1. Are You Ready For Revenue Cycle 2.0? Presentation Summary & Tools
Presented by: Daniel J. Marino

2. The Healthcare Reality of Today
Healthcare costs continue to rise placing pressures on patients, employers and healthcare providers
Movement from volume-based reimbursement to value-based contacts
Fee-for-services plus shared savings
Shared savings with PMPM care management fee
Risk-based contracts
The importance of data continues to rise
Process-driven outcomes
Performance and care results

3. Shift in Revenue Cycle Activities
Future
Present
Based on fee-for-service encounters
Encounter-based contract management
Based on fee schedule
Accounts receivable indicators
Based on clinical performance
Performance-based contract management
Bundled payments
“New” business metrics Consumer driven healthcare
Requires proactive vs. reactive approach to care
Must know the patient population (who are the out of control diabetics, etc., etc.?)
Requires patients on an active plan of care
Engaging the patients outside the physician’s office

4. New Generation of KPIs New Generation of financial metrics include:
Tracking “Cost of Care”
Clinical performance
Patient satisfaction/engagement
Beneficiary/program management
Bundled payment indicators
PM systems tracking by value –based contract
Bundled service
Shared savings
Partial or full risk
A/R management reflecting performance incentive opportunity

5. Physician Key Performance Indicators
Revenue Cycle
Payment Analysis
Cost / Profitability
Production
Care and Outcomes
Patient Access
Patient Satisfaction

6. Focused Analytics Help Identify Where to Begin
Stratify Data based PMPM, Cohorts
Build the total cost of care model on per member, per month bases
Indicators should include:
Allowed versus paid amount
Employee, spouse, child
With and without high cost claims

7. Top 10 Diagnoses by Total Cost
* Diagnoses appeared in the primary, secondary or tertiary codes

8. Evaluating the High Cost Services Support Bundled Service Tracking
On a per encounter basis, colorectal cancer is the most expensive cancer type assessed, whereas breast cancer had the highest encounter rate
*Figures provided are in Paid Amounts.
*Disease categories based off of grouped diagnoses corresponding to condition.

9. Collected vs. Collectable
Similar to net collection rate, but allows for more accurate review
Collected:
Payment received and line item posted (includes co-pay and deductible)
Collectable:
The allowable amount as negotiated in contract (includes co-pay and deductible)
Great metric to evaluate overall revenue cycle performance
Forces you to ask specific questions and drill down to find answers
Dependent on knowing contract fee schedule
Allows for better contract negotiations

10. Collected vs. Collectable
90 Day CvC: Goal 92-94%
Payments received in the next 3 months
Allowable posted 4 months ago
180 Day CvC: Goal 95-97%
Payments received in the next 6 months
Allowable posted 7 months ago
Annual CvC: Goal 97-99%
Payments received in the next 12 months
Allowable posted 13 months ago

11. Sample 90 Day CvC Report JANUARY, 2014 INSURANCE PLAN CHARGES
ALLOWABLE
COLLECTED
(Coll./Allow.)
% COLLECTED
AETNA
$1,639,044
$1,062,610
$1,043,451
98.20%
AMERIHEALTH
$185,361
$145,090
$140,925
97.13%
USHC
$1,986,460
$1,267,667
$1,210,398
95.48%
UNITED HEALTH
$1,653,396
$1,283,729
$1,219,456
94.99%
MEDICARE
$4,532,591
$1,799,580
$1,679,789
93.34%
CIGNA
$1,146,525
$911,439
$847,316
92.96%
OXFORD
$1,318,334
$1,053,521
$960,497
91.17%
HEALTHNET
$579,508
$477,573
$418,675
87.67%
HORIZON
$258,003
$195,264
75.68%
SELF
$272,173
$188,777
69.36%
TOTAL
$13,571,395
$8,531,385
$7,904,548
92.65%

12. End Uses of Clinical Information to Support Revenue Cycle Performance
Program Management
Quality scorecards
Patient chart view through continuum of care
Use of referrals and ancillaries
Physician Performance
Chronic disease registries
Care gap management
Patient satisfaction
Financial Effectiveness
Total cost of care reports
Payer analytics
Areas of improvement
Domestic Utilization Mgmt

13. Contact Health Directions, LLC Two Mid America Plaza, Suite 1050
Daniel J. Marino
President/CEO
Health Directions, LLC
Two Mid America Plaza, Suite 1050
Oakbrook Terrace, IL 60181
Phone:
@HDirections