Health Center Revenue Cycle Optimization

Transcription

1 Health Center Revenue Cycle Optimization Olivia Dear, MPA Project Consultant December 11,

2 Today s Objectives Provide ready-to-use ideas as well as numerous key strategic practices and tools to use to optimally manage your revenue cycles. Establish an understanding of influences on health center revenue cycle management. How can we improve on processes that result in more efficiencies and bigger dollars? 2

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4 Success Requires Getting Many Pieces Right FRONT END MIDDLE BACK END Collect and validate critical demographic and service data elements Utilize automated technologies to verify insurance coverage in advance of the visit Confirm or complete pre-registration work flows Collect co-payments and execute collections agreement Reconcile charges to appointments in a timely manner Submit and track all claims, coordinate benefits Set payment exceptions and establish payment solutions before services are delivered Comprehensive documentation of patient care supported by coding and charge capture technologies Manage insurance denials and appeals; and execute automated patient-pay solutions 4

5 High Performing Revenue Cycle Commonalities Organizational culture that elevates the importance of the revenue cycle. Master areas important to their particular circumstances. Accelerate improvements. Take action and execute strategies to achieve goals. Understand the connection between RCM and the clinic s bottom line. 5

6 Making The Connection Performance Snapshot Chinatown Service Center Family Health Clinic

7 Making The Connection NET DAYS IN AR PAYER MIX Performance Snapshot Chinatown Service Center Family Health Clinic CASH ON HAND 7

8 Patient Flow Modeling & Revenue Cycle If you don t pay attention to patient flow modeling your patients, your staff, your finances all may suffer. 8

9 Patient Flow Modeling & Revenue Cycle To implement the changes that achieve improved patient health in a fiscally-sound way, staff must learn how their organizations currently operate. 9

10 Sample Patient Modeling Registration/ Check-in - Process 10

11 Process Perception: Reality & Ideal Perceived Process Realistic Process Ideal Process 11

12 Key Areas To Consider PEOPLE PROCESSES TECHNOLOGY METRICS 12

13 Front End: Scheduling, Eligibility, and Pre-Auth SCHEDULING, ELIGIBILITY, PRE- AUTHORIZATIONS APPOINTMENT REMINDER REGISTRATION, CHECK-IN, COLLECT FEES 13

14 Front End: Scheduling, Eligibility, and Pre-Auth 14

15 Front End 15

16 Front End 16

17 Front End: Scheduling, Eligibility, and Pre-Auth Key Functions of Front Desk Staff Confirm and schedule patient appointments. Assess a patient s needs in order to schedule with the appropriate provider. Questions to Evaluate the Effectiveness of the Scheduling Function Does your clinic have an electronic system for appointments that collects contact info, insurance/payment source, and other patient information? Update patient demographic and insurance information. 17

18 Simplified Patient Scheduling Make all appointments the same length Improve efficiency appointment slots should be minute increments Review fill rate of appointment slots Start all visits on time Make appointments as close to the time of request for care as possible 18

19 Metrics SCHEDULE OCCUPANCY RATE 95% Capacity Physician Visits PRE-REGISTRATION RATE >98% 19

20 Front End: Appointment Reminder Call Key Functions of Front Desk Staff Contact patients by phone or electronically. Most Practice Systems have the capability to program and automate reminder calls/ s. Questions to Evaluate the Effectiveness of the Appointment Reminder Function Does your health center make reminder calls in advance? Is an or text reminder sent? 20

21 Front End: Appointment Reminder Call CONFIRMING AN APPOINTMENT Let me know if you can t make it. We re expecting you. We ve dedicated this appointment to you. 21

22 Metrics REMINDER CALL RATE 100% NO SHOW RATE 22

23 Front End: Registration, Check-in, & Collect Fees Key Functions of Registration/ Financial Counseling Staff: Review financial P&P and patient responsibilities Collect patient fees Verify coverage and eligibility Provide financial counseling resources for uninsured patients Questions to Evaluate the Effectiveness of the Registration/ Check-In Function Does your clinic have written protocols and procedures for staff to follow during the patient check in process? How are staff oriented/trained on this check in process? 2017 Capital Link 23 5 Revenue Cycle

24 Metrics REGISTRAR REGISTRATION RATE 40 per 8 hr. shift SCREENING RATE OF UNINSURED >98% 24

25 Front End: Registration, Check-in, & Collect Fees Ask us about how we can help you design, create and implement a pre-registration process for your clinic! 2017 Capital Link 25 5 Revenue Cycle

26 Success Requires Getting Many Pieces Right FRONT END MIDDLE BACK END Collect and validate critical demographic and service data elements Utilize automated technologies to verify insurance coverage in advance of the visit Confirm or complete pre-registration work flows Collect co-payments and execute collections agreement Reconcile charges to appointments in a timely manner Submit and track all claims, coordinate benefits Set payment exceptions and establish payment solutions before services are delivered Comprehensive documentation of patient care supported by coding and charge capture technologies Manage insurance denials and appeals; and execute automated patient-pay solutions 26

27 Middle CHARGE CAPTURE, CLINICAL DOCUMENTATION, CODING CHARGE MASTER CHECK OUT 27

28 Middle: Charge Capture, Documentation & Coding Key Functions of Clinical and Billing Staff Ensure comprehensive documentation of patient care supported by coding and charge capture technologies. Consistent coding of patient diagnoses codes on the encounter form. Questions to Evaluate the Effectiveness of Charge Capture, Clinical Documentation, and Coding Function Does your health center use an encounter form/superbill? How is it kept up to date? 28

29 Metrics TOTAL CHARGE LAG DAYS 7 DAYS NET REVENUE 29

30 Middle: Charge Master Key Functions of Financial Management Staff Manage, monitor, and maintain the charge master. Ensure the charge master is comprehensive for all services delivered. Questions to Evaluate the Effectiveness of Charge Master Function Does your organization have tools in place to aid in tracking and management of the individual charge item records in the charge master file? 30

31 Metrics CHARGE MASTER ITEMS UPDATED IN REPORTING PERIOD 100% WHAT THEY MEASURE These metrics provide insight on charge master integrity during periods between full annual audits. 31

32 Middle: Checkout Key Functions of Financial Counselors/ Checkout Staff Educate patient on health center financial policies, including co-pay, self-pay, prompt pay options, and past due account balances. Collect payments. Questions to Evaluate the Effectiveness of Check out Function Does your health center have written protocols and procedures for staff for the patient checkout process? How are staff trained on this process? 32

33 Metrics DAYS TO CHARGE ENTRY SAME DAY OR 24 HOURS BILLING ACCURACY 33

34 Success Requires Getting Many Pieces Right FRONT END MIDDLE BACK END Collect and validate critical demographic and service data elements Utilize automated technologies to verify insurance coverage in advance of the visit Confirm or complete pre-registration work flows Collect co-payments and execute collections agreement Reconcile charges to appointments in a timely manner Submit and track all claims, coordinate benefits Set payment exceptions and establish payment solutions before services are delivered Comprehensive documentation of patient care supported by coding and charge capture technologies Manage insurance denials and appeals; and execute automated patient-pay solutions 34

35 Back End BILLING, PAYMENT PROCESSING, REIMBURSEMENT, POSTING CONTRACTS MANAGEMENT AR, PATIENT COLLECTIONS, DENIAL MANAGEMENT 35

36 Back End: Billing, Claims Submission, Payment Processing Reimbursement, and Posting Key Functions of Billing Staff Code and bill claims Establish contracts with payers Monitor eligible and allowable services Document payment and post amount to patient s account Questions to Evaluate the Effectiveness of Billing/Claims Function Does your health center have a Practice Management System with a review feature? 36

37 Metrics % CLAIMS BILLED ELECTRONICALLY 95% CASH FLOW 37

38 Back End: Contracts Management Key Functions of Contracting/ Finance Staff Conduct review of complex language and financial analysis with major payers Implement legal, financial, and business requirements through negotiations Questions to Evaluate the Effectiveness of Contracts Management Function Does your health center have a payer profile on file for each managed care contract? Does the health center know what the key terms of the contract are and how they impact it? 38

39 Metrics TOTAL DENIALS BY PAYER AS A % OF NET REVENUE <5% PAYER PROFILES Not understanding the payers practices increases denials, late payments, and lack of authorizations for services. It also increases A/R days, leading to poor financial stability. 39

40 Back End: Accounts Receivable, Patient Collections, & Denial Management Key Functions of Billing, Claims & Collections Staff Collect and enter claim information Post insurance and patients payments and manage accounts Questions to Evaluate the Effectiveness of AR, Collections & Denial Management Function How often does the health center review A/R? Does your health center have systems to track if a payer has not acted on a claim? 40

41 Metrics WHAT THEY MEASURE Days in accounts receivable is the number of days before patient payments are collected. DAYS IN AR DAYS DENIAL RATE 5% The denial rate measures claims that are unpaid. 41

42 Key Performance Indicators FRONT END Insurance Verification Pre-Registration Rate Reminder Call Rate Call Abandonment Registrar Registration Percent of Patient Schedule Occupied Screening Rate of Uninsured Conversion Rate of Uninsured to Payer Source MIDDLE Cash Collection as a Percentage of Adjusted NPSR Bad Debt Charity Care/Sliding Scale Cash to Collect Cash to Collect by Functional Area Point-of-Service Collection Rate Total Charge Lag Days Days in Total DNFB Days in Total DNSP BACK END Net Days in Accounts Receivables Aged A/R as a % of Billed A/R Aged A/R as a % of Billed A/R by Payer Group Initial Denial Rate Zero Pay Professional Services Denial Percentage 42

43 RCM Toolkit Toolkit provides an overview of the revenue cycle management process and best practices for each function. It also includes suggested key performance indicators and helpful resources. For health center leadership teams and revenue cycle staff. 43

44 Patient Access RCM Toolkit Toolkit provides an overview of the revenue cycle management process and best practices for each function of the front end of the revenue cycle. Managing Patient Access Functions of the Revenue Cycle: A Toolkit for Community Health Centers It also includes suggested key performance indicators and helpful resources. For health center leadership teams and revenue cycle staff. 44

45 Access More Information about Our RCM Toolkits Visit our webpage: To Order Copies of the RCM Toolkits visit: 45

46 PERFORMANCE PROFILES Visit us Online: Performance Snapshot Chinatown Service Center Family Health Clinic See our Resources Page that contains several free publications, manuals, and health center highlights Get more information about the Performance Profiles and how to receive your custom report ance-evaluation-profiles 46

47 Questions? Contact Jonathan Chapman Director of CHC Advisory Services Visit us Online: Learn more about our products and services Download our free publications and resources Register for upcoming webinars Sign up for our e-newsletter, Capital Ink Subscribe to our blog at capitallinksblog.blogspot.com 47