Effective Billing and Collections. Copyright 2017 State Volunteer Mutual Insurance Company

Changing Environment Shift in responsibility, payment models and adjustments High deductible health plans (HDHP) Expanded collection effort Transparency 2

HSA Qualified High Deductible Health Plan Enrollment March 2005 to January 2016 AHIP, 2017 Census of Health Savings Account High Deductible Health Plans 3

Results u Patient s portion can be as large as 30 percent of income u Front desk must attempt to collect this increased portion from the patient u If a patient leaves without paying, the likelihood of collecting decreases by 30 percent 4

Revenue Cycle Flow Financial Clearance Patient Check-in & Check-out Charge Capture Coding & Documentation Review Claims Processing Payment & Denial Posting Account Follow-up Denial Management Patient Collections Reporting & KPIs 5

Revenue Cycle Reporting Financial Clearance Reporting & KPIs Patient Check-in & Check-out Patient Collections Charge Capture Revenue Cycle Reporting Denial Management Coding & Documentation Review Account Follow-up Payment, Adjustment & Denial Posting Claims Processing 6

Financial Clearance u Staff understand financial policy and expectations u Demographic information obtained and insurance coverage and benefits verified u Referrals and authorizations prior to service u Patient payment responsibility Financial Clearance >95% accuracy 92% of consumers reported that it was important to know payment responsibility prior to provider visit InstaMed, 2017 7

Patient Check-in & Check-out Verify and/or update demographic and insurance information Obtain required signatures and/or any additional paperwork Collect and post time of service (TOS) payments and balances Establish credit card on file (CCOF), debit (ACH), or other payment arrangements 8

Time of Service Collections InstaMed, 2017 9

Charge Capture Schedule all office visits, surgeries, lab, and diagnostics within scheduling system Generate Unlocked Visits Report or some type of reconciliation Capture hospital, surgical and nursing facility charges Ensure that providers are completing charts timely Charge Lag Days Office 24 hours Non-office 48-72 hours 10

Charge Capture Fee Schedule Individual CPT fees should be priced higher than your highest paying payer Identify Top 25-50 codes, extract EOBs for each code from a sample of payers Do you know how and at what level fees are priced? 11

Coding and Documentation Review Coding responsibilities Audit at least quarterly Update providers and staff Non-specific code use Coding & documentation guidelines Focus of reimbursement 12

Risk Adjustment Model u Implemented to more accurately pay Medicare Advantage (MA) plans for treatment of high risk patients u Used by Centers for Medicare & Medicaid Services (CMS) and other payers as a way to estimate future patient costs u Assess individual s health status and demographic details to calculate risk score u Data reported from claims and documentation 13

Hierarchical Condition Categories (HCC) Diagnosis codes sorted into groups then into categories Diagnosis categories sorted into condition and given risk adjusted factor Related conditions are assigned to one category - only most serious counted Higher ranked condition causes lower ranked conditions in same category to be ignored (some exceptions) Unrelated conditions in different categories are both counted - score is additive 14

Risk Score Example 68-year-old man with pneumonia, emphysema, diabetes with retinopathy, and respiratory failure BCBSAL Complete Picture of Health Documentation and Coding Improvement Initiative 15

Claims Processing Review or scrub claims prior to submission Submit claims daily Submission of secondary claims Reconcile claims receipt Track and resolve edits Claim Edits Resolved 0-48 hours 16

Payment and Denial Posting Post within 24 hours of receipt Balance! Institute policy for working credit balances 17

Adjustments Use of appropriate adjustment types Track adjustments by reason code Review adjustments monthly Use non-contractual adjustments as a training tool 18

Account Follow-up Run Open Claims Report at least weekly Organize by Payer, DOS, and dollar amount Utilize insurance collections automation or work queues 19

Denial Management Develop process and timelines for working denials accountability Meet appeal guidelines Track denial reasons Identify and fix root cause denials Denial Rate <3-5% 20

Patient Collections u Utilize Patient Collections Module or work queues u Become familiar with Fair Debt Collection Practices Act and state laws u Patient statements should be patient friendly u Establish protocols for payment plans InstaMed, 2015 21

Patient Collections Develop a formal process and routinely work Collection accounts should be written off of A/R using a specific adjustment code (or isolate from A/R) Transfer electronically Flag account so all personnel can identify patients in collections Account to Collection Vendor 75-90 days 22

Reporting and Key Performance Indicators (KPIs) Measures the current performance and status of your practice s financial health Helps in identifying practice improvement areas Assists in trending performance over time for comparison Review at least monthly and compare to benchmarks 23

KPI Description Frequency Comments Days in AR Calculates the average number of days it Total Current Receivables (net of credits) divided by (Sum of Previous takes to collect payment on services Monthly 12 months gross charges/365) Net Collection Rate Measures revenue cycle efficiency and Collectable Revenue (exclusive of contractual and non-contractual opportunities to improve Monthly adjustments) divided by Net Charges (allowables) % of Patient Schedule Occupied Identifies opportunity to maximize slot Number of Patient Hours Occupied Number of Patient Hours utilization and improve productivity Monthly Available Denial Rate Tracks payer denials and impact on cash flow. Trends payment opportunity and Total number of billed $/units divided by Total number of denied process improvement Monthly $/units Provides opportunity to increase collections, Time of Service Collection % decrease collection costs, and accelerates cash flow Monthly Total TOS Collections Total Amount Collected Bad Debt Ratio Credit Balance as % of AR % of AR >90 days Trending indicator of patient receivables that have been written-off as uncollectable. Measures effectiveness of revenue cycle Tracks accounts that have a negative balance as the result of overpayment or Monthly Total amount of charges written off over a period (annually) divided by total charges overadjustment Monthly Total Credits Total Outstanding AR Trending indicator of receivables reaching an age of difficult collectibility Monthly Sum Aging AR >90 Days New Patient Visits as % of Total Visits Tracks growth of practice Monthly Total Number of New Patients E&M Codes Total E&M Codes 24

Report Description Frequency Comments Lag Days Measure charge capture workflow efficiency and identifies delays in cash Monthly Average number of days from date of service to posting date Trending indicator of receivable aging Aged AR distribution and collectibility; shows payment delays Monthly 0-30, >30, >60, >90, >120 days Total Outstanding AR Details frequency of each CPT by Provider; Service Analysis includes total charges for each code (frequency multiplied by charge) Monthly Year End and Year-to-Date by CPT by Provider Summarizes charges, payments and Year-to-Date Activity adjustments for the fiscal year or, preferably for each of the last 12 months, by Provider Monthly Individual month by Provider Payer Mix Aged AR by Insurance Shows charges, payments, adjustments by insurance Trending indicator company of for receivable a specific aging time period Monthly distribution and collectibility by payer; shows payment delays by payer Monthly Year-to-Date and Previous Year by Payer 0-30, >30, >60, >90, >120 days By Payer Group Outstanding AR By Payer Group Report of Open Charts/Tasks Not Billed Tracks Reports unbilled acceptance encounters of electronically filed Daily EDI Report claims Daily Verify all claims accepted and all denials worked Claims On Hold Tracks claims that were submitted to clearinghouse but rejected for various reasons Daily Ensure accountability Unapplied Credits Tracks payments that have not been applied to specific patient accounts/dates of service Monthly Confirm each credit applied to correct DOS No Show/Missed Appointments measures number of times appointments not Total number of no shows divided by total number of patients kept Monthly scheduled 25