Critical Revenue Cycle Success Strategies In An Era Of Integrations - PowerPoint PPT Presentation

Critical Revenue Cycle Success Strategies In An Era Of Integrations Thursday, February 16, 2012 presented by: Susan E. Ziel, Partner Catherine M. Weaver Phil Roberts Krieg DeVault Somerset, CPAs Senex Services Corp. P: 317.238.6244 P: 317.472.2230 PH: 317.613.1002 Email: sziel@kdlegal.com Email: cweaver@somersetcpas.com Email: robertspt@senexco.com

Revenue Cycle and Payer C Contracts t t CATHERINE M. WEAVER CMPE, CASC, CHFA SOMERSET CPAS, P.C.

Today’s Discussion ‐ Overview Today s Discussion Overview Revenue Cycle Collections Legal Considerations of Collections Bad Debt – Now What?

Revenue Cycle Revenue Cycle  Scheduling S h d li  Registration Appointment  Time of Service Payments  Time of Service Payments Scheduled  Charge Capture Patient  Coding Patient Billed Cod g Registration and Charge  Charge Entry Patient Pays Capture  Claims Processing  Payment Posting  A/R Follow Up Insurance Charge Entry Payment and Claim  Patient Collection P ti t C ll ti P Posting ti Fil d Filed

Monitor Revenue Cycle Monitor Revenue Cycle  Internal Standards Internal Standards  Income statements  Balance sheets Balance sheets  Productivity and accounts receivable information  Prior operating performance and measures (front Prior operating performance and measures (front office task work ranges)

Monitor Revenue Cycle Monitor Revenue Cycle  External Standards External Standards  American Medical Association  Medical Economics Medical Economics  Medical Group Management Association  Specialty Specific Resources Specialty Specific Resources  Market Specific Resources  Peer Generated Resources

Payor Contracts – Basics Payor Contracts Basics  Contracts Contracts  Edit Reports  Denials by type  Denials by type  Denials by amount  Charges, Receipts, Adjustments  Days in A/R by Payor

Payor Contracts ‐ Essentials Payor Contracts Essentials  Copy of Contract C f C  Copy of all Exhibits and Addendums  Access to Provider Manual  List of the Payors Associated with the Network  Payment Files and Crosswalks y  Your Own Fee Analysis

Contracts Contracts ‐ Watch Out For Watch Out For “ The Provider shall not increase its Charges for any Covered Service more than three percent (3%) each C d S i th th t (3%) h contract year. “ Usual and Customary – Whose Usual and Customary? Change to "Provider’s Usual and Change to Provider s Usual and Customary Charges” Term and Termination - Long period, only at anniversary, only with cause Try for: With or without cause in 60-90 days

Contracts ‐ Watch Out For Contracts Watch Out For  P  Practices being purchased by a Hospital ti b i h d b H it l System ‐ New Tax ID means new contract and reimbursement. and reimbursement.  Carefully analyze the current contract Carefully analyze the current contract reimbursement to the new entity contract reimbursement –We have seen examples of the Independent Practices having negotiated a better paying contract than the Health System’s contract the Health System s contract.

Consume Driven Health Care Consume Driven Health Care  Impacts Revenue Cycle and Requires I R C l d R i Change

HDHPs & HSAs ‐ W hat are they? HDHPs & HSAs W hat are they?  A Health Savings Account (HSA) is a Special Account Owned by an Individual Used to Pay for Current & Future Medical Expenses Current & Future Medical Expenses  HSAs are Typically Used in Conjunction with a “High Deductible Health Plan” (HDHP) “Hi h D d tibl H lth Pl ” (HDHP)  It is Insurance that Does Not Cover First Dollar Medical Expenses (Except for Preventive Care )  Can be an HMO PPO or Indemnity Plan as Long  Can be an HMO, PPO or Indemnity Plan, as Long as it Meets the Requirements

HDHPs/HSAs ‐ How do patients manage? / p g W Worst Case: t C  Patients Chose for the Low Premium Option  They Do Not Fully Fund Their HSA  They Avoid Health Care to Avoid Extra Cost  They Do Not Actively Participate in Healthcare Choices & Healthy Lifestyle Choices  They Do Not Understand Their Plan

HDHPs & HSAs ‐ How You Manage HDHPs & HSAs How You Manage R Recognize When a Patient has a HDHP i Wh P ti t h HDHP  Identify HDHP Names with Your Payors d f h  Look for Zero co ‐ pay on Cards  Look for High Deductibles on Cards  Ask the Patient  When in Doubt, Call the Insurance Company

HDHPs & HSAs ‐ How to Manage HDHPs & HSAs How to Manage Collect at or Prior to the Time Of Service  Staff Should be Pre ‐ certifying Everything to Determine if Deductible Has Been Met  If the Deductible Has Been Met, Nothing is Due  If the Deductible Has Not Been Met, the Contracted Amount is Payable by the Patient Patient

Your Role with Insurance Your Role with Insurance Carriers Patients may not understand their plan  Educate yourself and your staff on the plans  Certain Plans may require differing Dx Codes C i Pl i diff i D C d  Ask Payors to attend monthly staff meetings to educate staff meetings to educate staff  Make it your mission to help the patient understand their responsibility understand their responsibility

Tools Tools  AMA Model Managed Care Contract  MGMA – Practice Perspectives on Payor Performance

Legal Considerations in the C ll Collection Process ti P SUSAN E. ZIEL NURSE ATTORNEY AND PARTNER KRIEG DEVAULT LLP

Bad Debt Requirements Bad Debt Requirements  42 CFR 413.80. Bad debt reimbursed by CFR 8 B d d b i b d b Medicare but only if:  Debt relates to covered services, derived from D b l d i d i d f deductible/coinsurance amounts  Reasonable collection efforts were made  Reasonable collection efforts were made  Debt uncollectible when claimed as worthless  No likelihood of recovery in future No likelihood of recovery in future

Covered Services Covered Services  Covered services C d i  Medically necessary  Prior authorization/certification  Fee schedule  Exceptions to fee schedule

Reasonable Collection Efforts Reasonable Collection Efforts  C  Comparable efforts for Medicare and all non ‐ bl ff t f M di d ll Medicare patients  Issuance of bill post discharge/death to  Issuance of bill post ‐ discharge/death to patient or third party responsible for financial obligations g  Subsequent billings, collection letters, telephone calls  May include collection agency and court action, as necessary  Documentation required

Collection Efforts (cont.) Collection Efforts (cont.)  Social Security Act S i l S i A  1128A: illegal remuneration to Medicare patients includes waiver of coinsurance/deductible includes waiver of coinsurance/deductible amounts, subject to certain exceptions  1128B(b): illegal remuneration to Medicare 1128B(b): illegal remuneration to Medicare patients  OIG Fraud Alert (1991) ( 99 )  Routine waiver of coinsurance and deductible amounts after billing Medicare for full charge represents a false claim

Collections Collections  Debt deemed uncollectible without applying D b d d ll ibl i h l i Medicare “reasonable collection efforts” if indigence confirmed and no evidence of indigence confirmed and no evidence of improvement in patient’s financial condition

Indigence/Financial Need Indigence/Financial Need  Establish before discharge or within reasonable  Establish before discharge or within reasonable time before current admission  Determined by provider not patient Determined by provider, not patient  Take into account patient’s total resources  Determine no other source legally responsible Determine no other source legally responsible for bill  File documentation : policy, application, supporting documentation  Sliding scale, extended payment, or both  Update at least every four (4) months d l f ( ) h

Patient Agreement to Pay for Services  Writing to confirm patient/guarantor W i i fi i / payment obligations beyond those made in admission paperwork admission paperwork  Scope of services  Anticipated fee(s)  Anticipated fee(s)  Anticipated third party payer payments, if any  Patient/guarantor obligations  Patient/guarantor obligations  Enforceability

B d D bt N Bad Debt – Now What? Wh t? PHIL ROBERTS PRESIDENT & CEO SENEX SERVICES CORP.

Bad Debt – Now What? Bad Debt Now What?  Best Practices You Should Expect p  FICO Scores for Bad Debt Patients  Patient Satisfaction at e t Sat s act o + Maximized Bottom Line  You Can Have Both! You Can Have Both!

Best Practices Best Practices  Expect Patient Stewardship  G Good Collections = Patient Retention Tool d C ll l  Selecting a Good Collection Partner:  Healthcare exclusive/focused  Compliance – Fair Debt Collection Practices Act, the Fair Credit Reporting Act (and the FACT Act), the Telephone Consumer Protection Act, the Health Insurance Portability and y Accountability Act (and the HITECH Act), the Graham Leach Bliley Act, and the IRS Dash 2 regulations (for buyers only to comply with issuance of 1099 ‐ C)  Industry – ACA, DBA, HFMA, MGMA  Patient Centric – training, principles, pledges, etc.