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

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.

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.

the Money Follow

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

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

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

Errors Created at Registration Inaccurate or Out of Date Demographic Information Patient Registered Under a Different Name than on Insurance Card Relationship of Patient to Policyholder error Failure to update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

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

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

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

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

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)

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.

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

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.

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!

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 45-60 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.

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

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

Questions?

Patty Harper 318-243-2687 pharper@inquiseek.com 7/7/2015 Slides may not be reproduced without permission.