be updated concurrently with the Superbill/Chargeticket/Encounter Form Fee Analysis annually If a fee schedule state, be certain that ALL fees are at (or above) the fee schedule If a Usual and Customary State (or for Urgent Care), utilize the formats previously outlined

    28. Revenue Management/Capture Strategies Chargemaster Revisions and Updates Be market sensitive to fees that are generally quoted by you and your competitors Be aware of how Fees are calculated by most payers (Mixed Models must be aware of Urgent Care charge impact) 24 month trail of Billed Charges Geozipcode specific Effect of charging too low

    29. Revenue Management/Capture Strategies Internal/External Training of Staff A Formal and Ongoing training programs should be in place, whether provided by internal and/or external staff E/M guidelines (and associated Policies and Procedures) Superbill/Chargeticket/Encounter Form utilization Chargemaster use Proper use of edit tools

    30. Revenue Management/Capture Strategies Electronic Medical Records (EMR’s) What are you trying to accomplish? How does training work, and what is the cost? Does the EMR code the Encounter? What rules does it use for E/M? Does it code the remainder of the encounter, and what clinical logic is used? How is it updated (and how often)? What is the Cost/Benefit?

    31. QUESTIONS

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