revenue cycle management - wild apricot info... · 2019-09-30 · o manual posting (insurance and...
TRANSCRIPT
Revenue Cycle Management:A Team Effort
Ryan Hackett, MHAAccount Executive, GBS
Solutions Architect, GBS
• Introductions
o Ryan Hackett
o GBS Corp
• Revenue Cycle Management (RCM)
• RCM Continuum
• New Rules of Engagement
o Automation
• Organizational Impact
• Improvement Activities
• RCM Benchmarks in Healthcare
• Insourcing vs Outsourcing
o Outsourcing Models
• GBS Vision and Market Penetration
• Best Practices
Agenda
Ryan Hackett, Account Executive, Healthcare
Ryan started his career at GBS in June of 2012 and came onboard
with over 8 years of experience in the Healthcare industry. Ryan
was originally hired as an Implementation Specialist and then in
2014, he joined the Healthcare Consulting division. This transition
led to his temporary (18 months) relocation to Clearwater Beach,
FL, where he acted as an onsite Project Manager for a NextGen®
re-launch. After two years in the Consulting division, he accepted a
position as a Solutions Architect in June 2016. Ryan leveraged his
operational knowledge and experience to drive sales before
eventually being promoted to Account Executive in 2018.
Introduction
• The Ohio State University College of Pharmacy (BSPS), 2008
• The Ohio State University College of Public Health (MHA), 2012
• 1971
• Ohio Based
• $100 Million
• 500+ Team
• 43 States
• No Debt
• 100% ESOP
GBS CorpSince our founding more than 48 years ago, GBS has evolved
as a technology solutions provider, helping customers better
create, manage, deliver, and retrieve information:
• Healthcare Solutions
• Revenue Enhancement
• Marketing Services
• IT & Networking Solutions
• Imaging & Content
Management Solutions
• Print, Labeling, & Filing
Solutions
Introduction
RCM Fact of the Day
RCM
Outsourcing
Valuation:
$11.7B in 2017
RCM
Outsourcing
Valuation:
$__B in 2023
RCM Statistics• 85% of providers are looking to replace current RCM
systems
o 29% of hospitals utilize advisors and consultants
o 90% of hospitals will outsource by 2019
• 70% of practices are considering outsourcing
• 93% of CFO’s report they will eliminate under-performing
vendors
• 94% of CFO’s believe transformation can impact their
financial health
• $33% who had a plan to replace in 2016 have failed
The Healthcare Financial Management Association (HFMA) defines
revenue cycle as:
All administrative and clinical functions that
contribute to the capture, management, and
collection of patient service revenue.
“Revenue Cycle” includes the entire life of a patient account from
creation to payment. Revenue cycle processes flow into and affect
one another. If properly executed, the cycle performs predictably and
profitably. Problems early in the cycle can have significant ripple
effects. As errors travels through the cycle, the more costly revenue
recovery becomes.
Revenue Cycle Management (RCM)
The Revenue Cycle Continuum
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• A focused unit supporting Billing, Payment Posting,
Account Receivables, and Denial Management
• Research
• Follow-up
• Appeals
• Denial tracking
• Claim transmissions
• Edits corrections
• Secondary and
patient billing
• Document review for
completion
• Reconciliation of ERA
• Manual posting of
EOB
• Identification of
payment variances
• Posting of
Correspondence
• Write off
management
• Reporting and
analysis
• Current and past due
receivables follow up
• Collection of unpaid
and partially paid
claims
• Follow-up on patient
accounts
Billing Payment PostingAccount
Receivable
Management
Denial
Management
The Heart of RCM
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• Charge Entry
• Eligibility Verification (Real-Time)
• Claim Scrubbing
• Claim Submission
• Payment Posting
• ERA
• Lockbox
• Denial Management
• AR Management and Resolution
o Insurance Follow-up
o Appeals
o Document/EOB Management
Billing and Collection Services
• Engaged in quality
• More involved in choice
• Higher portion of financial responsibility
Patients Have the Power
• Multiple payment points
• Wellness reimbursed higher
• Integration of new rules
• More complex coding
Fee-for-Service vs Value-Based Care
• Rapid rule changes
• Rapid turnover of staff
• Human retention turned into alerts and measures
Tools vs People
• Service levels
• Focus on patients
• Technology needs beyond EHR and PM
Outsourcing
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• Advanced Pre-Billing (APB) solutions are rules that automate
manual processes thus reducing cost and simplifying
Standard Operating Procedures
• Automates EMR charge passing and cleans billing data
before hitting the clearinghouse and/or PM system
• Accumulation of knowledge from revenue cycle experts so
everyone in the business office can perform at their highest
level
• Clean and accurate data helps supports the shift from Fee-
for-Service to Value-Based Care
Impact of Automation
16
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• Increase coder productivity
• Process more charge volume without adding staff
• Automate charge passing from your Electronic Medical Record
• Avoid missed charges
• Avoid bilateral billing issues
• Reduce denials and improve COH
Benefits of APB Rules
Organizational Impact• RCM solutions should encompass entire RCM continuum,
from patient registration through collections
• RCM solutions should focus on meeting and exceeding your
needs while generating revenue and creating patient
satisfaction
• Develop Standard Operating Procedures (SOPs) to ensure
all billings are completed accurately and in a timely fashion
• Develop Key Performance Indicators (KPIs) to monitor
progress and trends over time
o Forecasting is instrumental to sustainability
• Enhanced authorization and certification• Eligibility and authorization• Complete and timely billing• Improved registration data quality• Better front office processes and technology
• Improved follow-up processes all financial classes• Access to state-of-the-art, collection tools
• Enhanced accounts receivable management• Tasking• Processes re-engineered to standards• Benchmarks and standards implemented
training and certification
2% – 4%
5% – 10% loss of cash
Denial Mgmt.
2% - 3%Reduction of aged A/R and Bad Debt Write-offs
3% - 5%Process and WorkflowImprovement
3% – 5%Underpayments
• Automated contract management• Enhanced management and performance
evaluation• Technology-enabled tools to monitor payer
compliance with contract terms and conditions• Timely follow-up of underpayments
MGMA and HFMA
study of Physician
Practices
Patching “Leaks”
Improvement Activities• Integration
o Seamless workflows and automation
• Proper Organization
o Executive buy-in
• Shared Accountability
o Marry clinical performance and quality outcomes
o Dashboard monitoring (KPIs)
• Cross Collaboration
o Communicate constantly and tear down silos
• Continuous Improvement
o Culture change and regulatory awareness
• Strategic Partnership
o Find the correct RCMS partner (outsource)
RCMS Benchmarks
• Drive workflow redesign
• Payers’ complexities are increasing
• Maximize return on investment in technology
• Staffing issues
o Retention
o Certification
• Physician are not interested being in the Human Resource business and want to concentrate on getting back to the basics
• Automation tipping point
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Why Outsource
• Maximize utilization of PM features designed to
enhance cash flow
• Allow practices to operate in the moment (focus on
patients and managing the Accounts Receivable
• Perform daily billing and collections duties leaving
clinical staff to patient care
• Reduce staffing costs
• Reduce administrative aggravation
• Produce positive return on investment
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Why Outsource
• Fully leverage software investment
• High receivables and weak cash flow
• Decreasing profit/physician compensation
• Key staff turnover
• Patient dissatisfaction
• Aging technology and unsupported software
• Data integrity and compliance concerns
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Why Outsource
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Why Outsource
• Increased time to work on what’s really important
• Less time fighting firesTime
• Transparent client dashboards
• Every service with real-time performance monitoring reports Control
• Higher, faster reimbursement
• Reduction of overall cost of reimbursementMoney
• Broad service offerings with ultimate flexibility
• Dedication to client service - local presence, personal
attention
• Live by “Best Practices” methodology
• Complete transparency - internal and external
• Proven Revenue Cycle solutions - testimonials
• Proven PM tools on hand
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Due Diligence
• Backed by resources and reputation of proven PM
platform
• Strategic plan that ranks physician services as the
number one expansion objective to pursue
• Unprecedented experience in the RCM space
• EMR workflow guidance no matter what type of
software you are implementing
• Ability to improve physician cash collections
o Improvement of 5% to 10% of gross collection
rate
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Due Diligence
RCM Models• Management Service Agreement (MSA)
o Manage from afar
o Contract Terms highly variable
• A La Carte Outsourcing
o Delegation of duties defined in Contract Terms
• Complete Outsourcing
o Rules of engagement defined in Contract Terms
o Payer complexities are on the rise making it more and more
difficult to run an efficient billing office
o Physicians need to focus on quality more than ever during this
transition to Value-Based Care
o Demand for certified coders has surpassed the supply in most
American cities
o Recent studies have proven outsourcing to be more efficient
Departmental Responsibilities
• Charge Processing
o Manual charge entry
• Coding
o Edit processing and manual coding (clinical and surgical)
• Cash Application
o Manual posting (insurance and patient)
o ERA processing
• Claims Processing
o Deliver claim uploads to clearinghouse
• Customer Service - Incoming
o Patient support, collections review, and address management
• Patient Engagement - Outbound
o Remind and collect past due amounts
• Special Billing
o Manage patient bills and assistance programs
GBS Vision• Our goal and vision is to provide the most powerful,
flexible, and fully comprehensive Revenue
Cycle Management Services available
• Our solutions create differentiation in
the Revenue Cycle Management
marketplace with respect to increased
revenue and decreased cost, and is backed
by quantifiable ROI data and references, while
simultaneously driving strong margins
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Pre-Live Work
• On-site assessments
• Verification of provider
numbers
• Verification of lock box
addresses
• End-to-end testing
of claims
• A/R recovery
• “Best Practices”
pre-built system
• Detailed Go-Live plan with
“Best Practices” upgrades
What We Do
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Electronic
Eligibility
Checking
What We Do
Billing
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What We Do
Streamline
traditional
posting utilizing
deposit images
from bank
Posting from ICS
EOBs indexing
to payment
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Utilize claims department
to maximize use of ERA
posting
What We Do
Denial
Analysis
Denial Resolution:
• GBS Solutions
o Add Claim Edit
o System
Modification
• Client
o Attach Clinical
Documentation
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What We Do
Real-time
electronic
claim status
checking
Web-based
inquiry
Telephone
follow-up
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What We Do
• Rules Engine Automation
o Advanced Pre-Billing (APB)
• Service Desk
• Patient Collections
• ERA and Payment Reconciliation
• Contract Reconciliation
• Denials Management
• Standard and Custom Reporting
• Credentialing and Re-Credentialing
RCM Offerings
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TRANSPARENCY• Ability for you, the customer, to monitor
and participate
• Create, share, and train on the same
memorized reports we use to monitor
your operations
• Reporting on all aspects of the work
being performed
• Performance clarity:
o Practice Solutions
o Employee
o Location
o Practice
o Region
Best Practices
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• Denial Management:
denials and claim edits
• A/R Follow-Up: follow-up
on EVERY claim
• Customer-defined
processes for accounts
identified as possible bad
debt
• Integrated bad debt
management partner
Best Practices
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• Maximize ERA by leveraging
clearinghouse and Internal
Claims Department
• Utilize EOB image linking
• Accept digital lockbox
deposits
• Link each line item posted to
digitally imaged EOB
• Easy audit access to
transaction detail for
customer
Best Practices
• Get paid faster
• Improve efficiency
• Reduce staffing headaches
• Quick implementation timelines
• Focus on current strategy (i.e. growth and
acquisition)
• Get the information YOU need to run YOUR
organization
• Speed to value proposition for EMR implementations
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GBS Difference
YOUR success is OUR success!• We improve revenues by removing or
repurposing staff and reducing denials
to below 1%
• As an option, we include Value-Based Care initiatives by:
o Leveraging our Healthcare Professional Services Team
to assist with MIPS/MACRA
o Establishing and documenting all practice processes
o Helping you achieve (and exceed) MGMA/HFMA performance
benchmarks
o Helping maximize your ROI as we are vested in each dollar the
practice earns
Partner Benefits
RCM Fact of the Day
RCM
Outsourcing
Valuation:
$11.7B in 2017
RCM
Outsourcing
Valuation:
$23B in 2023
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