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Data-Driven Improvement
Instituting Quality-Focused Report Packages Data-Driven Improvement
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Establish data-driven report packages designed to drive improvement
Overview Identify data elements important to the facility Develop oversight responsibility for each data set Determine frequency Establish data-driven report packages designed to drive improvement
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Data Packages Evaluate current state and commit to areas of focus
Establish acceptable metrics Routinely produce consistent, accurate data packages for review by departments and senior leadership
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Act on the Data Are daily, weekly, monthly reports distributed?
Patient Financial Services Hospital Report Report-November Previous Fiscal YR 195,756,157.60 Avg Daily Revenue 536,318 AR Total AR Credit Balances Collections POS Late Charges Denials Claims Generated-Meditech Held Accounts Unbilled Accounts Total Unbilled + Held Weekday Date Gross AR Days (Excluding S/P and Pending Medicaid Self Pay Pending Medicaid $ # Total Collections Posted Blue Cross Commercial Medicare Medicaid Medicaid HMO Medicare HMO Managed Care Tricare Workers Comp Total POS Billed $ Medicare RTP ($) Held/Failed ($) ePremis Held ($) Total ($) Medicare RTP (#) Held/Failed (#) ePremis Held (#) Total (#) Total Un-Billed ($) 0-7 Days ($) >7 Days ($) Total Un-Billed (#) 0-7 Days (#) >7 Days (#) Tue 1 74.41 41,730,884 ##### 4,104,301 17,586,518 20,040,066 1,823,072 2,381 - 4,214,574 3,486,601 727,973 1,394 1,210 184 48,287 19,203 13,775 77 674 (541) 2 384,851 211 565,813 201 36,593 573,342 318,394 928,329 6 68 61 134 5,142,903 1,528 Wed 74.67 41,875,272 4,104,433 17,776,552 19,994,287 1,829,586 2,386 4,121,459 3,444,170 677,289 1,386 1,223 163 1,191 5,241 75,615 8,674 387 1,311 9 50,448 51 750,122 254 3,126 561,864 510,266 1,075,256 70 78 149 5,196,715 1,535 Thur 3 74.86 41,982,531 4,092,725 17,885,489 20,004,317 1,831,458 2,390 4,134,210 3,419,118 715,092 1,384 1,219 165 28,458 7,320 8,102 352 458 (870) 34,074 41 709,492 260 20,571 543,261 527,843 1,091,675 88 5,225,886 1,533 Fri 4 74.17 41,636,243 17,595,862 19,947,656 1,855,325 2,406 4,050,645 3,291,284 759,362 1,359 1,221 138 17,243 6,751 8 411 2,880 11 49,799 62 685,949 223 21,062 681,174 512,395 1,214,631 69 94 164 5,265,276 1,523 Mon 7 75.04 42,090,399 4,092,620 18,097,546 19,900,234 1,842,459 2,410 4,351,989 3,594,668 757,321 1,332 110 29,923 16,397 5,514 305 7,586 12 32,839 38 932,301 343 20,894 556,480 460,438 1,037,812 81 143 5,389,801 1,475 74.11 41,610,072 4,091,934 17,618,968 19,899,170 1,863,930 2,400 4,279,879 3,531,255 748,624 1,351 1,220 132 22,160 6,265 8,524 777 566,399 192 592,517 249 21,679 531,884 464,751 1,018,314 84 146 5,298,193 1,497 74.52 41,778,757 4,091,932 17,808,395 19,878,430 1,814,700 2,392 4,279,306 3,585,089 694,217 1,340 1,212 129 44,934 11,723 26 356 (686) 73,082 48 756,315 215 20,404 537,048 401,672 959,123 54 66 120 5,238,429 1,460 10 74.70 41,814,156 4,091,927 17,851,498 19,870,730 1,751,225 2,368 4,306,478 3,613,391 693,087 1,278 1,205 73 178 7,034 1,227 221 (171) 69,245 885,551 553,200 356,908 930,512 58 55 113 5,236,990 1,391 14 76.67 42,773,539 18,771,738 19,909,874 1,653,004 2,321 4,240,174 3,563,930 676,243 1,304 1,222 83 153,028 22,744 11,005 341 217 1,172 16 1,966,966 571 716,653 439,022 1,176,078 71 76 148 5,416,252 1,452 15 75.54 42,126,042 4,095,430 18,109,083 19,921,529 1,615,149 2,301 4,144,417 3,503,658 640,758 1,372 1,229 26,721 10,454 6,146 63 427,724 329 847,634 237 513,855 392,805 927,063 57 5,071,480 1,491 75.81 42,314,384 4,077,915 18,301,416 19,935,053 1,657,317 2,275 4,046,441 3,406,889 639,553 1,333 1,249 28,086 5,790 50 338 18,186 36 799,427 176 431,974 410,016 862,394 52 60 112 4,908,835 1,445 17 76.42 42,545,125 18,493,594 19,973,616 1,561,401 2,243 3,929,841 3,279,800 650,040 1,312 85 6,658 5,603 104 107 44,927 47 964,075 290 411,145 479,007 910,555 49 4,840,396 1,432 18 76.05 42,300,787 4,077,354 18,241,781 19,981,653 1,515,282 2,219 3,941,710 3,265,212 676,499 1,314 1,230 57,636 20,949 8,794 229 38,931 837,014 202 495,338 438,805 954,546 121 4,896,257 1,435 21 22 23 25 28 29 30 Act on the Data Are daily, weekly, monthly reports distributed? Are follow-up questions sent to changemakers? Does the team notice detail and act on it?
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Choose Data Elements Too much data becomes white noise
Assign responsibilities Expect results Establish regular report-outs
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Patient Financial Services
Monthly financial reports Denials Current period compared to Previous periods Averages Previous year for seasonal departments Trends Known issues Maximum drug units compared to minimum drug units Administration codes compared to injectable drugs Bedside procedures Evaluation and Management bell curve Average ER procedures per visit Ad hoc reports
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Daily Flash Report Gross A/R A/R Days Credit Balance Clean Claim Rate
Denial Gross Revenue By Payor By Reason Failed (Held) accounts Revenue Units Cash Deposited Average Daily Deposit Average Daily Deposit Required To Meet Goal
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(Excluding S/P and Pending Medicaid)
A/R Days Patient Financial Services Hospital Report Report-November Previous Fiscal YR 195,756,157.60 Avg. Daily Revenue 536,318 AR Total AR Credit Balances Weekday Date Gross AR Days (Excluding S/P and Pending Medicaid) Self Pay Pending Medicaid $ # Tue 1 74.41 41,730,884 4,104,301 17,586,518 20,040,066 1,823,072 2,381 Wed 2 74.67 41,875,272 4,104,433 17,776,552 19,994,287 1,829,586 2,386 Thur 3 74.86 41,982,531 4,092,725 17,885,489 20,004,317 1,831,458 2,390 Fri 4 74.17 41,636,243 17,595,862 19,947,656 1,855,325 2,406 Mon 7 75.04 42,090,399 4,092,620 18,097,546 19,900,234 1,842,459 2,410 8 74.11 41,610,072 4,091,934 17,618,968 19,899,170 1,863,930 2,400 9 74.52 41,778,757 4,091,932 17,808,395 19,878,430 1,814,700 2,392 10 74.70 41,814,156 4,091,927 17,851,498 19,870,730 1,751,225 2,368 14 76.67 42,773,539 18,771,738 19,909,874 1,653,004 2,321 15 75.54 42,126,042 4,095,430 18,109,083 19,921,529 1,615,149 2,301 16 75.81 42,314,384 4,077,915 18,301,416 19,935,053 1,657,317 2,275 17 76.42 42,545,125 18,493,594 19,973,616 1,561,401 2,243 18 76.05 42,300,787 4,077,354 18,241,781 19,981,653 1,515,282 2,219
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Total Collections Posted
- Total Collections Posted Blue Cross Commercial Medicare Medicaid Medicaid HMO Medicare HMO Managed Care Self Pay Thur 1 26,920.45 449.34 19,162.32 2,963.07 2,415.40 1,865.60 Fri 2 114,683.92 42,098.45 4,063.07 56,530.32 16.35 5,987.68 4,110.51 1,808.43 Mon 5 94,822.34 28,419.17 19,748.83 28,781.51 6,477.30 5,291.33 4,407.69 Tue 6 150,893.74 19,604.61 22,072.46 23,907.72 34,928.93 260.60 37,737.79 5,577.11 5,030.00 Wed 7 64,770.24 25,476.53 3,888.22 27,811.89 4,603.30 2,776.27 8 61,543.32 44,381.31 8,507.71 776.10 4,230.29 125.00 3,128.62 9 53,752.13 2,115.02 7,643.45 29,181.89 5,061.14 7,758.02 1,969.66 12 110,132.31 257.60 47,478.36 2,160.75 48,479.42 6,566.90 3,144.03
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Total Collections Posted
Blue Cross Commercial Medicare Medicaid Medicaid HMO Medicare HMO Managed Care Self Pay 134,602.25 2,246.70 95,811.59 - 14,815.36 12,076.98 9,327.99 573,419.60 210,492.24 20,315.33 282,651.60 81.73 29,938.42 20,552.56 9,042.16 474,111.70 142,095.84 98,744.16 143,907.57 32,386.48 26,456.65 22,038.45 754,468.68 98,023.05 110,362.29 119,538.60 174,644.64 1,302.99 188,688.93 27,885.55 25,149.98 323,851.18 127,382.65 19,441.12 139,059.46 23,016.48 13,881.37 307,716.58 221,906.55 42,538.56 3,880.48 21,151.46 625.00 15,643.12 268,760.63 10,575.09 38,217.25 145,909.46 25,305.69 38,790.11 9,848.29 550,661.55 1,288.00 237,391.79 10,803.76 242,397.08 32,834.48 15,720.17
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Gross Revenue Forecast goals Identify trends Assign resources Revenue
TODAY MTD TOTAL PRIOR YEAR Prior Actual Budget % Variance YTD I/P-HOSPITAL 493,998 10,403,322 9,681,550 7% 146,081,949 -5% O/P-HOSPITAL 801,418 15,030,905 15,275,557 -2% 259,887,759 0% CLINIC REVENUE 366,283 3,616,456 4,362,275 -17% 67,283,462 -9% NURSING HOME REVENUE 96,821 2,012,274 1,827,691 10% 30,637,064 8% TOTAL GROSS REVENUE 1,758,521 38,828,696 38,933,842 -0% 511,677,002
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Investigate Outliers What happened here? Root causes
What can be corrected? What is the future action plan? Other Metrics TODAY MTD DAILY AVG ACTUAL AVAILABLE BED OCCUPANCY % 76.51% OUTPATIENT REGISTRATIONS 187 129 ER VISITS 132 116 ER ADMISSIONS 15 20 ER LWBS 8 OBSERVATION HOURS 85 277 OBSERVATION PATIENTS 6 19
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Agency Collections Agency 1 Agency 2 $ # 93,936.70 95 107,016.24 165
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Sample Monthly Numbers Report
High-level snapshot of data elements that effect cash flow Look for possible root causes and corrective actions What drives unfavorable trends? What can be done to improve? Compare to previous months and identify reasons for variances Are variances correct? Can errors be corrected and resubmitted? Were they known? Were you prepared in advance? What can be done better to communicate and prepare in the future?
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Trend by Month Peak seasons not identified in averages of previous months Fine tune goals and expectations June July August September October November December TOTAL GROSS REVENUE 2016 38,683,672.02 41,647,144.92 42,890,423.66 39,042,037.42 38,279,634.04 41,136,855.87 38,828,695.60 TOTAL GROSS REVENUE 2015 45,123,526.07 43,013,252.35 43,742,823.49 39,858,962.82 40,008,618.00 40,370,371.03 38,933,841.81 TOTAL CASH COLLECTIONS 2016 14,510,321.91 12,247,219.35 15,811,125.52 13,416,884.57 14,190,453.81 12,211,326.55 11,903,517 TOTAL CASH COLLECTIONS 2015 13,393,414.29 14,901,173.46 13,741,003.98 12,393,465.72 12,430,944.94 12,584,230.18 12,164,563 Total Procedures 2016 14064 13131 12769 15206 13317 13747 Total Procedures 2015 14979 15469 14763 16944 14981 12456 TOTAL HOSPITAL DISCHARGES 2016 682 718 708 642 680 630 534 TOTAL HOSPITAL DISCHARGES 2015 789 811 767 722 780 676 543
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Pay Attention to Data Trends
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Pay Attention to Data Trends
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Track Cash Posted vs. deposited Goals Average three months
Previous period Revenue SUMMARY MONTH -TO-DATE-CASH PERFORMANCE Monthly Cash Goal: 4,245,609 * * Based Upon Last 3 Months Average of Net Revenues MTD Actual Cash Collections (Posted): 929,838 MTD Variance to Monthly Goal: 3,315,770 MONTH-TO-DATE CASH DETAIL Cash Collections (Posted): Current Day's Receipts (Unposted): 92,321 MTD Receipts (Unposted): 165,282 MTD Actual Cash Collections (Deposited) 999,929 MTD Cash Goal MTD Variance to Goal
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Pay Attention to Data Trends
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Sample Monthly Number Snapshot Report
FY 2014 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Departmental Visits EMROP - EMERGENCY ROOM OP B 2,397 2,439 2,472 2,413 2,247 2506 2,500 2,739 2,673 2,662 2,605 2,460 MNROP - EMERGENCY ROOM MINO 615 590 530 484 457 450 479 522 596 625 665 632 EMROP2 - EMERGENCY ROOM OP L 1,387 1,376 1,215 1,241 1,098 1250 1,243 1,319 1,385 1,377 1,399 1,267 Lag Days Emergency Room 5.81 8.04 8.29 9.96 8.89 8.70 6.53 9.30 9.65 8.87 9.64 8.35 Supplies Emergency 5.07 6.13 6.89 8.20 9.66 6.81 5.86 8.94 8.41 7.98 7.04 Emergency Room 2 3.91 5.33 4.98 4.95 4.49 3.89 4.01 5.57 6.72 6.48 5.21 4.22 Supplies Emergency 2 3.96 7.05 4.93 5.26 4.35 3.52 4.61 5.54 6.74 5.98 5.02 4.00 Late Charges $31,879.78 $200,832.00 $180,480.00 $200,387.00 $107,317.00 $136,432.00 $118,045.00 $137,446.00 $183,307.00 $142,034.00 $179,561.00 $33.87 $287.07 $270.90 $539.25 $167.05 $325.23 $126.24 $381.60 $924.65 $353.56 $503.57 Late GL $55,586.12 $695,512.00 $593,736.00 $722,733.00 $475,958.78 $435,449.00 $313,232.00 $386,365.00 $831,707.00 $483,144.00 $619,602.00 $547,328.00 $74.52 $1,607.51 $1,255.34 $1,949.23 $1,795.30 $1,345.46 $929.39 $2,034.47 $3,340.25 $1,488.39 $1,968.66 $1,258.60 $19,578.00 $114,639.00 $109,365.00 $40,977.00 $44,774.00 $50,683.00 $41,480.00 $15,445.00 $121,623.00 $54,757.00 $70,090.00 $29,278.00 $11.10 $991.76 $146.41 $313.32 $579.13 $356.60 $283.15 $69.87 $1,035.56 $383.89 $973.11 $69.19
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Detail by Chargecode Look for variance from previous month
Does variance make sense? Was change properly communicated and prepared for in advance? Can errors be corrected? Identify root cause and implement changes to ensure future success
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Detail by Charge Code Report
Jan 15 Feb 15 Bill Code Item # Proc's Description UNITS BILLED GROSS REVENUE UNIT VARIANCE REVENUE VARIANCE CATH COUDE 5CC 14FR $0.00 SURGICEL 4X8 STOCKINETTE ORTHOPEDIC 3 STOCKINETTE ORTHOPEDIC 6 GAUZE STERILE 36 X 36 FLUFF SURGIFOAM SPONGE 100CM 1 $41.50 GELFOAM POWDER CATH COUDE 5CC 16FR CATH FOLEY 3CC 10FR CATH 3 WAY 30CC 16FR $16.72 -1 -$16.72 CATH KIT FOLEY 16FR W BAG 7 $120.54 3 $51.66 10 $172.20 CATH 3 WAY 30CC 18 FR CATH 3 WAY 5CC 18FR CATH 3 WAY 30CC 20FR CENTRAL VEIN KIT SINGLE LUMEN KNEE IMMOBILIZER 12 UNIV -$14.50 SET TUR Y SPIKE IV VENOSET STERILE W CLAMP 12 $438.84 4 $146.28 -8 -$292.56 CATH COUDE 5CC 18FR $20.87 CATH 3 WAY 5CC 22FR BAG DRAINAGE URETERAL -$27.04 $81.12
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Evaluate Drug Units Identify the most commonly administered drugs
Work with pharmacy to establish minimum likely units by CPT Create grid to identify actual units administered at the patient level, and refer outliers to analysts to review for accuracy, correction and trending Focus should be on identifying root cause Correct the trend, not just the claim Depending on the size of the facility, identify top drugs
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Minimum/Maximum Drug Units
cpt_code cpt4_desc Min of Units Max of Units J0690 CEFAZOLIN SODIUM INJECTION 1 250 J0694 CEFOXITIN SODIUM INJECTION J0696 CEFTRIAXONE SODIUM INJECTION 25 J0744 CIPROFLOXACIN IV J0885 EPOETIN ALFA, NON-ESRD J1170 HYDROMORPHONE INJECTION J1459 INJ IVIG PRIVIGEN 500 MG J1642 INJ HEPARIN SODIUM PER 10 U J1644 INJ HEPARIN SODIUM PER 1000U J1650 INJ ENOXAPARIN SODIUM 700 J1885 KETOROLAC TROMETHAMINE INJ J1956 LEVOFLOXACIN INJECTION J2001 LIDOCAINE INJECTION J2354 OCTREOTIDE INJ, NON-DEPOT 100 J2405 ONDANSETRON HCL INJECTION 450 J2920 METHYLPREDNISOLONE INJECTION J3010 FENTANYL CITRATE INJECITON 4 500 J0131 ACETAMINOPHEN INJECTION
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Drug Administration Many facilities struggle with proper assignment of drug administration codes Create quick hit reports to augment auditing programs Look for multiple initial infusions Hydration as initial when other services have been performed Multiple additional pushes of the same substance Focus on providing education, fixing the root cause and not just the claim
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Review Drug Administration
Account # 96360 96361 96365 96366 96367 96368 96374 96375 96376 Grand Total Initial Addl Push Push 1 2 6 Rvw multiple initial 4 3 Rvw Multiple Initial Rvw time between push Rvw med pushed 8 5 Track the number of initials and (in orange) send multiple initials to coding for review. Retrain nurses and/or coders as indicated by results. Track the number of additional pushes of the same drug (in purple) and send for review to validate at least 31 minutes passed between pushes.
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Denial Management If no formal denial reports exist, clean up rejection and adjustment codes and use data to track denials Utilize summary reports of Clearinghouse edits Always focus on fixing the trends. Rework is extremely costly and redundant errors commonly occur in services such as lab where there is little benefit to fix claim by claim, but huge benefit to correct the trend. Root cause to the inception of the problem: Registration in ED can cause lab/radiology errors Primary care can cause lab/radiology medical necessity errors
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Denials by Summary Group
Step 1 Denials by Summary Group GROUP AETNA ANTHEM BCBS CIGNA COMMERCIAL MCR MCR OTHER MEDICAID TRICARE UNITED HEALTHCARE Totals CDM 52 1 547 600 Credentialing 2 51 16 14 19 104 Eligibility 12 25 4,014 36 48 2,996 89 1,376 33 8,629 File Limit 8 478 4 15 18 230 779 Medical Necessity 8,127 8,154 Medical Records 767 4,669 1,565 7,026 Non-covered Service 6 7,242 3 1,764 187 9,256 Other 44 389 1,926 359 1,500 1,154 5,113 67 10,604 Pre-Authorization 10 64 2,443 7 2,541 Referral 2,272 5 31 2,317 Registration 1,513 1,515 UR-Level of Care 506 1,063 1,574 59 436 17,342 109 447 20,134 1,577 12,847 148 53,099
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Coding Discharged Not Final Billed Decide what this means Not coded
Includes UB that has been coded/abstracted Track to affect change By provider By dept. Highest dollars Oldest day Most accounts
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Discharge not Final Billed Top 20 Providers by # Accounts Provider
Summary by Department Department # Accounts Sum of Chgs Oldest Account (Days) ?? Vet 1 26.00 359 Cardiology 1,622.00 9 COMMUNITY 16 185,787.23 24 ED 18 47,009.70 34 ER 112 110,807.05 197 General Surgeon 7 29,491.10 HemOnc 8 71,899.72 37 HOSPITALIST 142 2,902,423.47 39 LOCUM 212 276,402.58 21 OB/GYN 28 151,711.28 50 Psych 27,740.05 25 546 Discharge not Final Billed Top 20 Providers by Revenue Provider Sum of Charges Number of Accts PENJOH 1,095,499.99 48 COCAR 792,121.59 47 NEHJU 344,025.60 15 LOPROB 246,591.89 KISJA 244,578.82 7 URBVI 177,064.38 6 HARLI 151,438.68 9 TONTH 109,349.05 105 KAPJOS 83,546.70 95 POPOV 75,044.99 HEDHA 73,359.46 60 LEESI 69,100.12 2 BRISU 63,926.81 BORYO 63,011.01 18 PENRA 31,437.85 SHIWI 27,740.05 1 WYKDA 27,143.00 3 CHEDA 25,387.65 FERCA 20,761.40 BOLTI 13,614.28 3,734,743.32 453 Discharge not Final Billed Top 20 Providers by # Accounts Provider Sum of Charges Number of Accts TONTH 109,349.05 105 KAPJOS 83,546.70 95 HEDHA 73,359.46 60 PENJOH 1,095,499.99 48 COCAR 792,121.59 47 BORYO 63,011.01 18 NEHJU 344,025.60 15 LOPROB 246,591.89 CAMTH 12,790.20 10 HARLI 151,438.68 9 KISJA 244,578.82 7 URBVI 177,064.38 6 POPOV 75,044.99 BRISU 63,926.81 WHEGE 1,629.00 ERPHYS 631.00 GUTRA 7,932.85 4 TAPWI 2,541.20 MORWI 3,942.15 PURRU 2,348.10 3,551,373.47 475 Discharge not Final Billed Top 20 Providers by Oldest Accounts Physician Oldest Acct (Days) FLAREU 359 JOHWIL 197 BOLTI 50 BORYO 42 PENJOH 39 JOHKEN 37 CHEDA 34 POPOV 30 COCAR 25 SHIWI HARLI 24 MORWI PENRA DYEJA 21 NEHJU 18 URBVI KISJA 17
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Other Reports Audits in process, completed and planned
Standard benchmarks should be published daily and distributed to department leadership Final reports should be discussed at Revenue Cycle meetings for process improvement Clean claim rate Where can we improve? How do we compare to industry standard? Coding backlog How is this communicated to billing on a daily basis for preparation and scheduling? How can we improve? Provider behavior Coding education System checks: too few or too many A/R Revenue month to date Monthly target Days cash on hand
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Expectation and Responsibilities
Department leaders must take charge and drive progress Understand the intent of the data Review timely (daily, weekly, monthly as distributed) Assign research or improvement projects for outliers Ensure that all duties, responsibilities and due dates are clearly stated
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Keep Additional Goals in the Pipeline
Promote a culture of Continuous Quality Improvement Items may be preempted by more important issues, but should not be disregarded Even audits demonstrating success after an education initiative should be rescheduled to ensure that learned behaviors are reinforced and staff does not revert to previous habits Keep learning, keep growing, keep striving!
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“Excellence is the unlimited ability to improve the quality of what you have to offer.” -Rick Pitino
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Thank You Stroudwater Revenue Cycle Solutions was established to help our clients navigate through uncertain times and financial stress. Increased denials, expanding regulatory guidelines and billing complexities have combined to challenge the financial footing of all providers. Our goal is to provide resources, advice and solutions that make sense and allow you to take action. We focus on foundational aspects which contribute to consistent gross revenue, facilitate representative net reimbursement and mitigate compliance concerns. Stroudwater Revenue Cycle Solutions helps our clients to build processes which ensure ownership and accountability within your revenue cycle while exceeding customer demands. Contact us to see how we can help. John Behn, MPA
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