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Revenue Modelling in PPM

Revenue Modelling in PPM. Amanda Frankham. Introduction. Monitor and model revenue/funding from Private Health Fund contracts – variable based (DRG, episodic) Government Funding specifications – fixed based (grants, block amounts) Seamless data access

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Revenue Modelling in PPM

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  1. Revenue Modelling in PPM Amanda Frankham

  2. Introduction • Monitor and model revenue/funding from • Private Health Fund contracts – variable based (DRG, episodic) • Government Funding specifications – fixed based (grants, block amounts) • Seamless data access • Fully integrated with PPM Cost Manager data

  3. Methodology • Private Health Funds – 1 pass • Qualify patients, calculate funding • Government Funding – 2 pass • Pass 1 – Qualify patients • Pass 2 – Driver allocation tables

  4. RevenueManager Revenue Manager Cost Manager Calculate the distribution of incoming funds over the eligible patients & episodes Track and allocate the cost of delivering care to patients Profit and Loss Analysis Profit and Loss Analysis

  5. RevenueManager Revenue Process 1. Setup Rules 2. Maintain Rules PHS-supplied rules Idiom 3. Test Rules in Idiom 4. Release Rules Developing Rules 5. Setup Rules in PPM PPM 6. Test Rules in PPM 7. Activate Rules Using Rules in Live Billing Processes ActivatedBilling Rules

  6. Rules Engine Business Rules Engine • Maintain business rules • Dictate allocation of revenue to patient data • Separate from revenue program code • Engage seamlessly – PPM system and database • Users’ own rules rather than IT or vendor • View in logical English or GUI drag and drop

  7. Rules Engine Idiom Data Repository Schema(data structure) Scope(business rules) Repository formula

  8. Rules Engine Releasing Business Rules Client PC Business Rules Editor Release JAR Files

  9. Rules Engine Uploading Business Rules Server PC Client PC Business Rules Editor Release JAR Files RevenueManager Release Business Rules • Upload JAR files into PPM database • Refreshes business rules in Revenue Manager system

  10. RevenueManager BusinessRules Revenue Calculation PPM Database Rules Engine Filter XML RevenueManager XML Results

  11. Revenue Modellingat Cabrini Health Dr David Phillips

  12. Cabrini HealthNot-for-profit Catholic healthcare 6 sites with over 700 beds: • 2 acute care sites – Malvern & Brighton • 2 rehabilitation facilities – Hopetoun & Elsternwick • Palliative care facility - Prahran • Ashwood Aged care facility – both high and low level care

  13. Cabrini Hospital Malvern • Wide range of acute care services • Seen in equivalent tertiary institutions • ICU, Emergency, Neurosurgery, Cardiothoracic surgery, Obstetrics

  14. Cabrini Health Statistics • 73,463 separations (2 acute sites) • 57% sameday • ED presentations 23,023 • 35% admission rate

  15. Own Commercial Businesses • Linen • Chemtronics / Biomedical • Pathology • Radiology • Pharmacy

  16. New IT Strategy • New Systems • PAS ▪ Accounting system • SOE ▪Charm • Chris 21 • Installation of Patient Costing System • Opportunity to enhance product with Revenue Manager

  17. Inpatient Funding • Private Sector, activity-based funding,many years • ~13 funding models • mixture of Episodic & Per Diem funding • 57% of overnight stays episode funded • Funding negotiations • Usually biannual • An annual price review • Occur with each fund • Health funds • Subject to changing ownerships /amalgamations

  18. Revenue Manager • PPM Costing Manager implemented 2009 • Revenue manager installed in tandem • Idiom software to build rules engine • 7 revenue models developed by PHS: • Implemented over a 12 month period • Use of feeder systems already developed for costing • 1 additional feeder system developed specifically for revenue

  19. Implementation • Cabrini • Produce template to specify funding rules • Provide PHS reference tables, eg funding rates • PHS • Develop models to 75% accuracy • Provide back to Cabrini Health for validation • Signoff with model once accuracy over 95%

  20. Fund Models

  21. Costs of Implementation • Purchase costs no new hardware required • Software license • Support fees PA • Implementation • Knowledge acquisition and sharing

  22. Returns on Implementation • Significant • Aiding with funding negotiations • Run patient data through different funding models • Model new rates / trim points • Difficult to quantify benefit • Billing Audits • Process change

  23. Billing Audits • DRG changes • PAS discrepancies • Double check on correct application of rules/rates

  24. Process Changes • Chemotherapy flagging • Setup DRG change tracking • Changes in DRGs need to flagged quickly for funds that are DRG funded – each have different time frame for resubmission • Setup Idiom PPM database • Allow timely auditing of billing

  25. Issues Uncovered • Issue tracking • Version tracking

  26. Insuring Success • Executive Support • Strong links • PowerHealth • Fund manager • PAS team • Billing/Finance • Determination that would be Ainsley • Willingness to tinker that would be me

  27. ROI • Great return on investment during implementation • Expect to reduce as processes introduced to insure accurate billing

  28. Questions? 42

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