The Death of Revenue Cycle Management. NCAD2017

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THE DEATH
OF REVENUE
CYCLE
MANAGEMENT

OBJECTIVES
 Understand the problems faced in the behavioral
healthcare industry as a result of payer
reimbursements and shifts
 Learn how payer standards impact clinical care in
treatment facilities
 Gain an understanding of the correlation between
medical necessity and financial reimbursements
 Identify clinical and ethical alternatives available to
maximize payer reimbursements

Grief theory
perspective
Kubler-Ross

Shock and denial
Stage of Grief

CURRENT ISSUES
 Traditional billing and collections methods are
failing nationwide
 We are seeing:
- Increase in overall claim denials
- Decrease in reimbursement percentages
- Decrease in cash flow for providers
- Record high account receivables with payers
- Increase in the amount of payer audits and SIU’s

depression
Stage of Grief

RESULTS
 Lack of funds to employ treating experts and those
with exceptional experience
 Reduction of high level services and clinically
proven methods of treatment
 Disgruntled staff
 Decrease in customer satisfaction
 Marketing limitations

RESULTS
 Increase in chart audit requests overall
- 80% of all no cert cases required medical records
 Decrease in revenue
 Adjustments to admission process and criteria
 Most importantly- lower success rates for clients
 The decline of reimbursement rates,
underpayments, changing clinical requirements and
more are causing providers to make budget cuts
and even shut down operations

Anger, resentment,
and guilt
Stage of Grief

IMPACT OF PAYER STANDARDS ON
CLINICAL CARE
 Each payer has a unique set of standards and
guidelines
 Medical necessity criteria must be met as outlined
by each payer’s manual
 There are very specific timeframe guidelines for
almost every document and/or service
 Very detailed credentialing requirements for the
treating staff (who can treat/provide for which
services)

Bargaining
Stage of Grief

CORRELATION BETWEEN MEDICAL
NECESSITY AND REIMBURSEMENTS
 The ability to satisfy the medical necessity criteria
according to the payer in question will directly
correlate to the number of days authorized for
treatment
 Having an adequate admission process/pre-
assessment with admission criteria will garnish
higher pre-admission approvals and authorizations
(client matching)
 Most, if not all, payers rely on the ASAM criteria as
the foundation to determine medical necessity for

acceptance
Stage of Change

CLINICAL AND ETHICAL ALTERNATIVES TO
MAXIMIZE
PAYER REIMBURSEMENTS
 Taking a systems approach
- Looking into the clinical and admission
operations
 Ongoing audit and review of clinical documentation
 Training of key leadership and clinical staff
members on payer guidelines
 Going after accrued AR
 Implementation of Corrective Action Plans (CAP’s)

SOLUTIONS
 Pursuing accrued A/R
- Forensic Billing Services
- Clinical audits, oversight and
training
 Hiring of credentialed and
experienced staff
 Clinical Consultation Services

A NEW PARADIGM
IS NEEDED TO
HELP OPTIMIZE
REIMBURSEMENT
AND HELP
FACILITIES NOT
ONLY SURVIVE,
BUT PROSPER.

QUESTIONS
AND/OR
COMMENTS?
Lilliam Rodriguez, PhD
Vice President – Accrued A/R Services
Lilliam@panaceahcs.com
John Raymond,
Chief Marketing Officer
John@panaceahcs.com

THANK YOU

The Death of Revenue Cycle Management. NCAD2017

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