Billing, Collections and Practices

1. Billing, Collectionsand Practices 1

2. Overview • Changing Healthcare Environment. • Billing, Coding, and Collections. • Best Practices. • Summary and Discussion.

3. Changing Reality As the reimbursement pie continues to get smaller expect table manners to change.

4. Changing Environment 9 4 • Increasing Patient Responsibility for Higher % of Payment - Out of Pocket. • Economic Pressure for patients continues. • Bad credit and Slow Pay is common. • Transition to Data Driven System. • Increased Regulatory Oversight - costly, time consuming burden. • Payment Reform

5. Healthcare Environment • Assault on physician reimbursements continues. • Growing Costs and Uncertainty. • Medicare and Medicaid Payment Controls • Changing to “value purchasing” • Decrease payment for services. • Bundled payments (capitation) • Private Payors – smaller, select panels. • ACOs and Networks

6. Medical Care Costs Burdens The U.S. spends more than any other country on healthcare. Administrative Portion of Healthcare Spending U.S. - 27% (Medical Loss Ratio) Canada - 3% U. K. -10% Source: WSJ September 24, 2011 Invasion of the Body: Revolutions in Surgery Nicholas L. Tilney

7. #1 Develop expert collection practices

8. Collections are key • Update your Fee Schedule. • Check eligibility and deductibles. • Collect at point of service. • Train and Support “front office” • Patient accounts written off or moved to collections prematurely with out staff working the account. Ask why patients accounts are delinquent. • Educate staff and patients on financial policy

9. #2 Plan, Plan, Plan

10. Developing a Business Plan • A business plan should be a work in progress. That's because your business will evolve over time, and be influenced by outside factors such as the economy and local conditions. Even successful business owners should maintain a current business plan to ensure they remain knowledgeable on the elements that can affect continued success. SBA.gov

11. Developing a Business Plan • Essential Components • Executive Summary • Market Analysis • Company Description • Organization and Management • Marketing and Sales • Service Line • Financial Projections

12. Develop a Business Plan Required: Business plan with supporting Operating Budget based on realistic income projections. • Begin with outcome based on income and known costs. • Use realistic projections, not what you want. • Include business structure changes with cost and revenue expectations - accurate data. • Planning requires input and buy-in from all. • Declining margins mandate effective business practices.

13. Plan and Regroup • Business plan and operating budget. • Develop proforma that can be measured, adjusted, and explained easily. • Begin with desired outcome and work backwards. • Use realistic projections • Include business structure changes with cost and revenue expectations. • Planning requires input and buy in from all parties. • Tactical and Strategic Targets.

14. Planning for ICD-10 • Contact system vendors • Will they be able to accommodate the need to move to ICD10? • Will they be ready for 5010 on January 1, 2012? • When will they have software available for testing? • Is the practice going to need new hardware? • Server upgrades?

15. #3 Structure is the key

16. Structure your Business • Job responsibilities and accountability required for all positions. • Training and education required. • If expertise is lacking Acquire or Train. • Tools must be adequate for the job. • Protocols established must be adhered to by all. • Business decisions based on accurate data. • Performance reviews and accountability. • Effective communications.

17. Organization Structure • Accountability required for all positions. • Education and Training may be required. • If expertise is lacking acquire or train. • Must have the right tools for the job. • Protocols must be adhered to and monitored. • Data based decisions required. • Performance reviews. • Requires practice team focused on objectives. • Review what works and add to the tool box – Best Practices.

18. Pre-service Protocol • Scheduling/Collection of Patient Data (Patient internet portal?) • Eligibility check verification • Pre-certification/Pre- Authorization • Non urgent prepayments (deposit/patient responsibility) • Collect • Co-Insurance • Deductibles • Prior Balances 18

19. Post-service • Question all missed charges. • Check schedule vs. patient charges, DNKA, reschedule, and POS collections • Payer Specific Billing Rules. • Claims entry for missing charges. • Correct rejects quickly and know what works and communicate to staff. 19

20. Claims Follow-up • Claims Review • No response 15 days • Call • Resend • EOB Review • Posting • Appeals • When • How 20

21. #4 Embrace Electronic Records

22. EMR “Meaningful Use” Why What When

23. The Objectives Stage 1, - 2011-2012 Eligible professionals are required to meet 15 core objectives 5 objectives out of 10 from menu set 6 total Clinical Quality Measures 3 core or alternate core, and 3 out of 38 from additional set Stage 2 - 2013 -2014 The menu set objectives will all become core objectives, Stage 3 - 2015 TBA

24. EMR Implementation Be realistic Use Scribes for slower adopters or in transition Develop or acquire accurate Templates Be patient

25. Implementing EMR • Different timelines for different providers • Use Extenders to collect and enter data • Invest in training – develop an “expert” • Get help with Template design

26. Meaningful Use Tracking Board Core – 15 out of 15 required Status Required Record patient demographics in structured format 90% 50% Record vital signs 85% 50% Maintain problem list 100% 80% Maintain active medication list 100% 80% Record smoking status 40% 50% Provide patients with clinical summaries 80% 50% Provide patients with electronic copies of their info 60% 50% Transmit prescriptions electronically 98% 40% CPOE for medication orders 98% 30% Implement drug to drug & drug to allergy checks 100% 100% Electronically exchange clinical info among providers Complete 1 Test Needed Implement 1 clinical decision support rule Not Complete 1 Rule Needed Implement systems to protect privacy & security of PHI 100% 100% Report clinical quality measures to CMS or states PQRI PQRI Menu – 5 out of 10 required Incorporate clinical lab test results as structured data 90% 40% Generate list of patients by specific conditions Not Complete 1 List Needed Identify patient-specific education resources and provide 40% 10% Provide summary of care record for patients referred 80% 50% Send reminders to patients for preventive and follow-up care 60% 20% of 65+ Provide patients with electronic access to their health info 50% 10%

27. #5 Document and Code for What you do

28. Code for what you document Business Case: Proper coding improves ROI. Increase E&M Level 3 to 4 (Medicare) Increase 300pts 500pts 1,000pts New $49.77 $14,931 $24,885 $49,770 Established $42.56 $12,768 $21,280 $42,560 • Annual Volume is significant. • Accurate documentation for services. • Proper level of reimbursement. Work smarter.

29. Claim Entry and Release • Check Coding against Payer Rules. • Double check all charges and encounters with clinical and business team. • Collect from Patient. • Batch and Release. • Audit collections/deposits and Follow Up on All Issues - ALWAYS.

30. GLOBAL Unplanned Return to the O.R. Unrelated Services GLOBAL PERIOD Staged procedure Pre-Op Visit Intraoperative Services Complications Pain Management Post-Op Visits

31. AUA Coding Today • Free online coding tool for all AUA members

32. #6 Compliance as a Culture

33. Reasons to implement a compliance plan • CMS discussing Compliance Mandate • Solidifies practice commitment to structure and accuracy • Requires active monitoring • Good Business Practice!

34. Develop and Maintain a Compliance Plan • Conduct internal monitoring and auditing; • Implement compliance and practice standards; • Designate a compliance officer or contact; • Conduct appropriate training and education;

35. Develop and Maintain a Compliance Plan • Respond appropriately to detected offenses and developing corrective action; • Develop open lines of communication; and • Enforce disciplinary standards through well-publicized guidelines.

36. #7 Expand your reach

37. PA and NP a part of Medicine • Not enough physicians • Cheaper than a partner • Willing to do things Physicians are not • More time with patient • Can be trained to provide specific services

38. More Benefits • Can be billed incident to • Can have their own billing number • Sunk cost if salaried can provide services that do not generate revenue while freeing others to generate revenue

39. Common Services • Incontinence Services • Preventative Services • ED clinics • Rounds at the hospital • Emergency Triage • Assist at Surgery • PnBx

40. Add services • Add a Men’s Health Clinic • Add end of life services • Expand Incontinence Center • Vasectomy marketing • Sexual health center • Stone specialists • Pathology Services

41. #8 Start the Year on the Right foot

42. Super-Bill “Communication Sheet” Paper • Frame work for identification of billable services • Physician, Coders, Billing Staff • Discussion of codes and billing rules EMR • Template and code generation. • Review Each Encounter and Business Office Audits. 42

43. Annual Review Analyze key practice indicators from past year and year-to-date. • Patient/payor A/R balances and trends. • Production and ROI by payor. • Collection models and benchmarks. • Contracts including any carve-outs • Production % versus % of revenues • Collections as % of what’s owned not just % of collections. • Practice management is not a static business. 43

44. Annual Review • Take action based on Data and Explain. • Adjust Schedule for Access and Efficiencies. • Develop/Adjust practice marketing plan. • Established Eligibility check tools and use and review benchmarks. • Effective Patient Responsibility Collections at time of service. • Essential Basic Business Model • Insurance Filing is 80% and the easiest - the remaining 20% is time consuming and costly. • Effective Communications. 44

45. Annual Review Determine Processes/ Assign Tasks • Define each step in billing process • Decide who is best qualified to perform • Demand excellence Effective Billing and Collections Requires a Integrated Team Effort • Business Office Team. • Clinical Team. • Physician Team. 45

46. Annual Review • Review and Update All Forms. • Demographics/Business • Practice Rules • Hx & PE • EMR Forms and Templates. • Update Physician/Provider Schedules. • Update Practice Financial Policy. • Review/Update All Practice Policies and Procedures. 46

47. #9 Know your Data and Act accordingly

48. Data is Essential • Develop access to accurate practice data to include benchmarking tools. • Develop quality of care /cost efficiency data. • Patient/referral satisfaction surveys. • Know your cost of doing business. • Review billing and collections metrics – know what you are getting paid. • Compliance Review. • Define Business Objectives. 48

49. Payer Contract Analysis • Payment Rate and Collections. • Contract vs. Actual Reimbursements • Rules Variation, Carve Outs, Payment Delays - Profitable or Poor Payor • % of practice revenues and % of production – key metrics. • Panel Alignment. • Ancillaries and % of revenues. • Communicate to physicians. 49

50. Analyze key indicators from past year. • Patient A/R Balances and Trends • Collection models and benchmarks • Timing • Contracts including any carve-outs • Production % versus % of revenues • Collections as % of what’s owed not just % of collections. 50