“Improving Revenue Cycle Management with Clinical

and Operational Workflow”

Connecting the Dots:

Improving Health Center SustainabilityLearner Objectives

• The learner will gain insight into how to utilize Health Information Technology (HIT) to improve financial performance.

• Identify the critical success factors related to workflow integration.

• Understand the relationship between the role of health information technology, workflow, and revenue cycle management.

• Incorporate the principles of workflow integration into revenue cycle management.

History/Mission

Policy Information Notice

Health Information Technology Strategy

Sustainability4

3

2

1

Key Discussion Points

History • In 2015 Health Centers will celebrate 50 years of

expanding healthcare access and delivering quality primary to medically underserved and uninsured populations.

• The health center model targeted the roots of poverty by combining the resources of local communities with federal funds to establish neighborhood clinics.

• Health centers primarily provide health care to patients who are uninsured or covered by Medicaid.

• Community health centers rely on a combination of Medicaid payments, grant revenues, and other private and public funding sources to fund their operations.

• Health centers have established themselves as mission based healthcare providers that provide care to patients regardless of “ability to pay.”

Mission

• Medically underserved populations.– Uninsured– Underinsured– Chronically unemployed– Newly unemployed

• Migratory and seasonal agricultural workers.

• Homeless populations.• Residents of public housing.

Policy Information Notice

• Health centers must assure that any fees or payments required for services will be reduced or waived to enable the center to fulfill the assurance.

• The Health Center Program statute also requires “a schedule of fees or payments for services consistent with locally prevailing rates or charges.

• The PIN requires health centers to design a fee schedule to cover its reasonable costs of operation.

• And “to make every reasonable effort to secure from patients payment for services in accordance with such schedules.

• And to collect reimbursement for health services to persons covered by public or private insurance.

Health Centers

MissionSustainability

Margins

Business Operations

Financial Management

• Financial Culture

• Business Mindset

MedicallyUnderserved

• Healthcare Access

• Preventive Services

Grant Funds• Primary

Health Services

• SpecialtyServices

Financial Infrastructure

• Financial Quality

Improvement • Financial

Goals

MissionSustainabilityMargins

Health Center

Financial Infrastructure

Revenue Cycle Management

Leadership

Regulatory Compliance

Information Technology

Quality

Mission

SustainabilityHealth

Center

Margins

Financial Transformation

• Appointment Scheduling • Registration/Certification • Patient Reception • Clinical Visit/Service Delivery • Documentation and Coding of Visit • Charge Processing/Check Out • Patient Statement & Claim Production • Claims & Patient Payments Processing• Denied Claims Management • Accounts Receivable Oversight & Collections

Revenue Cycle Management

Revenue Cycle

ManagementExecutive

Leadership

Clinical

Operations

Financial

Operations

Operations

Revenue Cycle Management: RCM

Current Status of Business Operations and Workflow

• What are the health center’s financial policies and procedures?

• What is your current understanding of FQHC billing and reimbursement systems?

• Who currently manages the complexities of these billing and reimbursement systems?

• Who stands as your internal or external finance, billing, coding, and HIT content expert.

• How often does leadership assess financial workflow and operations?

• All Inclusive Rate • Medicare • Medicaid versus • Managed • Sliding Fee• Self-pay• Wraparound billing

What current HIT workflows are in place to support business operations?

– Leadership operations– Finance operations– Billing operations– Operations– Clinical operations

Current Status of Business Operations and Workflow

Leadership• Understand

operations• Team

competence• Cultivate

change

Operations

• Scheduling• Front Desk• Back Office

Finance/Billing

• Practice Management

• Billing Policies/Procedure

s• Collections

Clinical

• Credentialing Scheduling

• Documentation

• Coding• Productivity

Mission

SustainabilityHealth Center

Margins

Health Information Technology Optimization

Health Information Technology

Finance/Billing

Operations

Clinical Operations

Leadership

• Transformation• Financial

Solvency• Restructure

Workflow• Cultivate

Financial Culture

Health Information Technology

BeginsRCM

• Pt. Access• Appointment

Management• Initial Contact

• Eligibility• Credentialing

Patient InformationInsurance• Eligibility

• Credentialing HIPPA/Complianc

e• Copayment• Outstanding

Balances

ProviderAccountability

• Patient Experience• E&M

• Documentation• Coding• Time

Management

Fees for Service

• Patient Payments

• Charge Retrieval

• Appointment• Scheduling

HIT Process Improvement

SchedulingPatient

Check-Out

Registration Clinical

Encounter

Health Information Technology Workflow

Patient Scheduling Workflow

• The revenue cycle starts with scheduling the patient.• Health center staff should use a check sheet or script

guide to be sure all pertinent information is collected at the time of scheduling.

• Collecting insurance information will help the scheduler know what information to ask from the patient.

• Additional items to discuss with the patient include explaining what information the patient should bring to the appointment.

• The expectation of payment of co-pays at the time of the visit, and the arrival time of the patient if certain paperwork and registration work needs to be completed.

Patient Registration Workflow

HIT and Practice Management System

• Practice Management System – key driver of the RCM process.

• Establish mandatory registration data entry points.

• Verify patient information at every visit (phone numbers, UDS data points).

• Front desk must check insurance eligibility and check patient’s insurance card at every visit.

• Collect copayments at the point of registration. (Financial Policy)

Case Study

A new uninsured patient walks into the health center and requests a same day visit for a physical examination.

Develop a patient centered access friendly workflow for this scenario. What are the major factors to consider?

• The patient reports the following:– No current health insurance.– No current primary care provider.– No current history of present illness.– Working part-time at a local farmer’s

market.– Patient reports occasional headaches

possibly due to stress. “I would like to take better care of myself.”

Workflow Development Considerations

• Identify internal and external processes influences that prevent your health center from successful revenue cycle management.

• Does your health center currently have a financial policy that serves as the back bone of your RCM processes?

• How does your health center utilize your practice management system and electronic health record to optimize operations and workflow processes?

• What is your health center’s “WOW” factor? How do you make a memorable first impression? How best can you utilize HIT to develop sound walk-in registration/uninsured patient workflow processes?

• What HIT techniques are used to decrease incidences of registration backlog due to processing delays, patient literacy support, and triage needs?

Patient Financial Policy

Patient Financial PolicyALL PAYMENT IS EXPECTED AT THE TIME OF SERVICE

 Payment is required at the time services are rendered unless other arrangements have been made in advance. This includes applicable coinsurance and copayments for participating insurance companies. The Health Center accepts cash, Visa, MasterCard, flexible spending accounts, money orders, and debit cards.

Past Due Balances:

Unpaid past due balances create a financial burden for both you and the health center. To minimize the burden incurred by both parties, the Health Center will ask you to create a payment plan for all unpaid balances greater than $50. Any payment plan will be strictly associated with past due balances and will not replace charges due for current or future services.

Patients will not be denied services based on an inability to pay. The Health Center establishes payment plans as a courtesy to you.

 The Health Center realizes that financial difficulties may occur. In such circumstances, we advise immediate communication of your financial changes. The Health Center is committed to ensuring all patients have access to quality healthcare. 

Patients identified through the financial application process as having an ability to pay are expected to honor established payment plan arrangements. Refusal or failure to pay if ability to pay has been established may result in patient dismissal from the Health Center.

 Patients with an outstanding balance 60 days or more overdue must make arrangements for payment prior to scheduling appointments.

Refunds

Patient/guarantor credits in amounts less than $20.00 will be retained on account to be credited towards future balances unless written request for refund is received. Amounts $20.00 and greater will be automatically refunded to the patient/guarantor.

 Insurance:

 Providing Insurance Information

It is your responsibility to provide us with accurate insurance information. You are expected to bring insurance cards to every appointment. It is your responsibility to advise us of any insurance changes prior to scheduling any appointment or requesting any service, such as a medication refill or a referral.

 

Patient

Scheduling

Front Desk

Healthcare Team

Your Text

Your Text

Your Text

Your Text

Health Information Technology

Provider

Patient

Clinical Workflow

Integrated Care

Workflow

Check-out Workflow

Clinical Operations and Workflow

C

PatientEncounter

Chief Complaint

ExaminationClinical decision

Making

Evaluation and Management

• CPOE• Documentation

• E&M Coding• Plan of Care

Electronic Medical Record

Provider

Sustainability

Margins

Mission

Compliance

Clinical Workflow and HIT

Patient Centered Care

• Medical Decision Making

• CPOE• Documentation/Coding

Patient Accountability

• Self-Management• Patient

Responsibility• Ability to Pay

Information

Exchange

Medical

Orders

Medical

Charges

Information

Exchange

Financial

Responsibility

Medical

Billing

Electronic Health

Record

Practice

Management

Clinical Workflow and HIT

Improved Access

Quality Healthcare Delivery

Integrated Care

Financial Management

Financial Infrastructure

Healthcare Teams

Health Center

Patients

Sustainability

65 %

10 %

25%

100 % Mission vs

Margins

Health Center

Mission

Sustainability

Margins

Health Information Technology Workflow

Questions

DPM Healthcare Consulting

Stephanie J. Wroten BSN, MS, LNCstephaniewrotenlnc@gmail.com

Debra P. McGrath, President

DPM Healthcare Consultingdmcgrathnp@gmail.com

Contact Information

DPM Healthcare Consulting