Presentation - Best Practices


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A presentation that I frequently give to groups of docs, this focuses on "best practices" for every step of the physician revenue cycle. The goal is to help practices improve collections, reduce overhead, and gain control.

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Presentation - Best Practices

  1. 1. From Appointments to Collections: The Best Practices for your Practice How to Increase Your Practice Revenues and Gain Control Presented by: Brian Foster Director Avisena Inc. [email_address]
  2. 2. Agenda <ul><li>I. Introduction </li></ul><ul><li>Pre-Visit, Billing Best-Practices and Key Performance Indicators </li></ul><ul><li>III. Collection Best-Practices and Key Performance Indicators </li></ul><ul><li>IV. Management </li></ul><ul><li>V. Conclusion </li></ul>
  3. 3. Introduction <ul><li>There is downward pressure on reimbursements, and the costs of running a practice are going up. Getting squeezed in the middle: Profits. </li></ul><ul><li>So, how to increase revenues without changing the way you practice? </li></ul><ul><li>How to increase revenues without seeing more patients than you do today? </li></ul><ul><li>The answers: </li></ul><ul><ul><li>Understand the Physician Revenue Cycle , and know what to measure. </li></ul></ul><ul><ul><li>Understand defined benchmarks and best practices . </li></ul></ul><ul><ul><li>Insist on simple, well-defined improvements. </li></ul></ul><ul><ul><li>Track the results. </li></ul></ul>
  4. 4. Billing and Collections Maturity Levels: Where is Your Practice? <ul><li>4. Proactive Receivables Management </li></ul><ul><li>Mitigate problems before they happen - ongoing </li></ul><ul><li>Efficiently respond to denied and no-response claims </li></ul><ul><li>Analyze reimbursement to identify overpayments </li></ul><ul><li>Negotiate with payers for better rates </li></ul><ul><li>Recapture time for value-added activities </li></ul><ul><li>2. Limited collections Effectiveness </li></ul><ul><li>Limited ability to identify problem receivables and react to them </li></ul><ul><li>Calls made to payers are often wasteful </li></ul><ul><li>Inability to track denials and ignored claims at a detailed level </li></ul><ul><li>1. Always behind </li></ul><ul><li>Billing barely gets out </li></ul><ul><li>Payment processing is a crunch at end of month before producing aging reports </li></ul><ul><li>Can barely address collection activities </li></ul><ul><li>3. Reactive Receivables Management </li></ul><ul><li>Somewhat effective collections results based upon labor-intensive process </li></ul><ul><li>Typically overstaffed to accomplish this </li></ul><ul><li>(Very expensive) </li></ul>
  5. 5. The Physician Revenue Cycle: <ul><li>Pre-Visit: </li></ul><ul><li>Collection of patient demographics, eligibility verification and authorizations, handling over-the-counter payments (patient balances, co-pays and deductibles) </li></ul><ul><li>Billing: </li></ul><ul><li>Charge Capture and use of Rules Engine </li></ul><ul><li>Claims Submission </li></ul><ul><li>Subsequent Appointments, Recalls </li></ul><ul><li>Coding and Other Forms </li></ul><ul><li>Key Performance Indicators (KPIs) to track </li></ul><ul><li>Collections: </li></ul><ul><li>Payment Posting/Remittance Processing </li></ul><ul><li>Denial Management </li></ul><ul><li>No-Response Management </li></ul><ul><li>Underpayments/Downcoding </li></ul><ul><li>Patient Balances </li></ul><ul><li>KPIs </li></ul>
  6. 6. Agenda <ul><li>I. Introduction </li></ul><ul><li>Pre-Visit, Billing Best-Practices and Key Performance Indicators </li></ul><ul><li>III. Collection Best-Practices and Key Performance Indicators </li></ul><ul><li>IV. Management </li></ul><ul><li>V. Conclusion </li></ul>
  7. 7. Front-Desk Management <ul><li>Best-Practices </li></ul><ul><ul><li>Electronic Eligibility should be used wherever possible </li></ul></ul><ul><ul><ul><li>Integrated into appointment schedulers of practice management systems </li></ul></ul></ul><ul><ul><ul><li>Payer Internet portals can also be leveraged </li></ul></ul></ul><ul><ul><li>Electronic Authorizations/referrals gathered prior to patient being seen </li></ul></ul><ul><ul><li>Clear and standardized method for collecting patient demographics; scanning of insurance card and driver’s license </li></ul></ul><ul><li>Other Best-Practices </li></ul><ul><ul><li>Manual eligibility used for all other appointments </li></ul></ul><ul><ul><ul><li>Ability to track eligibility status in PMS </li></ul></ul></ul><ul><ul><li>Manual Authorization / referral gathered when electronic not available </li></ul></ul><ul><ul><ul><li>Ability to track authorization in PMS </li></ul></ul></ul><ul><ul><li>Emphasis on training of front-desk personnel </li></ul></ul><ul><ul><li>Careful management of personnel attitude towards patient (customer) </li></ul></ul><ul><ul><li>Use of check-in and check-out functions in PMS for patient flow management and control </li></ul></ul><ul><ul><li>Assigning and tracking of a unique encounter number in the PMS --- track unfulfilled encounters </li></ul></ul><ul><ul><li>Printing of superbill from PMS (showing unique encounter number, previous diagnoses, authorization number, referring physician, etc.) </li></ul></ul>
  8. 8. Over-The-Counter Payments <ul><li>Best-Practices </li></ul><ul><ul><li>Practice must be aware of all plan requirements for patient responsibility prior to visit (electronically via eligibility verification is often possible) </li></ul></ul><ul><li>Other Best-Practices </li></ul><ul><ul><li>Practice management system should notify front-desk of pre-obtained plan parameters (co-pay, deductible, etc.) </li></ul></ul><ul><ul><li>Practice management system should also have visibility into standard reimbursement levels for services rendered by plan </li></ul></ul><ul><ul><li>Over-the-counter payments and other transactions (adjustments, refunds, etc.) must be managed using cash register-type principles including: </li></ul></ul><ul><ul><ul><li>Receipts printed for all transactions from PMS (not by hand) </li></ul></ul></ul><ul><ul><ul><li>Daily balancing and reconciliation with patient activity (superbills), beginning cash balance and daily receipts(+/-) </li></ul></ul></ul><ul><ul><ul><li>Credit/debit cards should be an acceptable form of payment </li></ul></ul></ul><ul><ul><li>All of patient portion of bill should be collected at time of service </li></ul></ul><ul><ul><li>Direct debit authorizations can also be collected during visit </li></ul></ul>
  9. 9. Charge Capture & Rules Systems <ul><li>Best-Practices </li></ul><ul><ul><li>Charges are captured from a standardized superbill daily </li></ul></ul><ul><ul><li>Rules System is real-time, specialty- and payer-specific </li></ul></ul><ul><ul><li>Rules System learns from Electronic Remittance advice </li></ul></ul><ul><li>Other Best-Practices </li></ul><ul><ul><li>Average Rules Systems provide assistance with: </li></ul></ul><ul><ul><ul><li>Procedure/diagnosis crosswalk rules </li></ul></ul></ul><ul><ul><ul><li>Place-of-service rules </li></ul></ul></ul><ul><ul><ul><li>Inclusive procedures rules </li></ul></ul></ul><ul><ul><ul><li>Referring physician rules </li></ul></ul></ul><ul><ul><ul><li>Modifier rules </li></ul></ul></ul><ul><ul><ul><li>Diagnosis specificity rules </li></ul></ul></ul><ul><ul><li>Some fully integrated solutions are also available </li></ul></ul><ul><ul><li>Some provide payer-specific rules </li></ul></ul><ul><ul><li>Good ones provide frequent and accurate content management support (upgrades) </li></ul></ul>
  10. 10. Claims Submission <ul><li>Best-Practices </li></ul><ul><ul><li>Filing of HIPAA compliant electronic claims whenever possible </li></ul></ul><ul><ul><li>Frequent claim submission (daily) </li></ul></ul><ul><ul><li>Tracking of billed and value (expected collection) in the PMS </li></ul></ul><ul><li>Other Best-Practices </li></ul><ul><ul><li>Automated separation of claims requiring attachments </li></ul></ul><ul><ul><li>Confirmation of clearinghouse/payer receipt </li></ul></ul><ul><ul><li>Balancing of claim submission against practice management totals </li></ul></ul>
  11. 11. Subsequent Appointments, Recalls and Orders <ul><li>Best-Practices </li></ul><ul><ul><li>Subsequent appointment scheduled at time of check-out whenever possible </li></ul></ul><ul><ul><li>When appointment not appropriate due to nature of visit, use PMS “recall” feature </li></ul></ul><ul><ul><li>Ongoing tracking and marketing to patients performed using recall feature </li></ul></ul><ul><ul><li>Physician order entry tracked in PMS and managed to ensure successful completion and billing of all orders </li></ul></ul><ul><ul><li>Cancellation reasons tracked by patient in PMS </li></ul></ul>
  12. 12. Hospital Rounds <ul><li>Best-Practices </li></ul><ul><ul><li>Tracking of admitted / discharged patients in PMS </li></ul></ul><ul><ul><li>Track rounds schedule using PMS </li></ul></ul><ul><ul><li>Gathering of hospital round sheets from physicians at least once per week to prevent exposure </li></ul></ul>
  13. 13. Coding and Forms Management <ul><li>Best-Practices </li></ul><ul><ul><li>Pre-coded superbill, encounter form or round form whenever possible </li></ul></ul><ul><ul><li>Coding of both procedure codes and common diagnosis codes (based upon specialty) whenever possible </li></ul></ul><ul><ul><li>Coding done by physician whenever possible </li></ul></ul><ul><ul><li>Use of check-boxes, etc. for place-of-service, provider, etc. </li></ul></ul><ul><ul><li>User-friendly forms </li></ul></ul><ul><ul><li>Training of physician on proper coding and forms </li></ul></ul><ul><ul><li>Ongoing benchmarking related to level-of-acuity, ordering, etc. </li></ul></ul><ul><ul><li>Practice-wide communications regarding new payer requirements </li></ul></ul><ul><ul><li>Financial totals shown on superbills </li></ul></ul><ul><ul><li>Superbills batched and balanced each day against practice management and front-desk totals </li></ul></ul>
  14. 14. Billing Key Performance Indicators <ul><li>Best-Practices </li></ul><ul><ul><li>Billed amount vs. value at time of charge capture </li></ul></ul><ul><ul><li>Gap between date-of-service and date billed </li></ul></ul><ul><ul><li>Percentage of claims submitted electronically </li></ul></ul><ul><ul><li>Time-of-data-entry per encounter </li></ul></ul><ul><ul><li>Time-of-data-entry per patient </li></ul></ul><ul><ul><li>Percentage of claims denied due to front-end edits vs. due to coding oversights </li></ul></ul><ul><ul><li>Percentage of claims denied due to authorization/referral, insurance information or eligibility oversights </li></ul></ul>
  15. 15. Agenda <ul><li>I. Introduction </li></ul><ul><li>II. Pre-Visit, Billing Best-Practices and Key Performance Indicators </li></ul><ul><li>Collection Best-Practices and Key Performance Indicators </li></ul><ul><li>Management </li></ul><ul><li>Conclusion / Questions & Answers </li></ul>
  16. 16. Remittance Processing/Payment Posting <ul><li>Best-Practices </li></ul><ul><ul><li>Use of electronic remittance wherever possible </li></ul></ul><ul><ul><li>Posting of full adjudication information (approved, paid, disallowed, deductible, co-insurance, co-payment, etc.) including denials </li></ul></ul><ul><ul><li>Prompt posting of remittance </li></ul></ul><ul><li>Other Best-Practices </li></ul><ul><ul><li>Use of document imaging and retrieval technology for all (non-electronic) remittance items </li></ul></ul><ul><ul><li>Separation of remittance posting function from collections (only if made possible by PMS) </li></ul></ul><ul><ul><li>Use of centralized bank lockbox for receipt of all remittance </li></ul></ul><ul><ul><li>Effective dating of posting based upon deposit date </li></ul></ul><ul><ul><li>Balancing of remittance posting against bank deposits </li></ul></ul>
  17. 17. Denial Management <ul><li>Best-Practices </li></ul><ul><ul><li>Ability to identify A/R (detail and </li></ul></ul><ul><ul><li>summary) under denial status </li></ul></ul><ul><ul><li>from PMS </li></ul></ul><ul><ul><li>High-level categorization of denials </li></ul></ul><ul><li>Other Best-Practices </li></ul><ul><ul><li>Access to denials from PMS </li></ul></ul><ul><ul><li>Proper prioritization of denial pursuit efforts </li></ul></ul><ul><ul><li>Formal collection procedures in place by denial category </li></ul></ul><ul><ul><li>Ability to track collector effectiveness </li></ul></ul><ul><ul><li>Use of document imaging system to support collection efforts </li></ul></ul><ul><ul><li>Ability to annotate follow-up work in PMS </li></ul></ul><ul><ul><li>Feedback to other practice areas related to collection actions </li></ul></ul><ul><ul><li>Flow of denial scenarios back to billing and front-desk personnel and/or rules engine </li></ul></ul>
  18. 18. Reimbursement/Denial Management Denials and ignored/lost claims should be sorted by HIPAA-compliant code and routed to collectors based on skill if possible. Ability to sort, filter denials using multiple variables. Best Practices: If you can’t track denials, you can’t measure them. If you can’t measure them, you can’t improve collections performance. Do you know how many of each denial code? Do you know billed vs. value? Do you know how many days it takes to resubmit a denied claim? You should. Ability to see which denials have been worked vs. which have not.
  19. 19. No-Response Management <ul><li>Best-Practices </li></ul><ul><ul><li>Use of electronic claim status to </li></ul></ul><ul><ul><li>avoid a potentially wasted </li></ul></ul><ul><ul><li>phone call </li></ul></ul><ul><ul><li>Varying no-response thresholds </li></ul></ul><ul><ul><li>based upon payer type </li></ul></ul><ul><li>Other Best-Practices </li></ul><ul><ul><li>Frequent aging of receivables in PMS </li></ul></ul><ul><ul><li>(more than once per month) </li></ul></ul><ul><ul><li>Ability to easily identify no-response claims in PMS (typically enabled by denial posting) </li></ul></ul><ul><ul><li>Ability to annotate follow-up work in PMS </li></ul></ul><ul><ul><li>Ability to deliver electronic messaging to other practice areas related to collection actions </li></ul></ul>
  20. 20. Underpayments and Down-Coding Management <ul><li>Best-Practices </li></ul><ul><ul><li>Tracking of down-coding and underpayment as byproduct of remittance posting </li></ul></ul><ul><li>Other Best-Practices </li></ul><ul><ul><li>Use of PMS “value” to compare against remittance “approved” --- automatically, if possible </li></ul></ul><ul><ul><li>Aggressive pursuit of underpayment and down-coding issues with payer </li></ul></ul><ul><ul><li>Complaints to Insurance Commissioner </li></ul></ul>
  21. 21. Patient Collections <ul><li>Best-Practices </li></ul><ul><ul><li>Limit on statements sent </li></ul></ul><ul><ul><li>Use of dunning letters </li></ul></ul><ul><ul><li>Use of outbound calls for selected accounts </li></ul></ul><ul><ul><li>Proper management and tracking of collection agency </li></ul></ul><ul><ul><li>Use of credit bureaus </li></ul></ul><ul><ul><li>Collection of money up-front whenever possible </li></ul></ul><ul><ul><li>User-friendly statements </li></ul></ul><ul><ul><li>Patient-friendly procedure descriptions </li></ul></ul><ul><ul><li>Ability to process payments via phone, Internet, etc. </li></ul></ul><ul><ul><li>Aging stated on statements </li></ul></ul><ul><ul><li>Ability to view prior statements using PMS </li></ul></ul>
  22. 22. Refunds <ul><li>Best-Practices </li></ul><ul><ul><li>Proper management of all credit balances in PMS </li></ul></ul><ul><ul><li>Centralized issuance and management of all refunds </li></ul></ul><ul><ul><li>Ability to easily identify refunds in PMS </li></ul></ul><ul><ul><li>Issuance of refunds as per state law (not too soon or not too late) </li></ul></ul>
  23. 23. Collection KPI’s <ul><li>Best-Practices </li></ul><ul><ul><li>Days A/R </li></ul></ul><ul><ul><li>Net percentage collected, overall and by payer </li></ul></ul><ul><ul><li>Percentage of claims denied overall, and by payer </li></ul></ul><ul><ul><li>Percentage of no-response claims overall, and by payer </li></ul></ul><ul><ul><li>Average life of denials and no-response incidents </li></ul></ul><ul><ul><li>Denials by category (over time, a larger percentage should be due to payer error and/or request for further info, not due to practice mistakes) </li></ul></ul>
  24. 24. Agenda <ul><li>I. Introduction </li></ul><ul><li>II. Pre-Visit, Billing Best-Practices and Key Performance Indicators </li></ul><ul><li>Collection Best-Practices and Key Performance Indicators </li></ul><ul><li>Management </li></ul><ul><li>Conclusion / Questions & Answers </li></ul>
  25. 25. General Management <ul><li>The patient experience starts at the front desk – loyalty and good collections depend upon execution here. </li></ul><ul><li>Select numerous key performance indicators to manage the practice --- monitor them frequently. </li></ul><ul><li>Perfect various reports and use them daily/weekly/monthly to manage the practice – online and print combination is best. </li></ul><ul><li>Enable mobile/remote monitoring of practice. </li></ul><ul><li>Automate functions wherever possible and cost effective </li></ul><ul><li>Outsource non-core functions wherever possible and cost effective </li></ul><ul><li>Spend time and energy treating patients and marketing the practice </li></ul><ul><li>Utilize benchmarking to track utilization by disease </li></ul>
  26. 26. Key Performance Information <ul><li>Patient Activity </li></ul><ul><ul><li>Appointments per day per doctor; per location </li></ul></ul><ul><ul><li>Cancellations by reason </li></ul></ul><ul><li>Billing </li></ul><ul><ul><li>Billed amount and value per day per doctor </li></ul></ul><ul><ul><li>Average lag between date of service and date billed </li></ul></ul><ul><ul><li>Charges/new patients entered into PMS per day by person </li></ul></ul><ul><li>Collections </li></ul><ul><ul><li>Retail collections per day </li></ul></ul><ul><ul><li>Average time to collect </li></ul></ul><ul><ul><li>Adjudication quality per payer (underpayments) </li></ul></ul><ul><ul><li>Average collection per encounter </li></ul></ul><ul><ul><li>Percentage collected </li></ul></ul><ul><li>Accounts Receivable </li></ul><ul><ul><li>Receivable days overall and by payer </li></ul></ul><ul><ul><li>Payer mix </li></ul></ul><ul><ul><li>Extra effort required to collect by payer </li></ul></ul><ul><li>Collection Effort </li></ul><ul><ul><li>Outstanding denials by reason and aging since denial </li></ul></ul><ul><ul><li>No-Response claims by payer and aging </li></ul></ul><ul><ul><li>Collector productivity by day </li></ul></ul><ul><ul><li>Average time to respond to collection incident and effectiveness </li></ul></ul><ul><li>Marketing </li></ul><ul><ul><li>Appointment/patient/collection activity by campaign </li></ul></ul><ul><ul><li>Return on investment per campaign </li></ul></ul>
  27. 27. Minimum Management Requirements <ul><li>Daily </li></ul><ul><ul><li>Review daily activity and net production (Charges – payments – adjustments + Refunds, etc.) </li></ul></ul><ul><ul><li>Balance over-the-counter collections by source (cash, checks, remittance received, credit cards, etc.) </li></ul></ul><ul><ul><li>Quantify any billing backlog </li></ul></ul><ul><li>Weekly </li></ul><ul><ul><li>Quantify payment posting backlog </li></ul></ul><ul><ul><li>Quantify collection backlog </li></ul></ul><ul><ul><li>Quantify underpayments </li></ul></ul><ul><li>Monthly </li></ul><ul><ul><li>Review outstanding A/R (billed, value and days) </li></ul></ul><ul><ul><li>Review monthly production by doctor </li></ul></ul><ul><ul><li>Review denial activity during month </li></ul></ul><ul><ul><li>Review reverse aging of payments (payments received during month for what billing month did they pertain) </li></ul></ul>
  28. 28. Agenda <ul><li>I. Introduction </li></ul><ul><li>II. Pre-Visit, Billing Best-Practices and Key Performance Indicators </li></ul><ul><li>Collection Best-Practices and Key Performance Indicators </li></ul><ul><li>Management </li></ul><ul><li>Conclusion / Questions & Answers </li></ul>
  29. 29. Conclusion <ul><li>Even a limited adoption of Best Practices can yield real results </li></ul><ul><li>If you don’t measure, you can’t manage (use KPIs) </li></ul><ul><ul><li>Pick the most relevant KPIs from billing, collections and overall management. </li></ul></ul><ul><li>Your practice can achieve world-class results </li></ul><ul><li>Partner with experts that can assist you in this transformation </li></ul><ul><li>Focus on your core competencies </li></ul>