Developing a Business Plan to Increase Third Party Reimbursement June 28, 2003 Presented by: Michael R. Taylor Precision Resources, Inc.

2 Business Plan Purpose Estimate potential revenue from third party billing and collections Identify operational changes necessary to increase revenue from third party payers Document steps and resources needed to implement billing and collections functions

3 Program Profile: First Step to Plan Completion Developing a program profile is the first step to complete your business plan The program profile documents pertinent program operating characteristics that the financial model uses to calculate potential third party reimbursement

4 Sample Program Profile: Happy Center for Primary Care Grantee type: School-Based Health Center Services offered: –Primary care –EPSDT –Behavioral health services –STD/HIV screening –Family planning Annual patient volume = 1,000

5 Sample Program Profile: Happy Center for Primary Care Annual billable visits = 2,500 Patient income distribution: –<100% FPL = 40% –100 – 125% FPL = 30% –126 – 150% FPL = 10% –151 – 175% FPL = 10% –176 – 200% FPL = 10% Patient employment rate = 60%

6 Sample Program Profile: Happy Center for Primary Care Patient age distribution: –0 - 4 years old = 5% –5 – 10 years old = 38% –11 – 13 years old = 26% – years old = 26% –>18 years old = 5% Patient gender distribution: –Male = 40% –Female = 60%

7 Sample Program Profile: Happy Center for Primary Care Patient distribution by payer: –Medicaid FFS = 30% or 300 patients –Medicaid managed care = 15% or 150 patients –S-CHIP = 20% or 200 patients –Commercial FFS = 10% or 100 patients –Commercial managed care = 10% or 100 patients –Self pay = 15% or 150 patients

8 Sample Program Profile: Happy Center for Primary Care Visit distribution by payer: –Medicaid FFS = 30% or 750 visits –Medicaid Managed Care = 15% or 375 visits –S-CHIP = 30% or 750 visits –Commercial FFS = 5% or 125 visits –Commercial Managed Care = 5% or 125 visits –Self pay = 15% or 375 visits

9 Sample Program Profile: Happy Center for Primary Care Staffing levels (FTEs): –Billable providers –Other clinical staff Payer contact information & program service eligibility –Medicaid –Medicaid Managed Care: Majestic Care –S-CHIP: GLH –Commercial: Green Cross

10 Sample Program Profile: Happy Center for Primary Care CPT CODEMEDICAID RATESPRIVATE RATES 99203$63.47$ $21.20$ $31.09$ $82.82$ Managed Care (pmpm) $12.00 Third party payment rates by CPT code:

11 Sample Program Profile: Happy Center for Primary Care Missed Revenue: –Clinical staff who are not regarded as billable providers by health plans Additional costs: –Itemization of costs to implement billing and collections functions

12 Now It’s Your Turn Develop a program profile for your program –Accuracy is not important - guess if you need to –The point is to familiarize you with the process and the tool so that you can use it later –A blank profile template is included in your binders –Take 20 minutes to complete the template

13 Populate Financial Model: Second Step to Plan Completion Use the information in your completed program profile to populate the designated fields in the financial model

14 Review Populated Model: Third Step to Plan Completion Populated financial model for Happy Center for Primary Care

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