Leveraging Big Data to Stop Big Revenue Leaks

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Hillary Cameron
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1 INSIGHT GUIDE Leveraging Big Data to Stop Big Revenue Leaks One big way academic medical centers can obtain the highest hanging fruit

2 Contents PROFITABILITY IS GETTING HARDER AND HARDER TO REACH... 3 AMCS FIGHT TO REALIZE THE FRUITS OF THEIR LABOR Factors contributing to revenue leakage at AMCs Patient self-pay is expected to rise CAN BIG DATA INCREASE YIELD?... 7 THE TOP 10 THINGS AN INSURANCE DISCOVERY TOOL SHOULD HELP YOU DO... 8 TRANSUNION HEALTHCARE CAN HELP...9 OBTAIN THE HIGHEST HANGING FRUIT TransUnion LLC All Rights Reserved

3 For healthcare providers, profitability is getting harder and harder to reach By streamlining operations and leveraging new technologies like big data and analytics, AMCs can finally harvest the hardest-to-reach revenue. For the healthcare industry, one of the largest in the U.S., the only constant is change. The Affordable Care Act and attempts at repeal, tax reform, increased regulatory scrutiny, changing population demographics and industry consolidation all challenge existing processes and threaten profitability. Today's healthcare providers struggle to maintain a high standard of care, protect the bottom line and comply with the ever-evolving regulatory environment. And as the industry shifts from a fee-for-service model to a value-based care approach, they're seeking innovative ways to meet these struggles head on. While operational and revenue cycle challenges plague nearly every type of healthcare provider, they're particularly pronounced for academic medical centers (AMCs) which process large volumes of complex, high-dollar medical claims at a high risk for lost revenue. As with all hospitals, AMCs generate the majority of their revenue from direct patient care. However, they also receive funding from a variety of non-patient sources, including government subsidies, grants, investment income, and charitable donations. Historically, AMCs haven't had to rely solely on strong operating income for survival. However, today, patients are visiting hospitals less opting instead for outpatient settings. As new technology and innovative medicine have enabled shorter hospital stays, it has resulted in a great thing for patients but not for the hospital s bottom line. That, coupled with higher patient deductibles and a laser focus on decreasing overall healthcare spending in the U.S., have resulted in significant and growing revenue challenges, even for AMCs. Costs continue to grow faster than inflation, margins are eroding, and alternative sources of funding are increasingly scarce. Although the revenue challenges facing AMCs today are very real, with challenge comes opportunity opportunity to continuously improve and innovate. As complex issues arise, providers should take the opportunity to evaluate the things they're doing well, and address those that could be improved. By streamlining operations and leveraging new technologies like big data and analytics, AMCs can truly move the needle when it comes to patient care and revenue TransUnion LLC All Rights Reserved

AMCs fight to realize the fruits of their labor Providers must capture every dollar to survive yet revenue continues to leak for a variety of reasons.

4 AMCs fight to realize the fruits of their labor Providers must capture every dollar to survive yet revenue continues to leak for a variety of reasons. Revenue leakage the inability to collect earned revenue is a significant, pervasive challenge facing today s teaching hospitals. AMCs are at the core of the U.S. healthcare system, with top-tier education and research, leading edge technology and best-in-class patient care. Although they represent only 5% of America s hospitals, according to the Association of American Medical Colleges (AAMC), the roughly 400 major teaching hospitals and health systems in the U.S. provide nearly 25% of all hospital care, including 25% of all Medicare inpatient visits, 24% of all Medicaid inpatient visits and nearly 40% of the nation s charity care, making them especially vulnerable to at-risk revenue streams. 1 The tightening of already-narrow margins makes uncompensated care a topic of great concern and constant conversation among teaching hospital executives and boards. Despite Medicaid expansion, in 2016 uncompensated care increased by $2.6 billion (7%) to $38.3 billion, the first annual increase in uncompensated care since TransUnion LLC All Rights Reserved 1. Kirch M.D., Darrell G. (2016) Letter on Affordable Care Act Repeal from the President and CEO of Association of Medical Colleges to 115th Congressional Leaders 2. American Hospital Association. (2017). Uncompensated hospital care cost fact sheet. [Data file]. Retrieved from:

$.15 A McKinsey & Company study notes that 15 cents of every healthcare revenue dollar goes toward revenue cycle inefficiencies related to claims processing, payments, billing, bad debt and more.

94 95 96 97 98 99 00 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 $45B UNCOMPENSATED CARE COST *The above uncompensated care figures represent the estimated cost of bad debt and charity care to

5 $.15 A McKinsey & Company study notes that 15 cents of every healthcare revenue dollar goes toward revenue cycle inefficiencies related to claims processing, payments, billing, bad debt and more. 3 National Uncompensated Care Based on Cost*: (in Billions) 4 NUMBER OF HOSPITALS $10B $15B $20B $25B $30B $35B $40B $45B UNCOMPENSATED CARE COST *The above uncompensated care figures represent the estimated cost of bad debt and charity care to the hospital. This figure is calculated for each hospital by multiplying uncompensated care charge data by the ratio of total expenses to gross patient and other operating revenues. The total uncompensated care cost is arrived at by adding together all individual hospital values. The uncompensated care figure does not include Medicaid or Medicare underpayment costs, or other contractual allowances. Moreover, the figure does not take into account the small number of hospitals that derive the majority of their income from tax appropriations, grants and contributions. There are many factors that contribute to revenue leakage at AMCs the inability to capture insurance information at registration, missing and incorrect policy numbers and insurers, timing issues in payer eligibility databases, revenue cycle inefficiencies and claims denials, to name a few. According to The Advisory Board Company, more than 3% of net patient revenue is lost in denials. 5 Of those denials, nearly two-thirds are recoverable, and 90% are preventable TransUnion LLC All Rights Reserved 3. Finn P, Pellathy T, Singhal S. US healthcare payments: Remedies for an ailing system. McKinsey on Payments. April Source: Health Forum, AHA Annual Survey Data, Driving the Denials Management Initiative, a Renewed Focus, The Advisory Board Company, Washington, D.C., web conference, July An ounce of prevention pays off: 90% of denials are preventable. The Advisory Board Company, Dec. 11, 2014

6 PATIENT SELF-PAY IS EXPECTED TO RISE 100% A U.S. Government Accountability Office study reported that as many as one in four claims is denied a statistic that's not surprising considering the constantly changing insurance carrier landscape. 7 As providers are forced to choose between getting new bills out the door and evaluating whether or not old bills have been paid, recovering receivables has become a significant challenge. 40% 30% 0% Self-pay is expected to rise to $68 billion by 2019 Consumers paid $47 billion in 2015 Cost of care and patients inability to pay also play a significant role in revenue leakage for AMCs and other providers alike and this is likely just the beginning. Thirty percent of the average healthcare bill currently comes from the patient s pocket, and patient self-pay is expected to increase at a compound annual growth rate (CAGR) of 10% from $47 billion in 2015 to $68 billion by Studies show that consumers rank paying medical bills below paying their mortgage or rent, utilities, car payments, and even cable, cellphone and Internet bills. 9 Percent of customers ranking the following expenses in their top two choices Mortgage/Rent 72 Utilities 55 Health insurance premium 22 Credit card bills 18 Auto loan/lease 14 Cable/cell phone/internet 8 Medical Bills 7 Other Entertainment, discretionary TransUnion LLC All Rights Reserved 7. U.S. Government Accountability Office. (2011). Private Health Insurance. Data on application and coverage denials. (Report to the Secretary of Health and Human Services and the Secretary of Labor GAO ). Washington, D.C. 8. Aite Group Whitepaper: U.S. Hospital Bill Payments: A Patient Self-Pay Call to Action 9. Pellathy, T., & Singhal, S. (2010, March). Revisiting healthcare payments: An industry still in need of overhaul [PDF document]. McKinsey & Company. Retrieved from Payments_An_Industry_Still_in_Need_of_Overnaul.pdf

America s teaching hospitals will continue to care for patients who may not have the ability to pay for care, but will be forced to absorb the resulting uncompensated care costs, threatening their

7 America s teaching hospitals will continue to care for patients who may not have the ability to pay for care, but will be forced to absorb the resulting uncompensated care costs, threatening their ability to support and advance their research and education missions. According to a recent TransUnion Healthcare study, 68% of patients failed to fully pay off medical bill balances in 2016, up from 53% in 2015, and 49% in This number is expected to climb to 95% by The study also revealed that the percentage of patients who have made partial payments toward their hospital bills has gone down dramatically from 89-90% in to 77% in Additional TransUnion Healthcare findings for payment patterns between 2014 and 2016 showed that 63% of hospital bills were $500 or less, and of those hospital bills, more than half were not paid in full in And of the 14% of hospital bills that were above $3,000, almost all were not paid in full in While the aforementioned statistics are not limited to teaching hospitals, these numbers would likely be even more staggering for AMCs given the high level of at-risk revenue exposure. In a recent statement released by the AAMC, it was noted that America s teaching hospitals will continue to care for patients who may not have the ability to pay for care, but will be forced to absorb the resulting uncompensated care costs, threatening their ability to support and advance their research and education missions. 11 Can big data increase yield? For AMCs, leveraging the data within their own existing data feeds, in combination with the right analytics, offers the opportunity to improve current processes and mitigate the risk of revenue leakage. Patient data is being used by hospital administrators to help control costs, improve profits, and cut down on lost revenue and wasted overhead. Through the use of big data technologies, hospitals and other healthcare facilities have been able to reduce costs by more than 10% and grow revenue by 30%. 12 Providers are also leveraging the technology behind insurance discovery tools, which overlay the AMC s proprietary patient data with other data sources using data matching technologies to uncover additional insurance coverage and help minimize lost revenue. However, not all discovery tools are created equal. Through the use of big data technologies, hospitals and other healthcare facilities have been able to reduce costs by more than 10% and grow revenue by 30% TransUnion LLC All Rights Reserved 10. Transunion. (2017). Patients May Be the New Payers, But Two in Three Do Not Pay Their Hospital Bills in Full. [Data file] Retrieved from: Association of American Medical Colleges. (2017) AAMC Statement on the CBO Score of the American Health Care Act. Retrieved from: Big Data in the Healthcare & Pharmaceutical Industry: Opportunities, Challenges, Strategies & Forecasts Report by SNS Research

When evaluating solutions, here are the top 10 things an insurance discovery tool should help you do: 1. Identify hard-to-find insurance coverage and correct policy numbers. 2.

8 When evaluating solutions, here are the top 10 things an insurance discovery tool should help you do: 1. Identify hard-to-find insurance coverage and correct policy numbers. 2. Manage timing delays and changes in payer eligibility databases. 3. Identify the correct payer information for a specific service. 4. Address unique Medicare billing challenges. 5. Analyze accounts with no meaningful activity to look for information gaps. 6. Reexamine atypical billing requirements. 7. Revisit zero balance accounts classified as paid or written off as charity allowances. 8. Look at bad debt accounts for deductibles and copays to determine if there s additional coverage. 9. Uncover billing system and process issues resulting in incorrect or unbilled claims. 10. Identify missed shadow billing. Revenue leakage is just one of many challenges facing AMCs and the healthcare industry more broadly. But by taking the necessary steps, it s a challenge that can be significantly mitigated. By minimizing revenue leakage, AMCs can convert uncompensated care into steady revenue streams, improve efficiencies around time and productivity, and ultimately ensure that at risk earned revenue becomes paid revenue TransUnion LLC All Rights Reserved

9 TransUnion Healthcare can help TransUnion has been serving AMCs for nearly 20 years. We understand the complexities and the importance of protecting earned revenue to fund and produce the life-saving research, technology, physicians and patient care that Americans are so fortunate to access. TransUnion Healthcare's Revenue Assurance is a technology-enabled service that combines market-leading proprietary software with expert knowledge of billing processes, regulations and the revenue cycle helping to ensure that at risk revenue earned becomes paid revenue. Revenue Assurance goes beyond traditional insurance discovery operating under the assumption that all claims should be paid. The algorithm doesn t stop searching until insurance coverage is found or a manual review by a TransUnion Healthcare expert confirms there are no further opportunities to pursue. The combination of advanced algorithms and manual review often turns false negatives ignored by other software solutions into true positives, helping our customers secure additional claims reimbursements. Our proprietary software logic continuously reviews all accounts, all payer classes and all services sent by our customers for every cycle, helping clients find up to 2% of additional revenue that others cannot. This small percentage of revenue leakage what we call the highest hanging fruit has a big impact on the bottom line and can only be found with advanced algorithms and expert review. Revenue Assurance finds the "highest hanging fruit" 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% TU 95% -2% Other 10% Monthly A/R cycle to bill and collect 63% Hospital Internal Resources 88% 49% 0 days 30 days 60 days 90 days 120 days TU Other Vendors Hospital TransUnion LLC All Rights Reserved

10 Obtain the highest hanging fruit Revenue Assurance identifies hard-to-find insurance coverage; uncovers incorrect payer information or policy numbers; identifies billing system and process breakdowns that result in unreceived, unaccepted, returned or denied claims; and finds and recovers TDRG underpayments on historical Medicare accounts ultimately delivering insurance information that is actionable. We then share our knowledge and findings to improve our clients processes and systems. With advanced software logic and expert analysis, we maximize the value we deliver to our customers. The result: revenue earned becomes revenue paid. Join six of the top 12 AMCs already using Revenue Assurance to help stop revenue leakage. Learn more with a no-obligation Revenue Assurance assessment. For more information about TransUnion Healthcare s Revenue Assurance solution, please hcsolutions@transunion.com TransUnion LLC All Rights Reserved

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