1. DIY > Perform your own Revenue Cycle Assessment Keystone AAHAM Winter Meeting March 13, 2013 Presented by Mary Carpenter, FACHE Insight Health Partners, LLC

2. Keystone AAHAM Winter Meeting March 13, 2013 Page 2 Before you Start Tell the organization –Department Managers Meeting or E-mail announcement Establish a steering committee to review your findings –Include the CEO, COO and CFO Set a deadline for the report Keep the time frame as short as possible Get assistance within the organization or hire a temp help to prepare the various spreadsheets

3. Keystone AAHAM Winter Meeting March 13, 2013 Page 3 Before you Start Data you will need to complete the assessment: –Net and Gross Revenue by month for the prior 12 months –Bad Debt Expense from the P & L by month for the prior 12 months –Volume of patients for the prior 12 month period (or most recent fiscal year end) by Inpatient, Outpatient and Emergency –Payer mix for most recent month end –Net (from Balance Sheet) and Gross Accounts receivable by month for the prior 12 months –Aged accounts receivable by month for the prior 12 months –Most recent month ending credit balance amount –Charity and Bad Debt write-offs by month for the prior 12 months –Worked FTEs for two recent pay periods that don’t include a holiday –Denials by reason by month for prior 12 months Alternative calculation can be performed with Total Gross Charges, Total Cash and Total Adjustments for one month – at least 8 months prior –Total Point of Service collections total for the prior 12 months –Number of open billed accounts for prior month –Website with the spreadsheets referenced in this presentation: http://www.insighthp.com/DIYRevCycleAssessment

4. Keystone AAHAM Winter Meeting March 13, 2013 Page 4 Deployment Plan Detailed Recommendations Timeline Ongoing Reporting Deployment Plan Detailed Recommendations Timeline Ongoing Reporting Determination Investment ROI Determination Investment ROI Step 4:Opportunity Identification & Required Effort Interviews Detailed Data Interviews Detailed Data Step 1: Data Collection Indicator presentation Comparison with industry benchmarks Indicator presentation Comparison with industry benchmarks Step 3:KPI & Benchmarking Patient Access/Intake Productivity Review Process Assessment Entry Points Data Capture / Integrity Pre-Arrival Activities Patient Access/Intake Productivity Review Process Assessment Entry Points Data Capture / Integrity Pre-Arrival Activities Charging/Coding Charge Capture Coding Clinical Documentation Charging/Coding Charge Capture Coding Clinical Documentation Patient Financial Services Productivity Review Process Assessment/AR Denial / Reject Review Bad Debt / Write-offs Contract Management Patient Financial Services Productivity Review Process Assessment/AR Denial / Reject Review Bad Debt / Write-offs Contract Management Step 2: Valuation Management, System, Reporting, Organization Review Across the Revenue Cycle Revenue Cycle Assessment: Project Steps

5. Keystone AAHAM Winter Meeting March 13, 2013 Page 5 Patient Access and Pre-arrival Services

6. Keystone AAHAM Winter Meeting March 13, 2013 Page 6 Revenue Cycle > Patient Access & Pre-Arrival Services Assessment Observe Registration and Pre-registration activities in all areas that it is performed including Main Registration, Bedside Registration and Emergency Registration –Is there an order for the test/service being performed? –HIPAA regulations being observed? –Is EMTALA being honored with a quick/mini registration ahead of financial information gathering? –Are questions being asked in the correct way? “What is your current address?” NOT “Do you still live at 123 Main Street?” –Is positive identification being requested to assure that we are registering the correct patient? –Is the current insurance card reviewed to be sure that all insurance information on file is still correct? –Is MSP being completed for every occurrence of service? –Is there a process/tool in place to identify the need for an ABN Is the ABN obtained when required for the test/service being ordered? –What is the average amount of time it takes to complete a patient registration? Use at least 10 observed registrations in each area

7. Keystone AAHAM Winter Meeting March 13, 2013 Page 7 Revenue Cycle > Patient Access & Pre-Arrival Services Assessment Using the Calculation worksheet (DIYRC-Point of Service), identify the potential Point of Service collections based on your hospital’s volumes and payer mix Once you’ve identified the potential, then identify ways to achieve the improved collections like: –Incentive program –Patient Liability estimator –Reporting that identifies payments not collected

8. Keystone AAHAM Winter Meeting March 13, 2013 Page 8 Revenue Cycle > Patient Access & Pre-Arrival Services Staffing Assessment Identify average time to complete Registration –Be sure to include insurance verification and authorization if done at the time of registration Using prior 12 month volumes by patient type calculate the staffing need for each area –Working Days = 260/year –Productive Hours = 7/Day –Productive Work Hours = 1,820 Add as required the minimum staffing required in places like the Emergency Department Add non-working Supervisory and Management time to obtain full staffing requirement for each area Assume Financial Counselors average 30 minutes and have encounters equal to 25% of the population

9. Keystone AAHAM Winter Meeting March 13, 2013 Page 9 Revenue Cycle > Patient Access & Pre-Arrival Services Staffing Assessment Prepare a future state organizational chart if your FTE requirements are different from your current state

10. Keystone AAHAM Winter Meeting March 13, 2013 Page 10 Patient Financial Services

11. Keystone AAHAM Winter Meeting March 13, 2013 Page 11 Revenue Cycle > Patient Financial Services Assessment Observe the billing process –How are edits handled? In Health Information System In bill scrubbing software –What happens to the account if no resolution is obtained by end of day? –What is the average of dollars being held in bill scrubber for the past 3 months? –How old are the accounts being held in the bill scrubber? –How are re-bills handled – by the billing staff or the collections staff? –Are changes made in the billing system added/edited in the Health Information System for Patient Accounts? –What comments are entered in the account to identify that the bill has not yet been submitted to the payer? –What is the clean claims rates for bills passing through the bill scrubber? –What is the most common bill edit encountered by the billers? Be sure this is quantified through reports and not anecdotally –How is secondary billing handled – paper or electronic? –What percentage (if any) of accounts are billed on paper instead of electronically? –Is the response from the insurance company posted in the Health Information System?

12. Keystone AAHAM Winter Meeting March 13, 2013 Page 12 Revenue Cycle > Patient Financial Services Assessment Observe the collector process –Are web sites used appropriately? –When calling to follow up, does the collector overcome objections? Using billing data to challenge the assertion that claim in not on file –Does the collector understand the Payer guidelines and timely filing and appeal deadlines? –Does the collector frequently re-bill the insurance company instead of calling? –Are canned comments being used to save time and track productivity? –Are multiple accounts queried with the same payer in the same call? –If faxing additional information, does the collector call back to assure the information was received? –If Medical Records are requested, does the collector ask for specifics about what portion of the record is required to adjudicate the claim? –If there is a COB issue, does the collector attempt to conference the patient in on the call? –How does the collector prioritize their work? Work lists generated automatically? Accounts worked from list?

13. Keystone AAHAM Winter Meeting March 13, 2013 Page 13 Revenue Cycle > Patient Financial Services Assessment Observe the transaction posting process –What percentage of transaction posting is handled through electronic remittance? –Are transaction posting personnel working transactions by exception or are they working a remittance? –Are co-pays, coinsurance and deductible being recorded in the account? –Are payment variances routinely identified through the posting process? –How are payment variances and denials communicated to the proper staff? –Are all payments posted by end of business each day? –Does the lockbox provide an electronic remittance file for posting self pay and other payments? –How are credit card payments posted? –What reconciliation process is in place to be sure that payments posted balance with cash receipts for the day? –How are non-contractual adjustments posted? By collection staff? By transaction team with appropriate approvals? Combination of these? –How are small balance adjustments handled? –Are there any automatic adjustments like Bad Debt at certain dollar values?

14. Keystone AAHAM Winter Meeting March 13, 2013 Page 14 Revenue Cycle > Patient Financial Services Staffing Assessment Using HARA data is the easiest way to determine adequate staffing HARA reports are available from Aspen Publishing Most recent HARA report has the following averages for hospitals: –2,582 open accounts per biller –5,165 open accounts per collector Transaction posting staff can be assessed based on percentage of transactions that are manual versus electronic –Observe and calculate the average time to key individual transactions –Using the minutes methodology described for Patient Access Services, calculate FTEs required for this function –Using the transaction rejection list, use the minutes methodology described above and calculate the FTEs require based on volumes

15. Keystone AAHAM Winter Meeting March 13, 2013 Page 15 Revenue Cycle > Dashboard Assessment Using the data you gathered in advance of the project, enter the data on the dashboard (DIYRC-Dashboard)

16. Keystone AAHAM Winter Meeting March 13, 2013 Page 16 Account Life Cycle

17. Keystone AAHAM Winter Meeting March 13, 2013 Page 17 Revenue Cycle > Account Life Cycle > Unbilled Management Assessment Using the (DIYRC-DNFB Opportunity) Enter the Un-transmitted claims from the bill scrubbing software Enter the Unbilled amount from the Health Information System Enter the Gross ADR The opportunity is calculated

18. Keystone AAHAM Winter Meeting March 13, 2013 Page 18 Revenue Cycle > Account Life Cycle > Follow-Up Assessment Enter total Gross Billed AR from dashboard Enter AR > 90 from the dashboard Enter the Net to Gross ratio calculated in the dashboard Be sure to adjust if your billed accounts receivable is in a net state

19. Keystone AAHAM Winter Meeting March 13, 2013 Page 19 Revenue Cycle > Account Life Cycle > Denials Management Assessment Enter denials by reason code from data (DIYRC-Denials Opportunity) Evaluate each denial type by whether or not there is an opportunity and percentage of improvement Workbook calculates the dollar opportunity

20. Keystone AAHAM Winter Meeting March 13, 2013 Page 20 Revenue Cycle > Account Life Cycle > Denials Management Assessment An evaluation of the denials write-offs for the year 2010 was performed and an opportunity for improvement was identified in the amount of $2.1M The largest denial category was timely filing, however there are a variety of reasons why the claim became untimely, generally the lack of a precertification or other error that caused the account to time out

21. Keystone AAHAM Winter Meeting March 13, 2013 Page 21 Questions? mcarpenter@insighthp.com (480) 225-1338