(Title) Name(s) of presenter(s) Organizational Affiliation Welcome Fee-for-Service, Level I January...

(Title)Name(s) of presenter(s)Organizational AffiliationWelcome

Fee-for-Service, Level I

January 2012Project Funded by CSAT

OverviewWhat to expect in the next two days?HousekeepingInformation to assist you with your comfort

CurrentStateDesiredFutureThe Change Process1. Your Name/Organization/Role2. If the bike represents your organizations current change process, what part of the bike are you?

Health Care Reform*Janet ZwickJBS International and NIATx Coach

Leading Change: A Plan for Substance Abuse and Mental Health Services Administration (SAMHSA) Roles and Actions 2011 - 2014 Behavioral health is an essential part of health. Individuals and families cannot be healthy without positive mental health and freedom from addictions and abuse of substances. Behavioral health, prevention and treatment services are important parts of health service systems and community-wide strategies that work to improve health status*

SAMHSA Strategic Initiatives Prevention of Substance Abuse and Mental Illness Trauma and Justice Military Families Recovery Support Health Reform Health Information Technology Data, Outcomes and Quality Public Awareness and Support*www.samhsa.gov

SAMHSA Definition of Behavioral HealthState of mental/emotional being and or choices and actions that affect wellnessIncludes substance use, misuse, alcohol and drug addiction, serious psychological distress, suicide mental and substance use disordersRange of problems from unhealthy stress to diagnosable chronic disease treatment and recovery orientedSystems: promotion of emotional health, prevention of mental and substance use disorders, treatment and recovery support

Drivers of Health Care ReformGreater attention to preventing illness and promoting wellnessPrimary focus is on the prevention of Chronic IllnessesIncreased access to careIncreased focus on the coordination/integration of services between primary care and specialty servicesIncreased focus on quality and outcomesIncreased provider accountabilityGreater emphasis on home and community based services and less reliance on institutional care(Adapted from SAMHSA, John OBrien)

*

Aims of Health Care Reform Increase the number of individuals that havehealth insurance Increase accountability through the expansionof primary care, medical homes and accountable care organizations and financing structures Increase access to preventive services to improve health outcomes*

Aims of Health Care Reform (cont.)Expanded PopulationsNewly Medicaid Eligible--133% of the Federal Poverty Level (FPL)Health Insurance Exchange Participants--Individuals and Families at or below 400% of the FPL*

Implications of Health Care ReformBuy what is good and modernFocus on coordination between primary care and specialty care:Significant enhancements to primary careWorkforce enhancementsIncreased funding for Federally Qualified Health CentersBi-directional MH/SUD in primary carePrimary care in MH/SUD settings*

Implications of Health Care Reform (cont.) More Incentives to identify MH/SUD - SBIRThuge focus by SAMHSA and HRSA- Coverable serviceenhanced Medicaid matchMore payment strategiesPayment on successful episode of care*

Parity and Affordable Care ActAffordable Care Act includes Behavioral Health as an essential benefitParity legislation requires coverage same as physical health coverage

How Does Behavioral Health Fit?Become valuable partners with primary care or become one themselves

Establish your niche

Demonstrate value to insurers, medical providers and others

Rapid effective access!

Super Easy to work with!

OpportunitiesOpportunity to broaden your financial baseOpportunity to have good data to fine tune and improve careOpportunity to partner with primary medical care and improve overall health of your target groupsOpportunity to form new alliances and establish community supports for what you doOpportunity to invest in prevention

Geography is destiny..

Why here?Why now?How does geography change your billing destiny?

Pair up and share your expectations for the workshop. Add a wild prediction of the best possible outcome for the collaborative should your expectations be met.

Fee-For-Service * Deeper Dive

We will cover the following:

ExecutiveVision, Business Plan, Resource Allocation, Metrics

FinancialBudget, Performance Measures, Service Capture Level II Creating a Super Bill, Denial Management

ClinicalScreen, Assess, Diagnosis,Treatment Planning, Clinical Documents,Service Capture,

ContractingCompliance, Rules and Regulations

Front OfficeEligibility Verification, Registration, Intake Benefits, Pre-authorization, Scheduling

(Title)Name(s) of presenter(s)Organizational AffiliationThe NIATx Billing Guide

Reduce Waiting& No-Shows Increase Admissions& Continuation www.NIATx.net

Law of Supply and Demand

Unlike some business models there are plenty of customers and lots of demand


Thinking About Your Business

Where does the revenue come from?Do you provide easy access to services?What do you do better than your competition?What do you need to improve?


Patient Flow

Billing starts with your first interaction with the patient and ends when all possible payments have been posted and any balance has been written off.

Everybody in the organization plays a role.

Gervean Williams, National Association of Community Health Centers


NIATx Key PrinciplesUnderstand and involve the customerFocus on key problems that keep the CEO awakePick a powerful Change LeaderGet ideas from outside the organization or fieldUse rapid-cycle testing


NIATx Four Project AimsReduce Waiting Times

Reduce No-Shows

Increase Admissions

Increase Continuation Rates


The Patient ExperienceWhat is it like to be your patient?

Perform a detailed walkthrough and document your patients experience

Evaluate your findings and improve on the process

Tie in the ultimate patient experience with the ultimate revenue cycle

(Title)Name(s) of presenter(s)Organizational AffiliationThe NIATx Third Party Billing Guide


Creating Your Billing SystemNIATx Billing Guide OverviewEric Haram, Director OPBH-MidCoast HospitalDavid Moore Director Fayette Companiesand NIATx Coach


The Vast Unknown?Looking into your billing processes can be daunting.Where to start.



Page 10-14 Checklist page 10You will need to verify:Patient Co-Pay (PCP)Total benefits coveredCalendar year and lifetime max statusDeductible: amount met and how much overallCo-Pay: all levels of careClaims addressCertification (Pre-Authorization) numbers and phone #Policy effective and termination datesAuthorizations required and the name of the person who gave you the information.


Example of Verify Coverage Process Flow


Page 12-13 Template page 13

Process of obtaining approval of coverage for a treatment deliverable. (before the treatment occurs!)

Each payer may use a different term and has a different process.

Prior Authorization may be obtained at the time of benefits verification. Requesting auth. for the upcoming assessment, eval., session.

You may request to bill out-of-network if you do not have an in-network contract.

Operation Par in Florida hired a single staff person to obtain authorizations. This increased third party collections from $129,000-$436,000 within one year


Page 14

Record the authorized date and name of the person who granted the service.Record the authorization number. (if they tell you no prior auth. is needed, ask for an authorization number for administrative purposes).Record the number of authorized units, date range, and next review date.Include the contact name and direct phone number of the source for on-going reviews.


Level IThat is it for the first part of your pilot test. Did services get authorized?Here is what one agency found in their pilot.


AIM Increase Medicaid third party payments from 0 to 15 by March 31, 2011Current Billing or Baseline = 0 or $0.00

Target = 15 clients with Medicaid $1000.00 billed and received.Muskingum Behavioral Health Zanesville, Ohio


PlanHaving no experience with Third Party billing, work with change team and billing person on familiarizing ourselves with the NIATx billing GuideStart Documenting our process for third party billing informationAsk each person who calls if they have any insuranceRecord results on a tally sheetMuskingum Behavioral Health - Zanesville, Ohio


ResultsThe first step was to establish a process and being to document each step. Ask everyone who came in if they had insurance?Copy the insurance card when they arrivedDocument coverage using the NIATx pre-authorization templateWork with one clinician for one month to begin to track each service and match authorization and billing codes for that treatment plan

Not everyone was willing to ask for insurance cards. Needed to train staff, create a tally sheet, Educate customers about insurance - understand if they had possible insurance coveragePractice by role playing and then documenting the process and the results. Not everyone verified insurance every time.

Worked on establishing and improving process for 3 months. Kept working with the one clinician

In April of 2011, we had 15 clients who were covered by Medcaid.In 5 months we collected $1,875 in Medicaid revenue. Though this may not be a large amount of money, it is for a small organization. Thats $22,500 . per year more than we were getting before the project started!

Clients with third party payers have gone from zero to 10 per month.

Muskingum Behavioral Health - Zanesville, Ohio


Next StepsMake the current billing processes more formalized

Continue to foster relationships with third party payers.

Establish protocols for addressing denials

Increase marketing effort to people who have third party reimbursement.Muskingum Behavioral Health - Zanesville, Ohio

Provide the services that were authorized.Within the specified date range for approved units of service?Provided by appropriately credentialed staff member?Does the payer require specific deliverables? UDS, MAT, 12-Step, Family

Services documented in the clinical record?Dates of service match dates of charge?Correct demographic information?Correct billing form? UB-04 or the HCFA 1500Page 16

Thats it for the second part of your billing pilot. Did you get paid? Did you get a denial?

If the claim was denied, this may be because of problems with the bill not the service.You can correct these and re-submit.Staff responsible for collecting payment must become familiar with the rules for payers and the payers rules.Each company has its own set of rules & departments often operate in silos.Negotiating the communication barriers within payer systems can be challenging. Page 23

Accounting staff or managers will need to monitor receivables.Aging reports from your local accounting system are best for monitoring this activity.An aging report lists accounts receivable balances by customer, detailing the current status or delinquency of the balances owed or owing.Pay attention to accounts that are more than 69 to 90 days overdue. This will impact your cash-flow.Page 23

Why is the claim not being paid?Billing error?Rejected claim?Define the rejected claims specifically

Identify and document the reason, this will enable you to identify the processes you need to adjust and systems that you need to improve.

Page 24


Did you get paid? Did you get a denial?Here is what another agency discovered


AIMIncrease revenue collected from third party payers.

Decrease insurance claims error rate.


ChangesRegister clinicians on CAQH.

Create a list of insurance providers and the credentials needed to allow for reimbursement for services provided.

Work with our insurance clearing house on why we have claims errorshow to fix the errorshow to resubmit corrected claims

Create a checklist with information needed to collect from insurance companies when calling to verify coverage.


Results Our claim error rate has decreased from baseline of 33% to 16%.

Insurance reimbursements are increasing from 10% of total charges the beginning of the fiscal year to current 17%.


Next StepsCreate a system for collecting co-pays once we have implemented our new E H R.

Research how to bill IOP services in order to receive adequate reimbursement.

Research how to direct insurance clients to properly credentialed clinicians when in group and IOP sessions. Can supervisors sign off?

Track progress on insurance claims so we are aware when we need to recertify visits.

Monitor V code diagnosis codes since insurance companies dont usually pay for these codes.

Pursue inclusion on insurance panels.


Impact

By tracking claim activity we were able to better analyze the responses and make necessary billing adjustments for future claimsWe were also able to make the necessary claims corrections so the claims could be sent on to the insurance companies. An understanding of contract stipulations allowed us to follow more efficient procedures in obtaining authorizations thus ensuring that we have all required authorizations.Weve realized the importance of having personnel dedicated to insurance. There is much that it entails.


Next StepsGet together with key members of your team.Review your walk-through and share examples of the presentations you hear with them.Get familiar with the Billing GuidePilot the 8 steps from the Billing GuideAllow your PDSA process to point you in the correct direction for maximizing your efforts on this work.

Exploring New Business ModelsDiscussion at each tableWhat does that mean to you and your organization?How will this shift affect your team?How will this shift affect the people you serve?How will you help your customers navigate the insurance system?Do you provide the right services?Which services are billable and which are not covered?

Chalk Talk

Chalk TalkA silent way to do reflectionGenerate ideasCheck on learningDevelop projectsSolve problems

Now

Write your answers to the following questions:I think our agency does the best job providing the following serviceIn relationship to billing practices we are champions at doing the followingOur biggest barrier to creating a billing process will beReflections, solutions, ideas, draw connecting lines to other questions, pictures etc

Report out on Discussion and Observations

Nominal Group TechniqueNGTChalk Talk - Identified at least one problem or barrier

Need to generate creative solutions

Benefits of using the NGT

Makes it clear what decision is being madeAllows everyone to participatePrevents people with authority or with loud voices from dominatingAn easy, fast way to reach consensus around a decision

7 Steps to the NGTStep 1Prepare the room: Flip chart or wall to post ideasPost-it notesTwo colors of sticky dots for voting

Prepare the QuestionWrite it at the top of your flip chart paper.

Step 2- up to 5 minutesSilent idea generationRecord each idea you have on a separate sticky note

One sticky note, one idea and so on, keep all your notes in front of you

Step 3 5 minutesRecording of ideas (round robin)Go around the table and ask each person to read one idea from their list; next person reads one idea--and so on

Post each idea as it is read on the flip chart

Refrain from discussion or clarification of ideas

Step 4 5 minutesIdea discussion

Group can ask questions of each other to clarify the meaning of each idea.

Step 5 2 minutesPreliminary voting What ideas canwe test first?

For this step, you will each have three votes to cast

Each participant is allowed to cast votes for the idea or ideas they judge as most important

Step 6 3 minutesDiscussion of preliminary voting:

Brief discussion to ensure that everyone has the information they need to cast a final vote.

Step 7 2 minutesFinal voting on ideas:

Each participant casts one final vote

Record all ideas for future reference and possible PDSA Cycles

Video Leadership Lessons from the Dancing Guy

Here is the link http://sivers.s3.amazonaws.com/DancingGuy-ff.m4vThe final slides will have the power point embedded

Final Check-in

How did we do?

What can we do to improve (for tomorrow)?

Tomorrow we will begin at ____________

*Coach Notes Make the offer !!! Whats in it for them?Objectives Become familiar with the NIATx billing guideIntroduction (or Review) of the NIATx modelEncourage idea sharing and participationBegin to fill out the Change Project Charter and develop an AIM statementHousekeepingStart and end times, lunch logistics, rest rooms, breaksParking Lot items questions not answered, new questions that need resources etc.Ask the NIATx staff person to Hang a sheet of paper to record questions, ideas or resource additions - type this up (or bring home to type comments) Review with Amy to make sure that we address all unanswered questions.

Review of the NIATx Billing Guide Steps Share regional perspective on the billing climate in your state Meet new people and share ideas Intro to the NIATx change model

*Click through slides so you see how they transition.JBS could lead this exercise.Current state is where you are now in the next two days we will learn how to use the NIATx change process to get to your desired future.*********Convener summarizes the regional billing climate Strengths, opportunities and finally their expectations for the collaborative. 2 rounds of 3 minutes each.Participants Convener or Coach facilitated call out ask people what they heard and said quickly write comments on a flip chartNIATx staff person: Label two flip chart pages and take notes. (save, type up or bring back to the office to type up and archive.Expectations for the workshopWild prediction of the best outcomes*Over view of all of the components of a healthy/robust billing system. However it does not require that you do all these tasks in-house or have all of this in place immediately or by the end of the collaborative. We only ask that you have an awareness of how billing affects the organization.

Ask participants to take a few minutes to review this slide (2 minutes/silently) Thinking about where each of them has strengths/resources/staffing and where the gaps in people, infrastructure or knowledge lies. We will discuss strengths and barriers in a later module.We will only address the following in this collaborative.If you need assistance with other areas of the Impact model such as Medical Records (choosing an EHR) , Finance (cost accounting, pricing services doing the math) or Marketing and Research (market research) we can suggest resources but we are not going to focus on these topics in this Level. We are addressing billing process improvement. Take advantage of lunch and break times to ask your peers what they know about about these topics.**

*NIATx comes into play even when you think about improving your billing practices.Keep in mind the 5 principals#1 identified as being the most important more important than all others combined.#2 Get ideas from outside the field ask participants to share examples of other businesses they could look at for improvement ideas.*Remember Most important thing is to make sure that you can compete with health care measures and have proven outcomesIn addition you need to following and compete with the following good business practices:Immediate access, reducing no-shows, easy admissions process with no wait list and positive customer outcomes customers that complete treatment and recover.*Encourage people to complete a walk through. Hand out the walk through instructions. Watch your competition and get ideas from outside the field. How does your dentist or doctor office handle insurance paperwork? Is it easy? Other places to look handling a new car loan, bank refinancing, paperwork as a POA for another family member. Lots of paperwork and confidential information, how to they tell you about it? Reassure you that it will be kept private? Help you figure out your authorization limits?**

PCP**Operation Par in Florida hired a single staff person to obtain authorizations This increased third party collections from $129,000-$436,000 within one year*Add a story example of your choice. May need more than one illustration. If you need more stories/examples let me know- Amy*****Chalk Talk - Pass out the worksheet with directions and suggestions on how people can use this exercise back at their organizations.*Questions will be posted on paper around the room each participant will walk around the room and write their answer to each question in addition participants should draw lines to connect their ideas with others, comment on other input etc.*Preparing the question, not as easy as it appears. Coach and or NIATx take one or two of the barriers reported out on the chalk talk exercise and make it into a good NGT question. Offer 1 or 2 variations to show people how phrasing may change the outcome.How can we get staff to buy-in to the idea that we need to ask each person for an insurance card?VsHow can we ensure that we get current and accurate insurance information from every customer?

Then ask each table to decide on one barrier from the chalk talk that they would like to find a solution for.. Use that barrier to write an NGT question for the exerciseCoaches, NIATx,Conveners and JBS assist as needed*Remind folks that they do not veto ideas, this is discussion about the idea not if it is possible, affordable or reasonable etc.Saying We tried that or that will never work is not allowed!*Still no comments like that wont work, are you nuts etc.*If there is a tie, group may need to cast a final vote to break the tie only. Or agree on which idea will be tested first.Remind people to save all ideas, if they do not reach their goal with this first idea they can use this list to try other ideas untuil they have reached their aim.This is the parking lot*

(Title) Name(s) of presenter(s) Organizational Affiliation Welcome Fee-for-Service, Level I January...

Documents

Transcript of (Title) Name(s) of presenter(s) Organizational Affiliation Welcome Fee-for-Service, Level I January...