Practical Information for Your Revenue Cycle

Discover HFMA Website’s Information Discover HFMA Website’s Information Demonstrate Practical Application of the information Demonstrate Practical Application of the information Challenge - Do! Challenge - Do!

The Site Layout Includes the following: The Site Layout Includes the following: – Knowledge Center * – Education & Events * – Publications * – HFMA Initiatives &* – Career Center * – New & Opinion * – Marketplace * – Communities * – About HFMA

The Knowledge Center has a plethora of information in the following categories: The Knowledge Center has a plethora of information in the following categories: – Accounting and Financial Reporting – Finance and Business Strategy – Legal and Regulatory Compliance – Operations Management – Payment, Reimbursement, and Managed Care * – Revenue Cycle * – Technology *

There are areas that relate to Revenue Cycle in Knowledge Center, but the the HOT ones are: There are areas that relate to Revenue Cycle in Knowledge Center, but the the HOT ones are: – Legal and Regulatory Compliance – Payment, Reimbursement, and Managed Care – Technology

The Area of Greatest Interest for Revenue Cycle Leaders? The Area of Greatest Interest for Revenue Cycle Leaders? The Revenue Cycle Category!!!

Bad Debt Bad Debt Billings and Collections Billings and Collections Charity Care and Financial Counseling Charity Care and Financial Counseling CDM, Charge Capture and Coding CDM, Charge Capture and Coding Consumer-Directed Health Care Consumer-Directed Health Care Denials Management Denials Management Patient Access Patient Access Self-Payment Collection Self-Payment Collection

Key pieces to this part of the site: Key pieces to this part of the site: There are virtual conference trainings that are free. There are virtual conference trainings that are free. Certification information is available Certification information is available Credentialing for your Revenue Cycle Staff is available Credentialing for your Revenue Cycle Staff is available Training Products (Mastering Customer Service and Revenue Cycle) Training Products (Mastering Customer Service and Revenue Cycle)

HFM Magazine * HFM Magazine * Healthcare Cost Containment Newsletter Healthcare Cost Containment Newsletter Revenue Cycle Strategist Newsletter * Revenue Cycle Strategist Newsletter * Strategic Financial Planning Newsletter Strategic Financial Planning Newsletter Leadership Leadership Healthcare Finance Strategies E-Bulletin Healthcare Finance Strategies E-Bulletin Career Opportunities E-Bulletin Career Opportunities E-Bulletin Patient Friendly Billing E-Bulletin Patient Friendly Billing E-Bulletin Business of Caring Archives Business of Caring Archives

HFMA’s MAP * HFMA’s MAP * The Value Project The Value Project Principles and Practices Board Principles and Practices Board Healthcare Reform Healthcare Reform Patient Friendly Billing * Patient Friendly Billing * Healthcare Financial Pulse Healthcare Financial Pulse Research and Trends Research and Trends Financing the Future Financing the Future Coalitions Coalitions

Job Bank * Job Bank * Careers at HFMA Careers at HFMA Certification Certification Subscribe to Career Opportunities Subscribe to Career Opportunities

It has Healthcare Finance News It has Healthcare Finance News From the Chair and President From the Chair and President HFMA News HFMA News My favorite is the News Roundup (News from various sources talking about things that can impact Revenue Cycle) My favorite is the News Roundup (News from various sources talking about things that can impact Revenue Cycle)

Revenue Cycle Forum * Revenue Cycle Forum * – More Article Access – More Tool Access – Ask Experts Questions – Participate in List Serve and Message Board

Your Revenue Cycle is a Mess Your Revenue Cycle is a Mess You can’t fix it RESISTANCE IS FUTILE!!! You can’t fix it RESISTANCE IS FUTILE!!!

Net Days in A/R Net Days in A/R Aged A/R as a Percentage of billed A/R Aged A/R as a Percentage of billed A/R Point-of-Service Collections Point-of-Service Collections Cost to Collect Cost to Collect Cash Collections as a Percentage of Adjusted Patient Net Service Revenue Cash Collections as a Percentage of Adjusted Patient Net Service Revenue Bad Debt Bad Debt Charity Care Charity Care Days in Total Discharged Not Final Billed (DNFB) Days in Total Discharged Not Final Billed (DNFB)

Aged A/R as a % of Billed A/R by Payer Group Aged A/R as a % of Billed A/R by Payer Group Day in Final Billed Not Submitted to Payer Day in Final Billed Not Submitted to Payer Days in Total Discharged Not Submitted to Payer Days in Total Discharged Not Submitted to Payer Late Charges as % of Total Charges Late Charges as % of Total Charges Initial Denial Rate – Zero Pay Initial Denial Rate – Zero Pay Initial Denial Rate – Partial Pay Initial Denial Rate – Partial Pay

Denial Overturned by Appeal Denial Overturned by Appeal Net Days Revenue in Credit Balance Net Days Revenue in Credit Balance Pre-Registration Rate Pre-Registration Rate Insurance Verification Rate Insurance Verification Rate Service Authorization Rate Service Authorization Rate

Effective 12/01/10 MAP Application was made available. Effective 12/01/10 MAP Application was made available. Cost is based on size Cost is based on size – Solo Facility – System Not Necessary to Participate in MAP Award Not Necessary to Participate in MAP Award MAP Keys bring standard definitions and purpose to enable providers to compare with like facilities MAP Keys bring standard definitions and purpose to enable providers to compare with like facilities

New KPI’s New KPI’s Days in Final Billed Not Submitted to Payer (FBNS) tracks claims held by edits in claims processing system or secondary bills not sent out Days in Final Billed Not Submitted to Payer (FBNS) tracks claims held by edits in claims processing system or secondary bills not sent out Days in Total Discharged Not Submitted to Payer (DNSP) – Includes FBNS and DNFB Days in Total Discharged Not Submitted to Payer (DNSP) – Includes FBNS and DNFB

Ecclesiastes 1:9 NIV Ecclesiastes 1:9 NIV “What has been will be again, what has been done will be done again; there is nothing new under the sun.” Jason’s Translation: Don’t recreate the wheel…Steal !!!

Average Registration Time – unknown, but patient’s are complaining Average Registration Time – unknown, but patient’s are complaining Average Patient Wait Time – unknown. But patients and departments complaining Average Patient Wait Time – unknown. But patients and departments complaining Average patient registrations per shift – Unknown Average patient registrations per shift – Unknown Registration Data Quality – Unknown but a lot of patient and business office complaints Registration Data Quality – Unknown but a lot of patient and business office complaints MSPQs obtained – Accidentally eliminated MSPQs obtained – Accidentally eliminated

Average registration interview duration < 10 minutes Average registration interview duration < 10 minutes Average patient Wait time < 10 Minutes Average patient Wait time < 10 Minutes Average Registrations per shift (Varies by department and system - 35 inpatient 40 outpatient is Hammer’s KPI) Average Registrations per shift (Varies by department and system - 35 inpatient 40 outpatient is Hammer’s KPI) Data Quality 99% or better Data Quality 99% or better ABN and MSPQ when Required 100% ABN and MSPQ when Required 100%

Requested Productivity Reports with Detailed Registration Start and Stop Times Requested Productivity Reports with Detailed Registration Start and Stop Times – The times seemed reasonable 80% of the time – 20% of the time there were significant waits Worked with Staff and found that Incomplete Orders shut the process down Worked with Staff and found that Incomplete Orders shut the process down Designated an office individual to handle those situations with patient, physician and department Designated an office individual to handle those situations with patient, physician and department Increased percentage to 98% Increased percentage to 98%

Still had complaints Still had complaints – Volume of Accounts didn’t work due to rush periods and lulls after doing a traffic study. It wasn’t a productivity issue – Implemented a inexpensive check-in system Patients were waiting a long time for lab services and surgical services Patients were waiting a long time for lab services and surgical services – Implemented direct lab registration process – Implemented Quick-Registration for Surgical Patients Significant improvement (except for lab patients at peak times) Significant improvement (except for lab patients at peak times) Patient Access Perception Improved (Press Ganey) Patient Access Perception Improved (Press Ganey)

Complaints from Patient and Business Office Complaints from Patient and Business Office – Implemented Individual Auditing – Scanned Cards and IDs for Identity Protection and to Audit Accuracy

Expect Staff to “Bomb” the first audits. They need to fully understand expectations.

Scores will improve over time as staff see that quality is being monitored seriously

If you don’t ask the question, you don’t know what is going on. If you don’t ask the question, you don’t know what is going on. MSPQ’s were accidentally discontinued when an eligibility verification was implemented a year before. MSPQ’s were accidentally discontinued when an eligibility verification was implemented a year before. Training occurred and the MSPQ was initiated immediately following. Training occurred and the MSPQ was initiated immediately following.

Hospital Scenario Hospital Scenario – Cash flow diminishing – HIM days at 10 – Coder productivity unknown – Un-coded charts > 30 unknown

All coding done is in descending balance order, not first in/first out. All coding done is in descending balance order, not first in/first out. Consistently monitor and control Discharged-Not-Final-Billed A/R due to HIM. Consistently monitor and control Discharged-Not-Final-Billed A/R due to HIM. HIM “DRG development” D-N-F-B A/R days greater than the late charge hold ≤ 2 A/R days HIM “DRG development” D-N-F-B A/R days greater than the late charge hold ≤ 2 A/R days Inpatient charts coded, per coder per day Inpatient charts coded, per coder per day Outpatient charts coded, per coder per day Outpatient charts coded, per coder per day Emergency room charts coded, per coder per day Emergency room charts coded, per coder per day All coding is done by employees who report to the HIM director. All coding is done by employees who report to the HIM director.

Discovered that completed coding was being tracked by a paper report generated weekly. Discovered that completed coding was being tracked by a paper report generated weekly. Employee manually noted issues on paper. Employee manually noted issues on paper. High Balances were worked like low balances (No Pareto Principle gains) High Balances were worked like low balances (No Pareto Principle gains) – Discovered a software add-on not used by hospital and created queues for each coder – Productivity Reports created – Coding Days began to drop except for outpatient

Discovered that Facility-Based Urgent Care coding happened on-site Discovered that Facility-Based Urgent Care coding happened on-site Coder position was vacant and lead was coding when had time Coder position was vacant and lead was coding when had time Coding was 6 months behind Coding was 6 months behind – Used Scanning Technology to scan charts at site daily – Urgent Care coding position moved under HIM – Coding caught up – Increase Revenue due to coder put in charge for E/M codes

Bill hold 6 days Bill hold 6 days CDM duplicates - Unknown CDM duplicates - Unknown Incorrect CDM items – Unknown Incorrect CDM items – Unknown Item price less than HOPPS APC rate – Unknown Item price less than HOPPS APC rate – Unknown

Late Charge Hold Period 2-4 days Late Charge Hold Period 2-4 days CDM Duplicate 0 CDM Duplicate 0 CDM Codes Incorrect/Missing CPT HCPCS 0 CDM Codes Incorrect/Missing CPT HCPCS 0 CDM item price less than HOPPS APC rate CDM item price less than HOPPS APC rate

Worked with Departments and taught department directors how to review rejected charge reports, revenue reports, and enforced late charge policy Worked with Departments and taught department directors how to review rejected charge reports, revenue reports, and enforced late charge policy – Increase revenue and reduced late charges for many departments other lost their revenue already not being billed Discovered duplicate and incorrect CDM codes and prices below APC rate –Some rates hadn’t been updated since going on the system 2 years prior Discovered duplicate and incorrect CDM codes and prices below APC rate –Some rates hadn’t been updated since going on the system 2 years prior – Updated CDM and improved revenue, payment, and billing compliance

Discharge Not Final Billed (DNFB) 11.1 Discharge Not Final Billed (DNFB) 11.1 A/R Days 58.5 Gross (67 Net) A/R Days 58.5 Gross (67 Net) Days in Total Discharge Not Submitted to Payer (DNSP) – Not Tracked Days in Total Discharge Not Submitted to Payer (DNSP) – Not Tracked Days Final Billed Not Submitted to Payer (FBNS) Days Final Billed Not Submitted to Payer (FBNS) Insurance A/R aged more than 90 days from service/discharge 31% (w/o Self-Pay 19%) Insurance A/R aged more than 90 days from service/discharge 31% (w/o Self-Pay 19%)

DNFB A/R days A/R days DNFB A/R days A/R days Net A/R days - 55 A/R days Net A/R days - 55 A/R days Insurance A/R aged more than 90 days from service/discharge 15-20% Insurance A/R aged more than 90 days from service/discharge 15-20%

Focused on reducing HIM unbilled days Focused on reducing HIM unbilled days Started Tracking Unbilled in Electronic Claims System Started Tracking Unbilled in Electronic Claims System – Discovered Electronic Claims were not counted in unbilled numbers – Discovered Secondary and printed claims not mailed were not counted in any numbers – Months of paper billing had been backlogged and some reaching filing limits

HIM Days Started Going Down with HIM Focus and Tools HIM Days Started Going Down with HIM Focus and Tools All Paper Claims starting going through Electronic Claims system for Tracking All Paper Claims starting going through Electronic Claims system for Tracking – Initially DNFB Days in PFS went up because of the new tracking – Additional Biller Training occurred to ensure billers knew how to get claims out the door. – OCR Remit scanning for paper remits began to assist with secondary billing – Cash increased due to bills starting to go out that were not going out previously – Instituted Collection Tool, Auditing, and Productivity

Over 90 Aging is now below 20% including Self-Pay Over 90 Aging is now below 20% including Self-Pay Over 90 excluding self-pay is below 6% Over 90 excluding self-pay is below 6% Total DNFB averages under 5 days Total DNFB averages under 5 days FBNS is under 1 day FBNS is under 1 day DNSP is under 6 days on average DNSP is under 6 days on average 7% Cash increase in FY % Cash increase in FY 2009

1. Visits without charges as % of total visits 0% 1. Visits without charges as % of total visits 0% 2. Co-pay collections as % of total copay office visits $ 95% 2. Co-pay collections as % of total copay office visits $ 95% 3. EDI claims as % of total claims $ 90% 3. EDI claims as % of total claims $ 90% 4. Charge-entry lag period - 1 business day 4. Charge-entry lag period - 1 business day 5. Claims passing claim edits as % of total claims $ 98% 5. Claims passing claim edits as % of total claims $ 98%

6. Appointment no-show rate - 2-3% 6. Appointment no-show rate - 2-3% 7. Appointment bumped rate - 2-3% 7. Appointment bumped rate - 2-3% 8. Net A/R days (non-specialty practices) - 40 days 8. Net A/R days (non-specialty practices) - 40 days 9. Collections as % of net revenue $100% 9. Collections as % of net revenue $100% 10. Collections as % of gross revenue (non- specialty practices) $ 60% 10. Collections as % of gross revenue (non- specialty practices) $ 60%

11. Third-party A/R aging 90 days from service date - 10% 11. Third-party A/R aging 90 days from service date - 10% 12. Denials as % of net revenue (including “incidental to” services) - 2% 12. Denials as % of net revenue (including “incidental to” services) - 2% 13. Claims with no activity 90 days from last activity date 0% 13. Claims with no activity 90 days from last activity date 0% 14. Credit balances - 2 A/R days 14. Credit balances - 2 A/R days 15.Average patient wait time after office arrival - 15 minutes 15.Average patient wait time after office arrival - 15 minutes

Received a Grant in 2010 to do LEAN Training and CRCR Received a Grant in 2010 to do LEAN Training and CRCR 50% of staff that took the test certified 50% of staff that took the test certified 90% of Patient Financial Services 90% of Patient Financial Services Staff are more involved in fixing problems Staff are more involved in fixing problems

Choose a topic to research on HFMA site or take the MAP journey Choose a topic to research on HFMA site or take the MAP journey Prioritize Issues Discovered (Compliance/Care/Cost Savings) Prioritize Issues Discovered (Compliance/Care/Cost Savings) Study the topic or MAP Keys Study the topic or MAP Keys Implement Changes Implement Changes – Set SMART Goals – Involve Staff (Devil is in the details) Teach others (Leaders and staff) Teach others (Leaders and staff) Celebrate your success and tell your story Celebrate your success and tell your story