Revenue Integrity Black Holes
-
Upload
smartyjones -
Category
Documents
-
view
1.442 -
download
1
description
Transcript of Revenue Integrity Black Holes
EXPERIENCEV
AL
UE
RESULTS
Revenue Integrity Black Holes A Former CBO Director’s Perspective
Rob Jones, MBA, CPATDirector of Revenue Integrity
January 2011
Objectives
♦ Discuss some basics related to revenue integrity black holes
♦ Discuss why black holes exist
♦ Open forum discussion
♦ Walk through some “real life” examples of black holes
♦ Review solutions
Background?
♦ How many people come from Finance backgrounds?
♦ How many people come from Operations backgrounds?
♦ How many people have done both?
♦ Of the business office or patient accounting people in the room today, how many of you started off as a biller?
My Background / Perspective
♦ Representative, Medicare Billing (Hospital CBO)
♦ Supervisor, Account Maintenance (Physician CBO)
♦ Manager, Cash & Budget (Hospital CBO)
♦ Director, Patient Financial Services (Hospital & Physician CBO)
♦ Vice President, Revenue Management (Hospital CBO)
♦ Chair, Revenue Cycle Committee (various health systems)
♦ Consultant, Revenue Integrity (IMA Consulting)
What is Revenue Integrity?
♦ Revenue integrity can be summarized as follows:
“properly capture and correctly bill for services performed, maximize pricing opportunity, and ensure prompt accurate payment”
What is a Black Hole?
♦ A Black Hole is defined as follows:
“a region of space from which nothing, not even light, can escape”
What is a Revenue Integrity Black Hole?
♦ In healthcare Revenue Integrity, a Black Hole translates to:
“a system or process breakdown that prevents a hospital from getting paid accurately or timely”
WHY DO BLACK HOLES EXIST?
Why Do Black Holes Exist?
♦ Let’s start with billing requirements:
– Ultimately everything we do is summarized on a single form called the UB-04.
– Who can tell me how many fields exist on a UB04?
– Do payers have unique UB-04 data element requirements?
– How many fields on the UB04 is the business office responsible for?
Why Do Black Holes Exist?
♦ Assuming the UB-04 claim in billed, did it correctly capture all the services performed in field 44?
♦ The critical link between service delivery and billing on the UB-04 is the charge description master (CDM), which is basically the price book for the hospital. – Are all the services or supplies currently
listed in the CDM?
– Is the pricing relative to APC / other fee schedule reimbursement low?
– How often are CDM service codes / procedures with no assigned prices reviewed to ensure any internal manual pricing policies are compliant?
– How many people have “software” or “systems” that are supposed to take care of all this?
Why Do Black Holes Exist?
Assuming you’ve done everything correct and billed a perfectly clean UB-04 that captures all the services performed, are there processes and key performance indicators (KPI’s) in place to accurately record transactions and manage exceptions?
♦When is the claim adjusted?
♦Is it Systematic or Manual? If systematic, who is programming the contract management system?
♦Are transaction codes applied electronically or manually?
♦How are payment variances tracked and investigated?
Why Do Black Holes Exist?
Assuming everything is “perfect” on the UB-04 and the payers reimburse the correct amount, could there still be a black hole with revenue opportunity? YES! ♦Are the managed care contracts reviewed by a business office professional? ♦Is there an opportunity to unbundle certain services from and inpatient claim for additional reimbursement?♦Is there a strategic pricing opportunity based on contract terms?♦How are supply items reimbursed? What about supply expenses? Are you losing money due to supply costs?♦Are zero balances reviewed regularly for underpayment opportunity?
What’s The Bottom Line?
“You don’t know what you don’t know!”♦ No one person knows everything, the healthcare landscape is simply too
complex.
♦ Ensuring revenue integrity requires “subject matter expertise” in patient access, case management, charge capture, charge description master, coding, compliance, patient financial services, managed care, reimbursement, and finance.
♦ Coordination between all of these subject matter experts is essential to billing a clean claim with all the appropriate charges.
We Talked About People And Process, But What About Technology?
Let’s talk about technology…..
♦ Hospitals rely on information systems to link the revenue cycle departments and electronically push information flow from department to department.
♦ Information systems are not perfect and often have limitations. Additionally, these systems are only as good as the people who program them.
♦ Are your processes built around systems, or are systems built around your processes?
♦ Do you rely too heavily on technology?
Does an imbalance exist in your organization?
Systems Don’t Solve Problems, People Do!
♦ Our reliance on computer technology is one of the major underlying reasons why black holes exist.
♦ Over the last decade we have focused more on technology with a diminishing need for people.
♦ Computer automation has given us a false sense of security.
♦ Personal interaction has decreased.
♦ What about critical thinking or deductive reasoning?
Revenue Integrity: Discussion
Revenue Integrity: Discussion
1. Is there a person in this room that believes their hospital(s) does not have a single black hole?
2. If you had the choice to hire more people or implement a new computer system, what would you choose?
3. How has technology impacted our critical thinking ability and deductive reasoning skills?
4. Does anyone have an example of a black hole that you personally experienced?
Revenue Integrity: Discussion
Example #1 – After self pay collection efforts were exhausted, the accounts were not transferred or adjusted to bad debt
♦Black Hole Financial Impact:
– Medicare bad debt was not claimed
– Bad debt reserves were understated
Example #2 – Secondary balances were not getting transferred after the primary insurance company paid
♦Black Hole Financial Impact:
– Decreased collections
– Increased bad debt via reserve provision
Revenue Integrity: Discussion
Example #3 – The average assigned ER level was below the local and regional hospital average
♦Black Hole Financial Impact:
– An opportunity to assign a higher ER level exists
– Charge capture opportunity additionally identified
Revenue Integrity: Discussion
Example #4 – Assigned price is less than Medicare reimbursement. Impact of new OPPS coding requirements on reimbursement?
♦Black Hole Financial Impact:
– Lost revenue
Example #5 – Supply item cost exceeds actual case rate reimbursement. In some cases which require an invoice for reimbursement, nothing is sent.
♦Black Hole Financial Impact:
– Lost revenue
Revenue Integrity: Solutions
♦ Form a revenue integrity task force of seasoned and knowledgeable professionals in all areas of revenue cycle is the single most important critical success factor
♦ Assess current state to identify areas of weakness and create monitoring tools or KPI’s to monitor performance
♦ Cross train “intelligent” resources
♦ Do not solely rely on systems, instead build systems to support your processes
Contact Information
Rob Jones, MBA, CPAT
Director of Revenue Recovery
IMA Consulting
3 Christy Drive
Chadds Ford, PA 19317
(484) 840-1984 (office)
(484) 431-4324 (cell)
www.ima-consulting.com