Survival in 2012 and Beyond
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Transcript of Survival in 2012 and Beyond
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Survival in 2012 and BeyondLynne P. Byrd Lynne P. Byrd
V.P. of Revenue Cycle, Archbold Medical Center
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• ● IdentifyIdentify practical operation • strategies for survival.
• ● RecognizeRecognize pilots and specific • programs that have yielded• positive operation results.
• ● CompareCompare operation perspectives • from 4 hospital systems.
LEARNING OUTCOMES OF PRESENTATION
.
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Value Based Purchasing Performance = Reimbursement
Key Areas of Focus for Revenue Cycle
5010 and ICD-10 Conversion Do you have a plan?
Clinical Documentation Improvement Physician Education & Computer-Assisted coding
Career Ladders - Education is Key!! Staff development is essential to survival
Denials Management Establish an effective process now
Managed Care Contract Compliance Validate your reimbursement
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• ●Eligibility – 270/271• Improved transactions• Improved COB
• ●Electronic Claims - 837• ●Claims Status – 276/277• ●Authorizations - 278• ●Remittance Posting - 835• ●Know what your key payers are doing
Key Transactions to validate and test by payer
5010 Conversion
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• HIM Preparation• - Coder Education
plan early and provide LOTS!
• - Staffing and Productivity
• *Recruit now• *Augment with
Computer-assisted coding tools
• Clinical Documentation Improvement
• - Concurrent coding @ bedside
• - Improve physician documentation
• - Dedicated staff
• Cash Flow Protection
• - Reduce DNFC• - Reduce DNFB• - Reduce AR
days• - Clean up
denials• NOW• To make room for
the back log!
ICD-10 ConsiderationsWhat you need to be doing now……..
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• ●Concurrent coding of the patient record at the bedside
• ●Clinical Documentation Specialist (CDS) RNs will work with physicians to complete the documentation needed in the patient’s record for final coding during the stay
• ●Medical Records staff will perform final coding• ●Overall goal is ACCURACY of clinical record; and Improved QUALITY reporting → SOI and ROM index
• ●Documentation translates into proper reimbursement for care delivered
Essential program for ICD-10 success
Clinical Documentation Improvement
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• CMS will withhold a percentage of reimbursement (excluding critical access hospitals) beginning with 1% in fiscal year 2013 and ramping up to 2% by 2017.
• They will then redistribute those dollars as incentive payments based on performance.
• 1st Baseline Period complete: July 1, 2009 – March 31, 2010
• 1st Performance Period: July 1, 2011 – March 31, 2012
• 2 Domains for now : • Clinical Process (70% weight) & Patient
Experience (30%)
• 3 on the way: Mortality, Hospital-acquired Conditions, Patient Safety
Reimbursement Impacted by PerformanceValue-Based Purchasing
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Value-Based Purchasing
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PATIENT ACCESS
• Driven by training and certifications
• 5 levels:• Level 1 – HTH Pt Access
Cert• Level 2 – HTH Pt Access
Spec• Level 3 – HFMA CFC• Level 4 – HFMA CPAR• Level 5 – HFMA ACPAR
• Driven by experience, training, and certifications
• 5 levels: (under development)
• Level 1 – HTH Business office
• Level 2 – HFMA CPAR• Level 3 and 4 -
• HFMA CFC/ACPAR depending on job code
•
PATIENT FINANCIAL SERVICES
Career LaddersStaff development is a primary key to success
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• ICD-10: estimates of • 10-25% increase in government initial denials
• Imperative to have effective process in place now as pace will be accelerating
• Technical Denials are increasing from all payers
Denials ManagementThis is not new, but more important than ever……
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Validate your reimbursement
Check for “silent PPO” activity
Check for unauthorized discounts taken by contracted payers
Watch for 3rd party “Re-pricers” being employed by self-insured companies
Validate Managed Care paymentsAre your claims being re-priced by a non-
contracted 3rd party?
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• ● IdentifyIdentify practical operation • strategies for survival.
• ● RecognizeRecognize pilots and specific • programs that have yielded• positive operation results.
• ● CompareCompare operation perspectives • from 4 hospital systems.
LEARNING OUTCOMES OF PRESENTATION
.