Three New Technologies Your A/R Team May Be Missing Intelligent Process Automation For RCM. HFMA Education Series May 2018

Transcription

1 Three New Technologies Your A/R Team May Be Missing Intelligent Process Automation For RCM HFMA Education Series May 2018

2 Presenters John Fundingsland Dan Hillman Iselin, New Jersey 2

3 Sizeable Opportunity In 2016, billed professional and facility fees in the United States accounted for more than $3.2 trillion in healthcare spending, and resulted in >$60 billion in bad debt. Recovering just 1% of that lost revenue could yield $600 million in recovered cash. What if we could accomplish this while reducing our overall cost to collect? What if we could accomplish this with the same resources or possibly fewer and with better quality and consistency? 3

4 Current State - Measures that matter to your bottom line Some relevant metrics A recent poll of large hospitals consisting of 270 healthcare leaders revealed that close to half of the group does not track cost to collect metrics 39% use internally developed definitions 13% follow HFMAs definition for map keys Our research shows that roughly 41% of cost-to-collect comes from backend functions and also shows that agents spend an average of 1-2 hours per day on hold with payers Current generation of AR follow up team spends 50% on the phone with too much hold time 35% of claims after primary payments, are incorrectly transferred to patient pay without detecting the appropriate secondary payer 4

5 Current State Manual Processing Despite promised efficiency gains, recent technologies related to claims submission, AR follow-up, and account management do not always foster enhanced productivity Staff work in a highly manual way Staffing is increased as a result of manual process and hold time Staff sit on hold for hours a day Claim data is individually retrieved Accounts may not be segmented and allocated to staff intelligently 5

6 Current State Cumbersome Data Collection Data retrieval for healthcare billing and claims followup has created logistical hurdles: IVR Systems Log In Credentials Complex EDI data responses require understanding What are we after? Insurance discovery Eligibility Primary versus secondary Authorizations Support for re-filing claims, denial management and appeals 6

7 What do we do? We evolve our technology utilization! 7

8 Some Technologies to consider 1. IVR and Phone Automation 2. Business Rules and Robotic Process Automation (RPA) 3. Improved Electronic Data Interchange EDI Claims Data Notes from Calls Website Data By leveraging these tools and technologies, claims resolution can be improved by minimizing staff time in the use of web portals or phone calls to payers 8

9 What can technology do for us? Automation does not jeopardize security in the human sense One less aspect of cyber security and PHI to be concerned with Automation is a precise means of processing work Quality is improved and consistency is greatly affected Technology evolution far exceeds process evolution We contend with personnel conforming to new ways and methods 9

10 Poll Question The greatest obstacle to increasing productivity in the revenue cycle is: q Low degree of automation q Lack of standard process models q Complexity of navigating payer claims data systems (e.g. IVR, EDI, Agents on the phone) q Staff attrition q Other 10

11 #1 Optimizing Payer Calling Payer Concierge Current State Future State Billing reps schedule calls from payers based on current hold time Eliminate hours per day navigating IVRs and waiting on hold for payers Billing reps answer the phone with hold time minimized Enable billing reps to schedule a call with another payer while first call is wrapping up should be managed Hold time trends captured to feed a neural network for prediction purposes 11

12 #2 RPA in RCM Business Rules True efficiency would mean instantly applying tactics to claim status responses to automate the next action Score and allocate accounts based on complexity of claim status and staff skill Rules should also be applied to member eligibility issues Segment payers on claim status responses and tactics to improve throughput Create new business rules and tactics in real-time 12

13 Complexity Of Decision Making #2 RPA in RCM Pure Robotics Keeping your process capable 24x7x % Automation Month End Book Close Process Process Auditing Customer Relationship Mgmt. Patient responsibility management Compliance Monitoring Write Offs Low Threshold Quality Control Credit Balance Management Write Offs High Threshold Research & Analytics Analysis & Modeling Appeals and Denials management Reconciliation Client Reporting Personnel transaction Auditing Client Onboarding Claim Generation Performance Measurement Data Input & Capture Rejection Management Inbound Data File Management Demographics Entry Charge posting Document Management Transaction Reporting Claim updates and refile Eligibility and Insurance Discovery Reporting % Automation 20 30% Automation High Automation %, Standard RPA Extent of Unstructured Input Data Low Automation %, Cognitive RPA 13

14 #3 New Remit EDI With Major Payers Creates Automation Opportunities Comprehensive claim status responses with up to 25 additional data elements Comparison of claim status data to contractual amounts call avoidance Remit data from payers to enhance traditional 277 claim status response Auto post payments with minimal to little biller involvement true automation 14

15 #3 Reduce Self Pay With Improved Insurance Discovery Millions of dollars and countless hours are lost in the process of missing eligibility, unclear benefit detail, inaccurate demographics and inaccurate coverage information. Insurance discovery products are often useful to help identify coverage for patients that are not holding insurance cards Real-time eligibility and plan detail in the registration process and early in the billing process helps eliminate wasted effort Reducing statement volumes is accomplished by having the right plan detail and address information. 15

16 #3 Intelligent Workflow Account Prioritization Automated scorecard tools and related technology will play a major role in the development of workflows using EDI and other data capture mechanisms. The goal is to eliminate the need for Supervisors to segment accounts while allowing automation to do the work. Prioritization tools could be paired with automated status notifications and actions to increase efficiency Tools to identify accepted claims could enable staff to remove them from work queues immediately, preventing unnecessary follow-up 16

17 Case Study - Low Balance Performance Financial Class Volume $ Value Avg/Claim Avg Age Collections Active Value Blue Plan 64,518 $57,433,707 $ $13,684,142 $5,660,331 Commercials 285,289 $158,275,552 $ $20,732,775 $22,620,728 Medicare 45,624 $37,813,019 $ $3,892,382 $4,529,415 Medicaid 25,387 $22,785,892 $ $1,937,682 $5,364,368 MVA 8,823 $12,397,182 $1, $2,226,156 $- WC 24,155 $19,623,149 $ $5,788,992 $42,798 Self-Pay 3 $5,050 $1, $- $- G. Total 453,799 $308,333,551 $ $48,262,129 $38,217,640 G. Total (Collected from placed value) 16% Collections by category Commercials 13% Medicare 10% Medicaid 9% MVA 18% Work Comp 30% LOW BALANCE Above reflects a cut of AR performance on balances below $679 and aged over 222 days 17

18 Effective Integration While targeted tools can help increase the efficiency and efficacy of internal staff processes, those benefits often are not optimized if operations do not ensure technology is integrated effectively Effective change management can prove daunting for many providers, the basics are: - Bring the staff along and convey the why - Inform What s in it for ME (WIIFM) Manage change using reports built to monitor staff activity to ensure they re using new technology appropriately and effectively Optimize utilization by showing the why and measuring the results to showcase benefits and value A clear requirement to successful new tool adoption is process integration and refinement 18

19 Poll Question My top area of focus for improvement over the next 12 months is: q Increasing low balance collection rates q Lowering total cost to collect q Increasing collection rate among insured patients with balance after insurance q Improving staff productivity q Other 19

20 Follow Up Contact Information John Fundingsland Vice President Hexaware Technologies Direct (949) Dan Hillman VP Client Strategy Hexaware Technologies Direct (215)

21 Thank You! 21