Oregon Health & Science University: Revising Revenue Cycle Processes to Prevent Avoidable Denials and Increase Revenue

Transcription

1 Oregon Health & Science University: Revising Revenue Cycle Processes to Prevent Avoidable Denials and Increase Revenue Diana Gernhart, SVP Hospital Chief Financial Officer, OHSU Sondra Cari, Senior Director, Huron Healthcare June 19, 2013 Discussion Outline I. Introductions II. Learning Objectives III. New Imperatives for Effective Revenue Cycle Performance IV. OHSU Background V. OHSU Opportunities VI. Implementation Approach VII. Lessons Learned VIII.Q&A 2

2 I. Introductions 3 II. Learning Objectives 4

3 Learning Objectives After this session, you will be able to: Identify key processes and metrics needed to enable a proactive, risk-profiling approach to improving revenue cycle performance List actions necessary to empower staff to take a strategic, proactive approach to optimizing revenue cycle performance Describe key change management concepts that lead to implementation and long-term success 5 III. New Imperatives for Effective Revenue Cycle Performance 6

4 The New World 7 ACA Impact on Revenue Cycle 5 Essential Changes Cost Containment Pressure New Payer Contracting Models Changing Access Demands Clinical Metric s Impact on Net Revenue Integration of the Continuum 8

5 Cost Containment = Simple Challenge Work Smarter, Not Harder. 9 Audience Question Raise your hand if you have a focused initiative within your revenue cycle to reduce costs? 10

6 Optimizing Your Revenue Cycle Performance Leverage data/reduce rework Empower staff Automate routine decisions Prevent unnecessary losses 11 IV. OHSU Background 12

7 OHSU Campus 13 OHSU Healthcare Mission Through innovation, education and clinical expertise, we provide the best healthcare experience for patients and their families. 14

8 About OHSU Oregon Health & Science University Only academic medical center in Oregon $1.4B in net patient revenue Portland s largest employer Nationally ranked in several clinical specialties 15 Key Statistics FY11 FY12 FY13 Variance Inpatient admissions 28,686 29,787 29, % Average length of stay (ALOS) % Average daily census (ADC) % Casemix index (CMI) % Surgical cases 29,528 30,079 30, % Emergency visits 46,070 46,399 47, % Outpatient (OP) share of activity 42.2% 42.6% 42.8% 0.5% Ambulatory Visits 698, , , % CMI/OP adjusted admission 94,719 97, , % 16

9 V. OHSU Opportunities 17 18

10 Clinical Enterprise Goals Guiding Principles: Alignment with Clinical Strategic Plan Create high performing care delivery systems that strive to achieve the triple aim* Be an innovative and diverse organization Be an organization with highly engaged faculty, leaders and staff Innovate to meet Oregon s health and science workforce needs Operate as an integrated clinical enterprise Invest in programs with the greatest opportunity for advancing the clinical enterprise 19 Enterprise Revenue Cycle STEP 1 Focus on Reducing Costs Leverage data / reduce rework Empower staff Automate routine decisions Prevent unnecessary losses STEP 2 Integrate the continuum focusing first on patient impacted areas Customer Service Patient Collections Patient Statements Consolidated Coding 20

11 VI. Implementation Approach 21 VI. Implementation Approach A. Leverage data / reduce rework 22

12 Identified Data Sources Patient Access and Patient Financial Service data Billing scrubber Automated eligibility Additional third-party interfaces (self-pay outsourcing) / manual lists 23 Comprehensive Workflow and Business Intelligence Hospital Information Systems Eligibility Data Billing Scrubber Vendor Data Pre-Registration Secured? Sponsorship Secured? Billed Timely? Adjudicated Promptly? Denied? Paid Accurately? Positive Movement, Intervention Not Needed Manual Intervention Needed Negative Outcomes, Perform Root-Cause Analysis 24

13 Updated Business Rules Used to Trigger Workflow Days From Admission No Discharge Days Out From Expected Registration With No Confirmed Eligibility Delay From Expected Payer Timeframe From Payer Receipt Risk-Based/ Exception-Based Workflow 25 Consistent Workflow Structure Determine What Accounts Require Representative Intervention Combine With Manually Created Requests Risk-Based Prioritization (Financial Opportunity, Urgency, Efficiency Gains) Even Work Distribution Representative 1 Representative 2 Representative 3 26

14 Collection Improvements Insurance Work In Process Total ($) $9,000,000 $8,000,000 $7,000,000 $6,000,000 $5,000,000 $4,000,000 $3,000,000 $2,000,000 $1,000,000 $- Start Date Jan 2011 Feb 2011 Mar 2011 Apr 2011 May 2011 June 2011 July 2011 Aug 2011 February 2011 July 2011 Accounts Needing Intervention # % # % Total Number of Closed Accounts 44,911 55,216 Total Number Closed with No Touches 20,601 46% 36,907 67% Total Number Closed with 1+ Touches 24,310 54% 18,309 33% 27 VI. Implementation Approach A. Leverage data / reduce rework B. Automate routine decisions 28

15 Top Opportunity for Time Saving Work Shuffling / Account Triaging 29 Daily Account Triaging Total Volume of Work Number of Representatives to Complete Work Total Number of Work/Rep Accounts Assigned to Representatives by Alpha Daily Triaging Can They Take on More? Skills to Do This Work? Staff Here? 30

16 Consistent Workflow Structure HP MP LP = High Priority = Medium Priority = Low Priority Team Portfolio LP MP HP HP LP HP MP MP HP LP LP MP LP LP HP MP MP LP LP LP Representative 1 Representative 2 Representative 3 Representative 4 (OUT SICK) HP HP HP HP HP MP X MP MP MP 31 VI. Implementation Approach A. Leverage data / reduce rework B. Automate routine decisions C. Empower staff 32

17 Pre-Implementation Staff Feedback Top opportunities: Understand big picture results Strengthen revenue cycle expertise Consistency of prioritization Insights into job performance Team work mentality 33 Activities Improving Staff Satisfaction Focus on training of revenue cycle outside of their specific job function Consistency in where they get their work (one place in prioritized order) Refocus of energy on resolving the work rather then identifying what should be worked Increase visibility of personal and team outcomes Increase understanding of operational impact on financial outcomes Increase insight and accountability across revenue cycle management team 34

18 Example Metrics Need simple, consistent and comprehensive approach to measuring performance across revenue cycle. Example Metrics Doing the right things = measuring against priorities High, Medium, Low In the right manner = measuring effort Time to resolution In a timely manner = measuring against the deadline Not complete by due date 35 Post Implementation Staff Feedback Having visible metrics has helped me focus on where to spend my time. It has definitely helped prioritize my work more efficiently. The two biggest improvements are not seeing the infinite amount of accounts and not managing volumes of alpha split. Understanding the continuum of the revenue cycle has helped me work smarter. 36

19 VI. Implementation Approach A. Leverage data / reduce rework B. Automate routine decisions C. Empower staff D. Prevent unnecessary losses 37 Avoiding Losses Bringing people, process and metrics together to improve performance Denial Prevention Proactive Business Rules Denial Management Denial Prevention Root cause identification and accountability Denial Management Triggering workflow back to source department to expedite account resolution and bring awareness to overall process breakdowns Proactive Business Rules Triggering staff to review accounts when potential problem events occur 38

20 VII. Lessons Learned 39 Change Management Essentials Establish a vision Single accountable leader Proactively manage change 40

21 Leadership Responsibilities Designate a single accountable stakeholder and final decision maker Establish leadership vision Create a design/change leadership team that includes stakeholders from across the revenue cycle continuum Establish clear deadlines to ensure rapid implementation Execute communication plan 41 Managing Change 42

22 Lessons Learned: 10 Critical Success Factors 1) Leadership buy-in and partnership approach 2) Clear decision making process 3) OHSU-led, consultant-supported process 4) Collaborative processes across all levels and departments 5) Mission oriented 6) Build on accomplishments and leverage what is working well 7) System-ness 8) Accountability is crucial 9) Speed to implement; partner that can provide arms and legs 10) Flexible foundation to adapt to ongoing changes 43 Continuous Focus / Constant Change What s Next? 44

23 Revenue Cycle Initiatives One Customer Service Center for Billing Inquiries One phone number for patients to call (7/12) Centralized Coding Integrate Professional Coding within HIM (8/12) POS Collections Phase 2: Implement Patient Estimator for All Clinical Services (Est. 5/13) One Patient Statement (Est. 9/13) Phase 4: One patient statement for All Clinical Services 45 VII. Q&A 46

24 Today s Presenters Diana Gernhart Hospital CFO, SVP Oregon Health & Science University gernhart@ohsu.edu Phone: Sondra Cari Senior Director Huron Healthcare scari@huronconsultinggroup.com Phone: Denial Reporting Sample Questions As a leader over RC you want to know How much of my AR is denied / at risk? What of my denials are resulting in net revenue leakage? How does my denial occurrences compare to best practice? What are my biggest areas of opportunity / process improvement? As a leader of denial management you want to know What is volume of accounts denied (inflow and total AR)? Are accounts getting resolved timely and with positive outcomes? How is the team performing against their stated goals? As a stakeholder researching denial trends you want to know What are my trends by payer, denial code, and/or breakdown department? What are the account examples of the top opportunity areas? 48