10 RCM Concerns

10 Revenue Cycle Concerns For Radiology Practices & How to Fix Them

10 revenue cycle concerns for Radiologypractices and ways physician

practices can fix them.

Radiology practices are in a time of constant change with reimbursements, patient volumes and utilization of radiology

services declining. These changes are forcing physician practices to reevaluate processes and tackle inefficiencies.

Why we are here ?

1 | 10 Revenue Cycle Concerns for Radiology Practices & How to Fix Them

HIS is a physician management organization that specializes in Revenue Cycle Management and Technology services for Radiology practices.

Dave Wold, CHBC, Founder and CEO, Healthcare Information ServicesFounded HIS in 1999. Under Mr. Wold’s leadership, HIS’ corporate infrastructure has significantly expanded over the past seven years. HIS has grown from 40 employees in one location to an organization which now employs over 225 employees operating in two locations. To date HIS bills out over $800 million and collects over $300 million on behalf of our clients

Richard Sanchez, VP, Healthcare Information ServicesRichard Sanchez is a Vice President of HIS. Mr. Sanchez has been with HIS for 13 years and has extensive experience and knowledge of all levels of the revenue cycle. Richard has worked exclusively on radiology since 2007. He oversees all operations, client management, workflow, analytics, implementations and organizational operations for all of HIS. Richard is an active member of RBMA, HBMA, NSCHBC and MGMA along with other industry specific organizations.

Andy Salmen, Business Development, Healthcare Information Services:Andy Salmen is HIS’ Business Development manager. Mr. Salmen has over 10 years of marketing, media and business development experience spanning multiple industries and varying business verticals. His expertise ranges from start-up to established organizations providing business development activities, cross-platform marketing, multimedia management, public relations and consulting services. In his current role with HIS, Mr. Salmen designs, executes and manages HIS’ marketing, sales and client relations initiatives.

Who we are?


“It is more important now than ever to assess your practices health”

• Radiology practices should routinely reevaluate the management of their revenue cycle • Too often overlooked and accepting status quo

• There is a huge correlation between your practice's profitability and the efficient management of your revenue cycle

Correlation to Profitability


1. Charge Capture & Reconciliation

2. Achieving Optimal Coding

3. PQRS, ICD-10 and MPPR

4. Claim Submission

5. Managing Rejections and Denials

6. Develop A/R management strategy

7. Payor Contracts & Tracking Reimbursements

8. Critical Performance Indicators

9. Importance of Communication

10.Physician’s Involvement

What we will cover


Even some of the best practices will lose revenue from failing to capture all charges.

• Understanding all systems involved • PACS, RIS, HIS, Dictation, etc.

•Checks and balance:• Ensure accuracy of information• Coordination is key•Multiple check points to makes sure that charges are not missed

• Reconciliation along the Charge Capture Continuum•Automated manifest reconciliation•Variance lists (hospital CDM coding vs. MD documentation)•Prospective & Retrospective audits by modality •Front end and back-end audits

Charge Capture & Reconciliation1


Protecting #1 driver for Physician Reimbursement

Reconciliation Process ensuring all procedures are documented and

charges are captured.

Charge Capture & Reconciliation1


Achieving Optimal Coding2


Accurate, compliant coding is best achieved through the utilization of credentialed, expert coders.

Certified coders •Experienced and versed in both the business and clinical aspects of healthcare•Ensure proper coding and the accuracy of claims

Some best practices•Code directly from the dictated report to optimize charge capture•Establish Coding turnaround standards (48-72 hours from the time the dictated report is received )•Internal audit and quality control initiatives (5-10% of all charges audited daily)

Keep up to date on Coding changes:•2013 changes, ICD10, PQRS, MPPR, etc. •Can drastically affect reimbursement and effectiveness of revenue cycle

Physician Training and Feedback:•On-going documentation education for physicians•Send backs are vital step in this process

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On-going Education Process

Coding Education is Continuous

IMAGING PROCEDURE: CT ER PULM EMBOLI W/CONT CT chest with contrast utilizing P.E. protocol with coronal reformatted imaging

Indication: Substernal chest pain. Shortness of breath.

TECHNIQUE: Axial images of chest were obtained with contrast utilizing pulmonary embolus protocol. Subsequently, 3-D MIP images were obtained for pulmonary arterial CTA. Coronal reformatted images were also obtained. 100 cc of Optiray 320 was infused.

FINDINGS: There is normal contrast opacification of main pulmonary arteries and visualized segmental branches to both lungs. Thoracic aorta is tortuous with scattered atherosclerotic changes. There is mild aneurysmal distention of ascending thoracic aorta with maximum transverse diameter of 43 mm. Aortic arch measures 30 mm in maximum transverse diameter. Descending thoracic aorta at the level of carina measures 23 mm in transverse diameter. No evidence of dissection. No pericardial effusion is noted. No enlarged mediastinal, hilar, or axillary lymph nodes are present. Bilateral scattered axillary lymph nodes and mediastinal nodes remain nonspecific by size and appearance. Mild distention of esophagus is nonspecific and may relate to gastroesophageal reflux. Lung window images show no pleural effusion or lobar consolidation. Central airway is patent. There is no evidence of pneumothorax. There is mild biapical fibrosis and pleural thickening. There are few scattered indeterminate 3 mm size nodular densities in both lungs of uncertain etiology. No pulmonary mass is identified. There is minimal central bronchiectasis. Bone window images show degenerative changes in thoracic spine without other significant osseous abnormality.

IMPRESSION: 1. No evidence of pulmonary embolus. 2. No lobar consolidation, pleural effusion, or pneumothorax is noted. 3. Mild aneurysmal distention of thoracic aorta with maximum diameter of 43 mm. 4. Scattered scattered nonspecific appearing lymph nodes in the mediastinum and axilla. 5. Please see above discussion for further comments

IMAGING PROCEDURE: CT PULM EMBOLI W/CONTRAST

HISTORY: Rule out pulmonary embolism. Chest and back pain. Contrast: 80 cc Optiray-320 administered intravenously.

TECHNIQUE: Exam is made with nonionic contrast and pulmonary embolism protocol. Acquisition is helical. Imaging is made with 2mm coronal and axial sections and 20 mm thickness 4 mm skip coronal sections. Axial lung windows are also recorded.

FINDINGS: Pulmonary arterial opacification is adequate. There is no evidence of pulmonary embolism. The thoracic aorta shows normal appearing opacification without evidence of disruption or gross dissection. There are pulsation artifacts of the aortic and pulmonic roots. The lungs show no infiltrates or pleural effusions. No pericardial effusion. There is a 3 mm pleural based nodular density identified in the posterior left upper lobe, this is too small to characterize. A few other scattered small opacities are similarly nonspecific.

IMPRESSION: No current evidence of pulmonary embolism. 3 mm pleural based nodule lateral left upper lobe and other scattered and other scattered small opacities are nonspecific.

INSUFFICIENT DOCUMENTATION

Reimbursement Difference between the two: $36.60

CPT 71275


CPT 71260

COMPLIANT DOCUMENTATION

Physician Quality Reporting System3


The PQRS program is here to stay. And to avoid financial penalties of 1.5% of Medicare allowable in 2015, eligible providers must begin reporting on PQRS measures in 2013.

CMS will automatically decrease all Medicare allowable•-1.5% in 2015 for any provider who does not participate in PQRS in 2013•-2% in 2016•Penalties apply to all Medicare allowable, not just the allowable associated with the PQRS measures Fortunately, over the past several years, the requirements to participate in PQRS have decreased and the measure choices for radiologists have increased.

For claims-based PQRS reporting (the best choice for most radiology groups)•Report on three measures for 50% of the applicable studies in that measure •Prior to 2011, the 50% reporting threshold was at 80% •Additionally, the applicable radiology measures have increased for Radiology

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ICD-10 is not a simple update from ICD-9… Major structural changes

Expansion of Code Sets of Specificity in clinical documentation •Specificity in clinical classification •Specificity in why resources are used in care management

Completeness and accuracy of clinical documentation •Severity of illness •Risk of Morbidity and Mortality •Risk of Admission

Two primary considerations from the doctors perspective:•Impact to Work Flow •Documentation and charge capture

• More specific and detailed in documentation and wording of a completed exam• Dictation will depend on whether the patient is an inpatient or an outpatient

ICD-10 – Are you ready ?

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Radiologists are very dependent on the information gathered from the referring physician•With ICD-10 codes, the amount of information required from the referring physician increases dramatically.•Practices will need to work closely with referring physicians and help them prepare for the ICD-10 introduction on which radiology’s billing depends.

Documentation and coding•Acquire a much greater history for a patient when scheduling an exam for the purposes of precertification, dictation, and subsequent billing of a procedure.

It is not too early to begin training your physicians and staff. •Have a plan and execute it proactively•Not necessarily as quick as possible but as effective as possible

Failure to include the appropriate codes and detailed reporting will delay reimbursement and possibly cause a loss of revenue.

ICD-10 – Are you ready ?

MPPR and It’s Impact on your Reimbursement3


• MPPR-PC applies to advanced imaging services provided by one or more physicians

in the same group practice to the same beneficiary, in the same session, on the same day.

• The procedure with the highest RVU reimbursement will be paid in full, while the 2nd and for each subsequent procedure will be reduced by 25%.

Multiple Procedure Payment Reduction

Expanded to the Professional Component

(MPPR-PC)

MPPR and It’s Impact on your Reimbursement3


• While the reduction will apply to the less expensive procedure, it will cut across modalities.

• For example, if a patient receives an MRI of the brain and a CT of the chest in the same session on the same day, the reimbursement for the CT of the chest (the less expensive procedure) will be decreased by 25%.

“What is the affect on your overall reimbursement?”

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Claim Submission

Implement a process with internal and external scrubbing processes

SPEED OF CLAIMS SUBMISSION•Error–free, fast charge posting•Eliminates delays due to unforeseen staffing issues•Faster TAT = quicker reimbursement

CLEAN CLAIMS•System scrubs codes according to payor guidelines and Dx rules•Lower back-end denial rates

QUALITY ASSURANCE•Min of 5% of daily claims should be audited to ensure there is no lost revenue•Front-end and Back-end audits should be put in place

The number one reason for a controllable denials is inaccurate and/or incomplete insurance information

• The Good ole’ days (are long gone)• Procedures were getting paid in high volumes and physicians could afford to pay less attention to the insurance denials.

• The New Norm• Declining reimbursements along with increased denial rates• Focusing on why denials are happening will save a practice significant money.

If you have the wrong insurance information and perform a procedure, your cost to collect quadruples.

Managing Insurance Denials5


• Create and implement Front-End processes for improved results• Rather than losing money on insurance denials, • Work with practices and hospital front-end staff to avoid sending improper information to your payors.

Eligibility verification before a patient comes in

• Implement technology to verify coverage for patients procedure• Integrate with Practice Management system for work-flow efficiencies• As soon as the patient has been scheduled for a procedure, the insurance verification process should begin.

Pre-Authorization• No longer will allow for retroactive authorization• If you don’t do this, the service is “FREE”!!

“Denied claims due to unauthorized patient procedures or services can be a major loss in revenue that should not be taken lightly.”

5 Managing Insurance Denials


6 Develop A/R management strategy


Collective strategy

Payor Contracts & Tracking Reimbursements7

“Am I being paid correctly?”

• Verify accuracy of each and every payment• Monitor the amount reimbursed by payors versus the negotiated pay rate• Compare to all fee schedules and contracts

• Insurance Companies make mistakes• Incorrect fee schedules loaded• Underpayment

• Dedicated Resources and Technology• Can be challenging for smaller practices• At HIS, we have found even in large practices several examples where payors have underpaid to the tune of $100,000.


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• If you see a pattern of under payment, allocate additional resources to fix the problem.

• Communicate with the payor to fix problem

• “Demand” letter must be sent

Since 2010, HIS collected over $2.0M in underpayments on behalf of our clients

Payor Contracts & Tracking Reimbursements


Poor Cash Flow can be due to improper A/R ManagementWhat to look for or & how to affect positive change

• Too many Days and Dollars are tied up in accounts receivable• Billing must be sent out promptly, accurately

• Days outstanding – 43.2 (according to RBMA standards)

• Critical Performance Indicators CPI – key to managed success• We suggest you look at more than just the A/R Aging Buckets

•120+ should be 15% or better (according to RBMA standards)

• Aggressive follow up procedures must be in place•Identifying trends and acting promptly•Appeal and Denials

“Any unnecessary delay will cost a practice its profit.”

Critical Performance Indicators (CPI)8


“Are the lines of communication truly Open?”

• All parties involved need to be in concert:• Practice Administration • Physicians• Hospital staff• Billing department (external or internal)

• It should be a two-way street

• A well managed open-communication policy and process can positively impact the efficiencies and profitability of your practice.

Importance of Communication9


When none of the physicians in a practice are involved with the company's RCM … Problems can arise

• Disconnect on importance of complete documentation

Designate a lead physician to stay involved and be a point person • This can greatly benefit the entire practice• An interested physician who is educated about billing matters makes the entire practice more efficient

The Revenue Cycle starts with the physician.

Physician’s Involvement10


• Radiology practices must be aware of changes in reimbursements, regulations and coding-guidelines that have a direct impact on your practice’s profitability.

• Physician practice must re-evaluate their processes to hone in and position their practice for a more profitable future.

• Make sure you can answer the all important question…

Are you being paid what you are supposed to be Paid ?

Conclusion


Questions ?


About HIS HIS is a physician management organization that specializes in Revenue

Cycle Management and Technology services for Radiology practices.

“We worry about your business so you don’t have to”

Partnership Philosophy• Based on mutually shared success

Experts in Radiology• Manage the revenue cycle of over 450 providers

We are not just a billing company• Comprehensive Service Beyond Expectation.


We understand that our success is directly tied to the success of our Clients

“We do not succeed unless you do!”

Service that goes above and beyond: For us it is not just about increasing reimbursements and profitability but also about the service we provide. We partner with each client to understand their business needs intimately and position their practice for a more stable and profitable future.

Improved Reimbursement and Profitability: HIS clients typically see an increase of 11.2% or better of their average reimbursements through proper coding, aggressive appeals & denial management, in-house collections and expert approach. In addition, HIS can help you achieve operational efficiencies and provide group purchasing power lowering your overhead and boosting your bottom-line.

Expert partner for the future: With 30+ years of experience, HIS' staff of 225 professionals, including over 65 certified coders, understand the most complex management systems and clinical issues. HIS is a thought-leader in the industry and with an expert knowledge and experience in Radiology is a valued partner in these troubling times.

What you can expect from HIS


For follow up questions feel free to contact us:

Andy Salmen, Business Development HIS P: (847) 720-7007 E: [email protected]

Contact HIS:

350 S. Northwest Highway, Suite 200Park Ridge, Illinois 60068

(855) RING-HIS

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10 RCM Concerns

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