Are You Leaving Money on the Table? Presented by Kelley Lipsey February 24, 2016

A.The process by which you obtain patient-generated reimbursements? B.Your billing process? C.How and when you collect money? D.Your check in/check out processes? E.Depends on physician documentation and coding?

A.The process by which you obtain patient-generated reimbursements? B.Your billing process? C.How and when you collect money? D.Your check in/check out processes? E.Depends on physician documentation and coding?

Starts at the first contact with a patient Continues at Initial Intake/Check-In Develops during entire flow of patient visit Moves through Check-Out Lasts through the billing process Ends with complete charge adjudication/balance resolution of each encounter.

DocumentationDocumentation Patient Flow Front Office A/R Management BillingBilling CodingCoding

DATA INTEGRITY The fulcrum of the Revenue Cycle

DATA INTEGRITY Patient Demographics Complete and accurate Patient Financial Information Insurance Information Household Assessment Responsible Party/Guarantor

DATA INTEGRITY FINANCIAL IMPACT Time of Service Payments Insurance Eligibility/Benefits Sliding Fee Scale

DATA INTEGRITY FINANCIAL IMPACT SCHEDULINGVolume Patient Flow Provider Workflow

DATA INTEGRITY FINANCIAL IMPACT SCHEDULINGCOMPLIANCEHIPAA Financial Policy/Consent(s)

DATA INTEGRITY FINANCIAL IMPACT SCHEDULINGCOMPLIANCE POSITIVE PATIENT EXPERIENCE Telephone management/Etiquette Managing the Lobby/Wait time Asking for Money Scheduling Accommodation

WAIT TIMES HUGE issue with your patients! Waiting doesn’t JUST happen in the lobby Starts with scheduling, but clinical staff is responsible for keeping FLOW of patients moving. Do providers show up on time? Know how much time is being spent on specific tasks in clinical area (Time Study)

WAIT TIMES PROVIDER ENCOUNTER Does you provider have all necessary resources? Staff, supplies, coding/pharmaceutical references, etc. EHR access and training Seeing adequate number of patients per day (for provider specialty)?

WAIT TIMES PROVIDER ENCOUNTER DIAGNOSTICS and/or PROCEDURES Staff and supplies Routine protocols Procedure room vs tools/supplies in every room Scheduled vs unscheduled labs and procedures

WAIT TIMES PROVIDER ENCOUNTER DIAGNOSTICS and/or PROCEDURES BEHAVIORAL HEALTH INTEGRATION BH screenings? Warm hand-off vs In-house referral

WAIT TIMES PROVIDER ENCOUNTER DIAGNOSTICS and/or PROCEDURES BEHAVIORAL HEALTH INTEGRATION PATIENT EDUCATION & COORDINATION of CARE Easy access to Pt. Ed materials and Referral information Capturing Pt. Ed in system for meaningful use

COMPLETE & COMPLIANT DOCUMENTATION Do your providers understand the basics of documenting Evaluation and Management (E/M) services? Even when documentation is clinically sound, it often doesn’t capture all work done during an encounter Adequate documentation of lab results, injections, procedures, medication management

COMPLETE & COMPLIANT DOCUMENTATION ACCURATE/COMPLETE CODING & CHARGE CAPTURE Chart Audits reveal coding and documentation issues Over or under coding of E/M services (office visit codes) Inaccurate coding of other services Injections/injection administration, procedures, etc. Inappropriate ICD-10/CPT code linkage

GETTING PAID on the FIRST CLAIM SUBMISSION Claim errors and rejections delay/prohibit claims processing and payments Front desk staff, clinical staff, system set up Common reasons for claims denials Incorrect insured information Insurance expiration/ineligibility Service included in payment of another procedure/service Not medically necessary

GETTING PAID on the FIRST CLAIM SUBMISSION CORRECTING ERRORS/REJECTIONS and DENIALS Fix the ROOT of the problem (not just the claim) Correct patient account information/Train front desk staff Educate providers and/or billing staff on coding issues Utilize system set up and functionality to its fullest

GETTING PAID on the FIRST CLAIM SUBMISSION CORRECTING ERRORS & REJECTIONS USING CLAIMS DATA TO IMPROVE the ENTIRE REVENUE CYCLE Track errors/rejections and denials Using system reports and/or clearinghouse reports Look for trends/patterns by provider, by payer, by code(s)

Tracking Claims Making Sure Payment is Received (and posted accurately, including adjustments) Follow Up on Denied Claims

Diagnosing your Revenue Cycle Days in A/R – Average number of days it takes your practice to collect payments due for services With electronic claims submissions and payments (ERAs), your average Days in A/R should always be under 50 (preferably between 30 and 40). May be different by payer Submission of paper claims (especially to primary insurance) GREATLY increases your Days in A/R

Calculating Days in A/R (using the following formula) (using the following formula) Total A/R Balance Avg Daily Charges

Calculating Days in A/R 1.Calculate Average Daily Charges  Add all charges for a given period (at least 90 days) Month 1 (30 days) = $60,000 Month 1 (30 days) = $60,000 Month 2 (31 days) = $65,000 Month 2 (31 days) = $65,000 Month 3 (30 days) = $70,000 Month 3 (30 days) = $70,000 (91 days) $195,000 (91 days) $195,000  Divide Total charges from above by the number of days used to calculate total (in this case 91) $195,000/91 = $2143 $195,000/91 = $2143

Calculating Days in A/R 1.Calculate Average Daily Charges = $ Divide Total A/R by Average Daily Charges Total A/R (net of credits) = $80,000 Total A/R (net of credits) = $80,000 Days in A/R ($80,000/$2143) = 37 Days in A/R ($80,000/$2143) = 37 $135,

Reducing Days in A/R Analyze Days in A/R By Financial Class/Payer Type, By Payer, By Provider Other Considerations Slow paying insurance payers Impact of credits/adjustments Accounts written off to collections Patients on Payment Plans Balances greater then 120 days

Diagnosing your Revenue Cycle Days in A/R A/R Aging 50 % should be current (0-30 days) Percentages SHOULD get smaller as they get older 120+ Day “Pile Up” Drill down to find problems (payer, provider, procedures, etc)

Diagnosing your Revenue Cycle Days in A/R A/R Aging Collection Percentage Gross – Minimum 50-60% for average primary care Gross charges/Total payments Net – Minimum 90-95% Net charges (gross less adjustments)/Total payments

Diagnosing your Revenue Cycle Days in A/R A/R Aging Collection Percentage Average Daily Encounters Primary care providers should average encounters per day to cover cost of providing services

COLLECTING ALL THAT IS OWED TO YOU From third party payers Insurance Contracts, etc. From patients Statements When to write off to collections In House vs Outsourced

LET YOUR SYSTEM DO THE WORK FOR YOU Know your system’s existing functionality and capability Ensure your system is set up for maximum functionality Train your staff to use the system to its fullest

Schedule Intake Patient Experience FRONT OFFICE Triage Provider Encounter Charge Capture PATIENT FLOW Billing Follow Up/Collections Analysis for Process Improvement BACK OFFICE Patient-generated monies Increase efficiency