“Improving Health Center Sustainability” Revenue Cycle and Health Information Management

Improving Health Center Sustainability Learner Objectives The learner will gain insight into how to utilize Health Information Technology (HIT) to improve financial performance. The learner will learn how to execute health team workflow processes to improve RCM. The learner will understand the correlation between employing sound HIT processes, clinical outcomes and RCM. The learner will develop strategies to improve margins while expanding mission.

History/Mission Policy Information Notice Health Information Technology Strategy Sustainability Key Discussion Points

History In 2015 Health Centers will celebrate 50 years of expanding healthcare access and delivering quality primary to medically underserved and uninsured populations. The health center model targeted the roots of poverty by combining the resources of local communities with federal funds to establish neighborhood clinics. Health centers primarily provide health care to patients who are uninsured or covered by Medicaid. Community health centers rely on a combination of Medicaid payments, grant revenues, and other private and public funding sources to fund their operations. Health centers have established themselves as mission based healthcare providers that provide care to patients regardless of “ability to pay.”

Definition "Health Center": An entity that serves a population that is medically underserved, or a special medically underserved population comprised of migratory and seasonal agricultural workers, the homeless, and residents of public housing, by providing, either through the staff and supporting resources of the center or through contracts or cooperative arrangements. The Health Center Program statute requires health centers to “assure that no patient will be denied health care services due to an individual's inability to pay for such services.

Mission Medically underserved populations. –Uninsured –Underinsured –Chronically unemployed –Newly unemployed Migratory and seasonal agricultural workers. Homeless populations. Residents of public housing.

Mission Section 330 of the Public Health Service Act (42 U.S.C. §254b)Section 330 of the Public Health Service Act (42 U.S.C. §254b) –Program Regulations: 42 CFR 51c and 42 CFR CFR 51c 42 CFR –Grants Regulations: Uniform Administrative Requirements for HHS Awards 45 CFR 75Uniform Administrative Requirements for HHS Awards 45 CFR 75 Policy Information Notice: PIN The Health Center Program statute requires health centers to “assure that no patient will be denied health care services due to an individual's inability to pay for such services.

Policy Information Notice Health centers must assure that any fees or payments required for services will be reduced or waived to enable the center to fulfill the assurance. The Health Center Program statute also requires “a schedule of fees or payments for services consistent with locally prevailing rates or charges. The PIN requires health centers to design a fee schedule to cover its reasonable costs of operation. And “to make every reasonable effort to secure from patients payment for services in accordance with such schedules. And to collect reimbursement for health services to persons covered by public or private insurance.

Health Centers Mission Sustainability Margins Business Operations

Financial Management Financial Culture Business Mindset Medically Underserved Healthcare Access Preventive Services Grant Funds Primary Health Services Specialty Services Financial Infrastructure Financial Quality Improvement Financial Goals Mission Sustainability Margins Health Center Financial Infrastructure

Revenue Cycle Management Leadership Regulatory Compliance Information Technology Quality MissionSustainability Health Center Margins Financial Transformation

Appointment Scheduling Registration/Certification Patient Reception Clinical Visit/Service Delivery Documentation and Coding of Visit Charge Processing/Check Out Patient Statement & Claim Production Claims & Patient Payments Processing Denied Claims Management Accounts Receivable Oversight & Collections Revenue Cycle Management

Executive Leadership Clinical Operations Financial Operations Revenue Cycle Management: RCM

Current Status of Business Operations and Workflow What are the health center’s financial policies and procedures? What is your current understanding of FQHC billing and reimbursement systems? Who currently manages the complexities of these billing and reimbursement systems? Who stands as your internal or external finance, billing, coding, and HIT content expert. How often does leadership assess financial workflow and operations? All Inclusive Rate Medicare Medicaid versus Managed Sliding Fee Self-pay Wraparound billing

What current HIT workflows are in place to support business operations? –Leadership operations –Finance operations –Billing operations –Operations –Clinical operations Current Status of Business Operations and Workflow

Leadership Understand operations Team competence Cultivate change Operations Scheduling Front Desk Back Office Finance/ Billing Practice Management Billing Policies/Procedures Collections Clinical Credentialing Scheduling Documentation Coding Productivity Mission Sustainability Health Center Margins Health Information Technology Optimization

Health Information Technology Finance/Billing Operations Clinical Operations Leadership Transformation Financial Solvency Restructure Workflow Cultivate Financial Culture Health Information Technology

Begins RCM Pt. Access Appointment Management Initial Contact Eligibility Credentialing Patient Information Insurance Eligibility Credentialing HIPPA/Compliance Copayment Outstanding Balances Provider Accountability Patient Experience E&M Documentation Coding Time Management Fees for Service Patient Payments Charge Retrieval Appointment Scheduling HIT Process Improvement Scheduling Patient Check-Out Registration Clinical Encounter Health Information Technology Workflow

Patient Scheduling Workflow The revenue cycle starts with scheduling the patient. Health center staff should use a check sheet or script guide to be sure all pertinent information is collected at the time of scheduling. Collecting insurance information will help the scheduler know what information to ask from the patient. Additional items to discuss with the patient include explaining what information the patient should bring to the appointment. The expectation of payment of co-pays at the time of the visit, and the arrival time of the patient if certain paperwork and registration work needs to be completed.

Patient Registration Workflow

HIT and Practice Management System Practice Management System – key driver of the RCM process. Establish mandatory registration data entry points. Verify patient information at every visit (phone numbers, UDS data points). Front desk must check insurance eligibility and check patient’s insurance card at every visit. Collect copayments at the point of registration. (Financial Policy)

Case Study A new uninsured patient walks into the health center and requests a same day visit for a physical examination. Develop a patient centered access friendly workflow for this scenario. What are the major factors to consider? The patient reports the following: –No current health insurance. –No current primary care provider. –No current history of present illness. –Working part-time at a local farmer’s market. –Patient reports occasional headaches possibly due to stress. “I would like to take better care of myself.”

Workflow Development Considerations Identify internal and external processes influences that prevent your health center from successful revenue cycle management. Does your health center currently have a financial policy that serves as the back bone of your RCM processes? How does your health center utilize your practice management system and electronic health record to optimize operations and workflow processes? What is your health center’s “WOW” factor? How do you make a memorable first impression? How best can you utilize HIT to develop sound walk-in registration/uninsured patient workflow processes? What HIT techniques are used to decrease incidences of registration backlog due to processing delays, patient literacy support, and triage needs?

Patient Financial Policy

Patient Scheduling Front Desk Healthcare Team Your Text Health Information Technology Provider Patient Clinical Workflow Integrated Care Workflow Check-out Workflow Clinical Operations and Workflow

C Patient Encounter Chief Complaint Examination Clinical decision Making Evaluation and Management CPOE Documentation E&M Coding Plan of Care ElectronicMedical Record Provider Sustainability Margins Mission Compliance Clinical Workflow and HIT

Patient Centered Care Medical Decision Making CPOE Documentation/Coding Patient Accountability Self-Management Patient Responsibility Ability to Pay Information Exchange Medical Orders Medical Charges Information Exchange Financial Responsibility Medical Billing Electronic Health Record Practice Management Clinical Workflow and HIT

Improved Access Quality Healthcare Delivery Integrated Care Financial Management Financial Infrastructure Healthcare Teams Health Center Patients Sustainability

65 % 10 % 25% 100 % Mission vs Margins Health Center Mission Sustainability Margins Health Information Technology Workflow

Questions

DPM Healthcare Consulting Stephanie J. Wroten BSN, MS, LNC Anna Gard RN, FNP-BC Contact Information

DPM Healthcare Consulting