1. Maximizing Collections
December 2016

2. Grade for Patient Billing and Collections at CHCs

3. Why so Hard??????????? The complex nature of services to be billed;
The complex specifications for CHC billing;
The number of employees that contribute to the process;
The systems and tools used to capture and process billing information; and,
The unending variation that occurs in each of these dimensions.

4. Accurate information and the verification process is key.
Billing Issues
Accurate information and the verification process is key.
Training – there is frequently high turnover of front desk staff; and thus making sure that all staff understand their responsibilities is crucial.
Eligibility verification – explore all internet and system options.

5. Billing Issues
Proper completion and entry of registration information is key.
Feedback loop with the billing department must be established so that front desk staff understand the impact of their actions. Oftentimes the best form for the communication is a facilitated peer-to-peer interaction.

6. Operational Issues
Must know services you offer, plans you accept, operational structure.
Excessive wait times can result from slow patient processing.

7. Collecting Information Appointment Scheduling
Accuracy of Recording Information
Efficiencies of Staff
Communication with:
◦ Patients (Teaching Compliance)
◦ Providers and Staff
◦ Community
Patient Experience
Management Oversight

8. Best Practices Collect Copays & Nominal Fees at Time of Visit.
Know what the Patient Owes
Patient Statements
Payment Plans
Payment Options

9. Collect Copays & Nominal Fees at Time of Visit
• Your goal should be to collect 100 percent of copays and deductibles every day in every site. Establish dollar goals.
• Let patients know — via your website, your portal, appointment reminder calls, etc., — of your policy, and reschedule all but acutely ill patients who arrive without their copay.
• Track collection rates by site and/or staff member. Review each day of cash collections.
• Improve the "Ask." You will find that some employees are instinctively better at collecting patient payments. Have other employees observe their techniques. If you have a small staff, consider having your front-office personnel take a field trip to another site to learn.

10. Know What the Patient Owes
• Check insurance eligibility on every patient prior to every visit to: 1) Identify what copay and/or deductible are due; and 2) Ensure the patient's insurance is active.
• Again, let your patients know what payment you will expect at the time of their visit. Eliminate potential patient excuses, such as, "I didn't know the cost of today's appointment will apply to my deductible."
• Many eligibility checking products permit you to do real- time eligibility/benefit status verification at the time of service

11. Patient Statements • Patient statements should go out at least weekly.
• Remove the aging buckets (e.g., 0-30 days, days, days) from the bottom of your patient statements. Aging buckets are an invitation to patients to wait another 30 days to pay you.
• Patient statements should go out at least weekly.
• Your initial statement should simply state, "DUE NOW."
• Your second statement should state, "PAST DUE."
• The next step should be either a phone call or a final- notice letter giving the patient 15 days to pay before their balance is sent to collections. (Internal or External)

12. Payment Plans
• Set up payment plans for those patients who don't have the money and indicate that they are willing to pay their bill in installments.
• A payment plan should be documented in writing and signed by the patient.
• The payment plan should spell out what will happen if the patient misses a payment; this is critical.
• Payment plans should not extend beyond 12 months.

13. Payment Options
• Patients are creatures of their own habits. Make sure you have payment options that make it easy for them to pay you.
• Accept cash, checks, debit cards, and credit cards. More payment options mean more time-of-service collections.
• Accept payment through your patient portal.
• Accept payment through your website.

14. Net Collection Rate
There are so many reasons why a net collection rate may be subpar. Finding the root cause will help the CHC take proactive steps to improve collections and become more financially healthy.

15. Certified Coders
Some CHC’s may rely on individuals who don’t have formal coding training or credentials to perform the coding function. Although this may have been acceptable, the practice of hiring non-credentialed coders may become obsolete as CHCs continue to undergo billing and documentation scrutiny by external State and Federal auditors/reviewers.

16. Internal Audits
It is paramount for CHCs to perform proactive audits regarding coding and documentation quality. Internal audits may be performed with current staff or working with a consultant to perform these audits may be most effective.

17. Education and Training
The best way to mitigate denials and revenue loss is to provide comprehensive training for all staff members. This includes administrative staff, clinical staff, and coders.

18. The Revenue Cycle Appointment Scheduling
Registration/Patient Reception
Patient Clinical Visit – Service Delivery
Documentation & Coding
Charge Processing/Check Out
Patient Statement & Claim Production
Claims & Patient Payments Processing
Denied Claims Management
Accounts Receivable Management and Collections

19. Understand Your Revenue Cycle
Review current front office operations.
Analyze areas where revenue can be enhanced by assuring that information is captured correctly.
Improve processes by documenting work flows.
Provide feedback about how staff are performing.
Perform revenue cycle review .
Identify bottlenecks.
Aggressively screen all uninsured patients for eligibility.

20. Outsourcing Billing & Collections
FQHC billing is more complex or unusual than other medical practices.
You’re Struggling to Find and Retain Staff: The truth is that sometimes it is hard to find the qualified, well-trained staff you need to ensure quality medical billing for your CHC.
You Just Found Out Your Billing Metrics Aren’t Very Good: Often, CHC’s that choose to outsource do so because at some point someone saw dropping revenue or inconsistent cash flow.
It’s Time to Put the Focus Back on Patients: Times have changed, and patient expectations have changed with them.

21. Patient Access – Front Office Performance
Key Performance Indicator
Measure
Registration Error Ratio
TBD
Insurance Eligibility Verification Rate
≥ 98%
Point of Service Cash Collected
≥ 80%
Returned Mail Percentage
< 5%
Medicaid Eligibility Screening
100%

22. Revenue Integrity Key Performance Indicator Measure
Days to Posting of Charges (closing chart)
24-48 Hours
Denied Claims % of Net Revenue by Payor
TBD
Point of Service Cash Collected – by Site
Coding Error Rate (Billing &/or Provider)
< 1%
Provider Coding Performance - Practice Norms
100%

23. Claims Adjudication Key Performance Indicator Measure
Number of Claims Filed by Payor:
Medicaid & Medicare (per month)
2, ,000
Insurance (per month)
2, ,500
Self-Pay (per month)
1,000 – 1,500
Initial Denial Rate
≤ 4%
Denials Re-Filed within 2 days
> 85%
Clean Claims Submission Rate
> 90%

24. Identifying Action Steps to Achieve Maximum Revenue & Collections
Review current billing functions and analyze current provider documentation.
Analyze areas where revenue can be enhanced by identifying problems with rates, bad debts, increasing A/R, etc.
Improve coding for quicker claims adjudication turnaround and reimbursement.

25. Identifying Action Steps to Achieve Maximum Revenue & Collections
Clean-up Billing and Collection Efforts
Analyze outside collection agency and evaluate revenue implications. (If used)
Perform denial analysis.
Identify annual dollar amounts associated with improvements.

26. Are you billing wraparound for contracted MA plans?
Medicare
Increase your market share of Medicare patients.
Are you billing wraparound for contracted MA plans?

27. Do you get your PPS rate for crossover claims?
 Medicaid
Are there services reimbursable under PPS that could improve revenue stream?
Opportunities for applying for a change in scope of services, (i.e., increased costs, new services, intensity of services etc.)
Do you get your PPS rate for crossover claims?
PPS rate appeals, due to increased costs...not enough revenue.

28. Management Must be involved in the Revenue Cycle and
Billing Operations

29. Management must establish billing and collections direction for staff that result in maximization of revenue from all sources.
Management needs Board “sign-off” on Policy.
Management sets the tone, so all (CEO with final say-so) must agree on approach.
Management must monitor and oversee activities to assure staff is executing based on the planned approach.

30. Management should:
Develop and maintain a detailed billing and collections policies and procedures manual that delineates procedural differences for each payer.
Revise job descriptions and pay grades, as appropriate.
Assign responsibility and include a timeframe for completion of each defined task.
Educate ALL staff about newly defined policies, procedures, job functions, and regulatory changes. Monitor staff adherence to newly defined policies and procedures.

31. Management should:
Establish a liaison with each third-party payer.
Establish periodic (e.g., quarterly) meetings with a provider
representative from each major payer to resolve problem bills
and payment issues, and clarify regulatory and claims
adjudication changes.
Define the content, format, and production frequency and
distribution points of accounts receivable (A/R) management
reports (e.g., days in A/R, dollars in A/R).

32. Management should:
Periodically (e.g., semi-annually) engage a certified coder to audit sample health records to ensure adequate documentation and appropriate coding practices.
This is particularly important because of the potential of coding audits in health centers.
Educate providers during orientation and on an ongoing basis about coding and productivity expectations.
Consider incentive-based compensation program for providers and other support staff.

33. Management should:
Periodically review the physical flow of patients to ensure that registration, financial counseling, and collections activities can be easily and confidentially performed.
Periodically observe waiting room operations to see how established policies and procedures are carried out and can be improved.
Work with registration, financial counseling, care, and collections staff to improve your organization’s physical layout.

34. Questions?