The Revenue Cycle Contract Maze. Sandra J Gubbine, CPA, MBA, FHFMA, DBA AVP, Revenue Cycle

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2 The Revenue Cycle Contract Maze Sandra J Gubbine, CPA, MBA, FHFMA, DBA AVP, Revenue Cycle

3 Bio AVP, Revenue Cycle In Healthcare since 1995 Hospital Revenue Cycle since 2001 CPA, MBA, FHFMA, DBA

4 Revenue Cycle Process Flow Patient Access Hospital Documentation Of Services Billing Receivables Management Customer Service Scheduling Care Delivery Charge Master Claims Editor Payment Posting Customer Inquiries Pre- Registration Case Management CDI Bill Reconciliation Secondary Billing Issue Resolution Eligibility & Verification Utilization Management Coding/ CDMP Claims Submission Follow-Up / Unresolved Pmnt Financial Counseling Discharge Planning Charge Capture Contractual Adjustments Audits /Appeals/ Denial Mgmt Registration Patient Discharge Late Charges Patient Statements Bad Debt/ Write Offs

5 Real Process Flow for a Clean Claim

6 Focusing on One Facet of the Process How do we get paidin Healthcare? Who paysus? How do we know how to determine how much we get paid?

7 Determining Payment There are TWOcontracts involved in every payment a healthcare provider receives. The facility contract or lack of one. The patient s coverage contract

8 Charges Versus Payment Who pays full charges? Very few, if any payers No Fault Coverage can exhaust Workmen s Comp -UCR Non-Contracted Payers Tend to access network contracts

9 Know your Payer Contracts It is important to understand your contracts. Rev Cycle should be included when negotiating contracts: -Timely Filing -Appeal process -Audit Process -Carve Out Process

10 Know Contract Payment Structure DRG Know the trim days Percentage of Charges Case Rates Per Diem

11 Who pays how much? Facility Payer Contract indicates TOTALexpected payment Patient s coverage contract indicates WHOpays how much

12 Example Expected $2,000 Total Mr. Smith has a Same Day Surgery Procedure and he has Horizon PPO. Mrs. Jones has a Same Day Surgery Procedure and she has Horizon PPO. Mr. Grant has a Same Day Surgery Procedure and he has Horizon PPO.

13 Mr. Smith Mr. Smith s coverage pays 100% with no deductible and no copay. Horizon PPO pays $2,000. Mr. Smith pays $0

14 Mrs. Jones Mrs. Jones s coverage pays 90% with no deductible and no copay. Horizon PPO pays $1,800 Mrs. Jones owes $200

15 Mr. Grant Mr. Grant s coverage pays 100% once his deductible of $2,000 is met. Horizon PPO pays $0 Mr. Grant owes $2,000

16 SELF PAY Accounts Receivable Balance GOVERNMENT MGD MEDICAID MGD MEDICARE MEDICAID - O/S HMO SP BILLING NO FAULT WORK COMP MEDICAID - nj COMM FIN. ASST. MEDICARE BLUE CROSS - NJ Primary Ins Current Ins 20% 16% 12% 8% 4% 0%

17 SELF PAY GOVERNMENT Accounts Receivable Count MGD MEDICAID MGD MEDICARE MEDICAID - O/S HMO SP BILLING NO FAULT WORK COMP MEDICAID - nj COMM FIN. ASST. MEDICARE Primary Ins Current Ins BLUE CROSS - NJ 36% 30% 24% 18% 12% 6% 0%

18 Real Example Medicare Advantage Plan Inpatient 2 day stay Total Expected Payment $16,330 Medicare Advantage Plan pays $11,341 Patient owes $4,989

19 Real Example Medicare Traditional Plan Inpatient 2 day stay Total Expected Payment $16,584 Medicare Traditional Plan pays $15,268 Patient owes $1,316

20 Real Example PPO Plan Inpatient 2 day stay Total Expected Payment $12,539 PPO Plan pays $8,185 Patient owes $4,354

21 Real Example PPO Plan Inpatient 3 day stay Total Expected Payment $59,982 PPO Plan pays $59,232 Patient owes $750

22 Real Example Managed Medicaid Plan Inpatient 2 day stay Total Expected Payment $3,604 Managed Medicaid Plan pays $3,604 Patient owes $0

23 Medical Debt In 2016, TheNew York Timesreported that 20% of Americans under 65 with health insurance had trouble paying their medical bills over the past year. Of those, 63% claim to have used up all or most of their savings to tackle their healthcare expenses, while 42% took on an extra job to cover their costs.

24 #1 Reason Americans File for Bankruptcy Hint: It's not always avoidable

25 #1 Reason Americans File for Bankruptcy According to the Kaiser Family Foundation, more than a quarter of U.S. adults struggle to pay their medical bills. This includes folks who have insurance, whether independently or through an employer. In fact, medical debt is the No. 1 source of personal bankruptcy filings in the U.S., and in 2014, an estimated 40% of Americans racked up debt resulting from a medical issue.

26 #1 Reason Americans File for Bankruptcy In bankruptcy, medical bills are considered general unsecured debts just like your credit cards. This means that medical bills DO NOT receive priority treatment and can easily be wiped out by filing for bankruptcy.

27 Summary Know your payer contracts Understand that the patient s coverage determines the amount paid by payer and patient.

28 Questions????? Contact Info:

MAXIMIZING REIMBURSEMENT THROUGH COORDINATION OF BENEFITS

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