FOCUSING YOUR REVENUE CYCLE

Transcription

1 FOCUSING YOUR REVENUE CYCLE GAURAV GUPTA VP, PRODUCT STRATEGY AND PERFORMANCE MANAGEMENT

2 Connect the Data Linkage of previously disparate data promotes root cause analysis & action plan development Integration of data into a single reporting system will drive workflow processes and provide consolidated reporting Contract Management Reporting & Dashboard BI Application Workflow 835/837 Remittances

3 Leakage: Payment Variance to Expected Leakage = Expected Reimbursement Total Payments to Date If your Contract Management system does not generate a valid expected reimbursement amount, use the Cash Factor Cash factors at payer and service line levels should be calculated using accounts that have had a period of time to liquidate Important Restrictions: Evaluate 0 Balance Accounts Use a lag period (At east 90 Days) to allow accounts to resolve

4 Ex: Leakage Rate Payer-specific comparison of leakage rates shows revenue lost and targets areas of focus Leakage rate hits a high of over 5.5% for Commercial and Medicaid HMO Financial Clusters

5 Denial Rates Dependent on accurate capture of denial adjustments and well designed denial code structure Benchmark Total Net Denial Rate 2% 1% Net Technical Denial Rate 1% Clinical Denial Rate Utilize payer, service line, and physician level groupings to identify targeted areas of opportunity

6 Ex: Gross Denials

7 Ex: Gross Denial Rate Payer 1 Payer 2 Payer 3 Payer 4 Payer 5 Compare across payers to analyze how payer behavior compares to peers Payer 4 Denial Rate for Patient Info = 6.12%, compares to <2% for other payers

8 Ex: Net Denial Write Offs

9 Ex: Net Denial Rate Payer 1 Payer 2 Payer 3

10 Ex: Payments to Expected Reimbursement Denial Type Total Denial Amount Total Eventual Payments Sum Expected Reimbursement Payments to Exp Reim Ratio Authorization $1,220, $220, $612, Eligibility & Benefits $1,630, $280, $697, Additional Info - Patient $97, $13, $30, Coding $184, $75, $129, Provider $243, $43, $73, Timely Filing $890, $78, $132, Medical Neccesity $1,601, $1,190, $1,980, Technical Billing $571, $221, $357, Additional Info - Hospital $2,488, $2,072, $2,985, Coordination of Benefits $739, $405, $566, Non-Covered Service $8,512, $2,969, $3,948, Other Denial $1,607, $760, $993, Grand Total $19,787, $8,332, $12,508,

11 Ex: Payments to Expected Reimbursement Denial Type Total Denial Amount Total Eventual Payments Sum Expected Reimbursement Payments to Exp Reim Ratio Authorization $1,220, Drill $220, down total 835 denied $612, Eligibility & Benefits $1,630, $280, $697, amount to remove claims that Additional Info - Patient $97, $13, $30, paid at 95% + of expected and Coding $184, $75, $129, duplicate ERAs for the same Provider $243, $43, $73, Timely Filing $890, $78, denial type $132, Medical Neccesity $1,601, $1,190, $1,980, Technical Billing $571, $221, $357, Additional Info - Hospital $2,488, $2,072, $2,985, Coordination of Benefits $739, $405, $566, Non-Covered Service $8,512, $2,969, $3,948, Other Denial $1,607, $760, $993, Grand Total $19,787, $8,332, $12,508,

12 Ex: Payments to Expected Reimbursement Denial Type Total Denial Amount Total Eventual Payments Sum Expected Reimbursement Payments to Exp Reim Ratio Authorization $1,220, $220, $612, Eligibility & Benefits $1,630, $280, $697, Additional Info - Patient $97, $13, $30, Coding $184, $75, $129, Provider $243, $43, $73, Timely Filing $890, $78, $132, Medical Neccesity $1,601, $1,190, $1,980, Technical Billing $571, $221, $357, Additional Info - Hospital $2,488, $2,072, $2,985, Coordination of Benefits $739, $405, $566, Non-Covered Service $8,512, $2,969, $3,948, Other Denial $1,607, $760, $993, Utilization Grand Total of contract pricing $19,787, data to $8,332, $12,508, show true payment variance

13 Ex: Payments to Expected Reimbursement Denial Type Total Denial Amount Total Eventual Payments Sum Expected Reimbursement Payments to Exp Reim Ratio Authorization $1,220, $220, $612, Eligibility & Benefits $1,630, $280, $697, Additional Info - Patient $97, $13, $30, Coding $184, $75, $129, Provider $243, $43, $73, Timely Filing $890, $78, $132, Medical Neccesity $1,601, $1,190, $1,980, Technical Billing $571, $221, $357, Additional Info - Hospital $2,488, $2,072, $2,985, Coordination of Benefits $739, $405, $566, Non-Covered Service $8,512, $2,969, $3,948, Other Denial $1,607, $760, $993, Grand Total $19,787, $8,332, $12,508, Provides insight to cash lost due to specific denial reason using 835 data

14 Strategic Workflow Prioritization Utilize the ERA information to drive workflow to front line staff at the highest priority Further refine the payer responses to identify the type of work required: o Classify your CARC/RARCs into denial types that can feed into workflow o Compare remaining balance to Patient Liability Amount to isolate accounts requiring balance transfers o Compare payment amount to Expected Reimbursement to find remaining expected reimbursement o Prioritize work by remaining expected reimbursement (high to low) Denial Resolution Action Required Actionable CARC/RARC on ERA $0 Payment Transaction Payment Posted Expected Amount Requires Balance Adjustment/Transfer Payment Posted but Balance 0 Balance = Patient Liability

15 Workflow Productivity Productivity should be just as important in revenue steering committee meetings as other KPIs Average total weekly productivity is approx. 2,400 accounts

16 Workflow Productivity Productivity should be just as important in revenue steering committee meetings as other KPIs Break down your productivity to show productivity on denied accounts to make sure that denial inflow is appropriately covered and prioritized Average total weekly productivity is approx. 2,400 accounts Average weekly touches to denied accounts is approx. 650

17 Analysis of Work Performed Drill into specific user activity to analyze actions applied on denied accounts Assess correlation between denial leakage rates and how accounts are worked on the back end

18 Analysis of Work Performed Drill further to see actions by specific employee Pinpoint exactly where to focus additional training or QA efforts!

19 Speed to Cash as % of Expected X Days Broken out into 30 Day Increments out to 180, 180 to 270, 270 to 360 and 360+ Measures both Revenue Cycle Goals Totality and Speed o o Answer the age old question Why/Where is cash up/down/flat? Relies on good Net Revenue and Expected Reimbursement data Total % for sufficiently aged periods are leakage to expected o o Leakage goal best practices Medicare/Medicaid 99% Commercial Payers 95% Variance to Target Leakage x Annual Expected for payer = P+L Opportunity Trends are key. Performance changes will appear quickly in this analysis. Creating this report for specific payers, services is key.

20 Ex: Speed to Cash as % of Expected Reimbursement % of Expected Collection Within Payer Discharge Month Total Charges Expected 30 Days 60 Days 90 Days 120 Days 150 Days 180 Days 270 Days 360 Days Total Payer 1 8/1/2014 $2,891, $1,364, % 81.85% 88.97% 91.09% 93.17% 92.26% 92.50% 92.51% 92.46% 9/1/2014 $2,728, $1,335, % 80.86% 82.09% 84.05% 84.22% 85.13% 91.49% 91.31% 91.68% 10/1/2014 $3,252, $1,600, % 88.50% 90.10% 91.40% 93.45% 93.80% 94.61% 94.82% 95.14% 11/1/2014 $3,893, $1,936, % 88.22% 90.34% 95.02% 95.21% 95.31% 95.80% 96.08% 96.76% 12/1/2014 $4,082, $2,037, % 86.42% 91.22% 94.77% 95.36% 96.03% 96.43% 96.65% 96.83% 1/1/2015 $3,002, $1,479, % 74.75% 79.44% 86.30% 89.12% 89.78% 90.33% 90.89% 91.14% 2/1/2015 $2,021, $984, % 73.50% 79.01% 86.19% 87.89% 88.26% 89.43% 89.79% 90.28% 3/1/2015 $2,896, $1,424, % 80.81% 85.14% 85.53% 88.04% 88.31% 91.68% 91.84% 92.49% 4/1/2015 $3,316, $1,642, % 63.35% 64.61% 67.66% 68.43% 84.95% 89.95% 90.05% 90.18% Improvement in the 5/1/2015 $2,694, $1,324, % 74.78% 84.22% 88.68% 89.09% 89.44% 89.73% 89.99% 90.27% 6/1/2015 $3,032, $1,509, % 78.29% 83.89% 85.28% 85.85% 86.46% 90.40% 92.24% 92.04% 0 30 Day increment is 7/1/2015 $2,947, $1,457, % 68.99% 76.30% 82.35% 87.79% 89.03% 91.52% 91.61% 91.78% 8/1/2015 $2,903, $1,424, % 72.85% 77.33% 89.27% 89.51% 89.76% 90.20% 91.78% 91.84% 9/1/2015 $2,824, $1,390, % 83.46% 89.51% 89.95% 92.57% 92.73% 92.93% 10/1/2015 $3,566, $1,759, % 79.61% 85.76% 85.92% 86.98% 87.98% 89.74% 11/1/2015 $3,107, $1,533, % 85.52% 91.46% 91.96% 92.71% 93.06% 93.20% 12/1/2015 $3,355, $1,649, % 82.52% 84.01% 86.36% 87.62% 87.94% 1/1/2016 $2,616, $1,288, % 80.86% 82.46% 84.47% 85.20% 85.12% 2/1/2016 $2,915, $1,439, % 84.21% 86.62% 87.57% 88.06% 88.49% 3/1/2016 $4,076, $2,038, % 87.96% 90.12% 90.80% 91.06% 4/1/2016 $3,280, $1,619, % 85.58% 87.70% 88.24% 5/1/2016 $2,612, $1,293, % 82.76% 83.86% 6/1/2016 $3,017, $1,487, % 76.65% 7/1/2016 $2,996, $1,479, % Payer 2 8/1/2014 $29,608, $7,374, % 84.27% 87.21% 88.06% 88.67% 89.25% 89.93% 90.05% 90.75% 9/1/2014 $29,131, $7,173, % 86.36% 87.77% 89.09% 89.71% 89.75% 90.33% 90.75% 91.21% driven by DNFB reduction

21 Ex: Speed to Cash as % of Expected Reimbursement % of Expected Collection Within Payer Discharge Month Total Charges Expected 30 Days 60 Days 90 Days 120 Days 150 Days 180 Days 270 Days 360 Days Total Payer 1 8/1/2014 $2,891, $1,364, % 81.85% 88.97% 91.09% 93.17% 92.26% 92.50% 92.51% 92.46% 9/1/2014 $2,728, $1,335, % 80.86% 82.09% 84.05% 84.22% 85.13% 91.49% 91.31% 91.68% 10/1/2014 $3,252, $1,600, % 88.50% 90.10% 91.40% 93.45% 93.80% 94.61% 94.82% 95.14% 11/1/2014 $3,893, $1,936, % 88.22% 90.34% 95.02% 95.21% 95.31% 95.80% 96.08% 96.76% 12/1/2014 $4,082, $2,037, % 86.42% 91.22% 94.77% 95.36% 96.03% 96.43% 96.65% 96.83% 1/1/2015 $3,002, $1,479, % 74.75% 79.44% 86.30% 89.12% 89.78% 90.33% 90.89% 91.14% 2/1/2015 $2,021, $984, % 73.50% 79.01% 86.19% 87.89% 88.26% 89.43% 89.79% 90.28% 3/1/2015 $2,896, $1,424, % 80.81% 85.14% 85.53% 88.04% 88.31% 91.68% 91.84% 92.49% 4/1/2015 $3,316, $1,642, % 63.35% 64.61% 67.66% 68.43% 84.95% 89.95% 90.05% 90.18% 5/1/2015 $2,694, $1,324, % 74.78% 84.22% 88.68% 89.09% 89.44% 89.73% 89.99% 90.27% 6/1/2015 $3,032, $1,509, % 78.29% 83.89% 85.28% 85.85% 86.46% 90.40% 92.24% 92.04% 7/1/2015 $2,947, $1,457, % 68.99% 76.30% 82.35% 87.79% 89.03% 91.52% 91.61% 91.78% 8/1/2015 $2,903, $1,424, % 72.85% 77.33% 89.27% 89.51% 89.76% 90.20% 91.78% 91.84% 9/1/2015 $2,824, $1,390, % 83.46% 89.51% 89.95% 92.57% 92.73% 92.93% 10/1/2015 $3,566, $1,759, % 79.61% 85.76% 85.92% 86.98% 87.98% 89.74% 11/1/2015 $3,107, $1,533, % 85.52% 91.46% 91.96% 92.71% 93.06% 93.20% 12/1/2015 $3,355, $1,649, % 82.52% 84.01% 86.36% 87.62% 87.94% 1/1/2016 $2,616, $1,288, % 80.86% 82.46% 84.47% 85.20% 85.12% 2/1/2016 $2,915, $1,439, % 84.21% 86.62% 87.57% 88.06% 88.49% 3/1/2016 $4,076, $2,038, % 87.96% 90.12% 90.80% 91.06% 4/1/2016 $3,280, $1,619, % 85.58% 87.70% 88.24% 5/1/2016 $2,612, $1,293, % 82.76% 83.86% 6/1/2016 $3,017, $1,487, % 76.65% 7/1/2016 $2,996, $1,479, % Payer 2 8/1/2014 $29,608, $7,374, % 84.27% 87.21% 88.06% 88.67% 89.25% 89.93% 90.05% 90.75% 9/1/2014 $29,131, $7,173, % 86.36% 87.77% 89.09% 89.71% 89.75% 90.33% 90.75% 91.21% Improvement in the Day increment is driven by more efficient follow-up practices

22 Ex: Drill to Isolate Specific Payer/Services % of Expected Collection Within Patient Type Discharge Month Total Charges Expected 30 Days 60 Days 90 Days 120 Days 150 Days 180 Days 270 Days 360 Days Total 101 : Inpatient 8/1/2014 $1,136, $507, % 79.39% 92.87% 94.11% 94.12% 94.41% 93.96% 94.03% 92.82% 9/1/2014 $832, $416, % 77.02% 77.78% 78.08% 78.08% 79.80% 94.80% 94.17% 94.50% 10/1/2014 $1,437, $716, % 92.34% 92.95% 93.52% 97.09% 97.19% 97.54% 97.54% 97.54% 11/1/2014 $2,127, $1,063, % 93.54% 95.35% 97.26% 97.35% 97.38% 96.92% 97.06% 98.08% 12/1/2014 $1,555, $797, % 90.26% 92.53% 96.36% 96.71% 97.62% 97.67% 97.81% 97.94% 1/1/2015 $1,292, $644, % 79.37% 85.54% 90.35% 94.71% 94.78% 95.02% 95.28% 95.59% 2/1/2015 $669, $334, % 82.47% 91.29% 91.59% 91.74% 91.78% 93.66% 93.66% 93.66% 3/1/2015 $714, $357, % 85.73% 86.94% 87.05% 94.48% 94.62% 95.70% 95.71% 96.05% 4/1/2015 $1,694, $847, % 52.99% 53.14% 58.17% 58.23% 89.61% 94.90% 94.90% 94.91% 5/1/2015 $716, $358, % 69.47% 79.72% 95.04% 95.04% 95.04% 95.04% 95.04% 95.04% 6/1/2015 $979, $506, % 73.78% 75.89% 77.09% 77.32% 78.82% 86.32% 90.48% 89.76% 7/1/2015 $889, $444, % 74.85% 84.55% 94.84% 94.93% 95.06% 94.46% 93.81% 93.91% 8/1/2015 $930, $458, % 75.78% 83.83% 92.13% 92.19% 92.35% 92.71% 95.94% 95.94% 9/1/2015 $1,023, $511, % 85.83% 95.67% 96.35% 96.59% 96.63% 97.05% 97.13% 97.13% 10/1/2015 $1,745, $872, % 78.38% 88.01% 88.08% 88.12% 89.68% 92.19% 92.42% 92.42% 11/1/2015 $1,214, $607, % 90.03% 96.81% 97.04% 97.06% 97.06% 97.08% 97.08% 97.08% 12/1/2015 $1,379, $689, % 80.36% 80.54% 85.36% 85.70% 85.77% 93.78% 93.78% 93.78% 1/1/2016 $970, $485, % 86.94% 87.07% 87.27% 88.36% 88.41% 88.59% 88.59% 88.59% 2/1/2016 $1,010, $505, % 93.07% 93.94% 93.70% 93.90% 94.42% 94.62% 94.62% 94.62% 3/1/2016 $2,306, $1,177, % 93.81% 96.74% 96.79% 96.79% 97.10% 97.10% 97.10% 97.10% 4/1/2016 $1,260, $630, % 93.95% 95.77% 95.83% 95.91% 95.91% 95.91% 95.91% 95.91% 5/1/2016 $948, $474, % 86.69% 87.40% 87.79% 94.73% 94.73% 94.73% 94.73% 94.73% 6/1/2016 $1,148, $574, % 68.85% 77.69% 77.69% 77.69% 77.69% 77.69% 77.69% 77.69% 7/1/2016 $1,065, $530, % 85.89% 85.89% 85.89% 85.89% 85.89% 85.89% 85.89% 85.89% 103 : Emergency 8/1/2014 $666, $328, % 82.39% 85.66% 86.28% 86.39% 86.59% 85.89% 85.14% 87.08% 9/1/2014 $703, $347, % 77.11% 78.27% 80.60% 80.63% 81.49% 82.02% 82.19% 82.80% 10/1/2014 $715, $357, % 77.23% 79.58% 83.35% 83.88% 84.77% 87.06% 87.25% 87.61% 11/1/2014 $640, $322, % 82.96% 84.20% 88.45% 88.76% 90.09% 90.75% 91.40% 91.81%

23 Key Measures to Focus Your Revenue Cycle Contract Management Net Payments to Expected Ratio 835/837 Remittances Speed to Cash as % of Expected Reimbursement Prioritize workflow using Remaining Expected Reimbursement Leakage Rate Reporting & Dashboard BI Application Workflow Net Denial Rate Analyze actions applied to denied accounts Gross Denial Rate Leverage ERA data to drive workflow processes

24 THANK YOU GAURAV GUPTA