1. Health Center Revenue and Reimbursement Management
Julie M Vlasis
Consultant
Department of Health and Human Services
Health Resources and Services Administration
Bureau of Primary Health Care

2. Learning Objectives Understanding components of Revenue Cycle
Sliding Fee Scale Policy
Fee Schedule Development

3. Understanding Components of Revenue Cycle

4. What Does Real Revenue Cycle Look Like?
Appointment Schedules
Patient Registration
Provision of Care
Coding and Billing of Patient Encounter
Accounts Receivable Management Payments and Denials

5. Scheduling Scheduling Open Access Modified Wave
Structured Appointment Type
Scheduling Guidelines
Information to assist staff in maintaining adequate scheduling
Staff Training

6. Scheduling System Monitoring/Reporting Patient Scheduling Trends
Morning/Afternoon/Early Evening
Pediatrics vs. Adults
Provider Productivity

7. Patient Registration
Patient Registration
Demographic and UDS Data Collected
Patient Insurance Collected
Copies of Insurance Cards
Insurance Eligibility Verified
Managed Care – PCP Designated
Benefits Reviewed

8. Patient Registration
Patient Application for Sliding Fee Program Initiated
Application completed
Financial Information collected
Family Size Verified
Copays Collected
Ability vs. Willingness
Staff Training and Development

9. Provision of Care Provider Coding and Documentation Templates
Smart Phrases
Implementation of New Programs
IPPE – Medicare Initial Preventative Physical Examination
AWV – Medicare Annual Wellness Visit
Provider Coding Profiles - ICD-10 Implementation
Free Text
Auditing
QA/QI Inclusion

10. Provision of Care Annual Coding Update
Implementation Plan and Training for ICD-10
CMS Updates
Clinical Policies and Procedures
Progress Note Documentation
Understanding of Required Reporting
UDS Reporting
Other Health Center Gran

11. Coding and Billing Encounter Edit Process
Review Evaluation and Management Codes
Review Procedure/Other Services Codes
Review Diagnosis Codes – Highest Level Of Specificity – Important for ICD-10 Implementation
Confirms Insurance Eligibility
Posting of encounter within 3 days of service
Claim Submitted Electronically

12. Accounts Receivable Management
Process Driven
Receipt of Payments and Adjustments
Secondary Insurance Claims Submitted
Denials tracked and worked
Resubmission of claims
Patient Responsibility determined
Patient Statements mailed
Active Collection process completed

13. Accounts Receivable Management
Clear Communication with All Critical Departments
Scheduling
Registration
Clinical

14. Metrics and Measurements
Registration
Percentage of Accurate Insurance Verifications - 85%
Percentage Collection of Copays at time of Service – 90%
Percentage Sliding Fee Applications Processed Correctly -95%

15. Metrics and Measurements
Billing
Percentage of claims submitted in 3 days from date of service – 95%
Percentage of Clean Claims – 90%
Days in Accounts Receivable Aging – 45 Days
Percentage of Denials - 5%
Percentage of Underpayment – 5%
Percentage of successful appeals – 90%
Percentage of Claims over 90 days – 20%

16. Accounts Receivable Management
Team Work
Clear Communication
Scheduling
Registration
Clinical
Identification of Training Opportunities
Constant Report Analysis

17. Policies and Procedures
Essential Framework for Strong Revenue and Reimbursement Management
Provides Staff Accountability
Reduces Errors
Increases Reimbursement

18. Policies and Procedures to Identify
Appointment Scheduling
Registration
Sliding Fee Scale
Clinical Encounter Management
Billing Credit and Collections
Finance

19. Staff Development
A well trained knowledgeable staff reduces Accounts Receivable Aging and Increases Reimbursement.
Initial Staff Training – New Hire
Continuous Training – at least Annually
Successful Revenue Management Programs have continuous staff training

20. Revenue Cycle Recap Scheduling/ Productivity Registration/Eligibility
Provision of Care/ Documentation
Coding and Billing - Accuracy
Accounts Receivable Management
Continuous Report Monitoring
Team Work across all departments
Staff Development – Training
Communication

21. Development of Revenue Cycle Annual Action Plan
Annual Setting of Metrics
Annual Review and Revision P&P’s
Identification of new Medicare and Medicaid Programs
Monitoring all Components of Revenue Cycle

22. Sliding Fee Discount Policies

23. Sliding Fee Discount Policies
330 Grantee Requirement:
Health Center has a system in place to determine eligibility for patient discounts adjusted on the basis of the patient ability to pay.
This system must provide a full discount to individuals and families with annual incomes at or below 100% of the poverty guidelines (only nominal fees may be charged) and for those with incomes between 100% and 200% of poverty, fees must be charged in accordance with a sliding discount policy based on family size and income.*
No discounts may be provided to patients with incomes over 200% of the Federal poverty level.*
(Section 330(k)(3)(G) of the PHS Act and 42 CFR Part 51c.303(f))

24. Program Policy Requirements
Clear guidelines for qualifying for discounted fee
Clear guidelines how discounts are determined
Clear guidelines outlining required documentation
Available application form with guidelines

25. Program Policy Requirements
Procedure for verifying income and family size
Clear recertification process
Sliding Fee Scales updated on annual basis
Required Signage
Staff Training- annually

26. Best Practices Separate Sliding Fee Application
Separate Financial Class For Sliding Fee Scale Participants - Monitoring
Signage posted throughout Facility
Patient Financial Agreement
Reminders to patients regarding co-pay responsibilities – Appointments/Recall

27. Health Center Fee Schedule Development

28. Fee Schedule Development
Methodology of Development
Resource-based Relative Value Scale- RBRVS
True Center Costs
Medical, Behavioral Health and Dental
Updated Annually
Policy describing method and timelines

29. Fee Schedule Development
Current Medicare and Medicaid Prospective Payment System (PPS) Rates
Managed Care Wrap Rates
Medicare and Medicaid
Medicare Cost Report
Cost per medical encounter
UDS Report
Cost per medical encounter excluding lab, x-ray and nursing visits

30. Fee Schedule Development
Utilization Review
CPT utilization by facility/ by clinician
Auditing accuracy of services billed
Captured Revenues

31. Questions??

32. Contact Information
Julie Vlasis
Consultant