So Now You’re In-Charge of the Pro-Fee CBO…… Charlotte L. Kohler & Carolyn S. Tuttle September 2011

The Days of Referring the Problems to “Them” is Over ….. We are “Them” 2

Goals for Session Review purpose of MSO and CBO Evaluate differences between a hospital (or facility based) CBO and a pro-fee services MSO Evaluate why the pro-fee CBO should or should not be separate from Hospital CBO Update key factors and considerations for success Understand of the marketplace and reimbursement factors causing this physician migration Review case studies 3

Some of the Lingo MSO – Management Services Organization Generally the overall management of the medical practices Including contracting, staffing, practice operations Can include centralized scheduling, etc. CBO -- Centralized Business Office Encompasses the back- end of the revenue cycle BUT may include the charge capture and “access” activities Can be stand alone or be part of the MSO 4

What Do You Need To Know? As per the ad for “Director MSO Central Business Office” for Texas Children’s Hospital “To direct and lead operations of the CBO…including patient billing, collections, refunds, coding/compliance, standard fee schedules, transaction entry, customer service, and account follow up” “Knowledge and Skills: word processing, databases, spreadsheet, and physician billing software; Medicaid reimbursement…., printed and oral communications…., administrative management of a business office…. 5

What Do You Need To Know? Revenue Cycle of pro-fee services, including those in the “private practice settings” Drivers of the physicians Revenue Cycle – Physicians – Office staff Regulations – Provider-based (called “regulated” in Maryland) – How they differ from facility (hospital) – Billing/Payment impacted by POS and type of entity 6

Core Elements of the CBO Consider the cost/benefit of performing tasks internally Outsourcing can be effective or a disaster – can allow you to focus on “big issues” even if you’ll want to bring in house later What is not a “core function”? – Coding – Medicaid enrollment – Self pay collections – Billing/Follow-Up 7

Key Considerations – Should the Pro-Fee MSO be Separate from the Hospital CBO? YES! Same system Can handle all problems with a patient on one call Better use of resources Eliminate redundant processes NO! Skill sets are different Split should be by specialty Different Systems Pro-fee staff don’t understand UB billing and vice -versa 8

Challenges: Reporting Data to Physicians Understand the specific terms of the physician contract before the billing starts. Understand reporting requirements – match up to set of charge capture and billing data collection. Benchmarking and productivity analysis – may be part of CBO or part of MSO management – but data comes from MSO. 9

Challenges: 3 Day Window 2012 proposed regulations regarding employed or owned Practices – Rolls all diagnostic services into inpatient invoice – Pays physician services using place of service 22 Coordination between Pro-Fee CBO and Hospital CBO – Change lag time for billing? – Non-Medicare? – RVUs used for physician compensation? 10

Challenges: Compliance & Coding Multiple Provider Number attached to multiple Tax ID numbers Provider-based space – 2 co-pays Payers that ignore the “provider based status” Loss of volume due to provider-based status Do you have the physicians do the coding and then you review for compliance, or do you code the records? 11

Challenges: Getting the Right Demographic Information Challenges of going across system – hospital to pro-fee and/or multiple pro-fee systems. What ordering/ How to control updating of information. Insurance information -- Hospital vs. Pro-fee insurance requirements may be different and may cover different components of service. 12

Challenges: One Payment to Allocate Combined – Patient - Friendly Billing Physician – if paid based on collections – want their money first – EACH of them Handling inquiries and process 13

Case Study #1 Multiple primary care and specialty care Practices. Hospital buying Practices at clip of one a Quarter – size from one (1) doctor to five (5) doctors. All Practices must convert to CBO ‘EHR’ and Billing System. Discussion now going on with eight (8) doctor cardiology practice that wants to keep own systems. What issues are you facing? How can you deal with this politically? (You’re still responsible for revenue cycle performance.) 14

Case Study #2 Freestanding Cancer Center brought in as part of the Hospital and physicians employed. Covers RadOnc and Medical Oncology. All staff at Cancer Center stays. Systems at Cancer Center used for clinical (and billing) aspects do not interface. What are the factors that need to be considered in making this a successful transition? 15

Thank You Reach us at: Charlotte Kohler – Carolyn Tuttle –