1. Monitoring Payer Performance Mark Gagern Aurora Healthcare October 21, 2011 Maryland Chapter

2. Goals Establish Key Performance Indicators to: Identify process issues. Recognize Denial trends. Monitor Patient Responsibility. Forecast Cash. Predict and Manage Administrative costs. Monitor contract compliance.

3. Identify Key Performance Indicators Select KPIs based on goals. What information will help identify process issues, recognize denial trends, quantify administrative effort etc? Identify sources. Where can the information needed be found and how can it be measured? 835/Remit Data. Transactions. A/R.

4. Identify Key Performance Indicators Determine indicators to use based on: Suitability. How well does the KPI measure a specific process? Availability. Can the information be obtained from current sources? Consistency. Is the information consistently available? Automation. Can information be gathered without undue manual effort?

5. KPI Suggestions First Pass Payment vs. Additional Follow-up Required. Forecast percentage of claims which will pay on initial billing. Identify what percentage of claims will need additional action after billing. Sample: Payer Group1 st Pass PaidFollow-up Required MCO72%28% Blues75%25% Commercial82%27% Medicare93%8% Medicaid90%10% 82%18%

6. KPI Suggestions Patient Responsibility. Identify the total patient responsibility to measure against pos collections. Identify payers with increasing patient responsibility. Sample: PayerPT Res % of Charges Cigna8% United Healthcare8% Aetna6% Great West17%

7. KPI Suggestions Contractual Allowances. Verify appropriate discounts. Ensure out of state payments at HSCRC rates. Sample: PayerContractual % of Charges All Payers (Last 12 Months)7.25

8. KPI Suggestions Denials Denials. Monitor Denials in Key areas. Medical Necessity Denials. Sample: (last 3 months) PayerDenials as % of Charges Aetna1.24% Amerigroup.03% Bravo.39% CIGNA.96% Coventry1.2% JHHP.7% United Healthcare.04%

9. KPI Suggestions Denials Authorization / Pre-Cert Denials. Sample: (last 3 months) PayerDenials as % of Charges Aetna1% Amerigroup6 Bravo7.6 CIGNA1 Coventry3.7 JHHP.6 United Healthcare2.8

10. KPI Suggestions Denials Place of Service Denials. Sample: (last 3 months) PayerDenials as % of Charges Aetna Amerigroup.01% Bravo.11% CIGNA Coventry.05% JHHP.02% United Healthcare

11. KPI Suggestions Rejections Eligibility Rejections. Sample: (last 3 months) PayerDenials as % of Charges Aetna.86% Amerigroup1.7% Bravo.06% CIGNA1.5% Coventry1.5% JHHP2.4% United Healthcare1.4%

12. KPI Suggestions Other Additional Documentation Requests. Sample: (last 3 months) PayerDenials as % of Charges Aetna4% Amerigroup15% Bravo1.8% CIGNA.73% Coventry5.6% JHHP7% United Healthcare2%

13. KPI Suggestions Other Retraction Rate. Sample: (last 3 months) PayerDenials as % of Charges Aetna4.4% Amerigroup22% Bravo5.4% CIGNA6% Coventry4.5% JHHP5.9% United Healthcare2.8%

14. Sample Report Card

15. ???Questions???? Contact information: Mark Gagern mgagern@aurora-healthcare.com

16. Final Lets eat Grandma Lets eat, Grandma Punctuation Saves Lives!