Co pays and Deductibles: Polices and Procedures
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1 Co pays and Deductibles: Polices and Procedures :, Senior Operations and Management Consultant M.T.M. Services Web Site:
2 1
3 MTM Publication Ordering Information: or Call (202)
4 A Roadmap for Impactful Change! Operationalizing Health Reform was written by the entire Team to be an up to date view of what we have learned working to help hundreds of organizations across the country and abroad make the changes necessary to be successful in today s ever changing environment of health reform. Each of the book s 14 chapters deal with a specific change focus required to help vision based leaders improve their organization s quality of care, efficiency, and the compliance of their service delivery system! To Order or for more information visit: or If preferred call (202)
5 How to Get and Keep the Best Employees: A guide to workforce innovation Michael has over 25 years experience in clinical practice and mental health administration. He has extensive experience in Strategic Planning, Performance Improvement, Clinical Re-Engineering, Marketing, Business Planning, Leadership Training, Project Management Mergers and Acquisitions in healthcare He has lectured throughout the country on the national conference level on behalf of treatment and administrative issues. His work has been highlighted in Behavioral Healthcare Tomorrow, Behavioral Healthcare Technology, Health Care Technology, CMHC s One Magazine, and MD News Magazine. He is a frequent contributor to the NI Business News, and his work has been featured in numerous publications by the National Council for Behavioral HealthCare publications. Mr. Flora currently holds a position on the editorial board for the Joint Commission on Accreditation Healthcare Organizations (JCAHO) publication JCAHO Advisor for Behavioral Healthcare Providers and is listed in the Who's Who of Executives and Professionals. He currently serves on state and local committees to improve the behavioral health care of our children, families and adults in Illinois. Michael Flora, MBA, M.A.Ed., LCPC
6 Health Reform Implementer The Affordable Care Act, parity, Medicaid expansion, and new market and customer forces are ushering in rapid changes in how healthcare is accessed, delivered, and paid for. Your markets are expanding fast behavioral health coverage will expand to 62 million Americans by And it s not going to be business as usual! The team has led 700+ behavioral health organizations across the country in adapting to changing healthcare delivery and payment systems. Today, in partnership with the National Council for Community Behavioral Healthcare offers the Health Reform Implementer newsletter to prepare community behavioral health organizations, large health systems, managed care entities, and state and county behavioral health systems, for the dynamic new healthcare marketplace. Health Reform Implementer brings you the best of the MTM team s healthcare consulting expertise and is edited by Michael Flora. The newsletter is packed with tips and tools to help you improve quality and access to mental health and addictions care; achieve operational efficiencies; streamline billing and collections; improve staff productivity; establish outcome measures; design key community collaborations; and face up to the competition in the new era defined by the Affordable Care Act. Purchase your subscription to Health Reform Implementer via the National Council Store. Breaking news and articles are posted on our website for subscribers to access at any time with a password. Subscribers receive alerts every month, listing the latest articles available online. 5
7 The healthcare market place is changing. Behavioral Healthcare providers are finding it necessary to change their front office and back office procedures to assist in the capture of copays and deductibles. This session will focus on best practices in Co pay and collections from front desk scripts to sample policies and procedures to assist in collections.
8 Learning Objectives Identify what key scripting is needed to assist Customer Service Team members be successful in asking for co pays and deductibles Examine your daily sales figures to align incentives with co-pay collections Identify the key drivers in balancing clinical risk and payment
9 Questions? What percent of your population has deductibles? What percent have co pays? What percent have high deductibles? What are your daily collections?
10 Front Desk The further away from the from desk you consumer gets the less likely it is that you will collect the co pay What have you determined as your Client Fees in your budget? Set daily sale figure/collections targets at the front desk
11 Example Client Fees: $800, days you are open for business a day is needed across all sites/locations Break down by volume at each site Set KPIs for your front desk staff
12 Revenue Cycle Management A greater understanding of cash flows and management of billing practices will be needed in the new environment How long is your billing process? Are you billing weekly? Can you process third party claims daily? What is your percent of denials? What is your performance standard on reconciliation of billing errors? What percent of co-pays and self pay amounts are you collecting daily Do you establish a daily collection figure for your front desk? 11
13 Service Authorization Verify Payor Verify Co-Pay Verify client financial information
14 Third Party Payer Assessment Sheet Revenue Enhancement Work Sheet
15 Improving Access Management What are your days of sales outstanding? By facilitating improved workflow processes and eliminating the paper chase, The new behavioral healthcare organization will need to accurately authorize services, determine, validate coverage for payment, assess payment risk and schedule resources prior to the patient s arrival.
16 Fee/Billing Policies: At the time of your first appointment, you will need to complete and update annually, the Client Financial Information and Fee Agreement Form. You are expected to pay at the time of service, any co-pay/co-insurance, deductible, or balance that is due. You may need to reschedule your appointment if you are unable to make your payment. If you cannot make your scheduled appointment, you must notify AGENCY at least 48 hours in advance of the appointment. If you fail to call and cancel your appointment in this time frame, you may be referred to the Motivational Engagement Group or services will be terminated due to repeat no-shows. AGENCY applies collection procedures when necessary which may include collection agencies. Please notify AGENCY immediately of any address or telephone number changes. You are expected to immediately provide AGENCY evidence of financial status and/or insurance coverage changes. Loss of insurance/funding may impact your ability to receive services at AGENCY. Daily room and board charges are assessed upon admission into Program. These are separate from treatment charges.
17 KPIs
18 Health Insurance Most health insurance policies cover behavioral health and substance abuse services to some extent. IF YOU HAVE HEALTH INSURANCE, IT IS IMPORTANT THAT YOU GIVE US THIS INFORMATION RIGHT AWAY. We will bill your insurance company directly so that they can pay us directly. Should your insurance company pay us for what you have already paid, we will credit your account or give you a refund. Your insurance company is billed our full fee. You are responsible for any deductibles, co-pays, and the balance that is not covered by your insurance company. Any deductibles and co-pays are not eligible for a sliding fee adjustment. If your balance after insurance payments reaches $300, you will be required to make a payment to lower the balance below $300 or your next appointment will not be scheduled.
19 Extended Payment Plan If necessary, an Extended Payment Plan may be arranged. If this approach will assist you in paying your bill, please arrange to meet with our Client Accounts staff. Should your financial circumstances change, we reserve the right to renew and revise your extended payment plan at any time. If you are on an extended payment plan, you will be required to pay your pre-arranged amount at each appointment, or your next appointment will not be scheduled.
20 Sliding Fee If your financial circumstances are such that paying the full fee is impossible, you may be eligible for a Sliding Fee, which will allow payment at less than the full fee rate. If this approach seems necessary for you, please discuss it with our Client Accounts staff. For all services, except for substance abuse groups, you will be given one grace appointment of non-payment. If payment is not made at the next scheduled appointment, then no additional appointments will be made. Clients in substance abuse groups will be required to pay prior to each session in order to participate in the group. If you are put on a sliding fee schedule, there is a discount applied to your fee if you pay at the time of service.
21 Payment of Bills You will be expected to pay your fee each time you receive service. Credit cards may be accepted. If, however, you are unable to remain current with your account, a different approach may be necessary. Please discuss such circumstances with our Client Accounts staff or your clinician. If you do not, and payment is not made, we reserve the right to turn your account over to a collection agent.
22 Responding to Healthcare Consumerism Consumer self-service is becoming a standard part of day-to-day life. Access to a behavioral healthcare kiosk and portal will become an expectation in your patient community. Allowing consumers to research costs, schedule appointments, clinician profiles,receive online statements and make electronic payments are just a few of options that organizations will need to manage in the new healthcare delivery market to respond to consumer demands.
23 Accelerating Cash Collection After services are delivered your organizations revenue cycle solutions maximize revenue capture and streamline the billing and collection process with electronic claim processing, direct entry of Medicare claims, automatic secondary billing, remittance posting, document image retrieval, contract and denial management, and financial analysis
24 What about the payors? Improving Payor Performance Knowing Payor expectations What payors are in your market What is the % of Medicaid? What is the % of uninsured? What is the % of Insured?
25 July August September October November December January February March April May June How does your payor mix compare to your market? Intakes by Payor Source EAP 4% Requests for Service Monthly Trend by Payor Source FY010 Self Pay/Sliding Fee 35% Insurance 28% Medicaid 33% Insurance Self Pay/Sliding Fee Medicaid EAP
26 Pre-Visit Contract management Patient Scheduling Medical Necessity Eligibility/Benefits Management Registration Point of Service
27 Visit Collection of Co-Pays Clinical Care Documentation Charge capture Coding Utilization Management
28 Collections Script: Front Desk: Hello, welcome to. How may I help you? (Patient is checking in), Mr. /Ms is see that you have a co-pay amount. How would you like to pay that this morning cash, Visa, MasterCard of Discover? (process credit card or receipt as appropriate:
29 If client states that they did not bring it today: Well Mr. / Ms I can see that you owe a balance of. In accordance with our fee agreement that you signed, you realize that you will need to bring payment in at your at your next appointment this weeks co pay as well as next weeks co-pay amount or we will not be able to schedule you again.( inquire as to how much they can pay on their account. Collect even the smallest amount and thank them for payment and give them a receipt)
30 If they have already had one grace period for non-payment: Mr. / Ms. last week we did inform you that you needed to bring in for today s payment. I m sorry in accordance with our policy we will not be able to schedule you again for services until you pay this balance.
31 Scheduling a client with a balance: Mr. / Ms. I can see that you owe a co pay/ balance of we do require that you pay 50% of that before I can schedule you today. I can take your credit card information now if you like and would be happy to credit your account.
32 Confirmation calls: This is. I am calling to remind you of your appointment with at is that still convenient for you? I also see that you have a balance of. Please remember to bring in your co-pay amount so we can continue to schedule you for your appointments
33 Post visit Billing Collections Management Denial Management Data Warehouse Analytics
34 Revenue Cycle Management Admission Eligibility Authorization Verification Open to Schedule Treatment Co-Pay Collections Post Session Scheduling Post Discharge Account Receivable Management Billing Cash Posting Consumer Follow-Up
35 UR/UM Plan Clinical Tools Needed Re-Authorizations During Service 1. Who will: Confirm the number of sessions that have been delivered against the current authorization from payer Obtain re-authorization prior to the end of the current authorization if additional services are clinically needed, and Engage in appeals process with payer if re-authorization is denied? 2. What clinical tool(s)/reports will they need/use to monitor current authorization levels and confirm need for re-authorizations (i.e., Number of remaining session in current authorization are recorded in centralized scheduler, etc.)?
36 Roles of Support Staff In Third Party Billing Centralized Scheduling is needed to ensure referral is made to clinician on the appropriate insurance panel Ability to know at all times the availability of clinical staff that are credential on third party panels will be critical to timely acceptance of new referrals Re-think Front Desk functions/needs Collection of Co-Pays prior to Service Confirmation of Insurance via copy of Insurance cards prior to service
37 Roles of Clinical and Financial Staff In Third Party Billing 1. Completion and submission of all required clinical documentation by direct care staff will be needed to support authorizations after Intake (if required) and reauthorizations 2. Filing timely and accurate claims will be critical 3. Monitoring level of unreimbursed third party care determine reasons for non payment and correct issues
38 Market Area Data Points Total population in service area Total number of Medicaid eligible s Total number of Insured in your service area Demographics such as per capta income, household size, ethnicity ages ( how many 0-5 in your service area) what is the % of growth over the past three years what is the project community growth in the next five years Major employers What insurance companies to business in your state What INS companies do business in your service area? What is the unemployment rate in your service area? Do you have any quality of life assessments in your community you can draw from? How many people by age/ethnicity do you serve last year What is your market share? By payor? What are your competitors doing? How many requests for service do you have? By age By payor Do you have an idea of the number of competitors in your community What is their cost for service how many people do they see a year
39 Questions you Should be asking Who are our clients? Where do they live? What are the market Growth Indicators in our Community What are the commuter patterns?
40 Many CBHOs Face Substantial Barriers in Accessing Third Party Markets: Challenge with timely access to treatment to support third party payer referral requirements Challenge with Community Awareness and Branding strategies to increase capacity Inconsistent Revenue Cycle Management procedures that enhance timely collections Inconsistent message to the community Understanding of the target markets in our communities 39
41 Enhanced Revenue Solution Areas That Need to Be Addressed: Inconsistent Revenue Cycle Management procedures that enhance timely collections 40
42 Payer Mix In the new environment provider organizations must include in their dashboard payer mix profiles for all services Utilize Resource Deployment standards Review our medical loss ratio on a monthly and quarterly basis Develop effective Collection of co-pays and follow up on delinquent accounts in a timely manner
43 July August September October November December Payer Mix Dashboard Objective Measure Type Increase service delivery /market share to Third Party payers Financial FY10 Requests for Service Payor Mix YTD EAP 4% Self Pay/Sliding Fee 28% Insurance 31% Goal Third Party revenues will increase over previous fiscal year Medicaid 37% Result Comments Third party referrals are at 31%. Given the economic conditions market share remains consistent Requests for Service Monthly Trend by Payor Source FY010 Insurance Medicaid Self Pay/Sliding Fee EAP Presented By: MTM Services 42
44 Medical Loss Ratio This report provides a summary of the actual cost of service vs. the reimbursement for those services $ $80.00 $60.00 $40.00 $20.00 $- $(20.00) SAMPLE: Medical Loss Ratio Individual Counseling $(40.00) Medicaid Medicare Private Insurance Grant Funds Cost Charge Amount Collected Loss Ratio
45 Enhanced Revenue Solution Areas That Need to Be Addressed: Use and measure key performance indicators (KPI) for all staff to ensure the movement to a true group practice model 44
46 Thank you for attending Questions? Feedback? Next Steps?
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