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Hfma Georgia Chapter November 10, 2011.  Contracting and Payment Approaches  Payment Methodologies  Integrating Clinical and Financial Aspects of the.

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Presentation on theme: "Hfma Georgia Chapter November 10, 2011.  Contracting and Payment Approaches  Payment Methodologies  Integrating Clinical and Financial Aspects of the."— Presentation transcript:

1 hfma Georgia Chapter November 10, 2011

2  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  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  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  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  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 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  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  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  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  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  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  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  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  Board Of Directors  Senior Leadership Team (C-Suite)  Clinical and Financial Department Managers  The Revenue Cycle Team Leaders  All Revenue Cycle Personnel

16 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 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 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 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 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 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 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 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 Answer  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  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  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  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  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 Nick Hilger


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