Surgical Management Professionals 600 S. Cliff Ave, Suite 106 Sioux Falls, SD Revenue Cycle Management: Advanced Perspective CASA Annual Meeting September 6, to 5pm

Session Speaker Rebecca Overton, CPC Director of Revenue Cycle Management Surgical Management Professionals

In This Session…  Defining Revenue Sources  Strategy 1: Maximize Revenue Capture  Strategy 2: Managed Care Contracting  Strategy 3: Managing Processes to Affect Cash Flow  Strategy 4: Plan for the Future

Strategy 1: Maximize Revenue Capture  Standard Fee/Charge Master Analysis  Analyze Current Fees vs. Payer Reimbursement  Remember to Include Percent of Charge Based Payers  Establish standard formula for all procedures  ASC Approved  OPPS Procedures performed in ASC  CMS Inpatient Only Procedures Performed in an ASC  Unlisted Procedures

Strategy 1: Maximize Revenue Capture (cont.)  Coding Audits  Develop Compliance Policy  Establish Formal External Review & Structured Follow-Through on Results  Payer Based Billing  Educate Staff on Contract Interpretation  Bill According to Your Contract Provisions

Strategy 1: Maximize Revenue Capture (cont.)  Implant/Supply Tracking & Audit Process  Track billable items  Audit to ensure proper capture  Review Physician Trends  Look for differences in documentation and/or dictation style  Target by looking at differences in CPTs/Case and Net Revenue/Case  Continuously Review Service Line/Specialty Profitability  Neurostimulators  Uni-Knees  BAHA/Cochlear  ACL/RCR  FESS

Strategy 2: Contracting for Success  Gather Plan Information  Know key employer groups in your area  Understanding of Total Covered Lives & HMO market with major payers  Know Your Current Contracts & Challenges  Review contracts and create contract matrix/summary  Review data and meet with A/R staff to determine what is working and what needs improvement  Know your “must haves”, “would like to haves” and make a wish list

Strategy 2: Contracting for Success (cont.)  Perform Detailed Analysis  Review of Current Volumes  Query Physician Partners on Emerging Techniques/Procedures  Plan for future initiatives  Why Reimbursement Methodology Matters  Specialty Mix  Grouper vs. APC  % of Charge  Watch out for percent off state fee schedules

ABC Insurance Procedure Reimbursement Multiple Procedure % Unlisted Procedure Reimbursement Carve-Outs Supply/Implant/Imaging Coverage 8333 Rockside Road Suite 200 Cleveland, Ohio Contact Name: Mickey Mouse 407-WDISNEY Effective Date: 10/15/2005 Renewal: Auto renew every 12 months, after initial 2 years Termination: Without Cause: 90 days written notice anytime Timely Filing: 90 days from the DOS Grp 1 - $ 425 Grp 2 - $ 540 Grp 3 - $ 640 Grp 4 - $ 825 Grp 5 - $ 980 Grp 6 - $ 980 Grp 7 - $1,270 Grp 8 - $1,055 Grp 9 - $1, **Case Rates – No Payment for Multiple Procedures 75% of billed charge CPT $ 700 CPT $ 700 CPT $ 700 CPT $1,030 CPT $1,030 CPT $1,030 CPT $1,030 CPT $1,030 CPT $1,030 CPT $ 700 CPT $1,050 CPT $1,400 CPT $1,100 CPT $1,100 CPT $ 700 No Additional Payment Notes: – Received notification of new procedure groupings, filed in contract file, distributed to staff – Add’l payment of $16,985 received from project work for carve out rates – Spoke with Mickey Mouse regarding non-payment of carve out rates, project submitted for DOS for add’l payment Contract Summary Sample

Strategy 3: Managing Processes to Affect Cash Flow  Physician Dictation Turn-Around  Define expectations & Ask Board For Consequential Action  Transcription Turn-Around Time  24 Hours  Follow-up to ensure vendor is meeting contract requirements  Include provisions for consequence of vendor not meeting standards  Availability of Pathology Reports

Strategy 3: Managing Processes to Affect Cash Flow (Cont.)  Supply/Implant Data  Educate billing staff  Front End Demographic Capture  Manage through denial trending  Physician Communication  Cost vs. Reimbursement Case Data  Vendor Alternatives  Facility Needs  Effective Denial Management

Strategy 4: Plan for the Future  ICD-10  Plan for impact  Staffing  Contracting  Vendor Readiness  Staff appropriately  Ensure proper training administered  Plan for New Service Lines  Contracting  Reimbursement Analysis

Effective Revenue Streaming Revenue Capture Contract Interpretation Cost Management Process Management

Questions?

Rebecca Overton, CPC Director of Revenue Cycle Management Surgical Management Professionals Phone: (605) Speaker Contact Information