1. Follow the Money! A Look at the RHC Revenue Cycle
Georgia Rural Health Association
Rural Health Clinic Conference
April 10, 2017

2. Unfortunately, many of our clinics are taking whatever revenue they can manage to get in the door without evaluating and improving their revenue cycle. We keep our fingers crossed and keep doing the same things.

3. Revenue Cycle: All of the administrative and clinical processes which represent the “life” of a patient account from its creation until payment resolution for an encounter or a series of encounters. The inter-related functions, when executed efficiently, result in the maximum reimbursement in the shortest amount of time (A/R days). A weakness in any of the individual processes can directly effect the overall revenue cycle performance.
Don’t let anyone tell you that they have are providing RCM services when all they are handling is your A/R.

4. the
Money
Follow

5. Services Provided Insurance Patient Bad Debt Engagement Scheduling
Payment
Insurance
Patient
Bad Debt
Patient Access
Engagement
Scheduling
Registration
Services Provided
Charge Capture
Documentation
Medical Necessity
Coding
EHR/E-superbill
Claims Process
Billing
Adjudication
Denials and Rejections

6. Front Desk and Staff Training
Patient Engagement & Patient Access...the first steps to getting paid are processes that take place within the first few minutes of the patient entering the clinic or even before the patient enters the front door of your RHC.
Front Desk and Staff Training
Mission, Vision and Teamwork
Understanding Regulatory Compliance
Understanding How Registration Populates the Claim
Accurate Demographic Data
Eligibility
Scheduling – can either maximize or impede clinical workflow
Updated Practice Management Systems

7. MAXIMIZE YOUR FRONT DESK
Have the right players in this key position
Value these team players
Script or role play if necessary
Redesign your registration forms to facilitate data entry and improve patient communication
Understanding Customer Service
Understanding Clinical Workflow
Understanding Financial Processes
Upfront Collections
Financial Policies
Train and Re-train

8. Errors Created at Registration
Inaccurate or Out of Date Demographic Information
Patient Registered Under a Different Name than on Insurance Card
Relationship of Patient to Policyholder error
Failure to update Insurance or Personal Information
(Don’t just ask if it all still the same)
Policyholder Information Incorrect or Incomplete
Wrong payer selected in demographics
Date of Birth (DOB) missing
Medical Identity Fraud Issues (drivers license, photo on file)
Medicare Secondary Payer Questionnaire
Workers’ Comp Visit
Liability or TPL Visit

9. MAXIMIZE PROVISION OF SERVICES
Avoid the “But we are a RHC” mindset
Efficient Clinical Workflow
Document the correct level of service
Order sets and ordering protocols
Checks and balances to ensure charge capture and follow-up
Maximize your health information technology
Provider and staff training
Billing and coding reviews

10. Errors Occurring When Services are Provided
Medical Necessity Not Met
Service Not Provided at the Required Frequency
Local Coverage Determinations
National Coverage Determinations
Pre-authorization for Services/Procedures
Referral Required?
Advanced Beneficiary Notice Not Issued
Non-covered Services Performed
Door Knob Complaints
Not all charges captured

11. Charge Capture Errors Workflow inefficiencies
Poorly designed Superbills/Encounter Forms
Illegible or Sloppy Superbills
E-superbill/ EHR permissions
Visits not Reconciled
Missed Charges
Other Charge Errors
Open Tickets/Unsigned Records
Charges for services not performed
# of Units (Drugs)
NDC information
Time based services
Fee schedules and Pricing Methodologies

12. Documentation Errors Services Performed but Not Documented Lab
Injections
Nursing Services
E & M Level
Order not on chart
Chief Complaint not addressed or Diagnosis is inconsistent with CC. CC doesn’t support medical necessity.
Not all diagnoses documented
Lab results not on chart or reviewed
Poorly Designed Clinic Notes or EHR Templates
Inadequate EHR Mastery
Time Based Services
Counseling Time
Unsigned or Incomplete Records

13. Code Assignment and Modifier Use
Practice Management System tables not updated
Invalid or Obsolete CPT or Diagnosis Codes
Modifier not appended or appended incorrectly
CPT and Modifier Mismatches
Modifiers Hard Coded in the CDM/Fee Schedule
Not matching the CPT code to the correct corresponding diagnosis. (Pointer default in system)
Modifier -25 for E & M codes only
Modifier -26: Professional Component Only
Modifier -51: Multiple procedures
Modifier -59 (Modifier of Last Resort)
Surgical Care Modifiers (-54,-55,-56)
Non-Covered Services (condition code 21 for Medicare to trigger denial for secondary)

14. ICD-10
The CMS grace period for unspecified code assignment will end this year. Now is the time to make sure that you are assigning the codes which represent the highest level of specificity and that your documentation is adequate to support the codes. Many providers are relying on the GEM mapping tools in their EHRs and are not learning the coding guidelines for ICD-10.
Take time to self-audit and re-educated to correct coding errors and weaknesses in clinical documentation. Be ahead of the game! Find your own problems before a payer points them out for you.

15. Errors in Claims Processing
Payers not set up correctly in your PM system
Providers not set up correctly in your PM system
Incorrect submitter numbers
Clearinghouse/Software Problems/EDI Issues
Submitting Duplicate Claims
Missing or incomplete patient information
Claim submitted to wrong payer
Use of non-specified codes
Conflicts with payer’s business rules

16. Errors in the Denial or Appeal Process
Is it a rejection or billing error? Fix once and for all.
The biggest problems with handling denials properly are timing and following the payer’s specific instructions and guidelines for the correcting claims and for the appeal process.
Poor Communication, internally and externally, are also obstacles to clean claims.
Maintain relationships with provider representatives.

17. Collections/Payments
Errors in posting payments and adjustments.
Posting guidelines, checks & balances, and benchmarks.
Errors created by electronic posting of remittance advices.
Failure to reconcile A/R activity in PM system to cash reports, actual deposits, and EFTs. Use your system reports and tools.
Not collecting co-pays, deductibles and co-insurance amounts at the time of service.
Not having established, written financial policies.
Not having checks & balances with your billing company.
Not enforcing or following up with payment plans.
Not sending statements in a timely manner.
Patient-friendly billing practices!

18. Basic Revenue Cycle Metrics
Accounts Receivables: Total amount of all outstanding patient account balances; May include total charges for accounts not yet paid or adjusted yet; May include both insurance balances or patient responsibility balances.
A/R Days: A calculation of how long it takes on average to collect one day’s revenue. The calculation can be based on either gross or net amounts of revenue. Before EDI and EFT, we could expect this payment window to be days, but now we can expect a much shorter time period for clean claims. Know your norm and the norm for each payer. Look for red flags.
Total Revenue for a given period ÷ the average daily patient service revenue for the same period = A/R Days
Aging: Account aging represents the outstanding account receivable amounts assigned to aging bucket based on how many days have elapsed since the original date of service. The aging can represent both insurance balances and patient balances.
Bad Debt: Accounts receivable amounts which have been determined to be uncollectable.

19. Create A Feedback Loop to Ensure Performance Improvement in your Revenue Cycle
Registration
Front Desk
Nursing Staff and Providers
Coders & Billers
Back Office or Billing Company
Final Payment
Teamwork & PI

20. Pulling it all together:
Teamwork
Efficient Clinical Work Flow
Effective Work Processes
Communication
Continuous Performance Improvement

21. Questions?

22. Patty Harper 318-243-2687 pharper@inquiseek.com 7/7/2015
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