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Reimbursement, Governmental Relations, Contracting and Pricing Departments

Reimbursement, Governmental Relations, Contracting and Pricing Departments. Agenda. Reimbursement Department Overview Accounts Receivable (A/R) Performance, Metrics, and Payor Mix Key Reimbursement Strategies Rate Maximization Enhance EDI Connectivity

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Reimbursement, Governmental Relations, Contracting and Pricing Departments

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  1. Reimbursement, Governmental Relations, Contracting and Pricing Departments

  2. Agenda • Reimbursement Department Overview • Accounts Receivable (A/R) Performance, Metrics, and Payor Mix • Key Reimbursement Strategies • Rate Maximization • Enhance EDI Connectivity • Urgent Care Contracting and Credentialing • Reimbursement Trends

  3. Department Overview

  4. A/R Performance, Metrics, and Payor Mix

  5. Urgent Care Collection Challenges and Action Steps • Prior to January 2009, majority of centers operated in a manual environment for patient registration • All centers now have the urgent care system installed • Learning curve with new urgent care practice management system for both centers and CBO staff • Center data entry errors decreasing • Focus on tracking and reporting non-payment issues to field • Focus on collection of patient co-pay and/or deductible at time of service • Significant changes to cash deposit process • Centers began to make cash deposits in Q4 2008 • New cash management system tool was in place by end 2009 to simplify center cash deposit process • Centralization of all cash reconciliation management functions completed by end of 2009 • No insurance eligibility verification performed at time of service • In August 2009, centers began using a real time eligibility (RTE) tool • Reviewing new RTE tool to allow for more defined, easy to read and accurate information • Staffing delays at the centralized urgent care CBO • Staffing is now appropriate • Leveraging other CBOs to work aged receivable (Colorado) • Significant progress has been made

  6. Key Reimbursement Strategies Rate Maximization

  7. Employer Services Rate Initiatives • New Employer Sales • Annual standard market price adjustments • Existing Customers • Annual increase of existing services • Drug Screen and Exam Management TPAs • Annual increase of existing services

  8. Key Reimbursement Strategies for 2010Enhance EDI Connectivity

  9. Key Reimbursement Strategies Urgent Care Contracting and Credentialing

  10. Urgent Care Center Classifications GREEN- 203 Centers • % of state’s covered lives contracted above 65% • Providers have completed credentialing process YELLOW- 59 Centers • % of state’s covered lives contracted is above 65% • Providers have not completed credentialing process RED- 39 Centers • % of state’s covered lives contracted below 65%

  11. UrgentCare Contracting and Credentialing Status • 161 Contracts completed to date • 16 Signed YTD in 2010 • 49 Identified outstanding • 1,895 Total Providers/Facilities requiring credentialing • 1,628 Credentialed (86%) • 267 Remaining (14%)

  12. Reimbursement Trends

  13. Reimbursement Trends • Increased state mandated EDI compliance • Texas, California, Minnesota, Georgia (future) • More UCR states moving to fee schedules • In 2000, 9 UCR states • 2010, only 6 UCR states remain (NJ, MO, VA, IN, IO, NH) • Fee schedule structures • 44 states with a fee schedule of which 6 states have adopted annual cost of living increases • 24 of these states use RBRVS as the basis for their fee schedule • Recent RBRVS updates have favored primary care codes, primarily Evaluation and Management (E/M) CPT codes • 2010 RBRVS changes also increased fees to E/M and physical therapy CPT codes • We experience reoccurring annual rate increases in 20-25 states per year between general fee schedule changes, annual cost of living and UCR annual adjustments

  14. Reimbursement Trends • Increased penetration of specialty networks (SN) for physical therapy and pharmacy services is expected to continue • New PT SN contracts with MedRisk (GB), NSG and Smartcomp • Development of outcomes/performance based networks expected to increase (e.g. The Zenith, Bunch and Associates, Harbor Health and Sedgwick) • Requires pre-established tiered levels of outcomes performance and EDI billing to rank provider performance • If requirements met, payment at full fee schedule • Continue to see more global fee arrangements for urgent care services • In range of $105 to $115 per visit • Targeting increases for major contracts this year • Budgeted NRV is $90, already exceeding that in 2010

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