How to Measure Your Business Office s Knowledge Base

Transcription

1 How to Measure Your Business Office s Knowledge Base ICD-10 Preparedness Workshop Series Tuesday, April 2, 2013 John Behn MPA

2 Executive Summary Chargemaster Front End Back End 2

3 Why Do We Need to Measure Knowledge? Maximize gross revenue Identify and capture missing revenue Billing and processing guidelines change rapidly Maximize revenue stream reduce denials, A/R days, and costly rework Minimize compliance risk Maximize customer service and good will in the community The price of not keeping pace can be measured in real dollars, in compliance risk and customer service impact Entry level employees will excel if given the opportunity, training and support they need to grow Rewarding excellence with advancement is a win for all involved 3

4 Medicare Outreach Questionnaire Not limited to Medicare Population Evaluation incudes patient satisfaction Using any number from 0 to 10, where 0 is the worst hospital possible and 10 is the best hospital possible, what number would you use to rate this hospital during your stay? Would you recommend this hospital to your friends and family? Patient experience can be significantly impacted by billing errors Other payors are following suit and creating patient followup surveys 4

5 Why Do We Need to Measure Knowledge? What is the status of your BO s knowledge base? How do you know? Are you dependent on feedback from the business office manager? What is the role of the BO within the revenue cycle? Active Dominating Passive Withdrawn No communication between BO and Departments Do you have the ability to independently assess the information coming from the BO? Denial management AR days Productivity Process contributing to charge capture of missing services, supplies, drugs Additional Charge capture quantified 5

6 Business Office Expectations What is the expectation for the business office from Administration Departments Does the BO have a specific mission statement? Is mission statement aligned with facility goals and To whom does the Business Office directly report? CFO CEO When was the last full BO staff meeting with CFO/CEO present? Does the direct report know the names and job duties of business office staff? What is your facility culture surrounding the BO? Is the Business office one of us or one of them? 6

7 Business Office Expectations When expectations are present and communicated There is a team environment The team works together A process of continuous quality improvement is implemented and reinforced regularly Gross revenue and net reimbursement improve Compliance issues are identified and addressed Job satisfaction improves Customer service improves Rejects, denials, rework all decline Reduced cost per claim 7

8 Business Office Expectations When expectations are missing or misunderstood Team can be disengaged Lack of departmental trust Lack of administration trust Errors increase Lack of accountability Missed opportunities Gross and net revenue suffers Compliance risks elevated Customer service suffers 8

9 The Facility Must Invest in Success Business office culture should be one and done Quality must be a priority The team must have a zero-defect mentality Administrative support must be continually present Doing things correctly takes time, resources and commitment BOs that are invested in success Train the team to recognize errors and empower change Create audit processes to ensure complete and accurate charge capture, accurate claim submission and maximum reimbursement Again, all of the above requires administration commitment and support 9

10 How Do We Measure? Clearly identify the roles, responsibilities and duties of every team member Ensure that job descriptions are updated and reflect current practices Identify the facility s knowledge base outside of the business office If extensive, with BO leadership, develop production standards and ongoing testing requirements If limited, set up a schedule for administration to visit and audit processes for each position Use findings to create an agreed upon process flow Use process flow to develop production standards and ongoing testing requirements Set fair and reasonable quality and production standards for every function 10

11 Revenue Capture Specialist Expectations Revenue Recognition measured for: Accurate Data Entry Correct application of modifiers as indicated Diagnosis Codes Key stroke errors Patient identification Knowledge of hospital services and departments Encounter reconciliation to schedule Drug and administration reconciliation Proper drug unit identification Appropriateness of procedure to diagnosis codes Procedures and accompanying supplies Device dependent pairings Modifier requirements and placement Registration errors Department / Modality specific trends and practice patterns 11

12 Revenue Capture Specialist Expectations Revenue Capture Specialists should: Create a complete and accurate reconciliation process Develop and implement a prescreening and post-entry audit process Basic billing rules and requirements should be clearly identified, published, and available to all RPS s for the prescreening process. Evaluate production guidelines Do production guidelines encourage maximization of revenue or encourage speed over quality? Are production guidelines prorated to allow for complexity of some departments as compared to others? 12

13 Revenue Capture Specialist Expectations Why do we need to measure: First line of defense for optimal reimbursement Candidates should be excellent at typing numbers quickly and accurately Bank tellers are ideal revenue capture candidates Should be detail oriented and able to recognize patterns Ability to be a profit center rather than an expense 13

14 Revenue Capture Specialist Questionnaire 14

15 Revenue Capture Specialist Questionnaire 15 15

16 ROI for Revenue Capture Specialist When things go well Maximum revenue capture is realized Reduced need for claim scrubbing, rework and denial management Reduced AR days result from cleaner initial submissions Lower Billing and Follow Up staffing levels When the process needs improvement Incomplete charge submission money left on the table Higher volume of rejected and denied claims Opportunity for issues with departmental ownership and accountability 16

17 Billing Expectations Billing measured for: Subscription to updates for assigned payors Knowledge of payor specific guidelines Regular updates to the team in meetings, and prepared to evaluate and address Scrubber resolution Rev Code or CPT/HCPC Assignment by Payor Payor Specific billing requirements Accurate and effective claim checks Timely resolution and resubmission of scrubber errors Accurate trending and training Evaluate and correct the trend, not just the bill Reduction of unsubmitted claims by reason 17

18 Billing Expectations Why do we need to measure: Billing is responsible for ensuring that claims can be received and processed by payors Work any claims rejected by payor scrubbers Submit paper claims per prescribed payor guidelines Modify claim form logic based on UB or payor specific requirements Work claim checks if applicable Create a comprehensive database of payor claim requirements Devise and implement regular reviews to ensure consistent compliance with payor guidelines Trend and track payor rejections by payor, reason and dollars 18

19 Billing Expectations Team members should be able to Understand all aspects of claim form logic and be able to recognize and act on any claim rejected from scrubbers or from payor system Maintain and understand an online library of payor specific requirements Establish relationships with provider reps to ensure accountability and accurate up-todate information Demonstrate strong communication skills Identify trends and report back to Revenue Control Analyst for research and process improvement 19

20 Billing Questionnaire 20

21 Billing Questionnaire 21

22 Billing Questionnaire 22

23 ROI for Billing When things go well Billing process is compliant with all payor policies Improved lag days and A/R days Reduced rework Reduced denials When the process needs improvement Compliance risks realized Increased lag days, expansive and growing A/R More rework required, larger team required Lower reimbursement 23

24 Follow-up Expectations Follow-up measured for: Understanding of payor policies Maintenance of payor library Timeliness of appeal/corrected claim turnaround Success rate of appeals Trending and education Team members should Possess innate intellectual curiosity and strong communication skills Recognize patterns and be able to create basic tracking and trending tables Exhibit strong computer skills and proficiency with online payor processing systems Maintain control of backlogged issues under consideration, have strong organizational and prioritization skills Consider quality billing reps for advancement to follow-up team 24

25 Follow-Up Expectations Why do we need to measure: The Follow Up Team should be able to Recognize the difference between a denial and a claim pending for additional information Know the difference between an appeal and a resubmission of a corrected claim Understand that insurance companies make mistakes Read and understand Remittance Advices for all of the various payors Understand A/R days, A/R reports and be able to respond to the revenue implications of increased A/R, denial trends and lost appeals 25

26 Follow-Up Team Expectations Follow- Up Team members should Maintain and understand a complete library of payor medical policies Establish relationships with payor representatives and payor customer support staff Develop report mechanisms to track denials by modality, dollar, payor, etc. Report denial or pended claim trends to Revenue Control Analysts for research and process improvement education 26

27 Follow-Up Questionnaire 27

28 Follow-Up Questionnaire 28

29 Follow-Up Questionnaire 29

30 ROI for Follow-Up When things go well Follow-Up process is timely and consistent with all payor policies Improved A/R days and consistent, appropriate reimbursement Reduced exposure to RAC, OIG or commercial payor recovery initiatives Reduced rework Reduced denials When the process needs improvement Increased unresolved denials, or unnecessary write-offs Increased expansive and growing A/R Increased exposure to compliance issues Inappropriate utilization of adjustment categories More rework required, larger team required Lower reimbursement Increased bad debt 30

31 Business Office Director Expectations Strong experience in medical billing or insurance claim processing Must understand the hospital s entire revenue cycle Proficiency in all aspects of the billing office Ability to manage large disparate teams Strong multi-tasking skills Genuine desire to mentor and map progress Excellent organizational, report development, and problem solving skills Outstanding communication skills 31

32 Business Office Director Expectations Should be able to understand and address any claim, coding, billing, denial situation that arises Should be a strong leader with a personal commitment to team performance Must understand and invest in the concept of cradle to grave customer service. Patients are a part of the process from the minute they present at registration until the minute the insurance payment check and final payment check is deposited 32

33 Business Office Director Expectations Establish benchmarks, and reporting mechanisms to track progress Identify opportunities for improvement and empower the necessary team members to create change Develop and provide training initiatives for constant improvement Act as a mentor and role model for all members of the business office team. Each person should be inspired to stretch their skills and become more. Recognize and reward quality, capitalize on super-user abilities 33

34 Employee Evaluation 120 Employee Production by Month Emplyee 1 Emplyee 2 Emplyee 3 Emplyee 4 Emplyee Week 1 Week 2 Week 3 Week 4 Week 5 Monthly Average 34

35 Evaluation of Benchmarking Data Director should be able to explain Why employee 4 is consistently lower in production than peers Is data collection method accurate? Is workload more demanding? Should production values be weighted to account for complexity? Does employee 4 need mentoring? If so which of the highest producers (employee 1 or employee 3) would be the better mentor? Can BO director provide effective parameters for mentoring to ensure success? How would BO Director follow up with mentor, and provide necessary assistance to grow mentoring and ensure continuous quality improvement? 35