MGMA CURRENT TRENDS IN PHYSICIAN PRACTICE REVENUE CYCLE MANAGEMENT

Transcription

1 MGMA CURRENT TRENDS IN PHYSICIAN PRACTICE REVENUE CYCLE MANAGEMENT

2 RECENT ACQUISITION FRENZY Physician practice acquisitins have created a sense f urgency fr Hspitals and health systems t cmplete these transactins quickly t remain cmpetitive. Many f these rganizatins fcused their initial attentin n negtiating cntract terms, cnducting asset appraisals, and assigning vendr cntracts while deferring cnsideratins n hw t manage the revenue cycle aspects f physician practices. Lack f preliminary planning regarding Revenue Cycle standards fr physician practices result in a mixed bag f acquired practices that are bth difficult t manage and unprfitable. In particular, inadequate planning and preparatin can lead t pr perfrmance in physician billing peratins, as reflected in cash cllectins that are lwer than desired, high accunts receivable balances, frequent write-ffs, and patient/ physician dissatisfactin. This lack f perfrmance can necessitate majr investments t right the physician revenue cycle ship. Key actin steps in the early stages f building a physician enterprise will ensure the essential pieces f prfessinal fee billing are securely in place. 1

3 REVENUE CYCLE PUZZLE PIECES ADMITTING/REGISTRATION: Patient Check-in Cmpletin f Frms Pint f Service Cllectins Financial Cunseling and Charity Care REVENUE CYCLE FRONT MIDDLE BACK PATIENT FINANCIAL SERVICES: Claims & Patient Billing Accunts Receivable Management Claims Variance Review Payment Psting Technical Denial Management PRE-SERVICE: Centralized Scheduling Pre-Registratin Insurance Verificatin Pre-Authrizatin/Referrals Medical Necessity Validatin CLINICAL SERVICES: Patient Treatment Cding and Dcumentatin Charge Entry/Capture Charge Master Maintenance MANAGED CARE: Payr Cntract Negtiatins Manage Payr Relatinships HEALTH INFORMATION MANAGEMENT: ICD10 & CPT Cding f Inpatient and Outpatient Prcedures Respnd t Payer Requests fr Recrds Medical Appeals Supprt CASE MANAGEMENT: Crdinate with Physicians Utilizatin Review and Discharge Planning Prevent Denials Medical Appeals Supprt 2

4 PIECE #1: CAPABLE MANAGEMENT AND A QUALIFIED TEAM A Physician Practice Revenue Cycle Directr shuld be able t: Ensure apprpriate visibility f frnt-end prcesses that have an impact n the Revenue Cycle: Scheduling Patient Pre-registratin Insurance Verificatin Patient Estimatins Establish and enfrce perfrmance and prductivity standards fr Billing functins: Cding Charge Entry Insurance Fllw-up Payment Psting Prvide input n decisins regarding IT system selectin and cnfiguratin. Analyze data t identify, diagnse, and reslve billing issues quickly. Exercise apprpriate influence n matters pertaining t Revenue Cycle prcesses and prcedures nt nly within the Billing ffice, but als acrss a large and smetimes bureaucratic rganizatin. 3

5 PIECE #2: APPROPRIATE ORGANIZATIONAL MODEL Centralizing vs. Decentralizing If the acquisitin is early and the Hspital has nt handled prfessinal billing fr physicians, Decentralized billing may be apprpriate where the practices cntinue t bill with their legacy systems under a single tax ID. As the rganizatin grws, a centralized apprach can prmte increased expertise, reduce errrs, prvide flexibility fr new payment methdlgies, and minimize expsure t cmpliance issues. In a hybrid mdel, functins that d nt require face-t-face patient r physician interactin are centralized, while lcally managed clinical supprt staff are still expected t adhere t cmmn guiding principles under ne revenue cycle plicy. Insurcing vs. Outsurcing Cnsideratins: The current cmpetence f staff in prfessinal fee billing. The adequacy f the current electrnic health recrd (EHR) r billing system. The ability f the current staff and systems t expand with the grwth f the physician enterprise. 4

6 PIECE #3: SYSTEM FUNCTIONALITY Cnslidated Practice Management Systems: The impact that IT decisins can have n the revenue cycle is very imprtant t cnsider. The mst effective apprach is t transitin all acquired practices t a single practice management system that facilitates, prvides, r enables the fllwing: Key Perfrmance Indicatrs Reprting. A cnsistent apprach t primary wrk flws (i.e., registratin and demgraphic cllectins, eligibility verificatin, A/R fllw-up). Electrnic claims can be submitted real-time. Management f all wrk flws at the site f service and remtely (i.e., centralized business ffice, scheduling call center). Submissin and management f bth CMS-1500 and UB-04 claims frms t accmmdate prvider-based billing. The ability t mnitr payments variances/accrdance with cntract terms. Payments can be psted autmatically. Integratin with an EHR. Easy segmentatin f perfrmance if multiple tax IDs are in use (i.e., charge and cllectins vlumes, A/R), while still creating efficient wrk queues that enable staff t manage billing effectively. 5

7 PIECE #4: TRANSPARENCY, STANDARDS, AND CONTROLS Carefully manage prductivity, backlgs, prcessing time, and errr rates. Establish Prductivity and Accuntability measures t ensure staff btains the apprpriate infrmatin t avid edit errrs dwnstream. Clinics shuld be respnsible fr their wn errrs. Edits and Denials related t frnt-end errrs shuld be ruted back t the clinic fr reslutin. Establish prductivity standards fr the billing ffice and hld staff accuntable. Example: 6

8 PIECE #5: PATIENT SATISFACTION Waiting Rm Management: As value-based care mves t the frefrnt, patient satisfactin will becme a key factr in driving prfitability. Patients are mdern cnsumers and increasingly expect cnvenience, speed, and efficiency with all their transactins. Eliminate patient waiting as much as pssible. Develp standardized prcess f allcating patients t nearest lcatin with available appintments. Cnfirm every single patient appintment. Accurately track all patient n-shws. 7

9 PIECE #6: APPROPRIATE INVESTING IN CODING & COMPLIANCE A well-trained and experienced billing team is the mst imprtant indirect driver f revenue at yur practice. Knwledge f prprietary rules f each payer is essential. Timely filing methdlgies must be carefully mnitred. Experience appealing rejected claims is key. Ensure the charge submissin prcess is efficient and claims are billed and adjudicated apprpriately. Eliminate dual charge entry which is ften assciated with a mix bag f glbal billing vs prfessinal fee billing. Practices that lack in these key areas may need t evaluate if they are candidates fr utsurcing. 8

10 PIECE #7: PATIENT FINANCIAL SERVICES Ensure billing is perfrmed in regular intervals at the Business Office. Billing staff is respnsible fr: Accunt Fllw-up Cash Psting Obtaining Prir Authrizatin Services Denial Reslutin Credit Balances Identify staff specifically dedicated t Charge Entry. Submit claims electrnically when pssible. Claims with edit errrs are cmmunicated t specific departments via wrk queues t reslve issues. Chse Billing sftware with cmprehensive reprting capabilities, electrnic tracking f billed claims and varius ther metrics. 9

11 PIECE #8: KEY PERFORMANCE INDICATORS 10

12 PIECE #8: KEY PERFORMANCE INDICATORS (Cnt.) 11

13 REVENUE CYCLE SERVICES 12

14 Missy Geralds // Senir Manager DHG Healthcare Atlanta, GA P: E: Ketan Patel // Manager DHG Healthcare New Yrk City, New Yrk P: E: 13