13 New Ideas for Increasing Imaging Revenue...co-insurance, and co-pays • All self-pay patients...

13 New Ideas for Increasing

Imaging Revenue January 9, 2014

Imaging Performance

Partnership

Shaun Lillard Senior Analyst

[email protected]

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Maximizing Imaging Revenue Capture

2

Tactics for Ensuring Financial Sustainability

1 2 3 4

Ensuring

Patient-Friendly

Financial

Transactions

Preparing for

ICD-10² and

Coding Changes

Decreasing

Unwarranted

Denials

Model A: Referring

Physician-Retained

• Tactic : Proactive

Physician Education

• Tactic : Automated

Tracking Worklist

• Tactic : Modality-Specific

Preauth Owners

Model B: Hospital-Wide

Preauthorization

• Tactic : Referring

Physician Waiver

• Tactic : Tech-Led

Training

• Tactic : Radiology Sub-

Team

Tactic #1: Patient

Obligation Quick Guide

Tactic #2: Automatic

Payment Generator

Tactic #3: High-Risk

Patient Identification

Tactic #4: Formalized

Job Alteration

Tactic #5: Staff

Collections Training

Tactic #6: POS¹ Staff

Incentives

Tactic #7: Sponsored

Tech Training

Tactic #8: Interventional

Coding Task Force

Tactic #9: Dedicated

Imaging Coding Staff

Tactic #10:

Comprehensive

Case

Documentation

Tactic #11: Complex

Appeals Archives

Tactic #12: Denial

Origin IDs

Tactic #13: Monthly

Scorecards

Model C: Imaging

Program Ownership

• Tactic :

Pre-scan Audits

Model D: Third Party

Outsourcing

Model E: Clinical

Decision Support

Refining the

Preauthorization Function

1) Point-of-service.

2) Tenth revision of the International

Statistical Classification of Diseases and

Related Health Problems.

• Tactic #1: Patient Obligation Quick Guide

• Tactic #2: Automatic Payment Generator

• Tactic #3: High-Risk Patient Identification

• Tactic #4: Formalized Job Alteration

• Tactic #5: Staff Collections Training

• Tactic #6: POS Staff Incentives

Ensuring Patient-Friendly

Financial Transactions

3

Column 1

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The Tale of the Ever-Growing Deductible

4

Steady Growth in Cost-Shifting onto Patients

Source: Kaiser/HRET Survey of Employer-Sponsored Health Benefits, 1999-2012; KPMG Survey

of Employer-Sponsored Health Benefits, 1993, 1996; The Health Insurance Association of America

(HIAA), 1988; Imaging Performance Partnership research and analysis.

1) 200 or more workers.

2) 3-199 workers.

Percentage of Covered Workers Enrolled in High-Deductible Plan

Deductibles Greater than $1,000

6% 13%

28%

10%

22%

38%

16%

40%

58%

All Large Firms¹ All Firms All Small Firms²

2006 2009 2013

Average Annual Growth 2006-2013 for All Firms: 4%

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Patient Obligations Crucial to Revenue

5

All Regions Struggling with Increased Deductibles

Source: “Rising Patient Deductibles Spell Trouble for Doctors.” Medscape. Dec 14,

2012; Imaging Performance Partnership research and analysis.

1) Preferred provider organization.

2) High-deductible health plan.

Contracted Rates for MRI

$200 $400

$1,000 $800

$600

Patient Portion Payer Portion

PPO¹ 1 HDHP²

Patient Obligation by Payer

and Plan

Tricia Andriolo-Bull, VP Payer Strategy, Athenahealth

”

“The higher deductibles are a good way for employers to keep premium rates down. But

any increase in self-pay is bad for the physician because it’s hard to collect.”

Great for Some, Less So for Others

West: ↑ 20%

South: ↑ 20%

Midwest:

↑ 20% Northeast: ↑ 47%

Increase in Deductibles as a Percentage of

Contracted Rates from 2009-2011

PPO 2

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Exchanges Only Compound the Issue

6

Individual Purchasers Prioritizing Low Premiums

Source: Galbraith A, et al., "Some Families Who Purchased Health Coverage Through The Massachusetts Connector Wound

Up With High Financial Burdens," Health Affairs, 2013, 32: 1-10; McKinsey & Company, “McKinsey Consumer Exchange

Simulation 2011,” available at www.mckinsey.com; Imaging Performance Partnership research and analysis.

1) Excludes catastrophic plans.

2) Excludes young adult market.

3) Actuarial value.

57%

34%

9%

Bronze Silver Gold

Plan Choice Among

Massachusetts Exchange Enrollees²

Sample Monthly Premiums for

Massachusetts Connector Plans

Bronze (40-50% AV3): $225

Silver (63-75% AV): $313

Gold (80-85% AV): $390

2010

60%

70%

80%

90%

40%

30%

20%

10%

Bronze Silver Gold Platinum

Actuarial Value Covered

Out-of-Pocket Expenses

Actuarial Value and Expected

Patient Payment by Medal Tier

Percentage of Cost Covered1

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Collections Begin at Point of Service

7

Yet Most Providers Have Room for Improvement

Source: Revenue Cycle Benchmarking Initiative; Imaging Performance Partnership

research and analysis.

National Imaging Programs’

Point-of-Service Collections

Performance

Indexed for Comparison

High-

Performance

Quartile

Average

Performance

Low-

Performance

Quartile

Likelihood of Collecting from

Patients over Revenue Cycle

Scheduling

Through

Admission

Discharge Billing

Cycle

Bad Debt

Collection

High-performance quartile collects four

times as much as average-performance

quartile at POS

Average-performance quartile collects

four times as much as low-

performance quartile at POS

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Not Giving Patients Any Insight

8

Few Programs Providing Accurate Estimates to Patients

Source: Imaging Performance Partnership 2012 Strategic Topic Poll;

Imaging Performance Partnership research and analysis.

9%

91% Yes No

Programs Providing Estimates

of Patient Obligation

Percentage of Institutions n=48

Roadblocks to Information

“Estimates are just not

something we are able to easily

provide. Finance has that

information somewhere, but it is

difficult for us to access it, and

we definitely can’t do it in a

timely manner.”

Hospital Imaging Administrator

”

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An Across-the-Board Co-pay

9

Hound¹ Begins by Collecting Set Amount From All Patients

Source: Imaging Performance Partnership interviews and analysis. 1) Pseudonym.

Hound Co-pay Collection

Case in Brief: Hound Medical Center

• 302-bed community hospital located in the West

• Patient collections went through three iterations; began by charging every imaging patient

$50 up-front regardless of scan, payer type

• Found difficulties with patient pushback and refunding or further collection

• Built Excel tool using payer contract information on most frequent exams

• Eventually purchased automatic payment generator to increase accuracy, decrease workload

Patient walks in,

staff collect $50

After scan, staff

realize co-pay is

only $20

Process to

refund $30

takes weeks

Challenges to the Method

• Patients angry when they

over- or under-pay

• Follow-up burdensome to

program; takes several

weeks to refund money

when necessary, even

longer if they have to

collect more

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Taking a Further Step Toward Accuracy

10

Homegrown Guide Gives Estimates for Most Common Exams

Source: Imaging Performance Partnership interviews and analysis.

Tactic #1: Patient Obligation Quick Guide

MRI

BrainPayer 1 Payer 2 Payer 3

With

Contrast$930 $919 $1,125

Without

Contrast$778 $712 $859

Challenges to Method

• Time intensive

– 5-10 hours per week of maintenance

– Requires full attention of one FTE at

beginning of the year

• Updates required whenever payer

contracts change

• Prior outstanding balances not tracked

• Aggregates information on all exams

across 90% of payers, plan types • Estimates PFR based on average cost

to patient for specific exam with

specific payer

Excel-Based Patient Obligation Guide

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Buying an Off-the-Shelf Option

11

Burden of Homegrown System Leads Hound¹ to Buy Medeanalytics


Tactic #2: Automatic Payment Generator

1) Pseudonym.

2) Likelihood based on income, payment history, and other

factors that patient will pay.

Each patient called before

appointment; given estimate

for procedure

• Patient financial estimates are

auto-generated and include

insurance deductibles,

co-insurance, and co-pays

• All self-pay patients are

electronically scored by

propensity to pay² to prioritize

pre-registration worklists

• POS scripting is customized to

accommodate a variety of patient

scenarios and insurance questions

Medeanalytics System Capabilities

Tool embedded into

registration staff workflow;

no extra labor necessary

Automatically updates with

payer contract changes

1

2

3

Workflow

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An Array of Possible Vendors

12

Key Characteristics Define High Value Products

Source: Imaging Performance Partnership research and analysis.

Characteristics of High-Quality

Vendor Solutions

Combines data from the provider’s

chargemaster, payer contract terms,

and patient’s insurance benefits

Identifies patients needing

financial counseling

Can be integrated with other revenue

cycle solutions from same vendor

Automatically increases collection

rates for high-deductible patient

balances after insurance

Provides scripting and role-playing

to help staff learn to communicate

with patients

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Comparing the Options

13

Two Tactics for Patient Obligation Systems


Key Considerations

Obligation

Accuracy Costs Time

Staff

Training Automation

#1: Patient

Obligation

Quick Guide

Insurer-specific

price, not

always plan-

specific price

Low cost;

staff workload

Large time

commitment

Must be

manually

created by

program

Requires

human

intervention for

changes,

updates to

contracts

Assessment

#2: Automatic

Payment

Generator

Auto-

generates

detailed

financial

estimates for

every patient

Substantial

investment

decision must

often be

made at

executive level

Low time

commitment

beyond initial

training

Purchase

typically

includes

scripting,

resources for

training

Technology

greatly limits

need for

manual

interventions

Assessment

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Prioritizing Advance Notification

14

Pre-scan Calls Placed to Patients Owing Significant Amount


Tactic #3: High-Risk Patient Identification

1

2

High patient obligations

High deductible

health plans

Self-pay

Previous balances

• Unpaid obligations

from previous scans

Staff pulls

schedule for

the next day

Procedure Schedule – Jan. 1, 2014

8:00-

9:00 Bartz, N.

McGarry,

N.

9:00-

10:00

Lillard,

S. Lund, I.

10:00-

11:00

Brand,

R.

Identifies high-

yield patients

Staff call to

inform patient of

obligation

before arrival

Your total

will be $75

1

2

3

High-Risk Patients

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Connecting Patients to Financial Support

15

Counseling Informs High-Risk Patients of Potential Resources


Smith, Joe

Account Balance

March 2013: $250.00

June 2013: $450.00

Total due: $700.00

Patient Financial

Counseling Financial Support

Options

Potential enrollment

in Medicaid

Monthly payment plans

Charity care

Potential enrollment in

health care exchanges

in 2014

Staff search patient

records for previous

balances prior to

patient appointment

Patient directed to

financial counseling

after scheduled

scan completed

Financial counselor

discusses potential

financial options

for patient

Prior Balance

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Resetting Expectations of Staff

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Shields Redesigns Front-Office Roles to Emphasize Collections

Source: Shields Healthcare, Quincy, Massachusetts; Imaging

Performance Partnership interviews and analysis.

Tactic #4: Formalized Job Alteration

Altered job descriptions to

include “asking for and

collecting patient obligation”

Staff unable to meet expectations

after extensive training do not

remain with program

Radiology Front-Desk Receptionist

Primary Job Responsibilities:

1. Verify patient eligibility before patient arrival

2. Call to schedule patient appointment

3. Collect patient obligation

Necessary Background:

1. High school diploma or GED; Bachelor’s

degree preferred

2. Familiarity with PC, Microsoft Suite; medical

background preferred

Case in Brief: Shields Healthcare

• Imaging provider with 33 freestanding imaging centers based in Quincy, Massachusetts

• Revamped collections process, engaged in extensive training to improve front-end collections

• Contracted with PayNav for initial revenue cycle assessment

• Currently collecting almost 35% of revenue at POS

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Supporting the Transition

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Three-Pronged Training Assists Staff with New Responsibility


Tactic #5: Staff Collections Training

• Staff consistently

engage in role-playing

with one another

• Scenarios prepare

staff for patient

pushback, complaints

• Staff are trained on

how to inform patients

of payment up-front

• “How will you be

paying” vs. “We would

like you to pay…”

• Technology updates,

changes to process

taught to staff

through webinars

• Sessions also held

once per year to keep

staff up-to-date on skills

1 2 3

Script Training Role Playing Ongoing Training

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Dealing with Patient Pushback

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Role-Playing, Training Focus on Various Scenarios


If the patient says: Respond with:

“That can’t be right. I have insurance

that will pay.”

“We have verified your insurance coverage directly

with the payer and have determined that a

deductible/co-pay is your responsibility. Would you

like to pay by cash, check or credit card?”

“I didn’t bring my checkbook.” “That’s okay. We also accept cash or credit cards.”

“I’m currently not working, just bill me.” “We have a specialist who can work with you in

locating financial assistance for you. Let me get

someone to discuss this with you.”

“Just send me a bill.” “Similar to when you visit a physician office, our

policy is that you pay at the time of service. How

would you like to take care of your payment today?”

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Broad Redesign Results in Greater Collections

19

Executive Support Underscores Importance of Performance



>30% total revenue currently

collected at POS

• Monthly meetings for site

managers to discuss POS

collections performance

• CFO attends, reinforces

importance of patient collections

to financial health of

organization, gives feedback

on performance

Leadership Support

$660k

Projected 2012

Performance, Before

Process Improvements

Actual 2012

Performance

Point-of-Service

Collections at Shields

$2.6M

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Paying (Staff) for Performance

20

River County Hospital¹ Incentivizes Employees to Collect at POS


Tactic #6: POS Staff Incentives

1) Pseudonym.

River County launches

campaign to incentivize

employees collecting

patient obligations

Posters and other

collateral promote new

incentive program

across hospital

Hospital leaders meet

with service lines and

discuss details of

program, ways to

earn incentives

Case in Brief: River County Hospital

• 25-bed critical access hospital in Midwest

• Saw bad debt steadily increase

• Decided to focus on POS collections, launched campaign to encourage staff to

take patients to discharge center where counselors discussed obligations

• Staff incentive program offers gift certificates to teams, bonuses for individuals

• 40% of radiology patients informed of obligation before incentive program; now

almost to 100%

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Deciding on the Performance Metric

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Incentives Result in Changed Behavior


40%

100%

Before

Incentive

Program

After

Incentive

Program

Percentage of Patients Taken

to Discharge Center

Monthly incentives tracked and successful

teams rewarded with gift cards

Quarterly incentives tracked and

individuals rewarded with bonuses

Discharge Center

Radiology front office FTEs evaluated

on percentage of patients they steer to

payment discharge center after scan

Team Incentives

Individual Incentives 1

2

• Tactic #7: Sponsored Tech Training

• Tactic #8: Interventional Coding Task Force

• Tactic #9: Dedicated Imaging Coding Staff

Preparing for ICD-10 and

Coding Challenges

22

Column 3

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Coding Traditionally Managed by Finance

23

Yet Imaging Leaders Understand the Importance

Source: Imaging Performance Partnership 2013 Topic Poll; Imaging

Performance Partnership research and analysis.

1) GPA calculated out of 4.00: “A” weighted as 4.00, “B” weighted

as 3.00, “C” weighted as 2.00, “F” weighted as 0.00.

Ranking of Topic Importance by

Imaging Leaders

GPA Scale¹ n=142

3.3

3.1 3.0

2.8

Understanding

New Billing

and Coding

Requirements

Securing

Preauthorization

Minimizing

Administrative

Denials

Collecting

Patient

Obligations

POS

Collections Coding

Preauthorization

Imaging’s

Purview

Finance’s

Purview

The Revenue Cycle

Billing

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Plenty of Reasons for Imaging to Get Involved

24

Three Factors Increasing the Importance of Coding to Radiology


1) Tenth revision of the International Statistical Classification of

Diseases and Related Health Problems (ICD).

• Codes performed

together more than 75%

of time paid one lump

sum by CMS

• Most common bundled

radiology codes include:

74176 – CT abd & pelvis,

74177 - Ct abd & pelv

w/contrast, and 74178 -

Ct abd & pelv 1/> regions

• Codes not separately

payable by CMS, but are

performed in conjunction

with other payable CPT,

APC codes

• Reporting all codes

necessary despite

reimbursement status, as

CMS uses data to estimate

costs of services

• Transition from ICD-9

to ICD-10 scheduled to

be complete by

October 1, 2014

• Increase in number of

codes requires

training, education,

increases importance

of accurate coding

Packaged Codes

1 2 3

Bundled Codes ICD-10¹ Implementation

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Coding for Every Component of Care

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Under-Reporting of Codes Leads to Lower Reimbursement


Packaged Codes

Danger of Under-Reporting

• Many providers fail to

accurately report all of

these codes since they

will not be reimbursed

• Distorts the data CMS

uses to reflect costs in

setting reimbursement

amounts

Procedures

Performed:

CPT 47000 $410

!

Packaged Code Example

Needle Biopsy of Liver

Needle

biopsy

performed

Echo guide

for biopsy

required

CMS doesn’t realize echo

performed during liver

biopsy, doesn’t take cost

into account

Reimbursement for liver

biopsy lower as result of

cost formula calculations

1 2

3

Program doesn’t

code for echo

4

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Only Increasing in Prevalence

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Source: Coding Strategies, Inc., Atlanta, Georgia; Imaging


Bundled Codes

1) Relative value scale.

Bundling Process

• CMS continues to work with RVS¹ Update

Committee (RUC) to identify CPT codes billed

together 95%, 90%, and 75% of the time

• Any codes that fit this description are possible

targets for new bundled CPT codes in the future

• Once new CPT codes are approved, they are

assigned an APC for payment to hospitals under

the HOPPS

Likely Future Imaging Targets

Breast Biopsy

Interventional Radiology

Nuclear Medicine

“The trend is for more bundling on interventional procedures than

diagnostic in the near-term, but there will still be cases of diagnostic

bundling.” Melody Mulaik

President, Coding Strategies, Inc.

”

The Trend Continues

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The Agency that Cried Wolf?

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Delays on ICD-10 Create Uncertainty, Unwillingness to Act

Source: Strategic Radiology, Palmetto, Florida; Centers for Medicare and Medicaid Services; Imaging


ICD-10 Implementation

1) Department of Health and Human Services.

January 16, 2009

Final rule announced requiring

all HIPAA-covered entities to

implement ICD-10, with Oct. 1,

2013 compliance date

April 9, 2012

HHS announces proposed rule

to delay compliance date by

one year to Oct. 1, 2014

Major Dates in ICD-10 Implementation

October 1, 2014

ICD-10

compliance date August 24, 2012

HHS announces final rule

that delays compliance date

to Oct. 1, 2014

“It has really been a classic ‘chicken or the egg’ scenario as far as

when to invest with all the delays to implementation.”

Randy Roat

COO, Strategic Radiology

”

February 16, 2012

HHS¹ Secretary announces

intent to postpone

compliance date

!

To Invest or Not to Invest

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More Than Seven Times the Codes

28

Complex Coding System Presents New Challenges


Number of ICD-10

Diagnosis Codes

Number of ICD-9

Diagnosis Codes

Wrist Fracture Codes

Diagnosis Codes

ICD-9 ICD-10

4K

69K

Procedure Codes

ICD-9 ICD-10

72K

14K

33 1,818

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Mapping the Transition to ICD-10

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Imaging Plays a Role in One Key Component


9

Dedicated Imaging

Coding Staff

Tactics

Interventional

Coding Task Force

8

ICD-10 Transition Steps

Steering

Committee Coder Staffing

Information

Technology

ICD-10

Transition

Plan

Clinical

Documentation

Improvement

Health

Information

Management

Managed Care

Contracting

Sponsored Tech

Training

7

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Expected Decline in Coder Productivity

30

Transition Requires Training and Recertification


Coder Staffing

Some coding staff may

choose to retire or

transition to other roles

due to complexities of

learning ICD-10

Regular

coding duties

Recertification

in ICD-10

Training for

ICD-10,

other changes

Coder Productivity

20%-50%

Expected decline

in productivity

following

conversion

Challenges to

Coding Staff

Coder Duties in Preparation

for ICD-10

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Sponsoring Tech Training

31

Techs Take on More Responsibility for Coding


Tactic #7: Sponsored Tech Training

1) Pseudonym.

Case in Brief: Arya¹ Medical Center

• 800-bed academic medical center located in the South

• Realized needed greater incentive for technologists to code charges accurately,

saw abundance of coding errors within interventional radiology

• As a means to both reduce coding errors and enfranchise technologists, medical center

offered to sponsor coding certification for lead IR techs

• Certified techs responsible for daily charge audits, held accountable for coding accuracy

Numerous

coding

errors lead

to denials

Hospital

sponsors

tech

certification

in coding

Tech

becomes

accountable

for coding

accuracy

Arrangement in Brief

• Medical center pays for initial

certification of technologist, provides

time-off for classes

• Certified technologists evaluated

on coding accuracy, responsible for

charge audits

• Program voluntary, medical center

does not require certification for

technologist position

Tech audits

claims to

confirm

technical and

professional

components

match

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Engaging Key Interventional Stakeholders

32

High Interventional Coding Error Rate Leads to New Coding Policy

Source: Johnson City Medical Center, Johnson City, TN; Imaging


Tactic #8: Interventional Coding Task Force

1) Charge description master.

Case in Brief: Johnson City Medical Center

• 478-bed hospital in Johnson City, Tennessee, part of Mountain States Health Alliance

• Audit of interventional claims showed 60% coding error rate

• Convened task force with representation from radiology, finance, and IT services to

address issue

• Instituted educational seminars across system and created a comprehensive, clear

coding and charge capture policy

40%

60%

Interventional

Radiology Coding

Error Rate

Task Force

Membership

Coding

Education

• Director of Radiology

• IR Manager

• CDM¹ Coordinator

• IR Technologists

• RIS Manager

• Business Office Manager

55% Decrease in interventional

coding errors in 3 years

after coding education

implemented

Error in

coding No error in

coding

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Taking Ownership of Coding

33

Near-Zero Denial Rate for Dedicated Imaging Coders at Littlefinger¹


Tactic #9: Dedicated Imaging Coding Staff

Primary Responsibilities

Review all charges from previous

day, code appropriately

Route appropriate charges for

diagnostic coding

Maintain radiology chargemaster

Perform Correct Coding Initiative

(CCI) edits, denial appeals

Act as coding liaison

for department

10

31

HIM²

Coder

Dedicated

Coder

Reports Coded per Hour

<1% Errors in radiology coding,

as found by third-party

consulting firm audit

Two Coding FTEs

1) Pseudonym.

2) Health information management.

• Tactic #10: Comprehensive Case Documentation

• Tactic #11: Complex Appeals Archives

• Tactic #12: Denial Origin IDs

• Tactic #13: Monthly Scorecards

Decreasing Unwarranted Denials

34

Column 4

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Despite Perceived Importance,

Lack of Focus on Denials

35

Source: Imaging Performance Partnership 2013 Topic Poll; Imaging

Performance Partnership research and analysis.

1) GPA calculated out of 4.00: “A” weighted as 4.00, “B” weighted as

3.00, “C” weighted as 2.00, “F” weighted as 0.00.

2) Pseudonym.

Importance of Topic to

Imaging Administrators

3.3

3.1 3.0

2.8

Understanding

New Billing and

Coding

Requirements/

Risks

Securing

Preauthorization

Minimizing

Administrative

Denials

Collecting

Patient

Obligations

GPA Scale¹ n=142

“Finance tracks our denials,

but we don’t get to see the

numbers.”

Radiology Administrator,

Tarth² Hospital

”

“We keep track of our

denials, but we don’t have

a systematic approach to

reducing them.”

Revenue Cycle Coordinator,

Mormont² Medical Center

”

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Three Components of Denials Management

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Extending Imaging’s Focus to Include Recovery


Risk Avoidance Revenue Recovery Contract Negotiations

• Outside imaging’s purview

• Denial or underpayment

data is often poorly

leveraged or lacks

full transparency

• Preventing initial denials on

front end and mid-cycle of

revenue cycle

• Majority of denials are

preventable, yet

challenging to track and

execute against effectively

• Traditionally dealt with

by finance department

• Often require detailed or

clinical knowledge of

imaging revenue cycle

to successfully appeal

denied claims

Historical Imaging Focus

New Imaging Focus

1 2 3

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Holding on to the Evidence

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Recording Communications with Payers Aids Appeals


Tactic #10: Comprehensive Case Documentation

1) Pseudonym.

FTEs save recorded

conversations, faxes,

emails in electronic

database

If scan denied, FTEs

able to search

database to see if

scan was initially

approved

Front office FTEs record

conversations with

payers, RBMs regarding

preauthorization, other

functions

Evidence of

Preauthorization Searchable Database

Case in Brief: Drogo¹ Radiology

• Imaging provider with 15 freestanding locations based in the Southwest

• Maintained little documentation and frequently lacked ability to successfully appeal denials

• Director of radiology implemented plan requiring staff to record every phone conversation with

payers, and document digital and hard copies of all payer communications

1

2

90%

Percentage of

denials appeals that

are successful

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Documenting Complex Cases

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Shields Maintains Archives to Inform Forthcoming Appeals

Tactic #11: Complex Appeals Archives



• Staff study denials

justifications and

prepare

sophisticated

rebuttal materials

• Appeals specific

contract provisions

and historical

precedent

1 2 3

• Record

requirements for

successful appeals

• Includes contract

citations, clinical

indications, and

scripting used

with payer

• Populate searchable

database with

effective appeal to

access at later time

• Staff able to search

old appeals to aide

in current appeals

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Tracing Denials Back to the Revenue Cycle

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Analysis Allows Focus on Internal Accountability at Mormont¹


Tactic #12: Denial Origin IDs

1) Pseudonym.

2) Advance Beneficiary Notice.

45%

45%

Front End

• Coordination of

benefits

• Medicare ABNs²

• Medicaid

• Preauthorization

10%

Back End

• Duplicate claims

• Missing

documentation

Mid-cycle

• Coding

Initial Denials at Mormont by Origin in

Revenue Cycle

• Includes supervisor, three

FTEs overseeing one

portion of revenue cycle

• Involves representative

for each revenue

cycle function

• Monthly meetings to

review denials report,

discuss how to limit initial

denials, focusing on areas

with highest percentages

Dedicated Imaging

Billing Team

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Regular Focus Results in Decreased Denials

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Case in Brief: Mormont Medical Center

• 450-bed academic medical center in the West

• Imaging has own billing department with one supervisor and 3.5 FTEs

• Imaging billing department tracks every denial’s origin in revenue cycle and works to appeal

• Reduced initial denials from 15% to 11% in first year

<1% Bad debt write-offs as a

percentage of claims

15%

11%

Percentage of Claims Initially Denied

2011 2012

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Tracking Denials by Type at Seaworth¹

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Source: Imaging Performance Partnership interviews and analysis. 1) Pseudonym.

Top Denials

Target Area Solutions

ABN/Medicare

Denials

Meet with referrer

or responsible

internal employee

and explain cost to

patient and system

from requiring ABN

Referring

physician(s)

Meet with referrer

or speak by phone

to discuss pattern

of denials and

educate on required

clinical information

Procedures

Speak to payer

about pattern

behind denials, then

educate staff,

referrers on how

to avoid them

Procedure Example:

Back MRI

• Top denied

procedure in 2012

due to medical

necessity

• Payers want

patients to undergo

more alternative

treatment options

before scans

• Disseminated

payer remarks on

back imaging to

preauthorization

staff

• Staff now speaks to

patients and

referrers about

need for alternative

treatment

before scan

50% Reduction in lost revenue to outpatient

imaging denials in 2012

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Easing the Tracking Burden

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Shields Monitors Denials Through Comprehensive Scorecards



Tactic #13: Monthly Scorecards

Outpatient Location A

Benchmark 0.53%

Benchmark

35%

Month Monthly

Scan Volume

Percent of Denials to

Scan Volume

FL NA Dx

Percent of Revenue Loss

to Scan Volume

POS Collected Billed to Patient

Percent of POS

Collections

January 568 0.18% 6 4 0 1.76% $12,393.16 $24,706.13 33%

February 501 0.60% 1 4 0 1.00% $13,175.24 $34,779.75 27%

March 625 1.12% 3 0 1 0.64% $13,949.60 $35,949.27 28%

April 581 0.52% 0 1 2 0.52% $15,566.01 $24,819.14 39%

May 367 1.09% 0 5 0 1.36% $14,044.93 $21,291.38 40%

Denials due to

no authorization

Denials due to late

claims filing

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Data Used by Denials Support Team

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Tracking, Appeals Team Manage Discrete Parts of Process



Denials Support Team

Supervisor

Appeals

Team Tracking

Team

Filing Limits Preauthorization Diagnostic Errors

0.5% Goal for percentage of

claims initially denied

Track

denials due

to overdue

filing limits

Track denials

due to

preauthorization

errors

Track denials

due to coding

or physician

diagnosis

errors

Use appeals

archives to file

claims appeals

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44 2013 National Meeting Series

On the Brink of Accountability

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Positioning Imaging as a Vital Partner in Delivery System Transformation

Imaging Market Update

• Key pressures confronting providers

• Outlook for inpatient, outpatient, and ED volumes

• Impact of reimbursement and regulatory changes

Preparing Imaging for Risk-Based Payment Models

• Managing inpatient, outpatient, and ED utilization

• Strategies for care pathway transformation

• Outlook for clinical decision support tools

The New Radiology Quality Mandate

• Demonstrating value to key imaging stakeholders

• Coordinating patient care and managing population health

• Special Report: advancing radiation dose risk management

Maximizing Imaging Revenue Capture

• Smoothing point of service collections

• Optimizing the preauthorization process

• Identifying denials flashpoints

Calibrating Imaging Pricing

• Understanding current market pressures

• Strategies for competing with

lower-cost facilities

• The future of imaging pricing strategy

Day 2 Day 1

September 19-20 October 10-11 November 7-8

Washington, DC Chicago, IL Philadelphia, PA

December 9-10 January 15, 2014

Dana Point, CA Nashville, TN

Register now

www.advisory.com/ipp/nationalmeeting

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45

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13 New Ideas for Increasing Imaging Revenue...co-insurance, and co-pays • All self-pay patients...

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