Good Samaritan Hospital<br />William D. Kirsh DO, MPH<br />Chief Medical Officer<br />Sentry Data Systems, Inc.<br />1<br />
Sentinel RCM Application <br />Value<br />Financial Exposure<br /><ul><li>Provides linkage between divergent hospital data silos without additional IT FTE support.
Data is longitudinally compiled and warehoused in a proprietary, SAAS cloud with rigorous security controls and levels.
No impact to hospital’s data storage requirements, data processing capacity or data security risks.
Effective analytic tools without interfering with normal operational functions.
Claims Guardian, an application running in the background of Sentinel RCM , provides financial benchmarking, out-patient/ in-patient volume management, technology to up date and maintain charge master coding, provides billing and denial management analysis. .
All reports provide a track & trend option associated with a directed alert engine
BI solution that is non-intrusive, comprehensive, flexible and fast priced extremely completive </li></ul>No added fees<br />No added costs<br />No added costs<br />No added consulting fees<br />No added consulting fees<br />Value driven pricing<br />
Three regulatory changes, over next 24 months, that substantiallyalter hospitals profit and cash flow?(requiring change to systems of improving patient outcome and cost controls)<br />Cap on medical cost of insurance premiums(will change contracting shifting insurance administrative cost to medical costs)<br />ICD 10 coding(mapping engines will not work, will greatly affect cash flow)<br />Contracted performance measures(global contracting linked to outcomes will affect short term hospital payments and alter out-patient utilization)<br />To Adapt to the AboveHospitals must have an effective software application (BI) to aggregate & analyze high volume, divergent data (EMRs not developed for this application)<br />3<br />
Current Regulatory Changes Producing a “Cash Flow” Crisis in 24 months for Hospitals<br />Hospitals need a mechanism focusing on and understanding small variations of costsof services.<br />Hospital’s medical management will need applications to understand details of whichthird party payors contracts need specific utilizationcontrols to maximize profit. <br />Hospitals must be able to understand variations in care by controlling their physician network. <br />Improving administrative efficiency “not by cost cutting” but through continuous background analytics and alert engines that drive data supported administrative decisions.<br />Using data to support evolving information to provide a basis for actuarial sound contractingto hospital providers, vendors & third party payors. <br />4<br />
Hospital Administrators Must Have Data Analytic Capacity to Make CLINICAL and FINANCIAL decisions WITHINA FISCAL QUARTER<br />Sentry’s<br />Must Have Solutions<br />Sentinel RCM™ Claims Guardian<br />HealthBIT® Business Intelligence<br />Together provide a <br />Revenue Cycle Management <br />BI Application<br />5<br />
Sentry’s Revenue Cycle Management BI Application’s Immediate Value<br />Key Performance Indicators<br />Reduction in Days in A/R<br />Pharmacy cost reduction<br />Reduction in medication-related errors, lost billing opportunity<br />Third party payers, contract management<br />Value Drivers<br />Revenue enhancement<br />Cost avoidance, labor productivity<br />Quality of Care, patient safety, cost avoidance<br />Revenue enhancement, information for improved contract negotiations <br />6<br />
To Meet New Payment/Billing VariationsHospitals Must Integrate Healthcare Information…<br />Performance Indicators<br />Stricter regulations & billing requirements<br />Speed of collections<br />Reduced contractual allowances<br />Lower bad debt<br />Understanding underpayments<br />Controlling pre-authorization and pre-certification<br />Claims denial management<br />Identifying overpayments<br />Sentry’s RCM BIApplication<br />Recognition of meeting regulatory requirements<br />Tracks, monitors, alerts variation<br />Provides a picture into contract application verse group<br />Tool to help identify “at risk” population <br />Tool to identify high risk devises <br />Information on appeals<br />Tool to ID risk for audits.<br />7<br />
Sentry’s Revenue Cycle Management BIApplication Allows Hospitals to Evaluate Contract Reimbursement<br />Contract Terms <br />Claim submission timeframes<br />Authorization / referral processes<br />Payment Terms<br />Prompt-pay / payment timeframes<br />Explanation of payment / benefits<br />Governing Regulations<br />HIPAA, CMS (HCFA), NCQA, JCAHO, ERISA, State laws<br />Analyze & Profile Contract Specifics<br />Trends by payor, trends by employer group, claims in A/R, Global fee payments<br />Track Disputed Claims<br />Use information to improve payor’s contract language, i.e. pre-negotiate claim denial rate<br />8<br />
Sentry’s Revenue Cycle Management BI Application Provides Real Time Information to Focus on Front End Claims Management & Clinical Performance Measures<br />Analytics and Data Validation<br />Demographics<br />Insurance<br />Patient’s financial responsibility<br />Set performance standards<br />Maximize the amount of patient revenue<br />9<br />
Why Do Hospitals Need Sentry’s Revenue Cycle Management BI Application?To assure proper reimbursement in the shortest time at the lowest administrative cost<br />Hospital’s Requirements<br />Understand & manage costs and cash flow<br />Decrease write offs<br />Assure services rendered are billed<br />Link costs to specific contracts<br />Evaluate financial information timely<br />BI Output<br />Monitors electronic claims submission <br />Tracks claim outliers<br />Alerts when services are not billed<br />Allows for specific contract analysis <br />Provides high level and drill down for A/R<br />10<br />
Examples of Critical Information Evaluated By Sentry’s Revenue Cycle BIApplication<br />Hospital Charge Master Codes<br /><ul><li>Links charge master to revenue codes
Provides a tracking system that alerts missing charge master to revenue codes
Example: A service with no charge and consequently not linked to revenue code.</li></ul>Link Revenue Code to a Claim <br /><ul><li>Assures that all the revenue codes are linked to a claim
No volume or time limitation for alert system </li></ul>Explanation of Payment (EOP)<br /><ul><li>Links 837 claim to reimbursement form 835
No volume or time limitation for alert system</li></ul>Provides A Way To Analyze The Service Preformed<br /><ul><li>Eg. CPT, HCPC, J Code
Links patient and physician and location of service to the ICD-9 codes , Charge master and revenue codes associated with hospital’s intervention
Clinical aspect: Performed service, captured the service, billed for service, reimbursed for service, link to physician that performed service, link to patient that received the service and the diagnostic codes.
All of the key components are reflected in both physician and patient databases</li></ul>11<br />
Examples of Critical Information Evaluated By Sentry’s Revenue Cycle BI Application<br />Provides Linkage of Diagnostic Codes with Patient Event<br /><ul><li>The system captures both the primary and all secondary diagnosis codes (ICD-9 and ICD 10) which will allow institutes to better bill secondary insures</li></ul>Recognition of Utilization Patterns<br /><ul><li>Links specific revenue codes/charges/procedures to a specific third party payor (BCBS plan 123, with employer group 8910)</li></ul>Flags (Alerting) Change in Patient Clinical Severity <br /><ul><li>e.g.. Transfer from Med/Surg bed to an ICU bed.
e.g.. How does system recognize death events.</li></ul>8. Utilization<br /> Key linkage utilization of services other than pharmacy to location, physician, patient, and third party payor?<br />12<br />
Sentry’s RCM BIApplication Addresses Information Regarding Variation in Financial Risk<br />Traditional Hospital Financial Risks<br />Hospital’s Future Financial Risks<br />Capitation for specialists (PMPM)<br />Moving PCPs to “Fee for Service” away from capitation<br />Carve outs for Disease Management Providers (global fees)<br />Intense medical management at insurance plan<br /> - Daily hospital utilization review (nurse on site)<br /> - Preauthorization for out patient services <br /> Aggressive “Fee for Service” hospital contracting<br />Global Fee contracting with all health care providers<br />Detailed medical coding (ICD-10) to define global fee contracting<br />Significant reduction or complete elimination of medical management by insurance plan with shift to hospitals<br />Investmentin “Pay for Performance Models” (Care Targets)<br />Data converted to timely informationfor action within the fiscal quarter<br />13<br />
Hospitals Must Manage “Bundled Payments” (integrated & connected)<br />Must have health information technology that fits within the organization’s financial limitations and operational structure to assist in capturing data and converting it to informationto meet evolving “performance measures” & reimbursement requirements.<br />Must have SAAS technology systems allowing seamless integration for exchange and flexibility in capturing data to allow variations in software applicationsto manage the immediate future of radical variations in third party reimbursement.<br />14<br />
Sentry Data Systems Key Values<br />A non-intrusive Web basedaddition that integrates with any technology platform.<br />Operates in a cloud computing environment coupled with propriety aggregation engines to allow rapid development and implementation, both retrospectively and prospectively, of unique applications empowering the management team to make critical decision within a financial quarter.<br />Software flexibility to aggregate and link all financial and healthcare data into individual longitudinal patient and physician records which then can be reassembled with focused applications on medication utilization/purchases, charge Master entries, quality initiatives, clinical/ financial protocols, third party contracting and risk management without a tether to a technical team.<br />Sentry’s platform will import divergent elements, store, aggregate, integrate vendors and export data to generate informationto effect financial and quality drivers, which if altered, improves a institution’s bottom line. <br />15<br />
William D. Kirsh DO, MPH<br />Chief Medical Officer<br />Sentry Data Systems, Inc.<br />800-411-4566 ext 2403 office<br />16<br />