Specialty Reimbursement. Focused Results. Specialty Reimbursement. Focused Results. Medical Reimbursements of America

Transcription

1 Specialty Reimbursement. Specialty Reimbursement. Focused Results. Focused Results. Medical Reimbursements of America

2 A More Granular Approach to Revenue Cycle: Digging Deeper into Specialty Reimbursement Niches 2

3 3 More than ever hospital CEO s and CFO s are under extreme pressure

4 More than 16.4 million people are newly insured as a result of the ACA - However, medical spending continues to outpace deflating reimbursements Dramatic increase in payer and provider consolidation Increased consumer engagement into their own healthcare - More than 145 million now commercially insured Employers with high-deductible plans has nearly doubled since 2012 Information Technology still remains a costly necessity in order to maintain growth and compliance The concept of Big Data is largely a still out of reach tool for strategic insights 4

5 5 Focus on traditional indicators of a healthy revenue cycle are no longer enough

6 Hospitals have traditionally segmented and managed their payers into four primary categories Commercial 42% Self Pay 9% Other 6% Medicaid 18% Medicare 27% This leaves approximately 6% of their revenue in an other bucket 6

7 7 Who are these other payers and why are these Specialty Reimbursement Payers becoming increasingly important

8 8 Understanding and managing Non-Traditional payers, especially Auto No-Fault and Auto Liability, might not seem worth the effort, but consider a few facts

9 2015 was 14% ahead of 2014 in motor vehicle accidents Patient s treated as a results of an MVA represent a higher % of self pay volume In 2013, almost 25% of MVA related accounts had no commercial or government health In total the P&C industry paid out $30 billion in medical claims for MVA and WC injuries in 2013 The Insurance Research Council reported in October 2015 that the average cost per bodily injury claim from an MVA increased by 32.1% from 2005 to 2013, from $11,738 to $15,506 The average cost of a PIP claim increased 38.2% from $5,802 to $8,017, according to that same IRC study Attorney representation in these cases increased 31% between 2007 and 2012 to around 50% 9

10 10 Interested yet?

11 11 Interested yet?

12 12 Interested yet?

13 13 Interested yet?

14 14 Interested yet?

15 15 A strategy around Motor Vehicle Accidents is no longer an optional decision

16 16 5 Emerging Trends to Consider:

17 5 Emerging Trends to Consider: 1. Accident Claims, when managed effectively can represent meaningful revenue gains: Treat MVA s as a separate financial class in order to set goals and to manage the overall effectiveness of your internal program. 17

18 5 Emerging Trends to Consider: Compliance is a non-elective focal point. 2. Medicare Secondary Payer Compliance COB Provisions - Liability vs. No-Fault and Commercial Health - Hold Harmless clauses - Numerous Class Actions; Meaningful Damages 18

19 5 Emerging Trends to Consider: Patient Satisfaction has become increasingly important 3. Increased Patient $ Responsibility Experience must engage patient beyond clinical and into revenue cycle especially so within non-standard insurance scenarios like MVA s Map the entire patient experience to better understand the impact of each touchpoint Align with organizations who serve as advocates for your patients clinical and financial 19

20 5 Emerging Trends to Consider: Partnerships are becoming increasingly important 4. For MVA Patient Accounts: - Patient access teams must receive ongoing training - Patients must be educated - KPI s must be established and monitored Increase in hospitals partnering with outside vendors to secure this specialty expertise within the MVA space: - 7 / 10 largest health systems - 2 / 3 largest full service revenue cycle management outsourcing firms 20

21 5 Emerging Trends to Consider: 5. Regulatory and Case law changes are consistently changing in today s healthcare market: Particularly within the specialty reimbursement arena Increased consolidation drives the need to standardize processes across multiple jurisdictions with differing laws Internal tracking, communication and auditing must occur in order to maintain compliance and optimal management of specialty claim population Example: Shands Teaching Hospital v. Mercury Insurance Company County Ordinance vs. Special Law 21

22 Choosing to implement a strategy on motor vehicle accidents begins with determining whether to: Build an internal team; or Outsource to a specialized partner In either scenario, understanding a few key basics is highly important: First, you must understand why this niche is so highly problematic and lacks current automation 22

23 Pain of Accident Claims

24 Thus, internal teams will need to understand that these claims will require heavily manual components for each phase of accident investigation, billing, follow-up and payment posting Second, it is important to ensure teams understand the technical nuances of the various insurance types within the MVA space 24

25 Auto Accident Insurance Basics No-Fault Insurance Medical Payments (Med Pay) Insurance coverage that pays medical bills up to the insurance limits. Typical limits are around $5,000. This is an elected insurance by the insured. Exists in approx. 35 States. Personal Injury Protection (PIP) Mandatory insurance coverage that pays medical bills, lost wages, etc. up to the insurance limits. It limits the injured party from suing the at-fault party. Exists in approx. 15 States. Liability Insurance Insurance that is paid by the at-fault driver to the injured party for their medical bills and other injury related expenses. Remember, both of the above insurances typically pay at much higher rates than traditional insurance. Typically about 30% of all payments are paid at full gross charges. 25

26 Third, providers must have a good understanding of how their state specific laws dictate coordination of billing within these MVA patient accounts. At a high level, you must understand: Relevant state s lien law (if any) - Timeline and process for filing - Payout formula (if any) - Common Fund Doctrine? Med Pay or PIP coverage provisions Hold Harmless provisions / Commercial payer agreements 26

27 Fourth, whether managing in-house or by outsourcing, ensure you track manageable KPIs Whenever possible, track by month and use 12 month views this allows for much better visibility into trending Some suggested KPIs. 27

28 KPI s for Accident Claims 1 Identified Accident Claims 2 Identified Accident Gross Charges Knowing how many accident patients you are treating each month is a very simple but important metric. Motor Vehicle Accidents and Workers Compensation Patients should always be tracked separately. 28

29 KPI s for Accident Claims 4 Accident Insurance Leads How good is your registration process? It is very important to measure the % of Property and Casualty and Attorney leads that your Registration team captures. This saves enormous time and increases revenue on the back end. Similarly, how many workers compensation patients have documented employer/carrier information? Best Practices Tip: In non-pip states, MVA Insurance leads should be on excess of 30% of patient accounts. 29

30 KPI s for Accident Claims 5 Total Accident Claims Closed 6 The Corresponding Reimbursement Rate Do you know how well your Accident Claim population is performing? 30

31 KPI s for Accident Claims 7 The % which were paid by Med Pay and/or Liability payment sources Best Practices Tip: Liability and No-Fault recoveries should be in excess of 50% of all payment sources This is not so intuitive The reason you should track this is because Liability and No-Fault payer sources pay at much higher rates than Commercial and Government insurance. The more you identify, the better your reimbursement rates! 31

32 KPI s for Accident Claims 8 Payments by Recovery Type and Reimbursement Rates Typical Reimbursement Rates. This is meaningful and obviously worth the effort! 32

33 KPI s for Accident Claims 10 Reimbursement Rates by Attorney 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% John Smith, Esq Jane Bart Teaque, Goodall, Esq Esq Sam Ford, Esq Michael Chance, Esq Tabryia McCall, Esq Jose' Gonzalez, Esq This allows much more visibility into who is paying the best rates. Once identified, a provider can then better negotiate from a position of strength when dealing with underperformers in this case, Attorney Bart Teaque 33

34 KPI s for Accident Claims 11 Average Age of Resolved Accounts It is important to segregate Liability claims as best efforts will not speed liability settlements. Measure what you can control. Best Practices Tip: Average age of non-litigated Auto Claims should be about 90 days and 45 for Workers Comp Accidents 34

35 Specialty Reimbursement. Focused Results.