2010 UBO/UBU Conference Title: The MHS Revenue Cycle and UBO Strategic Planning Session: T

Objectives Provide basic information on: – The Uniform Billing Office Organization – Cost Recovery Programs – The MHS Revenue Cycle – Strategic Planning 2

Outline Uniform Business Office (UBO) Organization UBO Cost Recovery Programs MTF Revenue Cycle Data Quality and How It Affects Each Phase of the Revenue Cycle UBO Strategic Planning and Success Factors Resources 3

UBO Advisory Working Group TMA CFO Mr. David Fisher Director, Management Control & Financial Studies Division TMA UBO Program Manager Service UBO Program Managers (Army, Navy, Air Force) ASD (Health Affairs) Director, TMA Deputy Director, TMA Intermediate Commands (Army, Navy, Air Force) MTF UBO Army, Navy, Air Force Surgeons General Army, Navy, Air Force Chief of Staff Army MEDCOM BUMED AFMS Command – Control - Execution Policy & Guidance Secretary of the Army, Navy, Air Force Service IM/IT, legal reps & subject matter experts (SME) TMA/IRD, Unified Biostatistical Utility (UBU) Work Group, Defense Health Information Management System (DHIMS), Defense Health Services Systems (DHSS), MEPRS Management Improvement Group (MMIG) UBO Organizational Relationships 4

Our Goals TMA, Three Services, Three Programs dedicated toward the same UBO overarching goals: Identify those entities who owe the MHS money Present bills to those who owe the MHS money Collect what we are due in a cost-effective manner 5

Third Party Collections Program (TPCP) Medical Services Account (MSA) Medical Affirmative Claims (MAC) UBO Cost Recovery Programs 6

Who We Bill Under Each Cost Recovery Program Third Party Collections Program – Bill insurers for care provided to eligible DoD beneficiaries (excludes Active Duty) with other health insurance (excluding Medicare & TRICARE) Medical Services Account – Includes billing for care provided to eligible patients from Veterans Affairs/Coast Guard /NOAA/ PHS/Foreign Military, etc. & their Family Members – Civilian Emergencies – Cosmetic Services Medical Affirmative Claims – Bill for care provided to eligible DoD beneficiaries injured by third parties 7

Other Health Insurance (OHI) Information Use DD Form 2569 to capture OHI information about your patients – All Non-Active Duty Patients required to complete it every 12 months or if data changes – OHI needs to be entered into CHCS or it “doesn’t exist” for billing purposes – Direct correlation between presence of a current DD Form 2569 in patient record and rate of TPC billing – Reported monthly in Commander’s Data Quality Report 8

9 Collections by UBO Cost Recovery Program Third Party Collections Program (TPCP) – $220M (FY 2010) Medical Services Account (MSA) – $177.5M (FY 2010) Medical Affirmative Claims (MAC) – $12.2M (FY 2010) ALL funds collected are retained by your MTF – TPC funds are in addition to the MTF’s O&M budget

MHS Billing Systems Third Party Outpatient Collection System – Government developed system for billing outpatient TPCP (includes outpatient visits, lab/rad/pharmacy prescriptions) CHCS Medical Services Account (MSA) Module – Government developed module used for billing TPCP inpatient claims (both institutional & professional charges) & MSA Relationship to other systems – Provider Specialty Codes – Collection of other health insurance (OHI) information in CHCS – Centralized OHI Repository on DEERS – Assignment of Diagnosis Related Groups and Relative Weighted Products in CCE 10

MSA Claims TPCP Inpatient Claims Financial Personnel Workload Legend Database Subsystem Data Documents CHCS DEERS TPOCS TPCP OP Claims MAC Claims EAS IV MDRM-2 ADM WAM PDTS CCE AHLTA Existing MHS Systems Billing/Collections 11

The Big Picture ~ MHS Revenue Cycle The MHS Revenue Cycle is made up of the administrative functions that contribute to the creation of billable events, submission of bills, collection, payment and posting. The revenue cycle is paramount for the success of UBO. We must minimize the “leaks.” An interdependency exists among all MTF staff from the registration clerk (in the collection and confirmation of OHI) to the provider (for accurate documentation), to the coder and the biller. All these people are interconnected to make the UBO Program successful. 12

The Big Picture ~ MHS Revenue Cycle Data quality is critical!!!!! Why? Every phase of the revenue cycle is highly dependent on the completeness and accuracy of the data collected. Starting from the beginning of the revenue cycle, every data point is passed along to the next person and ultimately affects reimbursement for the MTF. An error in one part can affect the whole cycle. 13

MHS Revenue Cycle Results are increased resourcing with reliable outcomes in the form of usable data Improved patient access, records documentation and coding accuracy Data quality Management Controls are the driving force and conduit for ensuring effective and efficient operations Visual review for validating and streamlining major clinical business and resource management processes CHCS (Files & Tables) Patient Access Payer Education Appeals Payment Posting Denial Management Account Follow-up Claims Submissions Coding Utilization/ Referral Management Pre-cert/ Auth Encounter Document Patient Check-in Ins Verify & Auth Data Quality Management CCE TPOCS Electronic Billing

Strategic Planning Strategic planning is an organization’s process of defining its strategy, or direction, and making decisions on allocating it resources to pursue this strategy. – “What do we do?” – “For whom do we do it?” – “How do we excel/how do we reach the goal?” 15

Strategy – Compliance Plans Why have a compliance plan? – Not an option – you must have one – Establish a culture to ensure compliance with DoD policy & guidelines, private payer requirements, state & federal law An effective compliance program… – defines or redefines behavioral objectives – ensures support flows from top management – is compatible with corporate culture – satisfies legal requirements in form and substance – is implemented with serious commitment of resources 16

Strategy – Measuring Program Success Quarterly TPC reporting done via the DD 2570, Third Party Collection Program, Report on Program Results Metrics derived from the reported data – Observed OHI Rate – Collected-to-Billed Ratio – Adjustments and Write-offs vs. Amount Billed – Total Collections Must have benchmark for improving collections and decreasing costs 17

Measuring Program Success…cont. Monthly review of Accounts Receivable (AR) – Review dollar amounts for all outstanding accounts – Reasonable goal all accounts in AR are < 60 days – Must follow-up and either close or transfer accounts to DFAS Reconcile monthly with FSO or Budget Offices Ensure rates are updated at start of FY 18

Strategy – UBO Success Factors MTF Revenue Cycle – Team Effort (not the just the UBO’s challenge) – Patient/Staff Education & Training Patient targeted marketing and staff training ensure collection of OHI information Need to explain benefits of programs to patients Each OHI not gathered is a “missed opportunity” for billing Leadership Involvement – Brief them on UBO Performance (e.g., OHI Capture, Billings & Collections for TPCP, MSA & MAC) – MTF senior leadership’s involvement and aggressiveness are the keys to a successful UBO Program Think like a business – sometimes you have to spend money to make money (aka return on investment (ROI) 19

Resources UBO Web Page – UBO Help Desk Contact Information – – Defense Health Information Management System (DHIMS) Web Site – Defense Health Services Systems (DHSS) Web Site – is/DHSS.aspx is/DHSS.aspx 20