1. RCM Challenges in Healthcare Reform
hfma Georgia Chapter
November 10, 2011

2. Presentation Outline Contracting and Payment Approaches
Payment Methodologies
Integrating Clinical and Financial Aspects of the ACO
New Revenue Cycle Requirements
Basic Revenue Cycle Challenges and Solutions
Advanced Revenue Cycle Challenges and Solutions
A Practical Health System Discussion Guide

3. The Three Tiers of Payment Approaches
Tier 1: Fee-For-Service and the World we have lived in for the past 20 years Approach
Tier 2: The Near Term changes of Procedure and Episode of Care Bundling, and Combined P4P with Physicians and Hospitals Approach
Tier 3: Managing an Accountable Care Organization Approach

4. Tier 1: Fee-For-Service
Hospitals Separate and Physicians Separate
CMS maintains Part A and Part B
APCs, DRGs, Fee Schedules, UBs and HCFAs
Payers/Providers negotiate the methodologies
%Charges, DRG Case Rates, Procedures, Per Diems, Fee Schedules, % Medicare, etc.
Administrative and Clinical Utilization Review
Denials, Underpays, Disputes, etc.

5. Tier 2: Bundling and Value-Based Contracting
Physicians and Hospitals Combined Services
All-Inclusive Procedures and Services
Procedure Specific or Episode of Care
Single Site (Acute Care) or Multiple Site (IP,OP, Office, Rehab, Home Care)
Performance Payments Severity Adjusted
EBM Guidelines Across Continuum
Contracting and Claims Adjudication

6. Tier 3: Health Systems as Accountable Care Organizations
Integrated Physician/Hospital Organization
Responsible for Identified Populations
Direct Contracting with Buyers
Accept Risk for Defined Patient Services
Have an Information Platform to Measure Clinical Performance and Perform Financial Transactions
Act like a Payer?

7. A Combined Solution for All Three Tiers
A Common Platform for All
Manage Scenarios Simultaneously
80% Tier 1, 15% Tier 2, 5% Tier 3
Combined Performance Reporting
CMS and Payer Tier Profiles
MC & PFS Desktop Simplification
Physician/Hospital Care Coordination
Enrollment and Payment Functionality

8. New & Expanded Payment Models
Patient-Centered Medical Home Payment
Primary Care Driven Front End of Acute Services
Bundled Procedure Payment
High Cost Services – CABG, Joints, Backs, etc.
Bundled Episodes of Care Payment
Tied to Patient Condition and Time Related
Performance Based Payment
EBM Based, Severity Adjusted, Outcome Based
Partial and Total Capitation Payment
Population and Condition Driven

9. ACO Integration Roadmap
Clinical Service Line Alignment
Clinical Pathway Development
Benchmarking Complex Procedures
Benchmarking Episodes of Care
Modeling Episodes and Procedures
Creating Bundled/Performance Contracts
Adjudicating Bundled Claims
Reporting/Managing Utilization

10. Expanded RCM Requirements
Utilization Reporting Across Continuum
Health System and Payer Driven
IP, OP, Physician, Ancillary Providers
Data Aggregation in Multiple Delivery Sites
Clinical Data from Physicians, Rehab, and Home Care
Financial Data Across the Continuum
Revenue Cycle Calculations & Transactions
Contracting, Claims Management, Adjudication
Patient/Payer Membership Management

11. Basic Revenue Cycle Challenges
Create and Model Bundled Contracts
Develop and Manage Combined Charge Masters and Fee Schedules
Aggregate Bundled Claims and Payments
Calculate Performance Payments
Provide Timely, Accurate and Transparent Clinical and Financial Reporting

12. ACO-Like Revenue Cycle Challenges
Patient Enrollment and Eligibility
Contract Modeling across Continuum
Maintenance of Multiple CDM/Fee Schedules
Case Management/Referral Services
Claim Re-Pricing/Clearing/Payment
Dispute Resolution/Collections
Risk Sharing, Gain Sharing, Treasury Services

13. The Basic Solution Bundled Payment Capabilities
Contract Modeling and Management
Integration of Fee Schedules and CD
Patient Eligibility for Bundled Programs
Performance-based Payment Capabilities
Clinical/Severity-based Calculations
Financial/Spend-based Calculations
Integrated Reporting Capabilities
Robust Utilization and Financial Reports

14. The ACO-Like Solution Claims Management, Clearing, Posting
Enrollment and Provider Rostering
Case/Referral/Utilization Management
Dispute and Collections Management
Provider Credentialing
ACO Patient Self-Service Portal
Treasury Services
Multi-Level Reporting – Financial/Clinical

15. An Organizational Discussion
Board Of Directors
Senior Leadership Team (C-Suite)
Clinical and Financial Department Managers
The Revenue Cycle Team Leaders
All Revenue Cycle Personnel

16. Who is in Our Integrated ACO?
Answer
All of our Facilities
All Active Medical Staff
Contracted Ancillary
Physicians and Extenders
Facilities (Rehab, ASC, etc)
Home Care, Hospice
RCM Solution
Provider Demographics
TINS and Sites
Facility Identifiers
CMS Information
RCM IT Information
Clearinghouse Info

17. Which Service Lines are in the ACO?
Answer
Cardiovascular
Orthopedic/Joints
Spine Surgery
Stage 2 Cancer
RCM Solution
Physician Roster
Sites of Service
Services Benchmarks
Model Claims
Contract Terms
Fee Schedules, Codes

18. Who are the Covered Enrollees?
Answer
The Hospital Employees
Aetna Fully Insured
United ASO Employers
Tri-Care
RCM Solution
Contract Terms
Payment Method
Enrollment Database
Patient Demographics
Patient Benefits

19. What Payment Models Included?
Answer
PCMH – Primary Care
Episode of Care
Medicare SS
Blue Cross Performance based grouper outcome
RCM Solution
Charge Coding
Calculation Engine
Contractual Discounts
Payment Posting
Performance Measures
Distributions

20. What Rates will ACO Charge?
Answer
Will vary by Payer
Likely % Medicare
Performance-based
Individual Provider
Whatever we can
RCM Solution
CDM & Fee Schedules
By Provider, By Contract
Grouper and EBM performance calculator
Medicare Values for all ACO Providers

21. How Will ACO Monitor Performance?
Answer
Across Care Continuum
Primary Care
Specialty Care/OP
Acute Care/IP
Sub-Acute
Home Care/Follow up
RCM Solution
Capture Claim Activity
Report Care Variance from Benchmarks
Facilitate interfaces to Providers in ACO

22. How Will the ACO Handle Claims?
Answer
Receive Claims from Providers and Facilities
Send Claims or Claim Summaries to Payers
Receive Payments from Payers
RCM Solution
Bundled Claims Scrubbing
Bundled Claims Clearing
Calculation Engine
Performance-based
Payment Posting
Variances

23. How Will The ACO Prepare Reports?
Answer
From the Claims Data
From Payer Data
From Clinical Data
RCM Solution
Standard Reports from ACO RCM Database
Payer Report Validation
External Data Imports
Ad Hoc Reporting

24. Who Will Manage the ACO? Answer RCM Solution
We will for the Transactions side
The Medical Staff will run the care delivery management
RCM Solution
Implement a Platform that will manage these transactions

25. So Then, How to Start – Part 1
Be Sure that the Revenue Cycle Team is an Integral Part of the Health System discussions about Integrated Care
In a nice way, remind leadership that this Reform is Revenue Cycle Management reform
Take an Inventory of your Hospital Patient Accounting, Contract Management, and RCM reporting capabilities
Identify the likely Providers (Physicians and other facilities) that will be a part of your Integrated Network
Talk with your big Payers about their Interests
Monitor CMS ACO Progress

26. How to Start – Part 2
Identify missing parts in existing RCM IT infrastructure
These will likely be in complex contract management, cost reporting, CDM and Fee Structure Management, etc.
Research opportunities with existing RCM IT vendors
Do they have platforms to integrate the new RCM functionalities for providers across the care continuum? What are their plans?
Explore the Market for New or Added Solutions
Look for platforms that accommodate the entire continuum
Remember the new requirements – enrollment, bundled modeling, bundled claim adjudication, treasury, etc.

27. How to Start – Part 3
Present your researched RCM Functionality Plan to the Health System Integrated Care Leadership Group
Incorporate the Clinical Benchmarks, EBM Standards, and Services (CMS ACO, Cardiovascular, Ortho, etc.) under consideration by the Clinical Leadership
Determine what Services and Payment Models are being considered by your major Payers
Using your new processes, Model the potential arrangements that are being discussed by the ICLG
Bring the Information back to the Leaders for Discussion
Sign a Contract & Manage the Transactions

28. Summary The Shift from FFS will likely be gradual and incremental
There is sufficient time to design your plans
But, it will take time culturally and operationally.
Clinical Change Management will require consensus building and professional compromise
Revenue Cycle Change Management will require operational retooling, distributed accountability, and technical upgrades to maintain a shared RCM Platform
The Market Winners will be Ready for the Change

29. Thank you !!
Nick Hilger