From Registration to Accounts Receivable – The Whole Can of Worms 2007 UBO/UBU Conference 1 Briefing:TPCP Claims Follow-up and Denials Management Date:21 March 2007 Time:

2007 UBO/UBU Conference From Registration to Accounts Receivable 2 Objectives Demonstrate three interdependent approaches to enhance and control the revenue cycle associated with the third party collection program – Remote OHI Discovery – Pre-Admission/Pre-certification – Denials Management

2007 UBO/UBU Conference From Registration to Accounts Receivable 3 Agenda TAMC Collection Target TAMC Experience TAMC Initiatives – OHI – Pre-Certification – Denials Management Initiatives Progress Conclusion

2007 UBO/UBU Conference From Registration to Accounts Receivable 4 TAMC Collection Target TAMC Collected to Billed Ratios: FY02 thru FY07* MEDCOM Ratio 40% *1 st Quarter FY 07 Inpatient collections only

2007 UBO/UBU Conference From Registration to Accounts Receivable 5 Industry-wide Issue Health Insurance Association of America (HIAA) Study 2002 – 900,000 claims examined – 14 Payers – 26 Million Insured’s Findings: – 86% Approved (Industry Benchmark) – 14% claim denial rate – 1 in 7 claims need rework, resubmission and/or appeal (TAMC: 57,000 claims in FY 06 = 8,142) HFMA Publication, August 2004

2007 UBO/UBU Conference From Registration to Accounts Receivable 6 TAMC Experience FY02-06 $29 M Total (I/P and O/P) Billed and $12.7 M Collected Why is this important? Recapturing revenue is key!

2007 UBO/UBU Conference From Registration to Accounts Receivable 7 Interdependent Revenue Initiatives Revenue Initiatives Pre-Authorization Pre- Certification Denials Management OHI Contract: February 2006 Data Sharing: September 2006 Processes: March 2006 GS Nurse: April 2006 Software/Data Sharing: February 2006 Consultant Contract: April 2006 Keys to Success: HIPAA Compliance MEDCOM Coordination

2007 UBO/UBU Conference From Registration to Accounts Receivable 8 Automated OHI Identification Goal: To discover and verify other health insurance coverage's from TAMC beneficiaries in advance of their visit through the utilization of national database queries. The query is conducted prior to the patient visit and insurance information is updated in the DEERS and TPCP processes. “Desire is to enhance the Patients Experience by reducing the hassle factor” Phases: 1. Inpatients / Ambulatory Procedure Visits / Emergency Room – Implemented March 2006; Clinic APVs remain 2. Outpatients / Ancillary – Estimate remote OHI cost to rise as increase Contractor support Automated OHI Identification

2007 UBO/UBU Conference From Registration to Accounts Receivable 9 Tasks: 1. Establish a contract for Benefit Recovery, Inc. – Challenge: write a statement of work/ non- competitive contract (Oct’05); implemented in April Build CHCS Ad-hocs to identify non-military APVs; multiple methods of appointing (or central appointments, ER visits) manual process to send contractor data 3. Open the ports for Contractor access; – September Send beneficiary information to Contractor for Insurance identification Automated OHI Identification

2007 UBO/UBU Conference From Registration to Accounts Receivable 10 Results Maximized FY06 OHI identification by utilizing Electronic Search Engine Increased OHI Discovery by 6% – Identified new OHI policies Increased Collected to Billed Ratios 100% Pre-Authorization of Admissions and APVs where required by Third Party Insurance - Reduced denials Increased reimbursements by $309,075 to date ROI was 8.5:1

2007 UBO/UBU Conference From Registration to Accounts Receivable 11 Goal: To review and verify the admission to include: demographics, insurance carrier (if applicable), concerns of the patient, and completion of required forms prior to admission, permitting patient to bypass the administrative processes on day of admission and report directly to the point of care “ Public Relations and Revenue Enhancement Effort” Pre-Admission / Pre-Certification Phases: 1. Establish the hospital processes – Ongoing 2. Establish the team; hired the nurse – Completed April 2006

2007 UBO/UBU Conference From Registration to Accounts Receivable 12 Pre-Admission Clinics to Date APV Center ORTHOPEDICS OPHTHALMOLOGY ENT PLASTIC SURGERY UROLOGY GENERAL SURGERY ORAL SURGERY VASCULAR SURGERY GYNECOLOGY OBSTETRICS PODIATRY NEUROSURGERY HAND SURGERY A&D Office INTERVENTIONAL RADIOLOGY GASTROENTEROLOGY BRONCOSCOPY CLINIC GENERAL SURGERY PEDIATRIC SURGERY CARDIOLOGY ENT PLASTIC SURGERY ORTHOPEDICS GYNECOLOGY

2007 UBO/UBU Conference From Registration to Accounts Receivable 13 Pre-Authorization Pre-Certification Team Centralized Location “Insurance Mission Oriented” Hub Co-Located with A&D ADMISSIONS AND DISPOSITION OCEANSIDEENTRANCEOCEANSIDEENTRANCE Treasurer’s Office and Cashiers Cage 2569 Clerk GS Clerk GS-5 Pre-Cert Clerk Contract A&D Clerks Available 24/7 Based on Customer Preference For Pre-Admitting Services Nurse GS-9

2007 UBO/UBU Conference From Registration to Accounts Receivable 14 Pre Authorization/Certification Process For Scheduled Appointments Clinic Schedules Procedure for Patient Pre-Cert Office obtains listing of future surgery schedules 2 weeks in advance Run list through OHI Pre Cert Phone Calls to Patients Verify Surgery Date/Time Verify Ins. Coverage and Demographics Inform patient where/when to arrive for pre-op and procedure Answer any questions Informs patient will be transferred to A&D clerk to set up time to come in and sign paperwork (24/7) Pre-Cert Office calls Ins. Co, verifies benefits, obtains Auth # Objection from Ins. Company All objections handled by Nurse Nurse can speak clinician to clinician Pre-Cert Office Enters Auth # into CHCS/TPOCS which feeds Claim Saver Pro Patient arrives at Pre-Cert Office for PRE-OP paper work Patient signs documents Pre-Cert Office completes Authorization Form Copy given to Patient for file Patient brings Authorization Form to Pre-OP Clinic Clinical checks completed Patient informed date/time for procedure Day of Procedure Patient receives treatment Customer satisfaction achieved

2007 UBO/UBU Conference From Registration to Accounts Receivable 15 Goal:To preclude claim denials; develop an expertise for appeals management; and increase the bill-to- collection ratio to 70%! Tasks: 1.Find and Purchase an Industry Denial Management Software – ClaimSaver Pro: Cost $55K – Began work in November 2005 Implemented February 2006 – Establish CHCS/TPOCS PAS interface to share data Completed February 2006 – ClaimSaver Pro User/Management Utilization Completed February Establish Consulting Contract to Identify Missed/Future Revenue Opportunities – Denials Management, Inc. Commenced April 2006 Denials Management

2007 UBO/UBU Conference From Registration to Accounts Receivable 16 Software Benefits ClaimSaver Pro: – Eliminated time-consuming manual claim entry and spreadsheets – Automatically assigns cases to users – Easily transfers notes and other information – Tracks denials by: Payer Department Status Root Causes Code Sets Denial Reason Financial Impact – Context sensitive help references – Provides over 100 standard reports and graphs – Custom report writing

2007 UBO/UBU Conference From Registration to Accounts Receivable 17 Consulting Benefits DMI Consulting Contract: – Identified revenue opportunities (Past and Present) – Improved interdepartmental coordination and processes – Collected newly identified revenue – Discovered denial prevention opportunities – Trained TAMC staff on the following: Obtaining necessary documents for appeal Drafting appeals and doing resubmissions Principals of health insurance collection Effective communication with Third Party Payers Exhausting administrative claim remedies Preparing accounts for litigation

2007 UBO/UBU Conference From Registration to Accounts Receivable 18 Conclusion/Reasons for Success Automation Technology Eliminated need for outsourcing Better metrics For-profit mentality Control payer performance Improve MTF operational strategies Denial prevention

2007 UBO/UBU Conference From Registration to Accounts Receivable 19 Denials Management Workflow Process Necessitates well defined operational disciplines for the MTF staff and procedures

2007 UBO/UBU Conference From Registration to Accounts Receivable 20 ProgramInitiative Expense $ Cost to DateBENEFIT $ROI Pre-Cert GS Nurse $67,000$56,000$471,649 bill $180,730 coll 3.2:1 OHI Benefits Recovery Inc $86,000$36,115$431,301 bill $309,075 coll 8.5:1 Denials Mgt Denials Mgt Inc $187,030$133,247$670,143 coll5:1 Total$340,030$225,362 $1,159, :1 So what’s our ROI to date? ROI