2. Setting Your Organization Up for Success: Understanding the Complexities of the Revenue Cycle
Kentucky Primary Care Association, 2016 Fall Conference
Thursday, November 10, 2016
9:00am – 10:15am

3. The following information was used as visual aid during a presentation/training session led by a BKD, LLP advisor. This content was not designed to be utilized without the verbal portion of the presentation. Accordingly, information included on these slides, in some cases, are only partial lists of requirements, recommendations, etc. and should not be considered comprehensive. These materials are being issued with the understanding they must not be considered legal advice.

4. Containing Costs

5. The Revenue Cycle

6. The Revenue Cycle Charge structure Patient scheduling
Patient registration
Pre-appointment activities
Patient flow
Charge capture & entry
Third-party billing
Denial management
Patient collections

7. Do All of the Pieces Fit?

8. Key PIECES of the Revenue Cycle Puzzle
Patient Scheduling
Patient
Check-In/Out, Appointment
Post-
Patient Visit
Validate patient demographic data
Utilize automation/ technology to verify insurance coverage in advance of visit
Set payment expectations
Notify patients of required documentation needed at appointment
Re-confirm registration/ insurance information
Collect copay
Collect outstanding balance
Schedule follow-up appointment
Correct documentation; coding & charge capture
Charge reconciliation to services rendered
Clear & understandable statements
Claims scrubber process (PMS and/or clearinghouse)
Manage claims rejections & denials
A/R follow-up
Collections process

9. Resources

10. Charge structure Health Centers: PIN 2014-02
Sliding fee discount schedule
Fee schedule
Services
Reasonable costs
Local prevailing rates
Other provisions to consider

11. Billing & Collections Health Center programs must:
Maintain adequate cash flow to support operations
Maximize revenue from non-Federal sources
Have systems in place to maximize collections & reimbursement for its costs in providing health services, including written billing, credit & collection policies & procedures. (Section 330(k)(3)(F) & (G) of the PHS Act)

12. Billing & Collections, CONT.
Revenue maximization requires:
An adequate & competitive fee schedule
A corresponding schedule of discounts
Prompt & accurate billing of third-party payers
Billing of patients in accordance with the schedule of discounts
Timely follow-up on all uncollected amounts

13. Billing & Collections, CONT.
Process necessary to ensure that federal grant resources address true financial access barriers to the maximum degree possible
Health Centers are expected to utilize information to monitor performance compared to internal & external benchmarks, as well as for tracking trends

14. Patient Collections

15. Time of Service (TOS) Collections
Best opportunity to collect
Educate patients regarding payment for services
Financial policy
Co-pay
Self-pay
Prompt pay options
Past due accounts

16. Patient Collections Set the tone
Expectations consistently communicated by all personnel
Initial telephone contact & front desk staff
Providers & clinical staff
Administration
Accountability
Measuring & reporting cash collections

17. Patient Collections, Cont.
Patient consequences
Make money owed an issue – past balances are not ignored
Payment plans
Collection agency
Attorney
Staff consequences

18. Internal Controls Does cash received & cash posted balance daily?
What happens to overpayments?
Is every patient payment posted immediately?
End of day reconciling forms
System generated receipt
Ability to post adjustments
Statements generated

19. Patient Collections, Cont.
After the visit
Accuracy
Understandable statements
Speed
Follow-up

20. Patient Collections, Cont.
In-house collection efforts
Daily productivity target per FTE
45 to 70 accounts worked
Can use 70 contacts per FTE per day as a reasonable expectation
On average it takes 2.5 contacts to achieve account resolution

21. Impact of Clinical Processes

22. Impact of Clinical Processes on Revenue
Scheduling
Highly restricted patient types & times
Acute patient/same day scheduling process
Volume
Charge tickets/Electronic Health Record (EHR)
Accuracy & completeness
Timeliness of completion
Off-site services rendered
Legibility (if by paper)
Provider signature/esignature

23. Impact of Clinical Processes on Revenue, cont.
Coding
Fear of over-coding
Under-coding to “help” the patient
Patient flow
Taking patients back before front office processes are completed
Directing patients to check-out process

24. Impact of Clinical Processes on Revenue, cont.
Additional issues to consider
Advance Beneficiary Notices (ABNs)
Staff & provider buy-in to collections process

25. Benchmarking for Improved Performance

26. Key Performance Indicators (KPIs)
Recall the key components of the revenue cycle
Begins with appointment scheduling & ends with payment resulting in $0 balance due
How do I know if we are doing a good job?
You’ve done well this week, Bob. Stand by the machine & press the button.

27. KPIs, cont. Monitoring tools/dashboards
Monitored & reported to executive management monthly
Feedback provided to staff
Visualization is often beneficial

28. Do you have the basics in place for a successful revenue cycle
at your organization?

29. Training Program Comprehensive training
Practice management system is just a component
On-the-Job (OTJ) training should be a part, not the entirety
Effective trainer
Written training materials
Dedicated time
Competency assessments

30. Policies & procedures Written, compliance-driven policies & procedures
Undocumented = leaves room for interpretation
Detailed guidance in procedure format
Billing third-party payers
Credit balances
Insurance follow-up
Small balance adjustments
Budget plans
Bad address
Patient correspondence

31. Technology Impact on the Revenue Cycle
Most practices only use 50% of their practice management system’s capabilities – what percentage does your organization utilize?
Incorporate more automation versus utilizing manual staff hours

32. Technology Impact on the Revenue Cycle, cont.
Multiple channels for patient communication
Automated Phone Systems Appointment reminder calls, answering services
Kiosks Automated patient (self-service) check-in, complete forms, review of HIPAA documentation, access to information & educational materials regarding health conditions, treatments, medications or preventative care
Web-based Tools, On-Line Portal Options Allow patients to communicate with providers & other clinicians, review test results, update demographic information, make payments, schedule appointments, request medication refills and referrals

33. Billing Practices
Is your organization receiving Medicare payments from Medicare Part A & Part B?
Have you recently reviewed services based on payer coverage or payment changes?
Initial Preventive Physical Exam (IPPE)
Annual Wellness Visit (AWV)
Diabetes Self-Management Training (DSMT)
Telehealth
Medicare Advantage
Is your PMS/EHR updated with the most current CPT & ICD-10 codes?

34. Billing Practices, cont.
Billing requirements for RHC/FQHC services
Revenue codes
Define FQHC services
Encounter understanding
Non-billable services
Nurse-only visits
Non-FQHC services
Laboratory services
Technical component

35. Missing Revenue Missing Charge Rate: < 1%
< 1% of charges missed on audit (quarterly) of encounter form (paper or electronic health record equivalent) to charges entered
Processes in place to ensure all encounter forms are entered into the practice management system
Processes in place to ensure no missed offsite visits

36. Accounts Receivable Management
Who is managing your A/R?
What information do they provide?
What changes have they implemented within the last 60 days?

37. KPIs Average days in accounts receivable (A/R)
Annual revenue divided by 365 days = average daily
revenue
Current accounts receivables divided by average daily
revenue = average days in A/R
Multi-specialty, All Practices:
Better performers: 28.45*
Others: 42.32*
Primary Care, Single Specialty:
Better performers: 23.54*
Others: 39.56*
* Source: MGMA Performance & Practices of Successful Medical Groups, 2015 Report based on 2014 data

38. MULTI-SPECIALTY, ALL PRACTICES PRIMARY CARE, SINGLE SPECIALTY
KPIs, cont.
METRIC
MULTI-SPECIALTY, ALL PRACTICES
PRIMARY CARE, SINGLE SPECIALTY
Percent of total A/R over 90 days old
Better performers:
13.76%*
12.20%*
Others:
33.78%*
34.88%*
Adjusted fee-for-service (FFS) collections
99.30%*
98.62%*
96.39%*
96.50%*
Gross FFS collections
54.94%*
62.73%*
49.32%*
53.72%*
* Source: MGMA Performance & Practices of Successful Medical Groups, 2015 Report based on 2014 data

39. KPIs, cont. Percent of claims billed electronically
Best practice & average: 95%*
Days to charge entry
Best practice & average: Same day or 24 hours
Days to claim submission
Best practice & average: 2 days
* Source: MGMA Performance & Practices of Successful Medical Groups, 2015 Report based on 2014 data (Multispecialty, All Practices)

40. KPIs, cont. Measure performance to determine success
Set goals for financial performance related to the revenue cycle
Various performance indicators

41. Accounts Receivable Follow-up
What is your denial rate? How does it relate to the industry benchmark?
What happens when a claim is not paid?
How many outstanding claims do you have?
What guidance is provided to staff on prioritization of claims?

42. Accounts Receivable Follow-up, cont.
Claims denial rate
Target = < 5% of total claims
Better performers: 4.90%*
Reduce re-work & get paid faster
Improve cash flow
* Source: MGMA Performance & Practices of Successful Medical Groups, 2015 Report based on 2014 data

43. Accounts Receivable Follow-up, cont.
Staff productivity indicators
Outstanding claim follow-up
Approximately 800 – 1,000 claims per month

44. Accounts Receivable Follow-up, cont.
Quick follow-up on non-payment
Tighten statement cycles
Example:
Days from Initial Statement
Billing Cycle ― 
Initial statement
30 days
2nd statement
45 days
1st pre-collect
60 days
2nd pre-collect
75 days
Refer to agency

45. Common Billing Issues to Avoid

46. Common Billing Issues Failure to verify insurance
Incorrect patient information
Upcoding (downcoding)
Unbundling (bundling)
Documentation not supporting code(s)
Lack of documentation
Lack of medical necessity
Incorrect modifier usage
Wrong diagnosis or procedure code
Duplicate claims

47. Billing & Coding Common Sense
If it wasn’t documented, it wasn’t done.
If it wasn’t done, it can’t be billed.
If the service isn’t necessary, it shouldn’t be provided.
If you weren’t there, your name shouldn’t appear in the medical record or on the claim.

48. Medicare Regulations: Living in the Present & Planning for the Future

49. Bob, do you have time for an audit?

50. Compliance Considerations
Changes in regulations & evolution of technology
ICD-10
FQHC Medicare PPS Rule
Chronic Care Management (CCM)
Advance Care Planning (ACP)
Practice Management System (PMS)

51. Compliance Considerations, Cont.
Medicare Access and CHIP Reauthorization Act of (MACRA)
Physician Quality Reporting System (PQRS)
Medicare & Medicaid Electronic Health Record (EHR) Meaningful Use incentive programs
Social Security Number Removal Initiative
E-consults
Telehealth
Is your organization prepared?

52. THE Many Layers of Audit Agencies
Office of Inspector General (OIG)
Health Care Fraud Prevention & Enforcement Action Team (HEAT)
Unified Program Integrity Contractor (UPICs)
Medicare & Medicaid Recovery Audit Contractors (RACs)
Comprehensive Error Rate Testing Program (CERT)
Supplemental Medical Review Contractors (SMRCs)

53. QUESTIONS

54. Monique D. Funkenbusch, CPC Managing Consultant mfunkenbusch@bkd.com
910 E. St. Louis St.
Springfield, MO
Office:
Fax:
Thank you
Monique D. Funkenbusch, CPC
Managing Consultant

55. Disclosure
Information contained in this presentation is informational only & is not intended to instruct providers on how to use, or bill for health care procedures. Providers should consult with their respective insurers, including Medicare fiscal intermediaries & carriers, for specific information on proper coding & billing for health care procedures. Additional information may be available from physician specialty societies & hospital associations. Information contained in this presentation is not intended to cover all situations or all payers' rules & policies. Reimbursement laws, regulations, rules & policies are subject to change.
The information in BKD sessions is presented by BKD professionals for informational purposes only. Applying specific information to your situation requires careful consideration of facts & circumstances. Consult your BKD advisor before acting on any matters covered herein or in these seminars.