Health Center Revenue and Reimbursement Management

1. Health Center Revenue and Reimbursement Management Julie M Vlasis Consultant Department of Health and Human Services Health Resources and Services Administration Bureau of Primary Health Care

2. Learning Objectives • Understanding components of Revenue Cycle • Sliding Fee Scale Policy • Fee Schedule Development

3. Understanding Components of Revenue Cycle

4. What Does Real Revenue Cycle Look Like?

5. Scheduling • Scheduling • Open Access • Modified Wave • Structured Appointment Type • Scheduling Guidelines • Information to assist staff in maintaining adequate scheduling • Staff Training

6. Scheduling • System Monitoring/Reporting • Patient Scheduling Trends • Morning/Afternoon/Early Evening • Pediatrics vs. Adults • Provider Productivity

7. Patient Registration • Patient Registration • Demographic and UDS Data Collected • Patient Insurance Collected • Copies of Insurance Cards • Insurance Eligibility Verified • Managed Care – PCP Designated • Benefits Reviewed

8. Patient Registration • Patient Application for Sliding Fee Program Initiated • Application completed • Financial Information collected • Family Size Verified • Copays Collected • Ability vs. Willingness • Staff Training and Development

9. Provision of Care • Provider Coding and Documentation • Templates • Smart Phrases • Implementation of New Programs • IPPE – Medicare Initial Preventative Physical Examination • AWV – Medicare Annual Wellness Visit • Provider Coding Profiles - ICD-10 Implementation • Free Text • Auditing • QA/QI Inclusion

10. Provision of Care • Annual Coding Update • Implementation Plan and Training for ICD-10 • CMS Updates • Clinical Policies and Procedures • Progress Note Documentation • Understanding of Required Reporting • UDS Reporting • Other Health Center Gran

11. Coding and Billing Encounter Edit Process • Review Evaluation and Management Codes • Review Procedure/Other Services Codes • Review Diagnosis Codes – Highest Level Of Specificity – Important for ICD-10 Implementation • Confirms Insurance Eligibility • Posting of encounter within 3 days of service • Claim Submitted Electronically

12. Accounts Receivable Management Process Driven • Receipt of Payments and Adjustments • Secondary Insurance Claims Submitted • Denials tracked and worked • Resubmission of claims • Patient Responsibility determined • Patient Statements mailed • Active Collection process completed

13. Accounts Receivable Management • Clear Communication with All Critical Departments • Scheduling • Registration • Clinical

14. Metrics and Measurements • Registration • Percentage of Accurate Insurance Verifications - 85% • Percentage Collection of Copays at time of Service – 90% • Percentage Sliding Fee Applications Processed Correctly -95%

15. Metrics and Measurements • Billing • Percentage of claims submitted in 3 days from date of service – 95% • Percentage of Clean Claims – 90% • Days in Accounts Receivable Aging – 45 Days • Percentage of Denials - 5% • Percentage of Underpayment – 5% • Percentage of successful appeals – 90% • Percentage of Claims over 90 days – 20%

16. Accounts Receivable Management • Team Work • Clear Communication • Scheduling • Registration • Clinical • Identification of Training Opportunities • Constant Report Analysis

17. Policies and Procedures • Essential Framework for Strong Revenue and Reimbursement Management • Provides Staff Accountability • Reduces Errors • Increases Reimbursement

18. Policies and Procedures to Identify • Appointment Scheduling • Registration • Sliding Fee Scale • Clinical Encounter Management • Billing Credit and Collections • Finance

19. Staff Development A well trained knowledgeable staff reduces Accounts Receivable Aging and Increases Reimbursement. • Initial Staff Training – New Hire • Continuous Training – at least Annually • Successful Revenue Management Programs have continuous staff training

20. Revenue Cycle Recap • Scheduling/ Productivity • Registration/Eligibility • Provision of Care/ Documentation • Coding and Billing - Accuracy • Accounts Receivable Management • Continuous Report Monitoring • Team Work across all departments • Staff Development – Training • Communication

21. Development of Revenue Cycle Annual Action Plan • Annual Action Plan • Annual Setting of Metrics • Annual Review and Revision P&P’s • Identification of new Medicare and Medicaid Programs • Monitoring all Components of Revenue Cycle

22. Sliding Fee Discount Policies

23. Sliding Fee Discount Policies 330 Grantee Requirement: • Health Center has a system in place to determine eligibility for patient discounts adjusted on the basis of the patient ability to pay. • This system must provide a full discount to individuals and families with annual incomes at or below 100% of the poverty guidelines (only nominal fees may be charged) and for those with incomes between 100% and 200% of poverty, fees must be charged in accordance with a sliding discount policy based on family size and income.* • No discounts may be provided to patients with incomes over 200% of the Federal poverty level.* (Section 330(k)(3)(G) of the PHS Act and 42 CFR Part 51c.303(f))

24. Program Policy Requirements • Clear guidelines for qualifying for discounted fee • Clear guidelines how discounts are determined • Clear guidelines outlining required documentation • Available application form with guidelines

25. Program Policy Requirements • Procedure for verifying income and family size • Clear recertification process • Sliding Fee Scales updated on annual basis • Required Signage • Staff Training- annually

26. Best Practices • Separate Sliding Fee Application • Separate Financial Class For Sliding Fee Scale Participants - Monitoring • Signage posted throughout Facility • Patient Financial Agreement • Reminders to patients regarding co-pay responsibilities – Appointments/Recall

27. Health Center Fee Schedule Development

28. Fee Schedule Development • Methodology of Development • Resource-based Relative Value Scale- RBRVS • True Center Costs • Medical, Behavioral Health and Dental • Updated Annually • Policy describing method and timelines

29. Fee Schedule Development • Current Medicare and Medicaid Prospective Payment System (PPS) Rates • Managed Care Wrap Rates • Medicare and Medicaid • Medicare Cost Report • Cost per medical encounter • UDS Report • Cost per medical encounter excluding lab, x-ray and nursing visits

30. Fee Schedule Development • Utilization Review • CPT utilization by facility/ by clinician • Auditing accuracy of services billed • Captured Revenues

31. Questions??

32. Contact Information Julie Vlasis Consultant 559-907-4760 559-454-8942 jvlasis@pacbell.net