By Elizabeth W. Woodcock, MBA, FACMPE, CPC

Transcription

1 By Elizabeth W. Woodcock, MBA, FACMPE, CPC

2 Elizabeth W. Woodcock, MBA, FACMPE, CPC Speaker, Author, Trainer MBA, Wharton School of Business, University of Pennsylvania BA, Duke University Fellow, American College of Medical Practice Executives Certified Professional Coder Author, 12 textbooks and more than 500 Articles Founder and Principal, Woodcock & Associates Former Consultant, Medical Group Management Association; Group Practice Services Administrator, University of Virginia Health Services Foundation; Former Senior Associate, Health Care Advisory Board The content of this presentation represents the views of the author and presenters. GE, the GE Monogram, Centricity and Imagination at Work are trademarks of General Electric Company. 2

3 Financial clearance Communication of expectations Cultural shift Information distribution Payment options Staff training Denial Prevention/Management Technology Audit Productive workforce Dashboard of revenue cycle indicators 3

4 1 2 3 Insurance Coverage Financial Responsibility Benefits Eligibility 4

5 Initial scheduling call Appointment confirmation When patient presents Arrival Time

6 Dual Monitors 6

7 Appointment Scheduling Balance General statement re: time-of-service obligations Appointment Confirmation Balance General statement re: time-of-service obligations Pre-service deposit Time-of-Service Balance Specific time-of-service obligations Copay Deposit Coinsurance/Unmet Deductible (checkout) Don t Forget! Account for Financial Counseling Time 7

8 When you bring up money, you don t care about me... When you can t tell me what I owe, you don t care about me... Transparency 8

9 Provide patients Insurance confirmation and benefits summary, including unmet deductible Explanation of benefits Price estimation from the payer Initial patient statement/ledger Financial agreement for scheduled procedures and surgeries 9

10 Orange!! Financial Worksheet You are scheduled for a XXXX on May 4, We will file the claim for this service with your insurance company, CIGNA. This financial worksheet outlines the estimated cost of the surgery*, your discount and financial responsibility, and what your insurance company is estimated to pay on your behalf. Estimated Cost of Your Surgery: Your Discount: $XXX.XX Your Financial Responsibility: Your Insurance is Estimated to Pay: (XX%) 50% of your financial responsibility is due prior to the date of the surgery. We would be happy to accept cash, check or charge. The remainder is due within 90 days after the date of the surgery. There is a $200 charge that will be applied to your account in the event that you do not present for your surgery. This charge will be deducted from any refund due as a result of the cancelled surgery. Plan of Payment: If you have any questions regarding your insurance coverage or your financial responsibility, which is assigned by your coverage, please contact your insurance company at We recommend that you have your insurance card handy when you speak with them. Signed (Patient): *This agreement is for the surgeon only. You may receive bills from the hospital and other health care providers. Please note that this financial agreement outlines our best estimate for what will be performed, however, additional or different procedures may be necessary to complete the treatment. We follow the national coding guidelines as issued by the American Medical Association. The estimate includes customary post-operative care in our office. Your follow-up care may result in additional appointments for unforeseen circumstances, and these may result in additional financial responsibility.

11 Offer payment options Lead with: How much more time do you need, Ms. Woodcock? Encourage payment options based on your cost to collect Capture the best rate Pre-establish parameters of a payment plan Maximum time (e.g., 6 months) Minimum payments (e.g., $25) Offer swipe, hold and charge credit card option Identify a separate payer category for payment plans 11

12 How will you be paying today? Collecting a balance Ms. Jones, our practice s policy is to request payment at the time of service. Your insurance plan requires a copayment of $. Will you be paying with cash, check, or credit card? [Wait for card.] I also note that you have a small balance of $. Can we go ahead and run your card to take care of that balance? Source: E. Woodcock, Front Office Success, MGMA, 2010 ( 12

13 Requires employees who are capable of collecting: 1. Mr. Walker owes $ His health plan requires a 20% coinsurance. How much does he owe? Source for image: hsi.org 2. Mr. Wood does not have insurance, but he would like to take advantage of your discount for uninsured patients who pay in full at the time of service. His bill is $213, and your practice offers a 30% discount for payment in full. How much does he owe if he pays in full today? 1. Answer: $ Answer: $

14 If not, why not? report Patient Amt Due Status of Collection 7:45 a.m. Janet Jones $10 8:15 a.m. Jill Scoot $ :30 a.m. Cade Williams $0 8:45 a.m. Virginia Jacobs $

15 Reason Code 1 - Deductible Amount 15 - The authorization number is missing, invalid, or does not apply to the billed services or provider. Soft Denial Hard Denial 15

16 Policy and procedure Action and timeframe Initial, subsequent Denial Management Guide Is it worth your time? Need Thresholds! Effort & Money 16

17 Reason Code CO18 Exact Duplicate Claim / Service Payer PeachCare Action Post $0 Payment; Put Claim on Hold Worklist Biller-Medicaid

18 Prevention is the best medicine Provider enrollment and credentialing Accurate registration information, backed by financial clearance Non-office services Accurate time-of-service payments Accurate, timely procedure and diagnosis coding, with appropriate modifiers, linkages and places of service charge editing system 18

19 If so, write it off using the appropriate adjustment code Does the claim need to be written off? Does the claim need to be corrected? If so, correct it and resubmit it If so, develop your case and, using the payer s process, appeal it Does the claim need to be appealed? Find support in your contract Carbon copy the patient, if applicable 19

20 Implement feedback loop List top denials ($/#) at staff and physician meetings Discussion regarding new services with billing office Add denial rate to your management dashboard Monitor denials by reason code Return denials to origin (e.g., registration errors to front office), ideally automatically 20

21 Paid Claims Denied Claims Open Claims 21

22 Run an open claims report At minimum, every 60 days Best practice: follow payer payment cycles Use on-line claims status 22

23 Software/hardware Code edits/scrubber Remote deposit; pre-authorized credit card acceptance Insurance coverage, benefits eligibility and financial clearance Price estimation Registration/time-of-service payment Kiosk Charge capture mechanism Coding/reimbursement support Payment monitoring Online bill payment Electronic remittance/funds transfer Analysis and reporting Business intelligence tools Clearinghouse 23

24 Easy to blame poor performance on the payers Easy to hide poor performance via adjustments 24

25 1. Choose a single date of service nine months ago 2. Query for all open invoices 3. Randomly choose 50 of them 4. Pull all activities and notes associated with the invoices 5. Evaluate Terrific approach to employees performance evaluations! 25

26 Remember, this is a biased sample Who was responsible for non-payment? Were appropriate and timely actions taken? Were appropriate adjustments taken? Is the invoice in the hands of the correct financially responsible party? Did the notes explain the employee s actions? Can you understand them? 26

27 Complex, elaborate work Customers never grateful Compulsive, Type A workforce Photo Corbis.com 27

28 Charge tickets Rejections Remittances Denials Refunds Due guarantor accounts Professional Highlighter! 28

29 Per day Per hour Coding - Evaluation and Management codes n/a 15 to 20 - Surgeries and procedures n/a 6 to 12 Charge entry line items - Without registration 375 to to 75 - With registration 280 to to 55 Payment and adjustment transactions posted manually 525 to to 125 Refunds researched and processed 60 to 80 8 to 10 Insurance account follow-up - Research correspondence and resolve by telephone n/a 6 to 12 - Research correspondence and resolve by appeal n/a 3 to 4 - Check status of claim (telephone or online) and rebill n/a 12 to 60 Self-pay account follow-up 70 to to 13 Self-pay correspondence processed and resolved 90 to to 15 Guarantor billing inquiries (by phone or correspondence) 56 to 84 8 to 12. Walker, Woodcock, Larch, 2009, as published in The Physician Billing Process by MGMA 29

30 72 Hours 50 to 70 Daily 30

31 0.55: Patient Accounting Support Staff per FTE Physician source: MGMA, Back-end Business Office Employee to 10,000 Claims (Primary + Secondary) per Annum source: Woodcock & Associates,

32 Key Performance Indicator Your Practice High Performers Expected Range Days in Receivables Outstanding to 45 Percent of Receivables Over 120 Days 9.84% 12 to 17% Adjusted Collection Rate 99.16% 96 to 98% Cash $? $? Source for High Performers : MGMA Performance & Practices of Successful Medical Groups, 2013, median data for multispecialty practices. 32

33 Identifying Opportunity: How much are you writing off for noncontractual (controllable) losses? TIP: Use your adjustments as a guide to performance improvement; most opportunities are within your purview 33

34 100% Adjustment Report [line item level] 34

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36 Pre-Employment Test for Business Office Staff me for the elizabethwo odcock.com 36

37 Elizabeth W. Woodcock, MBA, FACMPE, CPC Woodcock & Associates Speaker, Trainer, Author Atlanta, Georgia These handouts may not be reproduced without the written consent of the speaker. 37