Connect the Dots: Contracts to Revenue...
Transcript of Connect the Dots: Contracts to Revenue...
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Connect the Dots: Contracts to Revenue Cycle
SIM/TCPi Webinar Series:Moving Into Value-Based Models
April 24th 201912pm – 1pm MT
Copyright 2016. Medical Group Management Association® (MGMA®) . All rights reserved.
All information contained in this presentation is the intellectual property of Prosper Beyond.
Doral Jacobsen, MBA, FACMPECEO, Prosper Beyond, Inc.
Pamela Ballou-Nelson, RN, MSPH, PhDPrincipal Consultant, MGMA Health Care Consulting Group
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Learning Objectives
Determine contracting foundationUnderstand how contracts impact the revenue cycleLearn how to create a plan to optimize contract
performance
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Agenda
1. Payer Contracting Foundation2. Revenue Cycle Implications 3. Best Practices: Optimize Contract
Performance4. Summary
Indicates Tool =
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1. Payer Contracting Foundation
2. Revenue Cycle Implications
3. Best Practices: Optimize Contract Performance
4. Summary
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Contracting Principle 1
Why participate? Supply and demand Discount in exchange for referralMarket share Do you need this relationship?
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Quadruple Aim
Ideal Care System
Source: Adapted from Don Berwick 2008
Satisfied Patients
Best Quality
Care
Reduced Cost of Care
Satisfied Providers
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Catalogue Contracts
Steps:1. Identify payer contracts
a. Where do you take discounts?b. Billing team can assistc. Are all providers credentialed?
2. Request copy from payer (usually via email)3. Request current fee schedule4. Complete contract grid5. Complete contract quick reference guide6. Create a system for easy access to contracts and fee schedules
a. Binder with quick reference guideb. Electronic storage
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Catalogue Contracts
PayerCopy of Executed Contract?
Products Covered
Through a Network?
Next Negotiation Start Date
Contact
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1. Payer Contracting Foundation
2. Revenue Cycle Implications
3. Best Practices: Optimize Contract Performance
4. Summary
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Connecting the Dots
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Scheduling
Ask about insurance carrier – contracted? Gather information to verify
Can you pull out your card?Can you please read me your subscriber ID?
Document detailsCommunicate with patient regarding next steps
New patient packetOnline access/tools
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Pre-Visit Clearance
Verify insurance coverage – deep diveProduct? Are you participating?Deductibles? Copay?
Document the details AND the plan for next stepsCommunicate with patientEstablish payment expectations as appropriateFinancial counseling?
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Time-of-Service Collections
Understand what is due at time of serviceEnsure appropriate staff are available to address issuesFace-to-face collections before the visitStaff education and training
Do you have the right skills at the front?Do they have policies and procedures?Who can they turn to for challenging conversations?
Any other service considerations (i.e., lab, facility)?Dealing with different types of patients Allowable = insurance carrier payment + patient responsibility
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Charge Entry and Coding
Workflow Are all charges captured? How do you know?What is your charge lag time?Any plan specific considerations (i.e., modifiers)?
Coding accuracyAny outside assessments?What is your education plan? Staff training?Compliance plan?Some major payer contracts penalize for errors
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Claim Submission
WorkflowValidation process
Did all charges move through to the payer?What documentation do you keep?Are you up to speed on clearing house tools?
Timely filingPay-for-performance programs – electronic submission
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Payment Posting
Allowables loadedTop 80% revenue generating CPT codesAll contracted payers
VariationHow are inaccurate payments flagged?Who works those and how is the loop closed?Contract parameters – time limits for reporting discrepancies
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Accounts Receivable Follow Up
Are accounts receivable (AR) worked by payer?Relationships…Payer tools and websites
Payer edit systemsDo you understand them? Very impactful….How does your team keep up to date?Ever find discrepancies? How do you handle?
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Contract Management
Understand payers agreementsExecuted copy?Products?Narrow networks?
Provider credentialing, and linking and websiteTransparency informationContract performanceMarket shareRenegotiation schedule
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1. Payer Contracting Foundation
2. Revenue Cycle Implications
3. Best Practices: Optimize Contract Performance
4. Summary
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Optimize Performance
1) Consider implications throughout the entire revenue cycle2) Proactive management - renegotiations3) Monitor performance – collections, payer mix, products4) Load allowables5) Ensure charges are above allowables6) Cultivate relationships = collaborate7) Ensure staff has the right tools and adequate training8) Open lines of communication – front office/back office
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Sample Analysis - Contract Relevance
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Sample Analysis – Payer Mix/Gross CollectionsClinic Charges Est Payments Gross CollectionsSAMPLE PRACTICE Aetna 87,521$ 46,033$ 53%BCBS 1,101,886$ 803,671$ 73%Cigna 121,415$ 64,733$ 53%Commercial 169,994$ 24,036$ 14%Crescent 23,897$ 15,711$ 66%Government 57,042$ 19,523$ 34%Humana 87,735$ 49,187$ 56%Medcost 149,069$ 99,009$ 66%Medicaid 200,643$ 91,643$ 46%Medicare 617,134$ 284,083$ 46%Medicare Advantage 1,380$ 933$ 68%UHC 392,748$ 236,945$ 60%Total 3,010,465$ 1,735,506$ 58%
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Sample Analysis – Aggregate Medicare %
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1. Payer Contracting Foundation
2. Revenue Cycle Implications
3. Best Practices: Optimize Contract Performance
4. Summary
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Total Cost of Care
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Summary
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PAMELA BALLOU-NELSON RN, MSPH, PHD630.294.1072 [email protected]
DORAL JACOBSEN, MBA FACMPECEO - PROSPER BEYOND, INC.828.231.1479 [email protected]
Questions? Contact
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Copyright 2017. Medical Group Management Association® (MGMA®) . All rights reserved.