5 Steps to Reducing Administrative Costs in Physician Group Practices (A05)

Transcription

1 5 Steps to Reducing Administrative Costs in Physician Group Practices (A05) Presenters: Kenneth Willman, Director Provider Interface, Humana Melissa Lukowski, Director Outreach, athenahealth Mary Kelley, Vice President Product Solutions, Availity Cortnie Fricot, Practice Management Coordinator, GMS Christine Kean, COO, San Antonio Orthopaedic Group Melissa Lukowski Director Outreach, athenahealth 1

2 Healthcare Reform: Shifting Access to Care The Healthcare Reform Bill introduces some of the most dramatic changes to health care administration in a generation. Whatever its positive effects may be, it will mean massive change and expansion in the U.S. health care system. Between million people will gain access to health insurance through state Medicaid programs starting in 2014 programs which are already under a great deal of stress. The OIG documented issues in a report (OEI-OI-92-O100) that characterized physician hassle as follows: Physicians contend that the "hassle factor --administrative red tape associated with participating in Medicaid--discourages many doctors from treating patients who are covered by Medicaid. The perceived hassle compounds other factors contributing to low physician participation, most notably low fees relative to other payers. 3 Industry Trends When physicians refer to the administrative burden, they mean: Processing inefficiency increases total costs for doctors and hospitals by as much as $210 billion annually (Recent PNC Bank study) About 90% of rejected claims are denied simply because billing forms are incorrectly filled out (Advisory Board Company report) Practices spend as much as 14% of total revenue to ensure accurate reimbursement from insurers (2008 National Healthcare Exchange Services study) 77% of physicians agree that time spent with payers and third parties inhibits ability to spend time with patients (athenahealth and Sermo Physician Sentiment Index poll) 4 2

3 How do these Forces Impact Providers? Ever-changing landscape difficult for providers to build a repository of knowledge to manage their patient population Lack of transparency across the healthcare supply chain process and pricing Providers want to know what payers need for successful, timely claim processing s want providers to give them the info they need to process claims effectively Providers need access to real-time information on next responsible party liabilities Transaction standards not fully leveraged Resolution of claim denials has become more time consuming given the difficult transition payers have experienced in transitioning from proprietary codes on paper remittance to the standard electronic remittance code set Information obtained from the eligibility check often lacks additional benefits details needed to inform the provider s action to prevent denials 5 Mary Kelley Vice President, Product Solutions, Availity 3

4 Growth of CDHP Larger Patient Balance Rising Plan Costs Poor A/R Collection Growing Provider Bad Debt Market Influences Affect Providers Low Technology Adoption 7 Revenue Recognition Workflow Patient Schedules Appointment Coverage Determination Claims submitted/ Patient Billed Encounter Availity, LLC All rights reserved. 8 4

5 Revenue Recognition Workflow Patient Schedules Appointment Coverage Determination Claims submitted/ Patient Billed Encounter Availity, LLC All rights reserved. 9 Revenue Recognition Workflow Patient Schedules Appointment Coverage Determination Claims submitted/ Patient Billed Encounter Availity, LLC All rights reserved. 10 5

6 Cortnie Fricot Practice Management Coordinator, GMS GMS Florida West Coast, Inc. GMS was formed in 1997 by a small group of Primary Care Physicians Now operating with 16 locations, GMS is linked by a centralized computer system Billing is submitted, processed, and tracked out of the corporate office, leaving the physician s staff to focus on patient care Each office functions as its own profit center Each office sets its own hours, policies and procedures within corporate guidelines Corporate mandates are kept at a minimum GMS is a debt-free company It is owned, operated and managed by its physicians 12 6

7 We ve seen more patients enrolling in high deductible plans as their premiums have risen With patients having higher out of pocket expenses, we are seeing a drop in patient visits as they put off care to save money. Rising Plan Costs Growth of CDHP Larger Patient Balance As patient financial responsibility increases it has become critical that we collect the patients portion of the bill at the time of service. Poor A/R Collection What Providers Experience Growing Provider Bad Debt It has become increasingly difficult to collect for services rendered, so we have to be more creative in our collections process -- or risk losing money. For each month a balance is unpaid, the percent of accounts that will be uncollected increases. 13 Christine Kean COO, The San Antonio Orthopaedic Group 7

8 The San Antonio Orthopaedic Group 24 Orthopaedic Physicians & Surgeons Ancillary Services to include: Therapy Services (PT, Hand, Industrial Rehab) Imaging Centers (2 1.5T MRI s, 8 slice CT, Ultrasound) 6 O.R. ASC (Orthopaedic Surgery Center of San Antonio) Cast/DME/X-Ray 7 Clinical locations 285 Employees 10,000 Patient/MD Visits/Month 100% Physician Owned (No Joint Ventures) 15 Largest Physician Office Pressures/Trends Staying in business! Revenue vs. Expense Physician/Staff Satisfaction Regulatory Requirements RAC & other Audits Patient Expectations of Service 16 8

9 Trends in private practice Faster, Faster, Faster Transparency No longer the great and powerful Oz Focus on electronic office (EMR, interfaces, digital media) Increased need for identifying and reporting outcomes #1 is no longer Medicare, it is patients 17 Notable Influencers Relationships With patients With payers With hospital systems With vendors Political Local, State and Federal Stroke of the pen changes the rules 18 9

10 5 Steps to Reducing Administrative Costs in Physician Group Practices Step 1: Implement Staff and -Agnostic Processes Goal Allow consistent process to drive business activity regardless of payer: Standardize interactions with payers Leverage electronic transactions/data availability as an enabler Utilize a consistent approach for Patient processing Financial counseling Claim processing Centralize administrative functions so physicians can focus on treating patients Define job functions and tasks by the role, not the individual Minimize opportunities for tribal knowledge 20 10

11 Step 1: Implement Staff and -Agnostic Processes Impact For a group practice of 41 physicians similar to GMS, instituting consistent workflow using a multi-payer portal may yield significant ifi savings: Potential Physician Savings Annually $ 46,296.90* Potential Group Annual Savings $1,898,172.90* Labor costs estimated at $1.38 per call could be eliminated if insurance coverage verification were automated** * Calculated using data from Electronic Transactions Savings Opportunities for Physician Practices, Milliman (January 2006). ** Source: MGMA Benchmarking Studies and Healthcare Administrative Simplification Coalition Report, Step 1: Implement Staff and -Agnostic Processes Action Steps Implement a system that supports all payers with one, secure, consistent interface that is flexible enough to support office workflow with minimal disruption Explore web portal as well as direct connects through a PMS vendor Utilize standardized payer workflow as a tool for consistent practices across job functions 22 11

12 Step 2: Ensure Accurate Data Collection Pre-Encounter Goal Allow process to drive the way in which patient information is collected prior to the encounter Ensure the same steps are taken every time, with every patient Apply accurate data collected to the claim submission process Institute pre-encounter treatment cost transparency Operationalize collection prior to, or at the point of service, wherever possible 23 Step 2: Ensure Accurate Data Collection Pre-Encounter Impact Physician probability of collection:* Pre-access 96% Point of care 80% One month post-service 18% Pre-Auth requirements and criteria vary widely; the average annual cost for a 10-doctor practice to deal with pharmacy related issues was $137,000** Denied claims due to clinical or technical errors make up approximately 4% of practice s gross revenue*** *Source: National Association of Healthcare Access management (NAHAM) ** Source: MGMA Benchmarking Studies and Healthcare Administrative Simplification Coalition Report, 2009 *** Source: The Next Generation of Revenue Cycle Management, HFMA

13 Step 2: Ensure Accurate Data Collection Pre-Encounter Action Steps Verify information and insurance product from the patient s card at the time an appointment is scheduled Utilize the E&B transaction ti to: Verify patient s coverage/benefit level prior to treatment Determine whether the patient has co-insurance/primary coverage determination Determine if there is a requirement for a referral/authorization Provide information to the patient about their financial liability Use data collected to support the submission of clean claims to ensure high first pass rates Follow referral/authorization requirements to ensure full claim payment Utilize Patient Liability Estimators to provide financial liability information to patients prior to treatment Implement a means of collecting payment prior to treatment Explore card-on-file options 25 Step 3: Train Staff and Collect, Collect, Collect Goal: Set expectation up-front for patients (and staff) Identify benefits and out-of-pocket responsibility before time of service Communicate with patient prior to service, at time of service and after service (RTA) Track and report progress with staff Receptionists are no longer data entry clerks, they are financial counselors. Take inventory of skill sets may need adjustment here This is a process. You may not collect full payment initially, but expectation is set for future conversations/service Patients want to know what to expect. Healthcare system is stressful enough without the unknown financial impact. Offer multiple points and methods of payment options pre-collect, over the phone, website, statement, automatically with HSA/HRA plans, healthcare credit options 26 13

14 Step 3 Train Staff and Collect, Collect, Collect Impact: Collections will increase when expectation is set Prepare for negative (all you care about is money) Action Steps: Evaluate staff skills sets do you need to upgrade? Identify available resources Reach out to Vendors/s what services do they currently offer, what are your needs? Standardize payment options, do you offer enough? Train all staff (including physicians) Report progress frequently (Monthly is not enough) 27 Step 4: Leverage Technology to Eliminate Claim Delays Goal: Integrate technology at key points in the workflow Implement practice management and electronic health record systems to automate financial and clinical process steps Build interfaces to external systems to seamlessly integrate information from disparate systems Leverage standard transactions to inform claim life cycle: Eligibility Claim Status Inquiry Electronic Remittance Advice Employ point-of-service tools to determine patient liability Real-Time Claim Adjudication (RTCA) Estimators 28 14

15 Step 4: Leverage Technology to Eliminate Claim Delays Impact: Transition to a fully electronic environment will streamline data entry and reduce errors Practice Management Systems*: 6.9% improvement in collections 20% - 30% less cost as a percent of revenue Electronic Health Records**: 3.4% improvement in number of patients seen Average of $1,500/month from P4P programs over 5 years Use of standard transactions can provide information needed for a provider to correct errors in a timely manner***: Claim Status Inquiry***: 20% reduction in outbound telephone calls to payer Potential upside of 60% call reduction with payer specialized logic Electronic Remittance Advice (ERA)/Electronic Funds Transfer (EFT): Up to 50% decrease in time to receive payment*** Eligibility****: 56% reduction in eligibility-related denials 72% reduction in front-end rejection rate *Source: athenahealth Analysis: Q to Q1 2010,; included quarters have pre /post data for 27 or more provider groups. ** Source: athenahealth data *** Source: athenahealth data Q to Q ****Source: Q to Q Step 4: Leverage Technology to Eliminate Claim Delays Action Steps Have business process and rules integrated in the front-end so that errors can be identified and corrected prior to submission. Initiate t eligibility ibilit inquiry i prior to the patient t visit. it Look for the following information to inform next steps: Demographic: Verify member ID Check for changes in patient name, address, date of birth Plan expiration date Other Information Co-Pay, Co-Insurance, Deductible HMO PCP and Referral Management Check claim status 7-10 days after submission Use information returned to inform time of next action Sign up for electronic remittance and electronic funds transfer 30 15

16 Step 5: Create/Standardize Payment Analysis Process Goal: Separate payment posting and denial management processes so that normalization and analysis of denials can be performed for root- cause analysis Apply the cash and post per the payer s adjudication Don t allow judgment in portrayal of outcome - this obscures root cause identification and resolution 31 Step 5: Create/Standardize Payment Analysis Process Impact: Deviating from posting as the remittance indicates can lead to inconsistent interpretation of payer intent The dollars posted can be significantly impacted (e.g. contractual adjustments being reflected as write-offs, etc.) Action Steps: Create separate functions to manage posting and denials management Log discrepancies identified by the denials management function on payer deviation from the standard code set Confirm intent of codes returned with payer Codify and systematize knowledge as appropriate 32 16

17 Summary 5 Steps to Reducing Administrative Costs in Physician Group Practices Step 1: Implement Staff and -Agnostic Processes Step 2: Ensure Accurate Data Collection Pre-Encounter Step 3: Train Staff and Collect, Collect, Collect Step 4: Leverage Technology to Eliminate Claim Delays Step 5: Create/Standardize Payment Analysis Process 33 Questions: Thank You! Contact Information Chris Kean San Antonio Orthopaedic Group ckean@tsaog.comcom Cortnie Fricot GMS cfricot@gmsdocs.com Ext. 244 Mary Kelley Availity LLC mkelley@availity.com Melissa Lukowski athenahealth mlukowski@athenahealth.com Kenneth Willman Humana Inc kwillman@humana.com

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