Health Center Revenue and Reimbursement Management Julie M Vlasis Consultant Department of Health and Human Services Health Resources and Services Administration Bureau of Primary Health Care

Learning Objectives Understanding components of Revenue Cycle Sliding Fee Scale Policy Fee Schedule Development

Understanding Components of Revenue Cycle

What Does Real Revenue Cycle Look Like? Appointment Schedules Patient Registration Provision of Care Coding and Billing of Patient Encounter Accounts Receivable Management Payments and Denials

Scheduling Scheduling Open Access Modified Wave Structured Appointment Type Scheduling Guidelines Information to assist staff in maintaining adequate scheduling Staff Training

Scheduling System Monitoring/Reporting Patient Scheduling Trends Morning/Afternoon/Early Evening Pediatrics vs. Adults Provider Productivity

Patient Registration Patient Registration Demographic and UDS Data Collected Patient Insurance Collected Copies of Insurance Cards Insurance Eligibility Verified Managed Care – PCP Designated Benefits Reviewed

Patient Registration Patient Application for Sliding Fee Program Initiated Application completed Financial Information collected Family Size Verified Copays Collected Ability vs. Willingness Staff Training and Development

Provision of Care Provider Coding and Documentation Templates Smart Phrases Implementation of New Programs IPPE – Medicare Initial Preventative Physical Examination AWV – Medicare Annual Wellness Visit Provider Coding Profiles - ICD-10 Implementation Free Text Auditing QA/QI Inclusion

Provision of Care Annual Coding Update Implementation Plan and Training for ICD-10 CMS Updates Clinical Policies and Procedures Progress Note Documentation Understanding of Required Reporting UDS Reporting Other Health Center Gran

Coding and Billing Encounter Edit Process Review Evaluation and Management Codes Review Procedure/Other Services Codes Review Diagnosis Codes – Highest Level Of Specificity – Important for ICD-10 Implementation Confirms Insurance Eligibility Posting of encounter within 3 days of service Claim Submitted Electronically

Accounts Receivable Management Process Driven Receipt of Payments and Adjustments Secondary Insurance Claims Submitted Denials tracked and worked Resubmission of claims Patient Responsibility determined Patient Statements mailed Active Collection process completed

Accounts Receivable Management Clear Communication with All Critical Departments Scheduling Registration Clinical

Metrics and Measurements Registration Percentage of Accurate Insurance Verifications - 85% Percentage Collection of Copays at time of Service – 90% Percentage Sliding Fee Applications Processed Correctly -95%

Metrics and Measurements Billing Percentage of claims submitted in 3 days from date of service – 95% Percentage of Clean Claims – 90% Days in Accounts Receivable Aging – 45 Days Percentage of Denials - 5% Percentage of Underpayment – 5% Percentage of successful appeals – 90% Percentage of Claims over 90 days – 20%

Accounts Receivable Management Team Work Clear Communication Scheduling Registration Clinical Identification of Training Opportunities Constant Report Analysis

Policies and Procedures Essential Framework for Strong Revenue and Reimbursement Management Provides Staff Accountability Reduces Errors Increases Reimbursement

Policies and Procedures to Identify Appointment Scheduling Registration Sliding Fee Scale Clinical Encounter Management Billing Credit and Collections Finance

Staff Development A well trained knowledgeable staff reduces Accounts Receivable Aging and Increases Reimbursement. Initial Staff Training – New Hire Continuous Training – at least Annually Successful Revenue Management Programs have continuous staff training

Revenue Cycle Recap Scheduling/ Productivity Registration/Eligibility Provision of Care/ Documentation Coding and Billing - Accuracy Accounts Receivable Management Continuous Report Monitoring Team Work across all departments Staff Development – Training Communication

Development of Revenue Cycle Annual Action Plan Annual Setting of Metrics Annual Review and Revision P&P’s Identification of new Medicare and Medicaid Programs Monitoring all Components of Revenue Cycle

Sliding Fee Discount Policies

Sliding Fee Discount Policies 330 Grantee Requirement: Health Center has a system in place to determine eligibility for patient discounts adjusted on the basis of the patient ability to pay. This system must provide a full discount to individuals and families with annual incomes at or below 100% of the poverty guidelines (only nominal fees may be charged) and for those with incomes between 100% and 200% of poverty, fees must be charged in accordance with a sliding discount policy based on family size and income.* No discounts may be provided to patients with incomes over 200% of the Federal poverty level.* (Section 330(k)(3)(G) of the PHS Act and 42 CFR Part 51c.303(f))

Program Policy Requirements Clear guidelines for qualifying for discounted fee Clear guidelines how discounts are determined Clear guidelines outlining required documentation Available application form with guidelines

Program Policy Requirements Procedure for verifying income and family size Clear recertification process Sliding Fee Scales updated on annual basis Required Signage Staff Training- annually

Best Practices Separate Sliding Fee Application Separate Financial Class For Sliding Fee Scale Participants - Monitoring Signage posted throughout Facility Patient Financial Agreement Reminders to patients regarding co-pay responsibilities – Appointments/Recall

Health Center Fee Schedule Development

Fee Schedule Development Methodology of Development Resource-based Relative Value Scale- RBRVS True Center Costs Medical, Behavioral Health and Dental Updated Annually Policy describing method and timelines

Fee Schedule Development Current Medicare and Medicaid Prospective Payment System (PPS) Rates Managed Care Wrap Rates Medicare and Medicaid Medicare Cost Report Cost per medical encounter UDS Report Cost per medical encounter excluding lab, x-ray and nursing visits

Fee Schedule Development Utilization Review CPT utilization by facility/ by clinician Auditing accuracy of services billed Captured Revenues

Questions??

Contact Information Julie Vlasis Consultant 559-907-4760 559-454-8942 jvlasis@pacbell.net