MAP KEYS OVERVIEW and CASE STUDY - aipamaipam.net/doc/HFMap_and_Spectrum.pdfMAP KEYS – OVERVIEW...
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Association of Illinois Access Management
Patient Access No Bed of Roses
Rosewood Restaurant, Rosemont, IL
MAP KEYS – OVERVIEW
and CASE STUDY Thursday, March 10, 2011- 2 to 3:30 pm
Suzanne K. Lestina, FHFMA, CPC
Director, Revenue Cycle MAP
Healthcare Financial Management Association
Tracey McKnight, Senior Director, Revenue Cycle
Ami Kihn, Senior Director, Patient Financial
Operations
Spectrum Health System, Michigan
OVERVIEW
Reform and the revenue cycle
How hospitals are responding
Evidence-based improvement
A Case Study – Spectrum Health System
2
REFORM AND THE REVENUE CYCLE
INCREASING INSURANCE
COVERAGE
0
2
4
6
8
10
12
14
16
18
20
2010 2011 2012 2013 2014 2015 2016 2017 2018 2019
4
Am
erica
ns (M
illio
ns)
Source: CBO
CHANGING PAYER MIX
5
(32)
(5) (3)
16
24
(35)
(20)
(5)
10
25
Uninsured Non-GroupMarket
EmployerSponsored
Medicaid Exchanges
Am
erica
ns (M
illio
ns)
Source: CBO letter to House Speaker Nancy Pelosi
– March 20, 2010
FINANCIAL IMPACT ON
YOUR HOSPITALS
6
Sources: Health Care Facilities Managed Care Analysis; Bank of America Merrill Lynch;
March 4, 2010; p. 9
CBO letter to Speaker Nancy Pelosi; March 20, 2010; HFMA estimate
New payments for uncompensated care
Market basket update (MBU)
Disproportionate Share Hospital payment cuts
(Medicare & Medicaid DSH)
Reduced readmissions
Hospital-acquired conditions
Accountable care organizations
Net aggregate financial impact on U.S. hospitals
-36.1
-7.1
-1.5
-1.5
17.06
Payment reductions:
Payment Area Payment Reduction Over a
10 Year Period (in billions)
-112.6
177.3
OTHER REFORM CHANGES
New requirements
– Standardized charge reporting
– Requirements for tax-exempt hospitals
New economic incentives
– Payment linked to quality
– Accountable care organizations
– Bundled payment
7
HOW REFORM IS AFFECTING
THE REVENUE CYCLE R
evenue C
ycle
Im
pera
tives
8
Expanded
Coverage
New
Requirements
Payment
Cuts
New Economic
Incentives
Improve Performance and Efficiency
Eligibility
Processes
Charity Care
Policies/Process
Denials
Prevention ICD-10
Rational
Pricing
Documentation
and Coding
Physician
Integration
Bundled
Payments
HOW HOSPITALS ARE RESPONDING
PRINCETON BAPTIST MEDICAL CENTER BIRMINGHAM, ALABAMA
Consolidated pre-arrival unit
Automated insurance verification, including
identifying patient financial obligation
Communicating about and collecting this
amount prior to arrival
Instituting continuous quality improvement
process to identify and reduce errors
10
Area of Excellence: Cash Collection How They Did It
Reduce DNFB to 3.7 days
Increase cash as a % of net revenue to consistently
above 100%
Decrease denials to less than .25% of gross
revenue
Maintain cost to collect at less than 3%
11
DNFB Comparable Statistics
6.2 Median
5.4 Top Quartile Performance
Source: HFMA’s March 2010
Results
PRINCETON BAPTIST MEDICAL CENTER BIRMINGHAM, ALABAMA
TOUCHETTE REGIONAL HOSPITAL CENTREVILLE, ILLINOIS
Revising charity care policy
Adopting an automated patient
eligibility system
Incorporating charity care criteria
into the system’s database
12
Area of Excellence: Cash Collections How They Did It
TOUCHETTE REGIONAL HOSPITAL CENTREVILLE, ILLINOIS
Reduced bad debt charges by 48.6%
Increased charity care by 15.5%
Decreased overall uncompensated charges by 16.6%
Increased cash collections by $2.5 million over the goal
of102% adjusted net patient services revenue
13
Cash Collections Comparable Statistics
100.2 Median
102.1 Top Quartile Performance
Source: HFMA’s March 2010
Results
BAYLOR HEALTH CARE SYSTEM DALLAS, TEXAS
Centralize the business office
Centralize insurance verification
and pre-registration
Centralize denials management
14
Area of Excellence: Cash Position How They Did It
BAYLOR HEALTH CARE SYSTEM DALLAS, TEXAS
Improvements from 2000-2009
– Achieved consistent net revenue cash
collection rate of 100% or better
– Lowered net accounts receivable
days from 67.9 in 2000 to 39.9
– Decreased 91+ days from
discharge aging from 13.0% to 5.8%
– Reduced cost of collections
from 2.5%
15
Results
Source: HFMA’s March 2010
Days in A/R Comparable Statistics
44.5 Median
37.9 Top Quartile Performance
EVIDENCE-BASED IMPROVEMENT
EVIDENCE-BASED
IMPROVEMENT
Measuring Performance
– What are consensus measures of
revenue cycle excellence?
Comparing Performance
– How are peers performance and what
are performance targets?
Improving Performance
– How do high performers succeed?
17
Components
Identify and manage to trends
Validate best practices
Trigger corrective action
Forecast performance
Identify opportunities for process improvement
Compare performance with like organizations
Use data to change behaviors
18
Benefits
EVIDENCE-BASED
IMPROVEMENT
HFMA INITIATIVE
19
MAP is a comprehensive performance
improvement strategy
WHAT IS MAP?
Identify indicators
Track and improve performance
Recognize excellence
Share successful practices
20
EVIDENCE-BASED IMPROVEMENT:
MEASURING PERFORMANCE
MAP Keys are industry-developed
key indicators for revenue cycle
performance
MAP KEYS
Clearly defined
Measurable
Discerning
Comparable
MAP KEYS
Patient access
Revenue integrity
Claims adjudication
Management
23
MAP Keys focus on key areas of
revenue cycle performance
PURPOSE | VALUE | CALCULATION
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Example
Indicator
Purpose
Value
Calculation
Net days in A/R
Trending indicator of overall A/R performance
Indicates revenue cycle efficiency
Net A/R
Net patient service revenue
EVIDENCE BASED IMPROVEMENT:
COMPARING PERFORMANCE
COMPARING PERFORMANCE
Manage trends
Identify opportunities
Prioritize opportunities
Identify successful practices
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Industry trends
Performance over multiple
time frames
Pre-selected peer groups
Customized peer groups
COMPARING PERFORMANCE
27
Flexible comparisons are needed for
in-depth analysis
Source: HFMA’s
Bad Debt vs. Charity Care as of % Revenue
Jan 09 Mar 09 May 09 Jul 09 Sep 09 Nov 09
0%
1%
3%
4%
5%
PEER GROUP COMPARISONS
28
Need to choose appropriate peer
groups for meaningful comparisons
Source: HFMA’s
29
TIMELY DATA
You need recent data to set appropriate
performance targets; industry trends affect
expected performance levels.
Organizations need to “raise the bar”
as industry performance improves.
Although median days in A/R was
about 52 in 2004, it dropped to
about 46 in 2009.
This shows that data need to be
current to establish a relevant
benchmark.
Median Days in A/R
EVIDENCE BASED IMPROVEMENT:
IMPROVING PERFORMANCE
INSIGHTS FROM AND ABOUT
HIGH PERFORMERS
Research
– % of high performers citing
importance of investing in front-
end technology
– % of high performers having
estimates available for patients
at registration
Successful practices
– Sample scripts
– Use of dedicated trainers for
patient access staff
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Area for improvement: Cash collection
Cash collection as a % of
adjusted net patient services
revenue
– Median: 100.2
– Top quartile: 102.1
Source: HFMA’s March 2010
HFMA’s MAP Award recognizes healthcare
organizations that achieve excellence in the
revenue cycle and serve as models for the
healthcare industry
MAP AWARD
32
SUCCESSFUL PRACTICES
SUCCESSFUL PRACTICES
Culture
People
Processes
Technology
Communication
34
CULTURE
76%
86%High Performing
All Other
SUPPORT FOR REVENUE
CYCLE
36
7 = Extremely high to 1 = None at all
37
PEOPLE
High Performers >10 days
5-10
days 3-5 days 2-3 days
1 day
or less
Registrars 57% 14% 14% 14% 0%
Billers 57% 14% 14% 14% 0%
Collectors 50% 21% 21% 7% 0%
Financial Counselors 64% 14% 14% 7% 0%
All Others >10 days
5-10
days 3-5 days 2-3 days
1 day
or less
Registrars 42% 25% 15% 11% 7%
Billers 54% 25% 7% 10% 4%
Collectors 47% 30% 10% 9% 5%
Financial Counselors 52% 26% 10% 7% 5%
DAYS OF INITIAL REVENUE
CYCLE TRAINING REQUIRED
38
STRATEGIES TO MOTIVATE,
RECRUIT, AND RETAIN STAFF
19%
31%
44%
43%
64%
86%
0% 50% 100%
High PerformingAll Others
39
Increase front-line staff salaries (beyond average organizational increase)
Provide incentives for staff who meet goals
Increase back-office staff salaries (beyond average organizational increase)
40
PROCESSES
Process centered improvement
team(s) meet at least weekly
Revenue cycle staff team meet at
least monthly
Cross-functional team meet at
least monthly (including reps
from clinical, IT, HIM, . . . )
3%
25%
51%
26%
84%
21%
50%
57%
50%
71%
0% 20% 40% 60% 80% 100%
High Performing All Others
Metric triggered leadership teams
(triggered by revenue cycle metric
outside defined parameters)
Other (responses generally include
more frequent, targeted meetings)
FREQUENCY OF REVENUE
CYCLE TEAM MEETINGS
41
20%
43%High Performing
All Others
USE OF PATIENT FOCUS
GROUPS
42
Routinely meet to discuss & implement
process streamlining initiatives
Routinely meet to review & discuss issues
regarding patient satisfaction
Routinely meet to discuss & implement
technology improvements and interfaces
Routinely meet to review & discuss
payment discrepancies
Do not routinely collaborate
with payers 35%
57%
26%
25%
21%
7%
86%
64%
64%
57%
0% 20% 40% 60% 80% 100%
High Performing All Other
COLLABORATION WITH
PAYERS
43
Registration
Financial Counseling
Admitting
Billing
27%
31%
21%
24%
23%
50%
29%
43%
50%
64%
0% 20% 40% 60% 80% 100%
High Performing All Other
Collections
SIGNIFICANT CHANGES TO THE
FOLLOWING AREAS WITHIN THE PAST 3
YEARS
44
1 = no improvement to 7 = complete overhaul
TECHNOLOGY
IT collaboration
with revenue cycle
IT support for
revenue cycle
51%
55%
71%
79%
0% 20% 40% 60% 80% 100%
High Performing All Other
TECHNOLOGY SUPPORT FOR
THE REVENUE CYCLE
46
7 = Extremely high to 1 = None at all
COMMUNICATION
We provide estimates to nearly every patient
At time of service, upon request
At scheduling, upon request
At registration, upon request
We do not provide estimates 10%
33%
40%
53%
16%
7%
43%
57%
36%
21%
0% 20% 40% 60% 80% 100%
High Performing All Others
AVAILABILITY OF ESTIMATES FOR
PATIENT OUT-OF-POCKET LIABILITY
48
0%
1%
9%
48%
84%
0%
7%
7%
64%
71%
0% 20% 40% 60% 80% 100%
High Performing All Other
Managers, Directors, CFO
Registrars
Financial Counselors
No approval needed if patient meets organizational Charity Care Policy
Schedulers
WHO HAS ABILITY TO APPROVE
PROVISION OF CHARITY CARE
49
Spectrum Health System
Successful Practices
2
Automated Eligibility, Address
Checking and Propensity to
Pay - Revenue Cycle Strategy combining
People, Process and Technology.
March 10, 2011 Prepared and presented for:
association of Illinois
Patient Access Management
3
Tracey McKnight, RN,MM,CMAC
Senior Director – Revenue Cycle Management
Spectrum Health Hospital Group
Ami Kihn
Senior Director – Patient Financial Operations
Spectrum Health System
4
MAP Case Study
About Spectrum Health
Spectrum Health is a not-for-profit system of care dedicated to
improving the health of families and individuals. Our
organization includes a medical center, regional community
hospitals (7), a dedicated children’s hospital, a multispecialty
medical group, affiliated physicians and a nationally recognized
health plan, Priority Health.
Spectrum Health has over 16,700 employees and 1,500
physicians
6
Mission, Vision, Values
MISSION: To improve the health of the communities we serve
VISION: To be the nation’s highest quality and most successful
healthcare enterprise
VALUES: Compassion, Excellence, Innovation, Integrity,
Respect, Teamwork,
7
Revenue Cycle
Overview Revenue Cycle Technology Systems Planning, Integration, Deployment, Stabilization
Revenue Cycle Policy and Procedure
Compliance and Payer Relations
Revenue Cycle Leadership and Direction
Revenue Cycle Education and Training
Phys Relationship
Access
Service
RequestScheduling
Clinical Prep
Registration/Check-
In
CodingClinical Encounter Patient Finance
Eligibility
Financial ClearancePre-Registration
Address
Pre-Arrival
Patient Readiness
Cash ApplicationDenial
ManagementAcct. Follow Up/Mgt.
Customer Svce Call Ctr.
Claim Submission
Check-out/
Discharge
CCAPPatient Placement
Discharge Planning
Social Work
Charge Capture
AuthorizationFinancial
Counseling
Time of Service PymntConsent/Forms
MSPMySpectrum Enroll
ID CardsScanning
WayfindingOrder Follow Up
Care Management/
UM
HIM
Revenue
Integrity
Charge
Capture
Clinical Treatment
Patient Billing
Project Methodology
Agenda
9
Initiate Idea
■Project Sponsor Identified
■Vision and Business Objectives
■Resource Estimates
■Leadership Support/Project Structure
Develop Concept
■Resource Estimates Defined and Resources Committed
■Project Plan Developed
■Project Plan Approval and Project Funding
Agenda continued
Plan & DO
■Project Overview
■Project Inclusions
■Integration Development
■Process Flow Changes
■Education and Training
Implement & Evaluate
■ Go-Live Decision Documented
■ Go-Live Statistics
■ Criteria to Measure Success (Dashboard)
Questions
Project Vision and Business Objectives
Project Vision
■ To provide tools and resources to the front-end/first patient contact areas to identify correct and accurate patient demographic and insurance
Business Objectives
• Decrease number of Self Pay designations at the time of service/registration due to valid insurance
• Decrease Self Pay referrals made to Financial Counseling because truly has insurance
• Decrease customer service phone calls
• Increase clean claims submissions
• Reduce front end edits for incorrect subscribers
Project Structure
Oversight Committee- Representation Includes Leadership supporting: Patient Access- Facility, Patient Financial Services- Facility, Professional Business Office, TIS, United/Kelsey, Reed City
Work Group Structure- Several Workgroups throughout project to include personnel from all areas as indicated above- work items included: Address Checking, Credit Checking, Propensity to Pay, Eligibility, Pre-Encounter
RevRunner Utilization Work group – established after go-live (s) to continue to monitor activities, questions, enhancements, reports, quality activities, etc of the RevRunner users and system
12
Project Overview
Automated Verification Tool
■ Patient Demographics (Patient ID)
■ Eligibility (Verifier)
■ Ability to Pay (Propensity to Pay)
Integrated with Core Technology
■ Cerner (Patient ID and Verifier)
■ Healthquest (Patient ID and Verifier)
■ Horizon’s Practice Plus (Verifier)
■ Misys (All Modules Stand Alone)
13
Overview- Address Checking
Patient ID:
This functionality will allow for us to verify and validate
guarantor address to ensure accuracy of the information in our
core systems. This will improve identification of the patient;
assisting with response to compliance with Red Flag
Regulations, as well as decrease the rate of returned mail;
improving the length of the billing and collection cycle with the
patient.
14
Overview- Eligibility Checking
Verifier:
Verifier allows us to verify and validate the accuracy of the
insurance information in our core systems. With this
functionality we can assure that the patient is still eligible for the
identified insurance and, as provided by the insurance plan, we
are also able to gather benefit levels, co-payments, and
deductibles to determine the patient’s out-of-pocket obligation.
This functionality will prevent unnecessary re-submission of
bills due to inaccurate or ineligible insurance information, as
well as, improve our ability to collect prior to and at the point of
service.
15
Overview- Propensity to Pay
Propensity to Pay Scoring:
Through utilization of the Propensity to Pay module we will be
able to identify a patient’s ability to pay for their healthcare
services either prior to or at the time of service, depending on
the nature of their visit. This will enable us to focus our
collection efforts, providing education on potential Medicaid
eligibility or assistance with determining payment options or
financial assistance as necessary.
16
Scope Inclusions
Locations:
■ Grand Rapids Hospitals
Butterworth
Blodgett
HDVCH
■ United Hospital
■ Kelsey Hospital
■ Reed City Hospital
■ Kent Long Term Acute Care
Hospital
Technology:
■ Horizon’s Practice Plus
■ Misys
■ Cerner
■ Healthquest
17
Integration
270/271 Transactions:
■ Allows for checking insurance eligibility real-time during the registration process (Cerner, Healthquest, HPP)
HL7 Transaction:
■ Allows for eligibility checking after the registration process (Cerner, Healthquest)
■ Added the ability to check guarantor address by a Yes/No Indicator (Cerner)
■ Allows us to pre-populate fields to cut down on manual entry during the credit checking inquiry
Testing Unique - Live patient testing required given nature of work
Batch File Reports – CCL out of Cerner, Healthquest or queried out of Ensemble (can set up when to run and how often)
18
Stand Alone versus Integration
Staff may elect to utilize as a stand alone system in
appropriate circumstances
Education and Training developed scenarios to guide
staff when to utilize in stand alone environment
Once data is entered into the technology system,
integration is forced through the 270/271 transaction sets
19
Integration Diagram
Process Flow Changes
Created new process flows for the use of automated eligibility
and address checking in the below areas:
■ Scheduling
■ Pre-Arrival
■ Point of Service
■ Emergency
■ Verification – Prior to Service
■ Financial Counseling – During Service
■ PFS – post service
■ Primary Care
Process Flow Example
Education and Training
■ Deliver education in e-Learning environment and paper
based education completed as well. Specific Modules
below:
■ Integrated Version
■ Standalone Version
■ Administrative Functions Module
■ Including education to support scripting and links to
procedures and process
■ Provided on-site training to each individual area
23
Examples of Education Materials
Go-Live Statistics/Successes
Rolled Out Verifier and Patient ID to over 68 department locations (October 2009 – July 2010)
Began Propensity to Pay roll out October 2010 (anticipate completion June 2011)
Currently have over 600 hundred users
Average about 200,000 eligibility checks per month
Average about 32,000 address checks per month
Go-Live Statistics/Successes continued
Mail returns per month are at about 2.0%
Insurance discrepancies from registration to billing has gone down from around 9% to 7.9% on average
Self pay/NA designation at registration changed to another insurance in Finance has decreased from 23% to 6% in a 9 month period
Dashboard
Dashboard Continued
Next Steps
Complete roll out of Propensity to Pay
Integration to Medical Group Technology and Processes
Key Lessons Learned:
Project Management Methodology
Strong Executive Leadership
Change the process, not just technology
Understand what done looks like
Metrics, Metrics, Metrics
Keep momentum going
Have fun/celebrate
Questions?
32
Propensity to Pay Evaluation –
A patient friendly process to support
the growing shift of financial
responsibility.
33
Agenda
What and Why
Propensity to Pay Validation/Scoring Matrix
Target Process Changes
Pilot Phase
Timeline
Next Steps
34
Propensity to Pay
What is it?
Why Consider it? .
An individual’s ability and likelihood to pay
for their healthcare services
To be able to communicate financial liability to the
patient
as early in the Revenue Cycle Process as possible.
Example: Propensity to Pay Scoring
Color and Score Assigned – Red = Low credit, low income – (Presumptive Charity)
– Yellow = High credit, low income – (Payment Plans)
– Blue = Low credit, high income -
– Green = High credit, high income
35
Process Changes
• Presumptive Charity Determination
• Reduction/Elimination of Manual Financial Assistance
Application Process
• Fewer Touch points along Revenue Cycle- predetermined
accounts flagged early, eliminating statements, phone calls,
and unnecessary collection effort and expense
• Targeted collection efforts based on Propensity to Pay score
• Care Management process enhancements
• Collaboration efforts with SH Medical Group
36
Phase 1: Validation
Target Goal= at least 85% of the validation accounts match P2P
Recommendation
37
92.2% 88.9% 91.3%
7.8% 11.1% 8.7%
0%5%
10%15%20%25%30%35%40%45%50%55%60%65%70%75%80%85%90%95%
100%
Self-pay pilot accounts Financial counseling pilot accounts Total pilot accounts
P2P pilot discrepancies
P2P score matches P2P score discrepancies
38
Validation Results
The majority of the time the tool produced the
Propensity to Pay score that we expected
For the accounts with discrepancies SH found the
tool was more conservative in scoring than what we
would have been in our determination process
39
December 22, 2010 – March 1, 2011
• Butterworth Campus Emergency Dept Financial Counselors
• Self Pay Patients
•Out Patient Accounts (not admitted from ED visit)
Phase 2: Pilot
40
Next Steps
• Run Batch file of existing Self Pay Accounts Receivable to
identify Presumptive Charity Accounts – Complete by
03/01/11
• Identify where in current collection process ongoing batch
files will be sent for scoring.
• Develop deployment Calendar for go live sites.
• Develop and Deliver Education materials to targeted staff to
coincide with go live planning.
• Update Financial Assistance Policy and Procedures
Next Steps (cont.)
• Increase awareness for all Revenue Cycle Staff
• Partnership and Communication with Medical Group on
Financial Assistance Determination
• Partnership and Communication with Care Management on
Financial Assistance Determination
41
42
Questions?
42
43