1. Robin Bradbury 800-355-0410 robin@ereso.com “Top Ten Questions”

2. Founded in 1998 120 consultants Safety net concept There when you need us. Gone when you don’t. Reducing cost to collect through proprietary technology We increase cash by implementing best practices along with technology when appropriate Services include: -Insourcing -Cash Acceleration -Revenue Cycle Assessments -Training and Mentoring -Interim Management and Staffing Focus on rural and community hospitals About re|solution 2

3. Time and Energy

4. When performance is measured, performance improves. Revenue Cycle 101

5. Objective measures are always better than subjective measures. Revenue Cycle 102

7. Preview MetricsSharing with Staff Cost to Collect Expectations Self PayCharge Capture DNFBContract payments DenialsMeetings

8. What are the “key” measures for the Revenue Cycle? Question # 1

9. Days in Revenue Outstanding Cash Collections Cost to Collect Cash as a % of Net Revenue Write-offs as a % of Revenue Aged AR Greater than 90 Days Days in Discharge to Final Bill Up-front Cash Collections Key Measures

10. Benchmark Data HARA report HFMA MAPS Zimmerman Regional Groups Your facility

11. Free Benchmark Study Free Benchmark Study http://www.ereso.com Sample Information: Facility Bed Size:122 Average Daily Census:38 Total Accounts Receivable:$8,000,000 Cash Receipts per Month$900,000 Gross Revenue per Month:$2,000,000 A/R Over 90 Days:$3,500,000 Monthly Cost of BO:$45,000 Write Offs per Month:$150,000 Number of Open Accounts:19,000 Number of FTE's in BO:12 Percent A/R in Self Pay:40%

13. Value Proposition Actual Example HospitalPeer GroupDifference Cash Opportunity AR Days Reduction824339$1,476,815 Days over 90 Reduction31.7%24.4% 7.3% $217,374 DNFB Reduction 24.2 7.2 17.04 $652,439 Cost to Collect Reduction $ 0.027 $ 0.025 $ 0.002 $33,356 Bad Debt Write off Reduction8.9%2.3% 6.6% $855,290 Charity Write off Reduction1.9%6.9% -5.0% NA

15. How do you document and share this information with the Revenue Cycle staff? Question #2

16. Monthly Dashboard Posted key measures in Revenue Cycle areas Monthly team meetings Incentives End of Month flurry to meet goal Key Measures

17. Incentive Plans 96% of other industries have incentive plans for employees Healthcare – less than 50% Be creative with incentives

18. What is our cost to collect a dollar? Question #3

19. Good comparative measure (common definition) Important consideration when evaluating investment in resources – more cash intake may be worth it National average for hospitals is $.03 per dollar collected Smaller and Critical Access hospitals closer to $.05 to $.10 per dollar collected Benchmarks

20. Do we have expectations and performance standards for our Revenue Cycle staff and ….. Question #4

21. …do we monitor performance and provide incentives for excellence? Question #4 (continued)

22. Measure metrics and behaviors Front end, middle and back office resources Raise performance level awareness Align goals Creates healthy competition Cream will rise to the top Expectations and Performance Standards

23. Expectations

26. Changing the Paradigm How do we measure effective follow up? Touch as many accounts as possible? Dollars in the door? Cost to collect? Use technology to reduce touches, increase effectiveness and reduce costs. Example of large hospital versus small hospital and eligibility.

27. re|discover Proprietary technology Focus on discovery quickly of outstanding issues Focus on dollars resolved not touches Paradigm shift Reduced human intervention Used in our cash acceleration, insource and wind down projects

28. Wildly Important Goal 1 Teams need to be engaged in pursuit of the goal Teams should be involved in goal setting based on higher level plan developed Where do you want to go and what do you want to be and how do you want to perform and be recognized in the industry? 1 Drawn from text The 4 Disciplines of Execution by McChesney, Covey and Huling

29. Lead & Lag Measures 1 Lead Measures –Those measures that are impacted and measured on a daily basis that impact the Lag Measures Quantity of calls made, quantity of accounts or credits resolved, promises to pay, etc Lag Measures –Measures that occur after the fact Gross Days, Cash, Net Days, % of AR > 90 days, etc 1 – Drawn from text The 4 Disciplines of Execution by McChesney, Covey and Huling

30. How are we managing the patient-responsible dollar? Question #5

31. The Process..… Payer Contract Claim CashSelf-PayAdjustment s Patient Data Other Payers CashBad Debt Charges Registration Billing Payment Collection

32. Institute for Health Care Revenue Cycle Research - A Division of Zimmerman, LLC. National Pledge to Reform Uncompensated Care Reform Underway: Adopting Best Practices to Reduce Uncompensated Care and Improve the Patient Experience. a special supplement to PATIENT PAYMENT BLUEPRINT™

33. When Respondents Who Had Received Recent Medical Care Learned the Cost of their Treatment 63% don’t know the treatment costs until the medical bill arrives; 10% never know the cost. Source: Great-West Healthcare 2005 Consumer attitude toward healthcare survey When did you learn what the total cost of the treatment would be, including the amount that the insurance company would pay?

34. Estimate, Validate, and Advocate Estimate Charges, insurance coverage and patient portion Validate the information Advocate for the patient to deal with the obligation – Cash, Check or Credit Card – Payment plan – Medicaid Eligibility – Charity Care – Reschedule? Software is available to do this

35. Cascading questions Will you be paying cash, check or credit card? Do you have a card on file with us? If, no…would you like to? Do you want to take advantage of our multiple payment plan options including interest free payment arrangements? Do you want us to help you qualify for Medicaid? Do you want us to help you qualify for our charity care program? Should we reschedule this procedure?

36. Emergency Room 1/3 of ER patients have no insurance 29% national average collect in ER Discharge collection process – Need centralized exit point – Keep license – Train staff to bring back to discharge

37. Technology Charge Estimators Multiple point of service collection points Eligibility Verification Stratification tools Payer Search tools

38. Page  38

40. Page  40 Self Pay Strategy Platform Deliverables Estimated Charges Eligibility Verification Estimated Income Charity Recommendation Maximum Payment Recommendation Payment Propensity Work-Flow Management Patient Demographic Data and Diagnosis Financial Data Financial Assessment Algorithm Client Specific Payment History

41. Results Reduced placements of self pay accounts to collection agencies by nearly 50% within first six months 2 3 Increased cash receipts on self pay accounts by over 22% during first 90 days 4 1 Measurable Results from Presumptive Charity Policy and Self Pay Stratification Reduced FTE allocation for follow up on self pay accounts by 25% Reallocated 60% of FTE staff previously assigned to charity application processing

42. Capture all of the charges for the services that your providers perform. Insure that you are billing all parties that are responsible for payment Collect all cash up front for all scheduled surgeries and all co pays from non scheduled services Segregate self pay into charity, other payers and accounts with a propensity to pay. Send the rest to collection.

43. Has a Chargemaster and charge capture review and assessment been performed recently? Question #6

44. DRG Coding APC Coding Inpatient Treatment Outpatient Treatment APC DRG Payment XRAY Lab EKG XRAY EKG Lab

45. Outpatient revenues are significant particularly in rural/community hospitals CMS indicates a 50% underpayment Better performers have these common aspects:  Dedicated ownership of process (75%)  Supported by technology (47%)  Independent reviews (46%) Marshalltown example Charge Capture Review

46. Effective Charge Capture Review Program Quarterly review of outpatient payments compared to charts Utilize a Nurse Auditor Change processes to capture all charges Retroactively re-bill when appropriate Improve reimbursement

47. What are our days in Discharge to Final Bill? Question #7

48. Indicator of effective front end, charge capture and coding process Clients have wide range from 3–25 days Break into parts Sample accounts Determine where the bottlenecks are  Doctors sign-off  Coding  Daily billing Days from Discharge to Final Bill

49. Potential Solutions Outsource some of the Coding Use Super Coders on an as needed basis – train staff Set goals and expectations Monitor top ten DNFB accounts

50. Are we getting paid what we should be paid for services performed? Question #8

51. EOB review – sampling Compare to net revenue calculation Use of software to monitor payment Outside review on contingency fee Payer report cards and payer meetings Most hospitals are leaving 2% to 5% on the table of non-government reimbursement if not using a contract management service Reimbursement % by Payer

52. Do we have an unpaid claims tracking mechanism? Question #9

53. Monitoring Trends Improve the front end processes Unpaid claims versus denial tracking Should take a systemic view - unbilled and denials Unpaid Claims Tracking

54. Unpaid Claims Measurement Tool

55. Do revenue cycle stakeholders regularly engage in clearing open items and process improvement meetings? Question #10

56. Collaboration between multiple functions, backgrounds, and skill sets Focus on large dollars – use a top ten concept Recurring errors Open communication and no finger pointing May require senior management involvement Regular Clearing Meetings

57. Discuss these questions with Revenue Cycle leader or key stakeholders Perform Benchmark Indicator Analysis (BIA) As a Revenue Cycle team, review the results Set realistic goals and expectations and achieve them Next Steps

58. Same Services More Dollars

59. “Learn from the mistakes of others – you can't make them all yourself.”

60. Questions?

61. Robin Bradbury 800-355-0410 robin@ereso.com