MAP KEYS OVERVIEW and CASE STUDY Thursday, March 10, to 3:30 pm

Transcription

1 Association of Illinois Access Management Patient Access No Bed of Roses Rosewood Restaurant, Rosemont, IL MAP KEYS OVERVIEW and CASE STUDY Thursday, March 10, to 3:30 pm Suzanne K. Lestina, FHFMA, CPC Director, Revenue Cycle MAP Healthcare Financial Management Association Tracey McKnight, Senior Director, Revenue Cycle Ami Kihn, Senior Director, Patient Financial Operations Spectrum Health System, Michigan

2 OVERVIEW Reform and the revenue cycle How hospitals are responding Evidence-based improvement A Case Study Spectrum Health System 2

3 REFORM AND THE REVENUE CYCLE

4 Americans (Millions) INCREASING INSURANCE COVERAGE Source: CBO 4

5 Americans (Millions) CHANGING PAYER MIX (5) (20) (5) (3) (35) (32) Uninsured Non-Group Market Employer Sponsored Medicaid Exchanges Source: CBO letter to House Speaker Nancy Pelosi March 20,

6 FINANCIAL IMPACT ON YOUR HOSPITALS Payment Area Payment Reduction Over a 10 Year Period (in billions) New payments for uncompensated care Payment reductions: Market basket update (MBU) Disproportionate Share Hospital payment cuts (Medicare & Medicaid DSH) Reduced readmissions Hospital-acquired conditions Accountable care organizations Net aggregate financial impact on U.S. hospitals Sources: Health Care Facilities Managed Care Analysis; Bank of America Merrill Lynch; March 4, 2010; p. 9 CBO letter to Speaker Nancy Pelosi; March 20, 2010; HFMA estimate 6

7 OTHER REFORM CHANGES New requirements Standardized charge reporting Requirements for tax-exempt hospitals New economic incentives Payment linked to quality Accountable care organizations Bundled payment 7

8 Revenue Cycle Imperatives HOW REFORM IS AFFECTING THE REVENUE CYCLE Expanded Coverage Payment Cuts New Requirements New Economic Incentives Improve Performance and Efficiency Eligibility Processes Denials Prevention Charity Care Policies/Process ICD-10 Rational Pricing Documentation and Coding Physician Integration Bundled Payments 8

9 HOW HOSPITALS ARE RESPONDING

10 PRINCETON BAPTIST MEDICAL CENTER BIRMINGHAM, ALABAMA Area of Excellence: Cash Collection How They Did It Consolidated pre-arrival unit Automated insurance verification, including identifying patient financial obligation Communicating about and collecting this amount prior to arrival Instituting continuous quality improvement process to identify and reduce errors 10

11 PRINCETON BAPTIST MEDICAL CENTER BIRMINGHAM, ALABAMA Results Reduce DNFB to 3.7 days Increase cash as a % of net revenue to consistently above 100% Decrease denials to less than.25% of gross revenue Maintain cost to collect at less than 3% DNFB Comparable Statistics 6.2 Median 5.4 Top Quartile Performance Source: HFMA s March

12 TOUCHETTE REGIONAL HOSPITAL CENTREVILLE, ILLINOIS Area of Excellence: Cash Collections How They Did It Revising charity care policy Adopting an automated patient eligibility system Incorporating charity care criteria into the system s database 12

13 TOUCHETTE REGIONAL HOSPITAL CENTREVILLE, ILLINOIS Results Reduced bad debt charges by 48.6% Increased charity care by 15.5% Decreased overall uncompensated charges by 16.6% Increased cash collections by $2.5 million over the goal of102% adjusted net patient services revenue Cash Collections Comparable Statistics Median Top Quartile Performance Source: HFMA s March

14 BAYLOR HEALTH CARE SYSTEM DALLAS, TEXAS Area of Excellence: Cash Position How They Did It Centralize the business office Centralize insurance verification and pre-registration Centralize denials management 14

15 BAYLOR HEALTH CARE SYSTEM DALLAS, TEXAS Results Improvements from Achieved consistent net revenue cash collection rate of 100% or better Lowered net accounts receivable days from 67.9 in 2000 to 39.9 Decreased 91+ days from discharge aging from 13.0% to 5.8% Reduced cost of collections from 2.5% Days in A/R Comparable Statistics 44.5 Median 37.9 Top Quartile Performance Source: HFMA s March

16 EVIDENCE-BASED IMPROVEMENT

17 EVIDENCE-BASED IMPROVEMENT Components Measuring Performance What are consensus measures of revenue cycle excellence? Comparing Performance How are peers performance and what are performance targets? Improving Performance How do high performers succeed? 17

18 EVIDENCE-BASED IMPROVEMENT Benefits Identify and manage to trends Validate best practices Trigger corrective action Forecast performance Identify opportunities for process improvement Compare performance with like organizations Use data to change behaviors 18

19 HFMA INITIATIVE 19

20 WHAT IS MAP? MAP is a comprehensive performance improvement strategy Identify indicators Track and improve performance Recognize excellence Share successful practices 20

21 EVIDENCE-BASED IMPROVEMENT: MEASURING PERFORMANCE

22 MAP KEYS MAP Keys are industry-developed key indicators for revenue cycle performance Clearly defined Measurable Discerning Comparable

23 MAP KEYS MAP Keys focus on key areas of revenue cycle performance Patient access Revenue integrity Claims adjudication Management 23

24 PURPOSE VALUE CALCULATION Example Indicator Net days in A/R Purpose Trending indicator of overall A/R performance Value Indicates revenue cycle efficiency Calculation Net A/R Net patient service revenue 24

25 EVIDENCE BASED IMPROVEMENT: COMPARING PERFORMANCE

26 COMPARING PERFORMANCE Manage trends Identify opportunities Prioritize opportunities Identify successful practices 26

27 COMPARING PERFORMANCE Flexible comparisons are needed for in-depth analysis 5% Industry trends Performance over multiple time frames Pre-selected peer groups Customized peer groups 4% 3% 1% 0% Jan 09 Mar 09 May 09 Jul 09 Sep 09 Nov 09 Bad Debt vs. Charity Care as of % Revenue Source: HFMA s 27

28 PEER GROUP COMPARISONS Need to choose appropriate peer groups for meaningful comparisons Source: HFMA s 28

29 TIMELY DATA You need recent data to set appropriate performance targets; industry trends affect expected performance levels. Organizations need to raise the bar as industry performance improves. Median Days in A/R Although median days in A/R was about 52 in 2004, it dropped to about 46 in This shows that data need to be current to establish a relevant benchmark. 29

30 EVIDENCE BASED IMPROVEMENT: IMPROVING PERFORMANCE

31 INSIGHTS FROM AND ABOUT HIGH PERFORMERS Area for improvement: Cash collection Cash collection as a % of adjusted net patient services revenue Median: Top quartile: Source: HFMA s March 2010 Research % of high performers citing importance of investing in frontend technology % of high performers having estimates available for patients at registration Successful practices Sample scripts Use of dedicated trainers for patient access staff 31

32 MAP AWARD HFMA s MAP Award recognizes healthcare organizations that achieve excellence in the revenue cycle and serve as models for the healthcare industry 32

33 SUCCESSFUL PRACTICES

34 SUCCESSFUL PRACTICES Culture People Processes Technology Communication 34

35 CULTURE

36 SUPPORT FOR REVENUE CYCLE 7 = Extremely high to 1 = None at all High Performing 86% All Other 76% 36

37 PEOPLE 37

38 DAYS OF INITIAL REVENUE CYCLE TRAINING REQUIRED High Performers >10 days 5-10 days 3-5 days 2-3 days Registrars 57% 14% 14% 14% 0% Billers 57% 14% 14% 14% 0% Collectors 50% 21% 21% 7% 0% Financial Counselors 64% 14% 14% 7% 0% All Others >10 days 5-10 days 3-5 days 2-3 days Registrars 42% 25% 15% 11% 7% Billers 54% 25% 7% 10% 4% Collectors 47% 30% 10% 9% 5% Financial Counselors 52% 26% 10% 7% 5% 1 day or less 1 day or less 38

39 STRATEGIES TO MOTIVATE, RECRUIT, AND RETAIN STAFF Provide incentives for staff who meet goals Increase front-line staff salaries (beyond average organizational increase) Increase back-office staff salaries (beyond average organizational increase) 19% 31% 44% 43% 64% 86% 0% 50% 100% High Performing All Others 39

40 PROCESSES 40

41 FREQUENCY OF REVENUE CYCLE TEAM MEETINGS Revenue cycle staff team meet at least monthly 71% 84% Process centered improvement team(s) meet at least weekly Cross-functional team meet at least monthly (including reps from clinical, IT, HIM,... ) Metric triggered leadership teams (triggered by revenue cycle metric outside defined parameters) Other (responses generally include more frequent, targeted meetings) 3% 26% 25% 21% 50% 57% 51% 50% 0% 20% 40% 60% 80% 100% High Performing All Others 41

42 USE OF PATIENT FOCUS GROUPS High Performing 43% All Others 20% 42

43 COLLABORATION WITH PAYERS Routinely meet to review & discuss issues regarding patient satisfaction Routinely meet to discuss & implement process streamlining initiatives Routinely meet to discuss & implement technology improvements and interfaces 21% 25% 26% 57% 64% 64% Routinely meet to review & discuss payment discrepancies 57% 86% Do not routinely collaborate with payers 7% 35% 0% 20% 40% 60% 80% 100% High Performing All Other 43

44 SIGNIFICANT CHANGES TO THE FOLLOWING AREAS WITHIN THE PAST 3 YEARS 1 = no improvement to 7 = complete overhaul Financial Counseling 23% 64% Registration Admitting Billing Collections 24% 21% 29% 31% 27% 43% 50% 50% 0% 20% 40% 60% 80% 100% High Performing All Other 44

45 TECHNOLOGY

46 TECHNOLOGY SUPPORT FOR THE REVENUE CYCLE 7 = Extremely high to 1 = None at all IT support for revenue cycle 55% 79% IT collaboration with revenue cycle 51% 71% 0% 20% 40% 60% 80% 100% High Performing All Other 46

47 COMMUNICATION

48 AVAILABILITY OF ESTIMATES FOR PATIENT OUT-OF-POCKET LIABILITY We provide estimates to nearly every patient 21% 16% At scheduling, upon request At registration, upon request 36% 40% 53% 57% At time of service, upon request 7% We do not provide estimates 10% 33% 43% 0% 20% 40% 60% 80% 100% High Performing All Others 48

49 WHO HAS ABILITY TO APPROVE PROVISION OF CHARITY CARE Managers, Directors, CFO 71% 84% Financial Counselors No approval needed if patient meets organizational Charity Care Policy 7% 9% 48% 64% Registrars 7% 1% Schedulers 0% 0% 0% 20% 40% 60% 80% 100% High Performing All Other 49

50 Spectrum Health System Successful Practices

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52 Automated Eligibility, Address Checking and Propensity to Pay - Revenue Cycle Strategy combining People, Process and Technology. March 10, 2011 Prepared and presented for: association of Illinois Patient Access Management 2

53 Tracey McKnight, RN,MM,CMAC Senior Director Revenue Cycle Management Spectrum Health Hospital Group Ami Kihn Senior Director Patient Financial Operations Spectrum Health System 3

54 4 MAP Case Study

55 About Spectrum Health Spectrum Health is a not-for-profit system of care dedicated to improving the health of families and individuals. Our organization includes a medical center, regional community hospitals (7), a dedicated children s hospital, a multispecialty medical group, affiliated physicians and a nationally recognized health plan, Priority Health. Spectrum Health has over 16,700 employees and 1,500 physicians

56 Mission, Vision, Values MISSION: To improve the health of the communities we serve VISION: To be the nation s highest quality and most successful healthcare enterprise VALUES: Compassion, Excellence, Innovation, Integrity, Respect, Teamwork, 6

57 Revenue Cycle Overview Revenue Cycle Technology Systems Planning, Integration, Deployment, Stabilization Revenue Cycle Education and Training Revenue Cycle Policy and Procedure Compliance and Payer Relations Revenue Cycle Leadership and Direction Access Clinical Encounter Coding Patient Finance Phys Relationship Service Request Scheduling Pre-Arrival Authorization Eligibility Address Pre-Registration Financial Clearance Patient Readiness Clinical Prep Financial Counseling Registration/Check- In Time of Service Pymnt Consent/Forms MSP MySpectrum Enroll ID Cards Scanning Wayfinding Order Follow Up Clinical Treatment CCAP Patient Placement Social Work Discharge Planning Charge Capture Care Management/ UM Check-out/ Discharge HIM Revenue Integrity Charge Capture Claim Submission Patient Billing Acct. Follow Up/Mgt. Customer Svce Call Ctr. Denial Management Cash Application 7

58 Project Methodology

59 Agenda Initiate Idea Project Sponsor Identified Vision and Business Objectives Resource Estimates Leadership Support/Project Structure Develop Concept Resource Estimates Defined and Resources Committed Project Plan Developed Project Plan Approval and Project Funding 9

60 Agenda continued Plan & DO Project Overview Project Inclusions Integration Development Process Flow Changes Education and Training Implement & Evaluate Go-Live Decision Documented Go-Live Statistics Criteria to Measure Success (Dashboard) Questions

61 Project Vision and Business Objectives Project Vision To provide tools and resources to the front-end/first patient contact areas to identify correct and accurate patient demographic and insurance Business Objectives Decrease number of Self Pay designations at the time of service/registration due to valid insurance Decrease Self Pay referrals made to Financial Counseling because truly has insurance Decrease customer service phone calls Increase clean claims submissions Reduce front end edits for incorrect subscribers

62 Project Structure Oversight Committee- Representation Includes Leadership supporting: Patient Access- Facility, Patient Financial Services- Facility, Professional Business Office, TIS, United/Kelsey, Reed City Work Group Structure- Several Workgroups throughout project to include personnel from all areas as indicated above- work items included: Address Checking, Credit Checking, Propensity to Pay, Eligibility, Pre-Encounter RevRunner Utilization Work group established after go-live (s) to continue to monitor activities, questions, enhancements, reports, quality activities, etc of the RevRunner users and system 12

63 Project Overview Automated Verification Tool Patient Demographics (Patient ID) Eligibility (Verifier) Ability to Pay (Propensity to Pay) Integrated with Core Technology Cerner (Patient ID and Verifier) Healthquest (Patient ID and Verifier) Horizon s Practice Plus (Verifier) Misys (All Modules Stand Alone) 13

64 Overview- Address Checking Patient ID: This functionality will allow for us to verify and validate guarantor address to ensure accuracy of the information in our core systems. This will improve identification of the patient; assisting with response to compliance with Red Flag Regulations, as well as decrease the rate of returned mail; improving the length of the billing and collection cycle with the patient. 14

65 Overview- Eligibility Checking Verifier: Verifier allows us to verify and validate the accuracy of the insurance information in our core systems. With this functionality we can assure that the patient is still eligible for the identified insurance and, as provided by the insurance plan, we are also able to gather benefit levels, co-payments, and deductibles to determine the patient s out-of-pocket obligation. This functionality will prevent unnecessary re-submission of bills due to inaccurate or ineligible insurance information, as well as, improve our ability to collect prior to and at the point of service. 15

66 Overview- Propensity to Pay Propensity to Pay Scoring: Through utilization of the Propensity to Pay module we will be able to identify a patient s ability to pay for their healthcare services either prior to or at the time of service, depending on the nature of their visit. This will enable us to focus our collection efforts, providing education on potential Medicaid eligibility or assistance with determining payment options or financial assistance as necessary. 16

67 Scope Inclusions Locations: Grand Rapids Hospitals Butterworth Blodgett HDVCH United Hospital Technology: Horizon s Practice Plus Misys Cerner Healthquest Kelsey Hospital Reed City Hospital Kent Long Term Acute Care Hospital 17

68 Integration 270/271 Transactions: Allows for checking insurance eligibility real-time during the registration process (Cerner, Healthquest, HPP) HL7 Transaction: Allows for eligibility checking after the registration process (Cerner, Healthquest) Added the ability to check guarantor address by a Yes/No Indicator (Cerner) Allows us to pre-populate fields to cut down on manual entry during the credit checking inquiry Testing Unique - Live patient testing required given nature of work Batch File Reports CCL out of Cerner, Healthquest or queried out of Ensemble (can set up when to run and how often) 18

69 Stand Alone versus Integration Staff may elect to utilize as a stand alone system in appropriate circumstances Education and Training developed scenarios to guide staff when to utilize in stand alone environment Once data is entered into the technology system, integration is forced through the 270/271 transaction sets 19

70 Integration Diagram

71 Process Flow Changes Created new process flows for the use of automated eligibility and address checking in the below areas: Scheduling Pre-Arrival Point of Service Emergency Verification Prior to Service Financial Counseling During Service PFS post service Primary Care

72 Process Flow Example

73 Education and Training Deliver education in e-learning environment and paper based education completed as well. Specific Modules below: Integrated Version Standalone Version Administrative Functions Module Including education to support scripting and links to procedures and process Provided on-site training to each individual area 23

74 Examples of Education Materials

75 Go-Live Statistics/Successes Rolled Out Verifier and Patient ID to over 68 department locations (October 2009 July 2010) Began Propensity to Pay roll out October 2010 (anticipate completion June 2011) Currently have over 600 hundred users Average about 200,000 eligibility checks per month Average about 32,000 address checks per month

76 Go-Live Statistics/Successes continued Mail returns per month are at about 2.0% Insurance discrepancies from registration to billing has gone down from around 9% to 7.9% on average Self pay/na designation at registration changed to another insurance in Finance has decreased from 23% to 6% in a 9 month period

77 Dashboard

78 Dashboard Continued

79 Next Steps Complete roll out of Propensity to Pay Integration to Medical Group Technology and Processes

80 Key Lessons Learned: Project Management Methodology Strong Executive Leadership Change the process, not just technology Understand what done looks like Metrics, Metrics, Metrics Keep momentum going Have fun/celebrate

81 Questions?

82 Propensity to Pay Evaluation A patient friendly process to support the growing shift of financial responsibility. 32

83 Agenda What and Why Propensity to Pay Validation/Scoring Matrix Target Process Changes Pilot Phase Timeline Next Steps 33

84 Propensity to Pay What is it? An individual s ability and likelihood to pay for their healthcare services Why Consider it? To be able to communicate. financial liability to the patient as early in the Revenue Cycle Process as possible. 34

85 Example: Propensity to Pay Scoring Color and Score Assigned Red = Low credit, low income (Presumptive Charity) Yellow = High credit, low income (Payment Plans) Blue = Low credit, high income - Green = High credit, high income 35

86 Process Changes Presumptive Charity Determination Reduction/Elimination of Manual Financial Assistance Application Process Fewer Touch points along Revenue Cycle- predetermined accounts flagged early, eliminating statements, phone calls, and unnecessary collection effort and expense Targeted collection efforts based on Propensity to Pay score Care Management process enhancements Collaboration efforts with SH Medical Group 36

87 Phase 1: Validation Target Goal= at least 85% of the validation accounts match P2P Recommendation 100% 95% 90% 85% 80% 75% 70% 65% 60% 55% 50% 45% 40% 35% 30% 25% 20% 15% 10% 5% 0% P2P pilot discrepancies 7.8% 11.1% 8.7% 92.2% 88.9% 91.3% Self-pay pilot accounts Financial counseling pilot accounts Total pilot accounts 37 P2P score matches P2P score discrepancies

88 Validation Results The majority of the time the tool produced the Propensity to Pay score that we expected For the accounts with discrepancies SH found the tool was more conservative in scoring than what we would have been in our determination process 38

89 Phase 2: Pilot December 22, 2010 March 1, 2011 Butterworth Campus Emergency Dept Financial Counselors Self Pay Patients Out Patient Accounts (not admitted from ED visit) 39

90 Next Steps Run Batch file of existing Self Pay Accounts Receivable to identify Presumptive Charity Accounts Complete by 03/01/11 Identify where in current collection process ongoing batch files will be sent for scoring. Develop deployment Calendar for go live sites. Develop and Deliver Education materials to targeted staff to coincide with go live planning. Update Financial Assistance Policy and Procedures 40

91 Next Steps (cont.) Increase awareness for all Revenue Cycle Staff Partnership and Communication with Medical Group on Financial Assistance Determination Partnership and Communication with Care Management on Financial Assistance Determination 41

92 Questions? 42 42

93 43