the dilution of the dollar€¦ · accureg. clint jones, chfp. promise: • you’re probably...
TRANSCRIPT
The Dilution of the Dollar
Vice President, Business DevelopmentAccuReg
Clint Jones, CHFP
Promise:
• You’re probably losing up to 40 cents on every dollar before you even render any patient services.
• By the end of this presentation, I’ll show you exactly where this leakage is occurring and what you can do to stop it.
Reframing:
The Traditional Revenue Cycle is Broken
Who is this for?
Anyone who plays any role in the Revenue Cycle• PAD• RCM• CFO• CEO• Etc….
Are you in any of these camps?
1. I believe I will see better results by implementing separate processes to drive payer revenue and patient revenue.
2. I believe a strong collections program on the back end will maximize patient revenue.
3. I believe that rules, edits and claim scrubbing delivers clean claims resulting in higher net revenues.
The Invisible Truth:
Belief1. I believe I will see better results by
implementing separate processes to drive payer revenue and patient revenue.
2. I believe a strong collections program on the back end will maximize patient revenue.
3. I believe that rules, edits, and claim scrubbing delivers clean claims resulting in higher net revenues.
TRUTH1. The “patient dollar” and the “payer dollar”
have a parallel if not symbiotic relationship.
2. Collections vendors by and large are VERY good at their jobs; however, most hospitals are using them incorrectly. Thus, the “net back” is not as great as it could be.
3. Claim scrubbers and payer edits through the clearinghouse do help generate “clean claims” but do very little to generate ACCURATE claims (the dirty little secret).
Quick Question:
What is the biggest cost you encounter in trying to collect patient dollars?
With your new perspective …
• You’ll quickly see how the “patient dollar” and the “payer dollar” have become inextricably linked
• How collections efforts are far more expensive than you think• Why accuracy and prevention will make an early and more substantial
yield than a clean claim alone
The 3 Keys to Higher Profits:
1. Understanding the relationship between patient dollars and payer dollars
2. Collecting on the front-end will provide “new” dollars to the back-end
3. Gathering data from the back-end can provide accuracy on the front-end, which will create a larger dollar pass-through
Profit Key #1
Patient Payment Optimization• Web Portal• Payment Estimator• Patient Statements• Internal Phone Calls• Collections Agencies
Payer Payment Optimization• QA Engine• Claim Scrubbers• Payer Edits at the Clearinghouse Level• Denials Management
Understanding the relationship between patient dollars and payer dollars
Revenue Cycle Timeline
Revenue Cycle Timeline
Patient
Scheduled either online or through Scheduler
Patient SchedulingPhysician Order Registration Insurance
Verification
Physician
Written orders for requested services
Registration Staff
Demographics entered. Patient consent forms.
Registration Staff
Insurance eligibility verified.
Admission/ Treatment
Charge Capturing
DischargeDiagnosis CodingBillingAppealsCollection Patient
Billing
Patient Care
All treatment/care provided by facility providers.
Provider(s)
Physician notes gathered and reviewed to ensure all services rendered are billed
Discharge Planner
Discharge documentation, consent
forms signed.
Biller/Coder
ICD-9-CM coding assigned for all services
Biller/Coder
Generation & submission of UB-92 for
facility services
Collections
Management of Payer Denials. FEFP Denials
reduced by 50%.
Collections
Bill patient for portion after insurance payment
Receivables Clerk
Collections follow-up for patient balance due or not yet paid by patient
Procedure C
oding
Biller/Coder
Services not captured by charge documents are assigned appropriate coding
Revenue Cycle Timeline
Patient
Scheduled either online or through Scheduler
Patient SchedulingPhysician Order Registration Insurance
Verification
Physician
Written orders for requested services
Registration Staff
Demographics entered. Patient consent forms.
Registration Staff
Insurance eligibility verified.
Admission/ Treatment
Charge Capturing
DischargeDiagnosis CodingBillingAppealsCollection Patient
Billing
Patient Care
All treatment/care provided by facility providers.
Provider(s)
Physician notes gathered and reviewed to ensure all services rendered are billed
Discharge Planner
Discharge documentation, consent
forms signed.
Biller/Coder
ICD-9-CM coding assigned for all services
Biller/Coder
Generation & submission of UB-92 for
facility services
Collections
Management of Payer Denials. FEFP Denials
reduced by 50%.
Collections
Bill patient for portion after insurance payment
Receivables Clerk
Collections follow-up for patient balance due or not yet paid by patient
Procedure C
oding
Biller/Coder
Services not captured by charge documents are assigned appropriate coding
Missteps along the cycle take a bite out of every dollar
0
20
40
60
80
100
120
Payer Dollar Patient Dollar Should be
The Ideal Path
The Shrinking Dollar
Front Middle Back
The Shrinking Dollar
Front Middle Back
0
20
40
60
80
100
120
Payer Dollar Patient Dollar
The Shrinking Dollar
0
20
40
60
80
100
120
Payer Dollar Patient Dollar
No collection from patient
Improper assessment of payer split
Front Middle Back
0
20
40
60
80
100
120
Payer Dollar Patient Dollar
The Shrinking Dollar
Collection of copay only
Improper insurance liability assessment
Front Middle Back
0
20
40
60
80
100
120
Payer Dollar Patient Dollar
The Shrinking Dollar
No patient portion estimate
Eligibility related denials
Front Middle Back
0
20
40
60
80
100
120
Payer Dollar Patient Dollar
The Shrinking Dollar
Copay only
Front Middle Back
0
20
40
60
80
100
120
Payer Dollar Patient Dollar
The Shrinking Dollar
Management of denials vs prevention
Front Middle Back
0
20
40
60
80
100
120
Payer Dollar Patient Dollar
The Shrinking Dollar
Creation and mailing of patient statement
Front Middle Back
0
20
40
60
80
100
120
Payer Dollar Patient Dollar
The Shrinking Dollar
Internal and external collection efforts
Front Middle Back
0
20
40
60
80
100
120
Payer Dollar Patient Dollar
The Shrinking Dollar
Front Middle Back
0
20
40
60
80
100
120
Payer Dollar Patient Dollar
The Shrinking Dollar
Front Middle Back
0
20
40
60
80
100
120
Payer Dollar Patient Dollar Should be
The Shrinking Dollar
The Ideal Path
Front Middle Back
Profit Key #2:
• “Net Back” is a determination of the total amount of revenue received less the expense to collect.
• Given there are always write-offs, up front collections capture dollars from patients willing to pay and leaves the collections efforts to those who are more difficult to capture.
• The result is a higher total net back.
Collecting on the front-end will provide “new” dollars to the back-end
Collections Dollars
Vendor Collections
Collections Dollars
Vendor Collections
Pre-RegCollects
Revenue Cycle Timeline
Registration Insurance Verification
Patient
Scheduled either online or through Scheduler
Patient SchedulingPhysician Order
Physician
Written orders for requested services
Registration Staff
Demographics entered. Patient consent forms.
Registration Staff
Insurance eligibility verified.
Admission/ Treatment
Charge Capturing
DischargeDiagnosis CodingBillingAppealsCollection Patient
Billing
Patient Care
All treatment/care provided by facility providers.
Provider(s)
Physician notes gathered and reviewed to ensure all services rendered are billed
Discharge Planner
Discharge documentation, consent
forms signed.
Biller/Coder
ICD-9-CM coding assigned for all services
Biller/Coder
Generation & submission of UB-92 for
facility services
Collections
Management of Payer Denials. FEFP Denials
reduced by 50%.
Collections
Bill patient for portion after insurance payment
Receivables Clerk
Collections follow-up for patient balance due or not yet paid by patient
Procedure C
oding
Biller/Coder
Services not captured by charge documents are assigned appropriate coding
Missteps along the cycle take a bite out of every dollar
Revenue Cycle Timeline
Registration Insurance Verification
Registration Staff
Demographics entered. Patient consent forms.
Registration Staff
Insurance eligibility verified.
Admission/ Treatment
Charge Capturing
DischargeDiagnosis CodingBillingAppealsCollection Patient
Billing
Patient Care
All treatment/care provided by facility providers.
Provider(s)
Physician notes gathered and reviewed to ensure all services rendered are billed
Discharge Planner
Discharge documentation, consent
forms signed.
Biller/Coder
ICD-9-CM coding assigned for all services
Biller/Coder
Generation & submission of UB-92 for
facility services
Collections
Management of Payer Denials. FEFP Denials
reduced by 50%.
Collections
Bill patient for portion after insurance payment
Receivables Clerk
Collections follow-up for patient balance due or not yet paid by patient
Procedure C
oding
Biller/Coder
Services not captured by charge documents are assigned appropriate coding
Pre-Registration
Pre-Reg Clerk
Typically done over the phone. Patient Collection
Missteps along the cycle take a bite out of every dollar
Patient
Scheduled either online or through Scheduler
Patient SchedulingPhysician Order
Physician
Written orders for requested services
New ProcessTimeline
Registration Insurance Verification
Registration Staff
Demographics entered. Patient consent forms.
Registration Staff
Insurance eligibility verified.
Admission/ Treatment
Charge Capturing
DischargeDiagnosis CodingBillingAppealsCollection
s
Patient Billing
Patient Care
All treatment/care provided by facility providers.
Provider(s)
Physician notes gathered and reviewed to ensure all services rendered are billed
Discharge Planner
Discharge documentation, consent
forms signed.
Biller/Coder
ICD-9-CM coding assigned for all services
Biller/Coder
Generation & submission of UB-92 for
facility services
Collections
Management of Payer Denials. FEFP Denials
reduced by 50%.
Collections
Bill patient for portion after insurance payment
Receivables Clerk
Collections follow-up for patient balance due or not yet paid by patient
Procedure C
oding
Biller/Coder
Services not captured by charge documents are assigned appropriate coding
Pre-Registration
Pre-Reg Clerk
Typically done over the phone. Patient Collection
Missteps along the cycle take a bite out of every dollar
Patient
Scheduled either online or through Scheduler
Patient SchedulingPhysician Order
Physician
Written orders for requested services
Reduced Patient Access-Related Write Offs by 55% in 8 MonthsIntegrated Health Delivery System in MO
POS + Prior Balance CollectedNY Based – 261 Bed Acute Care Facility
$0
$20,000
$40,000
$60,000
$80,000
$100,000
$120,000
$140,000
$160,000
$180,000
$200,000
Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17
Doubled POS Collections in Four Months MS 200 Bed Acute Care Facility
$0
$20,000
$40,000
$60,000
$80,000
$100,000
$120,000
Nov-16 Dec-16 Jan-17 Feb-17 Mar-17
Total Collected: $471,908
$58,012
$87,070
$103,967 $103,629
$119,230
Profit Key #3:
Gathering Data from the back-end can provide accuracy on the front-end, which will create a
larger dollar pass-through
New Process Timeline
Patient
Scheduled either online or through Scheduler
Patient SchedulingPhysician Order Registration Insurance
Verification
Physician
Written orders for requested services
Registration Staff
Demographics entered. Patient consent forms.
Registration Staff
Insurance eligibility verified.
Admission/ Treatment
Charge Capturing
DischargeDiagnosis CodingBillingAppealsCollection
s
Patient Billing
Patient Care
All treatment/care provided by facility providers.
Provider(s)
Physician notes gathered and reviewed to ensure all services rendered are billed
Discharge Planner
Discharge documentation, consent
forms signed.
Biller/Coder
ICD-9-CM coding assigned for all services
Biller/Coder
Generation & submission of UB-92 for
facility services
Collections
Management of Payer Denials. FEFP Denials
reduced by 50%.
Collections
Bill patient for portion after insurance payment
Receivables Clerk
Collections follow-up for patient balance due or not yet paid by patient
Procedure C
oding
835/837 FileClaims & remit file
Biller/Coder
Services not captured by charge documents are assigned appropriate coding
Pre-Registration
Pre-Reg Clerk
Typically done over the phone. Patient Collection
Rules Engine
Software Automation
Benefits, Address, Medical Necessity, Orders, Estimation, Financial Assistance.
Claims & remit analysis. Refinement of Rules Engine
Cut Eligibility Denials in HalfMS Based 200 Bed Acute Care Facility
50% Decrease in Six Months
Comparing Bad Debt to NPR Ratio Two AL Based Facilities
0.00%
5.00%
10.00%
15.00%
20.00%
25.00%
30.00%
35.00%
Year 0 Year 1 Year 2 Year 3 Year 4
Hospital A Hospital B
Question:
• When is the best time to ask a patient for money?• Do the dollars you collect up front have a higher value?• Would you collect fewer dollars on the back end if you simply collect
more dollars on the front end?
Let’s Review:
1. The patient dollar and the payer dollar have a parallel if not symbiotic relationship.
2. Collections vendors by and large are VERY good at their jobs; however, most hospitals are using them incorrectly, and thus the “net back” is not as great as it could be.
3. Claim scrubbers and payer edits through the clearinghouse do help generate “clean claims,” but they do very little to generate ACCURATE claims (the dirty little secret).
