AOA-35 Sept 17-20, 2017 Las Vegas

AOA-35 Sept 17-20, 2017 Las Vegas Step Up Your Game: Financial Reporting Like a Pro Presented by: Jeff Boomershine, CPA Principal, Somerset CPAs Todd Blum, MHA, MBA, CMPE Chief Executive Officer Ear, Nose and Throat Associates of South Florida, PA 3925 River Crossing Pkwy, Suite 300 Indianapolis, IN 46240 317.472.2200 / 800.469.7206 somersetcpas.com

Learning Objective 2 This session will allow attendees to understand benchmarking and how to use benchmarks to improve your practice. At the conclusion of the session, you will have an understanding of how to use the AOA s benchmarking tool to take home and use in your practice to compare each of your individual physician s productivity to your practice average to national averages.

Learning Objective 3 To understand the organization of various data elements that should be analyzed and reported on a regular basis by a practice to manage its performance To understand how to develop Dashboards for your practice To understand how to utilize data to analyze, study and make changes to improve performance for your practice

Introduction There Are a Significant Number of Financial & Statistical Measures that Should be Reviewed to Truly Measure How Well the Medical Practice is Performing. Statistics Should be Compared With the Same Statistics From the Prior Year as Well as From Industry Benchmarks (Current Month and Year-to-date). 4

Monthly/Quarterly/Annual Financial Benchmarking Considerations 5 Data Should Be Compared to Benchmarks Where Applicable. Benchmarks are the Starting Point for Additional Analysis, Not the End Point or the Conclusion Research is Required Before Conclusions or Recommendations Can Be Made Benchmarking is to Help With Your Aim! Serious Focus on Comparison of your Practice to Benchmarks Could Result in Economic Benefits. Do Not Fear Comparisons, Embrace Them as Opportunities.

6 Case Study: Todd Blum

Physician Practice Patterns Physician Case Study 7

Physician #1 Pre Ancillary Development ENT with surgically oriented practice Operating 7 days/month 323 patients seen/month Productivity 34% / 12% Charges/Receipts - Surgical 66%/ 88% Charges/Receipts - Office Practice Lower ancillary utilization (20%) Avg Monthly Collections = $80,000 Focused on running on time and on patients chief complaint and not on overall health 8

9 Physician #1 Post Ancillary Development Increased length of appointments slots more time spent on each patient MD continues to operate 7+ days/month 298 patients seen/month (-25/month) Productivity 34% / 8% Charges/Receipts - Surgical 66% / 92% Charges/Receipts - Office Practice Expanded the pie Ancillary utilization increased from 20% to 45% Monthly collections up $43,000 = $516K/year

500K Increase - How?? Increased monthly collections from expansion of: Allergy $16,000 Audiology $18,000 Imaging in office (Xoran) $9,000 Total Monthly Collections Increase $43,000 Total Annual Collections Increase $516,000 10

Key Factors Quality of care Improved with additional tools to help render a diagnosis Improved patient access Impact Same doctor Same training Same OR schedule Fewer patients seen per month Providing better care $250,000 increase in annual compensation 11

12 Monthly/Quarterly/Annual Financial Stability Considerations Sources of Benchmarks AOA 2017 Practice Benchmarking Survey AAO-HNS 2017 Survey AOA Staff Survey MGMA AMGA Sullivan Cotter State Medical Societies (good for staff compensation)

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Introduction Financial Reporting To Your Physicians Includes: Monthly/Quarterly/Annual Considerations Practice Management Data Considerations 15

Introduction Organization of the Data and Presentation are Keys: P&L the Income Statement Traditional Balance Sheet (applies more to some practices) Physician Productivity Revenue Cycle Data Operating Expense Data Ancillary Services Data 16 Other Practice Management Data Considerations

Statement of Income Current Month Current Month Compared to Same Month Prior Year Current Month Compared to Budget Year-to-date Year-to-date Compared to Same Period Prior Year Year-to-Date Compared to Budget 17

Benchmarks and Dashboards Once You Understand Your Data and How It Compares to Benchmarks the Next Step is to Begin Thinking in Terms of Short Summary Sheets of Results. 18

First Dashboard Item A Short Summary Sheet of High Level Results 19

Summary Data Current Month Year to Date Actual Prior Year Variance Actual Prior Year Variance Financial Revenue $ 1,500,792 $ 1,495,647 $ 5,145 $ 9,004,752 $ 8,973,882 $ 30,870 Operating Expenses 785,166 762,923 22,243 4,710,996 4,577,538 133,458 Net Income before Physician Comp $ 715,626 $ 732,724 $ (17,098) $ 4,293,756 $ 4,396,344 $ (102,588) Revenue per MD $ 60,032 $ 59,826 $ 206 $ 360,190 $ 358,955 $ 1,235 Operating Expense per MD 31,407 30,517 890 188,440 183,102 5,338 Net Income before Physician Comp per MD $ 28,625 $ 29,309 $ (684) $ 171,750 $ 175,854 $ (4,104) Operating Expenses as % of Revenue 52.32% 51.01% 1.31% 52.32% 51.01% 1.31% 20

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Productivity Data First Data to Analyze as it Establishes the Basis for all other Analysis. Comparing Your Productivity to the Benchmarks Enables You to Analyze the Other Areas of the Practice. We are Focusing on Dashboards in this Section But Wanted to Note Key Data Elements or Performance Indicators (KPI) 22

New & Established Patient Visits New Patient Visits For Practice in total By Location By Physician All compared to same month prior year & year-to-date Established Patient Visits For Practice in total By Location By Physician All compared to same month prior year & year-to-date 23

Total RVU / Work RVU For the Practice in Total By Physician By Payer By Physician by Payer Per Full-time Equivalent (FTE) Physician 24

Gross Charges/Net Charges/ Net Collections Analysis For the Practice in Total By Physician By Payer By Physician by Payer Per Full-time Equivalent (FTE) Physician 25

Key Practice Volume Metrics 26 Total New Patient Visits Total Established Patient Visits Total Inpatient Surgeries Total Outpatient Surgeries Gross Charges Net Charges All for the Practice in Total & by Physician & Compared to Prior Year

Production Stats Production - Aggregate Current Month Year to Date Actual Prior YearVariance Actual Prior Year Variance Office Visits 9,200 8,875 325 55,200 53,250 1,950 Surgical Cases - Outpatient 7,119 6,700 419 42,713 40,200 2,513 Surgical Cases - Inpatient 3,506 3,300 206 21,038 19,800 1,238 wrvu's 23,750 22,625 1,125 142,500 135,750 6,750 New Patients 2,500 2,375 125 15,000 14,250 750 Production - Aggregate Current Month Year to Date Actual Prior YearVariance Actual Prior Year Variance Office Visits per MD 368 355 13 2,208 2,130 78 Surgical Cases - Outpatient per MD 285 268 17 1,709 1,608 101 Surgical Cases - Inpatient per MD 140 132 8 842 792 50 wrvu's per MD 950 905 45 5,700 5,430 270 New Patients per MD 100 95 5 600 570 30 27

Production $$$ Production - Aggregate Current Month Year to Date Actual Prior Year Variance Actual Prior Year Variance Gross Charges 7,154,304 6,924,792 229,513 42,925,825 41,548,750 1,377,075 Contractual Adjustments (4,077,953) (3,867,496) (210,457) (24,467,720) (23,204,977) (1,262,743) Net Charges 3,076,351 3,057,296 19,055 18,458,105 18,343,773 114,332 Production - Aggregate Current Month Year to Date Actual Prior Year Variance Actual Prior Year Variance Gross Charges - Per MD 286,172 276,992 9,181 1,717,033 1,661,950 55,083 Contractual Adjustments - Per MD (163,118) (154,700) (8,418) (978,709) (928,199) (50,510) Net Charges - Per MD 123,054 122,292 762 738,324 733,751 4,573 28

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Production This Can All Also be Done for Each Individual Physician. The Ability to do this Will Be a Function of Internal Resources and Availability of Technology & Data Management Skills. 30

Production - Individual Current Month Year to Date Office Visits Per MD Actual Prior YearVariance Actual Prior Year Variance MD # 1 MD # 2 MD # 3 MD # 4 MD # 5 MD # 6 MD # 7 MD # 8 MD # 9 MD # 10 31 Current Month Year to Date New Patients per MD Actual Prior YearVariance Actual Prior Year Variance MD # 1 MD # 2 MD # 3 MD # 4 MD # 5 MD # 6 MD # 7 MD # 8 MD # 9 MD # 10

Current Month Year to Date Surgical Cases per MD Actual Prior YearVariance Actual Prior Year Variance MD # 1 MD # 2 MD # 3 MD # 4 MD # 5 MD # 6 MD # 7 MD # 8 MD # 9 MD # 10 32 Current Month Year to Date wrvu's per MD Actual Prior YearVariance Actual Prior Year Variance MD # 1 MD # 2 MD # 3 MD # 4 MD # 5 MD # 6 MD # 7 MD # 8 MD # 9 MD # 10

Revenue Cycle Performance Data 33

Contractual Adjustments Analysis For the Practice in Total By Physician By Payer By Physician by Payer Per Full Time Equivalent (FTE) Physician Contractual Adjustments Divided by Gross Production Equal Contractual Adjustment Percentage Contractual Adjustment Gross Production = Contractual Adjustment % Analyze % Change from yr.-to-yr.; qrtr.-to-qrtr.; mo.-to-mo. 34

Collection Analysis (To Gross Charges & Net Charges) Monitor on Monthly & Year-to-date Basis Gross Collections Minus Refunds Divided by Gross Charges Equal Gross Collection Percentage Gross Collections Refunds Gross Charges = Gross Collection % 35

Collection Analysis (To Gross Charges & Net Charges) Gross Collections Minus Refunds Divided by Net Charges (Gross Production Minus Contractual Adjustments) Equal Net Collection Percentage Gross Collections Refunds Net Charges = Net Collection % 36

Collection Analysis (To Gross Charges & Net Charges) Formula Consideration Consideration in formula should include change in accounts receivable (from beginning to end of period) as a +/- to gross & net charges. Prevents understatement of % of growing practice & overstatement % of shrinking practice 37

Accounts Receivable Analysis Current Accounts Receivable Divided by Average Monthly Gross Production Equal Accounts Receivable Ratio Current Accounts Receivable Accounts Average Monthly Gross Production = Receivable Ratio (Total Charges 12) Ratio Defines the Number of Month s Charges Outstanding in the Accounts Receivable 38

Accounts Receivable Analysis Additional A/R concept days in A/R (accounts receivable ratio) Step 1: Determine Average Daily Gross Charges (ADGC) Total Charges For 3-Month Period Number of Calendar Days in the Period = ADGC Step 2: Calculate Days of Revenue in Receivables (DRR) Accounts Receivable $ Balance Average Daily Gross Charges = DRR 39

Accounts Receivable Analysis Accounts Receivable Aging Report This report is used to assist in the identification of collection trends and status. Billing problems, collection difficulties, or payer delays could cause aberrant percentages or collection slowdowns. Normal Limits: 40 60% 0 30 days 20 30% 31 61 days 5 10% 61 90 days 5 10% 91 120 days 5 15% Over 120 days 40

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Other Data New Patients per FTE Physician wrvus per FTE Physician Office Procedures per FTE Physician Surgical Cases per FTE Physician Net Revenue Collected per Patient Visit Net Revenue Collected per wrvu 42

Practice Overhead Performance Data 43

Practice Overhead Total Operating Expenses as % of Total Cash Collection Total Operating Expenses per FTE Physician Direct Physician Expenses Per FTE Physician Fixed/Equally Allocated Expenses as % of Overhead Fixed/Equally Allocated Expenses per FTE Physician Variable/Allocated Expenses as % of Overhead Variable/Allocated Expense per FTE Physician 44

Practice Overhead Staff Cost as a % of Revenue Staff Cost per FTE Physician Staff Cost (Wages, Taxes, Benefits, Retirement Plan) as % of Total Overhead Facilities Expense as a % of Total Revenue of Total Operating Expenses Facilities Expense per FTE Physician 45

Medical Expense as % of Total Revenue Practice Overhead % of Total Operating Expenses Medical Expense per FTE Physician Marketing Department Expense as % of Total Revenue % of Total Operating Expenses Marketing Department Expense per FTE Physician 46

Technology Expense: % of Total Revenue % of Overhead Practice Overhead per FTE Physician FTE Core Practice per FTE Physician FTE NPs/PAs per FTE Physician FTE Ancillary Personnel per FTE Physician FTE Employees per FTE Physician 47

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Ancillary Services Performance Data 53

Ancillary Services Gross Charges / Net Charges / Net Collections Analysis For Practice in Total By Physician By Payer By Physician By Payer All of Above by Ancillary Service Line Per (FTE) Physician 54

Other Practice Management Performance Data 55

Payer Mix Analysis Gross Charges, Contractual Adjustment, Net Charge & Net Collections Should be Tracked From Year-to-year and Compared Year-to-year for Each Payer Medicare Blue Medicaid Self Pay HMO Private Pay PPO Workers Compensation 56

Payer Mix Analysis Gross Charges, Contractual Adjustment, Net Charge & Net Collections Benefit of Analysis Points out changes where your patients are coming from Points out changes in payment mechanism (fee-for-service, PPO contracts, HMO contracts, etc.) Points out potential risk having too much business concentrated in one payer or group of payers risk assessment 57

Referring Physician Analysis By Gross Charges By Procedures By Net Charges For Practice in Total By Collections By Physician Marketing tool to identify referring physicians to be thanked Identify shifts in referral patterns due to quality of care issues or contractual relationships Identify trends from year-to-year to locate lost business 58

Procedure Analysis By CPT Code Gross Charges by Procedure Contractual Adjustments by Procedures Collections by Procedure For the Practice in Total By Physician By Payer 59

Procedure Analysis By CPT Code Gross Charges by Procedure Code By Payer Could Come Into Play in a Population Health Management Scenario Where Your Group or Collection of Physicians is Trying to Determine ENT / Allergy Spend at a Particular Payer With the Top Volumes for Negotiating a Shared Savings Arrangement. 60

Other Data wrvus Produced Per Support Staff Hours Gross Charges & Net Charges Per Support Staff Hours Net Collections Per Support Staff Hours Overhead per Patient Visit Overhead per wrvu 61

62 Example Practice Dashboard

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STATISTICAL SUMMARY December 2014 YEAR-TO-DATE PRACTICE STATISTICAL SUMMARY Office New Surgeries Clinics Clinics Charges Collections Surg/Case Off Visits NP Surg/Cases WorkRVU Charges Collections Visits Patients or Cases WorkRVU Available Staffed per NP per NP per NP per Clinic per Clinic per Clinic per Clinic Physician 1 $100,000 $50,000 200 100 60 1000 15 12 $1,000 $500 0.60 13.33 6.67 5.00 83.33 Last Year $90,000 $40,000 150 80 50 900 13 11 $1,125 $500 0.63 11.54 6.15 4.55 81.82 Physician 2 $100,000 $50,000 200 100 60 1000 15 12 $1,000 $500 0.60 13.33 6.67 5.00 83.33 Last Year $90,000 $40,000 150 80 50 900 13 11 $1,125 $500 0.63 11.54 6.15 4.55 81.82 64

Fancier Dash Board (But More Expensive) 65

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Practice Dashboard It Will Take Time to Develop the Dashboard You Desire and the Physicians Desire as There is a Tremendous Amount of Data to Evaluate. Start Small or Simple and Build the Data Set Over Time Try to Limit the Size of the Packet or Dashboard Data Set in Terms of Total Pages. Always Balancing Too Much Against Not Enough. 72

Pulling It All Together With Analysis and Action 73

Benchmarking Considerations The Challenge Most Groups Have is Acting on the Data. Many Groups Participate in Many Data Sets, the Problem is Many Groups Fail to Research and Institute an Action Plan Based on the Data. 74

Monthly/Quarterly/Annual Financial Benchmarking Considerations First Step in Any Analysis of Financial Performance: Benchmark to determine practice production compared with the industry. Practice production should substantially influence resource requirements (i.e., overhead) for the practice. 75

Monthly/Quarterly/Annual Financial Benchmarking Considerations Practice Productivity Measures: Relative Value Work Units (wrvus) Gross Charges Net Charges Net Collections New & Established Patient Visits All calculated per Full Time Equivalent (FTE) physician 76

Monthly/Quarterly/Annual Financial Benchmarking Considerations Practice Productivity Measures Should be Compared to the Industry Benchmarks to Help Establish the Baseline for Where Your Practice Stands Relative to the Mean, Median, 25 th, 75 th or 90 th Percentile. You Want to Look at Multiple Measures to Verify Where the Practice Stands Relative to Percentile of Production in Order to Evaluate the Rest of the Practice Performance. 77

Diagnosing and Improving the Financial Health of Your Practice Todd Blum, MHA, MBA, CMPE Chief Executive Officer Ear, Nose and Throat Associates of South Florida 78 Past President Association of Otolaryngology Administrators

Rising Operating Costs Since about 1998, revenues per unit of work have not risen as quickly as expenses Expenses have risen at an average of about 6.3% annually for the last ten years Median ENT overhead of 56% in 2007 and 60% in 2008 compared with 45% in 1992 79 79

Future Reimbursements Medicare reimbursements 80 80

50.0% Medicare Conversion Factor, Multispecialty Group Operating Cost and the Consumer Price Index 43.1% 40.0% 36.0% 30.0% 29.0% 24.2% 20.0% 10.0% 0.0% -10.0% 20.2% 17.1% 13.8% 12.3% 10.9% 10.3% 7.5% 6.7% 3.9% 1.6% 0.0% -0.9% -0.9% -0.9% 0.0% 2001 2002 2003 2004 2005 2006 2007 2008* 0.0% -2.4% -3.8% -5.4% 81 Medicare Conversion Factor CPI Total Operating Cost per FTE Physician 81

Surveyed Physician Responses to Decline 42% of practices will limit the number of Medicare patients they treat 19% will close the practice to new Medicare patients 45% plan to reduce staff 59% plan to reduce physician comp 53% will reduce cap. equipment investments 57% will reduce staff health insurance coverage 82 82

Success Oriented Responses Increase revenues Ancillary Services Increase efficiency Maximize financial performance 83 83

Ancillary Services Ancillary Revenues generated: By other healthcare professionals Patient Care & Convenience Improves physician diagnostic capabilities Patient convenience same day testing Improved patient safety Physician oversees Q.C. Xoran Sinus CT 90% less radiation 84 84

Ancillary Services Include revenue generated from: Allergy testing and treatment Audiologic Testing Clinical Trials Hearing Aid Sales Imaging Xoran CT/Ultrasound Neuromonics tinnitus treatment Physician Extenders (NP) Physical Therapy Sleep studies Speech Therapy Videostroboscopy PQRI/E-Rx EMR Meaningful Use 85 85

86 Add Ancillary Services Track referrals sent outside of practice Can you keep revenues within the practice? Xoran Mini Cat Breakeven = 20-25 scans/month Allergy testing & treatment Sleep study interpretation local sleep labs & at home testing Increase Medicare collections 4% E-Prescribe Software = FREE PQRI Registry - $300/Doctor Spend money to make money Focus on compensation not on overhead Ancillaries have different cost structures Shared ancillaries with other practices MOB exemption Implement a compliance program to guard against overutilization 86

Maximizing Financial Performance 87 What to maximize? Charges Receipts Payor Mix Patient Volume # Employees Clinical productivity (# Procedures per Patient Seen) Number of Surgeries Overhead Ancillary Services???? 87

Keep Your Eye on the Ball Cash Flow Cash Accounts Receivable Financial Key Performance Indicators (KPIs) 88 88

Cash = Doctors Weekly/MTD Cash Receipts Prior Period Comparisons Seasonality Trends = Events >30 Days 89 89

No Patients = No A/R = No Cash Encounter Statistics E & M Visits AOA Benchmark = 276/month ENSTF = 359/month Charges Surgeries Office/Ancillaries 90 90

Large A/R, No Cash! A/R Days or Days Service Outstanding (A/R Balance Monthly Gross Charges) X 30 Days ($200,000 $100,000) X 30 = 60.0 DSO AOA Benchmark = 50.3 DSO ENTSF Benchmark = 28.9 Net Collection % Net Receipts (Annual Gross Charges-Adjustments) $1,000,000 ($2,000,000 - $900,000) = 91% AOA Benchmark = 94.4% ENTSF = 99.2% Goal = 100% 91 91

Keep the Cash Coming In! Accounts Receivable Aging Buckets < 60 days!! AOA Benchmark = 37.8% ENTSF = 72.2% Aging Buckets > 120 days AOA Benchmark = 25.4% ENTSF = 13.2% 92 92

Key Performance Indicators Overhead as a % of Receipts AOA Benchmark = 60.7% ENTSF = 44.8% Ancillary Revenues (case study to follow): Revenue stream diversification AOA Benchmarking = 21.7% MGMA = 15% ENTSF Boca Care Center = 42% 93 93

What does all this mean? 94 94

Figures often beguile me, particularly when I have the arranging of them myself in which case there are three kinds of lies: lies, damned lies and statistics. Mark Twain 95 95

Applying the Benchmarks Is the source reputable The physician urban myth Does the # even make sense Is the benchmark applicable? Requires an understanding more complicated than simply comparing #s 96 96

Understanding the Benchmarks My overhead is 45% compared to the national average of 61% - I have the best practice around! I see 50% more patients than Dr. Jones, why is he out-earning me? I have no accounts receivable over 120 days my billing department is excellent! 97 97

Conclusion There is a Tremendous Amount of Financial & Performance Data For a Practice Develop a Basic Packet of Information that is Delivered Timely Work With the Data Over Time to Determine Most Relevant Data For Your Practice 98

99 Questions?

Today s speakers: Contact Information Jeff Boomershine, CPA Jboomershine@SomersetCPAs.com 317-472-2159 Todd Blum, MHA, MBA, CMPE Chief Executive Officer Ear, Nose and Throat Associates of South Florida, PA tsblum@entsf.com Somerset CPAs, P.C. 3925 River Crossing Pkwy, Suite 300 Indianapolis, IN 46240 317.472.2200 / 800.469.7206 info@somersetcpas.com somersetcpas.com