martin cook director of reimbursement management …...revenue cycle new business contracting...
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September 22, 2016
Martin CookDirector of Reimbursement Management
Authorization &
Scheduling
Service Delivery
Service Documentation
Claim Prep & Submission
Payment & Denial Processing
Appeals
Collection or Write off
Revenue Cycle
New Business
Contracting
Credentialing
System configuration
Staff Training
Revenue Cycle: All administrative and
clinical functions that contribute to the
capture, management, and collection
of patient service revenue.Healthcare Financial Management Association (HFMA)
Authorization &
Scheduling
Service Delivery
Service Documentation
Claim Prep & Submission
Payment & Denial Processing
Appeals
Collection or Write off
Revenue Cycle
Increase FFS Revenue
Improve Cash Flow
Reduce Administrative Cost
Focus Attention
Authorization &
Scheduling
Service Delivery
Service Documentation
Claim Prep & Submission
Payment & Denial Processing
Appeals
Collection or Write off
Revenue Cycle
Authorization &
Scheduling
Service Delivery
Service Documentation
Claim Prep & Submission
Payment & Denial Processing
Appeals
Collection or Write off
Revenue Cycle
Authorization &
Scheduling
Service Delivery
Service Documentation
Claim Prep & Submission
Payment & Denial Processing
Appeals
Collection or Write off
Revenue Cycle
• Potential for lost Revenue
• Opportunity for quick wins
• Promote internal confidence in billing
and collection capabilities
• Lead by example
• Revenue
• Timeliness of Billing
• Suspended Billing
• Denial Rate
• Denials by category
• Write offs and Adjustments
• Cash collected
• Collections Rate
• Timeliness of collections
• Ability to drill down to Payer
Data Source
Information Needed
MCO Revenues & Collections Report
Service Dates: Sep 1, 2014 - Aug 31, 2015
Recognized RevenueOther Adj/Write
offs $Other Adj/Write
offs % of Rev Net Revenue Cash Collections
% of Recognized
Revenue Collected
As of 11/04/2015
Amerigroup $ 1,264,686 $ 41,200 3% $ 1,223,486 $ 1,215,387 97%
Superior Medicaid $ 986,809 $ 42,602 4% $ 944,206 $ 930,365 94%
United Medicaid $ 917,389 $ 22,292 2% $ 895,097 $ 875,581 95%
BCBS Medicaid $ 214,001 $ 8,242 4% $ 205,759 $ 167,251 78%
Seton Medicaid $ 159,388 $ 2,753 2% $ 156,635 $ 158,320 99%
Superior Foster Care $ 67,101 $ 5,983 9% $ 61,117 $ 59,489 89%
Sendero Medicaid $ 70,935 $ 1,738 2% $ 69,197 $ 68,734 97%
Molina Medicaid $ 5,880 $1,837 31% $ 4,043 $ 3,408 58%
Value Options Medicaid $ 5,423 $4,787 88% $ 635 $ 157 3%
BCBS CHIP $ 14,671 $ 1,005 7% $ 13,666 $ 5,786 39%
Superior CHIP $ 37,143 $11,090 30% $ 26,053 $ 25,559 69%
Seton CHIP $ 29,685 $ 457 2% $ 29,228 $ 29,025 98%
Sendero CHIP $ 3,062 $ 96 3% $ 2,966 $ 2,836 93%
Total MCO $ 3,776,170 $ 144,082 4% $ 3,632,088 $ 3,575,897 95%
Source Data: Cerner Revenues ReportCerner Cash Receipts Report
Collection Rate
# Billed # Denied Denial Rate
Amerigroup 25,382 10,699 42%
Superior Medicaid 13,159 1,347 10%
BCBS Medicaid 3,802 1,928 51%
United Medicaid 17,269 4,396 25%
Seton Medicaid 1,916 299 16%
Superior Foster Care 710 129 18%
Sendero Medicaid 1,182 298 25%
Molina Medicaid 117 49 42%
Value Options Medicaid 99 83 84%
BCBS CHIP 245 117 48%
Superior CHIP 584 111 19%
Seton CHIP 550 32 6%
Sendero CHIP 42 19 45%
65,057 19,507 30%
Source Data:Cerner Service Life Cycle Analysis ReportSep 1, 2014 – Aug 31, 2015
Denial Rate
Avg Days Claim to Payment
Denial Clean Total
Amerigroup 113.25 36.21 68.68
Superior Medicaid 28.66 19.83 20.73
BCBS Medicaid 84.71 10.61 48.19
United Medicaid 68.04 13.77 27.59
Seton Medicaid 107.99 11.03 26.16
Superior Foster Care 32.91 13.42 16.96
Sendero Medicaid 165.28 16.53 54.03
Molina Medicaid 8.47 5.71 6.86
Value Options Medicaid0.33 0.00 0.27
BCBS CHIP 9.07 1.50 5.11
Superior CHIP 9.43 4.70 5.60
Seton CHIP 52.28 4.02 6.83
Sendero CHIP 29.79 12.52 20.33
92.44 22.13 43.21
Average Days : Claim to Payment
Source Data:Cerner Service Life Cycle Analysis ReportSep 1, 2014 – Aug 31, 2015
FY 2015
Collection Rate 95%
Denial Rate 30%
Claim to Payment -Clean 22.13 days
Claim to Payment -Denial 92.44 days
Progress Note to Claim 9.62 days
FY 2015 Billing and Collections Summary
ATCIC Policy = 4 Business
Days
• Share results with Center Leadership
• Establish Cross-functional team Limit Team CharterIncludes leadership from key areasEstablish Ownership and AccountabilityStanding meetings
• Develop Management Reports
Charges for services
Contractual Adjs
Recognized Revenue
Other Adj/Write
offs $
Other Adj/Write offs % of
Rev Net RevenueCash
Collections% of Revenue
Collected% of Net Revenue
Medicare $ 122,278 $ 64,918 $ 57,360 $ 1,760 3% $ 55,600 $ 45,992 80% 83%
Medicaid $ 1,147,578 $ 233,943 $ 913,635 $ 16,496 2% $ 897,139 $ 831,124 91% 93%
Amerigroup $ 260,705 $ 36,423 $ 224,282 $ 6,104 3% $ 218,178 $ 194,000 86% 89%
Superior Medicaid $ 408,067 $ 189,354 $ 218,713 $ 1,984 1% $ 216,729 $ 174,750 80% 81%
BCBS Medicaid $ 115,016 $ 63,984 $ 51,032 $ 99 0% $ 50,933 $ 41,883 82% 82%
United Medicaid $ 243,358 $ 51,831 $ 191,527 $ 1,698 1% $ 189,829 $ 177,560 93% 94%
Seton Medicaid $ 47,629 $ 10,348 $ 37,281 $ 105 0% $ 37,176 $ 36,045 97% 97%
Superior Foster Care $ 16,558 $ 6,012 $ 10,546 $ (0) 0% $ 10,546 $ 9,523 90% 90%
Sendero Medicaid $ 29,256 $ 7,043 $ 22,213 $ 1,263 6% $ 20,950 $ 20,431 92% 98%
Molina Medicaid $ 174 $ 174 $ - 0% $ 174 $ 169 97% 97%
Value Options Medicaid
$ 382 $ 382 $ - 0% $ 382 $ 99 26% 0%
BCBS CHIP $ 6,442 $ 1,958 $ 4,483 $ - 0% $ 4,483 $ 2,530 56% 56%
Superior CHIP $ 5,407 $ 1,213 $ 4,194 $ - 0% $ 4,194 $ 2,123 51% 51%
Seton CHIP $ 9,571 $ 2,367 $ 7,204 $ - 0% $ 7,204 $ 6,994 97% 97%
Sendero CHIP $ 2,188 $ 906 $ 1,283 $ 135 11% $ 1,148 $ 1,148 89% 100%
Total MCO $ 1,144,753 $ 371,439 $ 773,314 $ 11,388 1% $ 761,927 $ 667,255 86% 88%
Total M, M & MCO $ 2,414,609 $ 670,300 $ 1,744,309 $ 29,644 2% $ 1,714,666 $ 1,544,372 89% 90%
Charges for services
Contractual Adjs
Recognized Revenue
Other Adj/Write
offs $
Other Adj/Write offs % of
Rev Net RevenueCash
Collections% of Revenue
Collected% of Net Revenue
Medicare $ 405,492 $ 229,162 $ 176,330 $ 11,793 7% $ 164,537 $ 160,193 91% 97%
Medicaid $ 4,204,651 $ 1,021,457 $ 3,183,194 $ 108,441 3% $ 3,074,753 $ 3,031,931 95% 99%
Amerigroup $ 943,640 $ 150,445 $ 793,195 $ 31,690 4% $ 761,505 $ 721,494 91% 95%
Superior Medicaid $ 1,241,864 $ 561,811 $ 680,053 $ 32,987 5% $ 647,066 $ 622,404 92% 96%
BCBS Medicaid $ 363,391 $ 216,129 $ 147,262 $ 1,495 1% $ 145,767 $ 133,128 90% 91%
United Medicaid $ 764,481 $ 168,543 $ 595,938 $ 10,003 2% $ 585,935 $ 560,934 94% 96%
Seton Medicaid $ 133,083 $ 31,890 $ 101,193 $ 1,940 2% $ 99,253 $ 98,473 97% 99%
Superior Foster Care $ 62,559 $ 22,498 $ 40,061 $ 7,174 18% $ 32,887 $ 31,753 79% 97%
Sendero Medicaid $ 87,497 $ 21,224 $ 66,273 $ 3,305 5% $ 62,968 $ 62,235 94% 99%
Molina Medicaid $ 1,720 $ 686 $ 1,034 $ 54 5% $ 980 $ 980 95% 100%
Value Options Medicaid
$ 974 $ 465 $ 509 $ 509 100% $ - 0% 0%
BCBS CHIP $ 22,482 $ 6,059 $ 16,423 $ 435 3% $ 15,988 $ 5,641 34% 35%
Superior CHIP $ 29,122 $ 8,158 $ 20,964 $ 3,803 18% $ 17,161 $ 15,068 72% 88%
Seton CHIP $ 27,158 $ 8,340 $ 18,818 $ 511 3% $ 18,307 $ 18,302 97% 100%
Sendero CHIP $ 4,551 $ 2,129 $ 2,422 $ 112 5% $ 2,310 $ 2,310 95% 100%
Total MCO $ 3,682,522 $ 1,198,377 $ 2,484,145 $ 94,017 4% $ 2,390,128 $ 2,272,724 91% 95%
Total M, M & MCO $ 8,292,665 $ 2,448,996 $ 5,843,669 $ 214,251 4% $ 5,629,418 $ 5,464,849 94% 97%
Suspended (Unbilled) Svcs All MCO's
Duplicate Service $ 18,923
No Provider # $ 16,544
No Final Approved PN $ 4,258
No Valid Diagnosis $ 3,795
Incorrect Rate
All other $ 1,248
Total $ 44,768
Source Data:Cerner 3rd Party Suspense Report
Denials and Appeals Amerigroup Superior BCBS United Seton
Superior Foster Care Sendero Total
Diagnosis not covered 1,955 1,955
Exceeds Authorization 7,911
1,057 679 9,647
No Auth prior to svc1,122 8,282 200 5,307 14,911
Claim does not match Auth 1,899 1,899
Non covered serivce714 4,315 2,120 7,149
Coverage Terminated 1,252
Svc Location not in Contract 1,327 1,327
Duplicate Service508 508
Provider not Qualified 252 252
Provider Rep Appeal5,069 2,108 7,177
All other1,005 617 1,336 3,901
$ 317 1,117 31 8,325
Total10,752 17,822 8,744 15,619 317 1,117 31 53,150
Payer issue
Denials and Appeals Amerigroup Superior BCBS United Seton
Superior Foster Care Sendero Total
Diagnosis not covered 1,955 1,955
Exceeds Authorization 7,911
1,057 679 9,647
No Auth prior to svc1,122 8,282 200 5,307 14,911
Claim does not match Auth 1,899 1,899
Non covered serivce714 4,315 2,120 7,149
Coverage Terminated 1,252
Svc Location not in Contract 1,327 1,327
Duplicate Service508 508
Provider not Qualified 252 252
Provider Rep Appeal5,069 2,108 7,177
All other1,005 617 1,336 3,901
$ 317 1,117 31 8,325
Total10,752 17,822 8,744 15,619 317 1,117 31 53,150
ATCIC issue
FY 2015 FY 2016
Collection Rate 96% See Above
Denial Rate 30% 12%
Claim to Payment -Clean 22.13 days 12.74 days
Claim to Payment -Denial 92.44 days 58.09 Days
Service Entry to Claim 9.62 days 7.21 Days
Authorization &
Scheduling
Co pay and deductible collection
Service Delivery
Service Documentation
Claim Prep & Submission
Payment & Denial
Processing
Appeals
Collection or Write off
Revenue Cycle
Priorities:AuthorizationsProvider ProductivityService DocumentationCo-pays and deductibles
