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Association of Illinois Access ManagementPatient Access No Bed of RosesRosewood Restaurant, Rosemont, ILMAP KEYS – OVERVIEWand CASE STUDYThursday, March 10, 2011- 2 to 3:30 pmSuzanne K. Lestina, FHFMA, CPCDirector, Revenue Cycle MAPHealthcare Financial Management AssociationTracey McKnight, Senior Director, Revenue CycleAmi Kihn, Senior Director, Patient FinancialOperationsSpectrum Health System, Michigan

OVERVIEWReform and the revenue cycleHow hospitals are respondingEvidence-based improvementA Case Study – Spectrum Health System2

REFORM AND THE REVENUE CYCLE

INCREASING INSURANCECOVERAGE2018Americans 6201720182019Source: CBO4

CHANGING PAYER MIX24Americans e: CBO letter to House Speaker Nancy Pelosi– March 20, 20105

FINANCIAL IMPACT ONYOUR HOSPITALSPayment Reduction Over a10 Year Period (in billions)Payment AreaNew payments for uncompensated care177.3Payment reductions:Market basket update (MBU)Disproportionate Share Hospital payment cuts(Medicare & Medicaid DSH)Reduced readmissions-112.6-36.1-7.1Hospital-acquired conditions-1.5Accountable care organizations-1.5Net aggregate financial impact on U.S. hospitals17.06Sources: Health Care Facilities Managed Care Analysis; Bank of America Merrill Lynch;March 4, 2010; p. 9CBO letter to Speaker Nancy Pelosi; March 20, 2010; HFMA estimate6

OTHER REFORM CHANGESNew requirements– Standardized charge reporting– Requirements for tax-exempt hospitalsNew economic incentives– Payment linked to quality– Accountable care organizations– Bundled payment7

HOW REFORM IS AFFECTINGTHE REVENUE CYCLEExpandedCoveragePaymentCutsNewRequirementsNew EconomicIncentivesRevenue Cycle ImperativesImprove Performance and rity tionand CodingPhysicianIntegrationBundledPayments8

HOW HOSPITALS ARE RESPONDING

PRINCETON BAPTIST MEDICAL CENTERBIRMINGHAM, ALABAMAArea of Excellence: Cash CollectionHow They Did ItConsolidated pre-arrival unitAutomated insurance verification, includingidentifying patient financial obligationCommunicating about and collecting thisamount prior to arrivalInstituting continuous quality improvementprocess to identify and reduce errors10

PRINCETON BAPTIST MEDICAL CENTERBIRMINGHAM, ALABAMAResultsReduce DNFB to 3.7 daysIncrease cash as a % of net revenue to consistentlyabove 100%Decrease denials to less than .25% of grossrevenueMaintain cost to collect at less than 3%DNFB Comparable Statistics6.2Median5.4Top Quartile PerformanceSource: HFMA’sMarch 201011

TOUCHETTE REGIONAL HOSPITALCENTREVILLE, ILLINOISArea of Excellence: Cash CollectionsHow They Did ItRevising charity care policyAdopting an automated patienteligibility systemIncorporating charity care criteriainto the system’s database12

TOUCHETTE REGIONAL HOSPITALCENTREVILLE, ILLINOISResultsReduced 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 goalof102% adjusted net patient services revenueCash Collections Comparable Statistics100.2102.1MedianTop Quartile PerformanceSource: HFMA’sMarch 201013

BAYLOR HEALTH CARE SYSTEMDALLAS, TEXASArea of Excellence: Cash PositionHow They Did ItCentralize the business officeCentralize insurance verificationand pre-registrationCentralize denials management14

BAYLOR HEALTH CARE SYSTEMDALLAS, TEXASResultsImprovements from 2000-2009– Achieved consistent net revenue cashcollection rate of 100% or better– Lowered net accounts receivabledays from 67.9 in 2000 to 39.9– Decreased 91 days fromdischarge aging from 13.0% to 5.8%– Reduced cost of collectionsfrom 2.5%Days in A/R Comparable Statistics44.5Median37.9Top Quartile PerformanceSource: HFMA’sMarch 201015

EVIDENCE-BASED IMPROVEMENT

EVIDENCE-BASEDIMPROVEMENTComponentsMeasuring Performance– What are consensus measures ofrevenue cycle excellence?Comparing Performance– How are peers performance and whatare performance targets?Improving Performance– How do high performers succeed?17

EVIDENCE-BASEDIMPROVEMENTBenefitsIdentify and manage to trendsValidate best practicesTrigger corrective actionForecast performanceIdentify opportunities for process improvementCompare performance with like organizationsUse data to change behaviors18

HFMA INITIATIVE19

WHAT IS MAP?MAP is a comprehensive performanceimprovement strategyIdentify indicatorsTrack and improve performanceRecognize excellenceShare successful practices20

EVIDENCE-BASED IMPROVEMENT:MEASURING PERFORMANCE

MAP KEYSMAP Keys are industry-developedkey indicators for revenue cycleperformanceClearly definedMeasurableDiscerningComparable

MAP KEYSMAP Keys focus on key areas ofrevenue cycle performancePatient accessRevenue integrityClaims adjudicationManagement23

PURPOSE VALUE CALCULATIONExampleIndicatorNet days in A/RPurposeTrending indicator of overall A/R performanceValueIndicates revenue cycle efficiencyCalculationNet A/RNet patient service revenue24

EVIDENCE BASED IMPROVEMENT:COMPARING PERFORMANCE

COMPARING PERFORMANCEManage trendsIdentify opportunitiesPrioritize opportunitiesIdentify successful practices26

COMPARING PERFORMANCEFlexible comparisons are needed forin-depth analysis5%Industry trends4%Performance over multipletime frames3%Pre-selected peer groups1%Customized peer groups0%Jan 09Mar 09May 09Jul 09Sep 09Nov 09Bad Debt vs. Charity Care as of % RevenueSource: HFMA’s27

PEER GROUP COMPARISONSNeed to choose appropriate peergroups for meaningful comparisonsSource: HFMA’s28

TIMELY DATAYou need recent data to set appropriateperformance targets; industry trends affectexpected performance levels.Organizations need to “raise the bar”as industry performance improves.Median Days in A/RAlthough median days in A/R wasabout 52 in 2004, it dropped toabout 46 in 2009.This shows that data need to becurrent to establish a relevantbenchmark.29

EVIDENCE BASED IMPROVEMENT:IMPROVING PERFORMANCE

INSIGHTS FROM AND ABOUTHIGH PERFORMERSArea for improvement: Cash collectionCash collection as a % ofadjusted net patient servicesrevenue– Median: 100.2– % of high performers citingimportance of investing in frontend technology– Top quartile: 102.1Source: HFMA’sResearch– % of high performers havingMarch 2010estimates available for patientsat registrationSuccessful practices– Sample scripts– Use of dedicated trainers forpatient access staff31

MAP AWARDHFMA’s MAP Award recognizes healthcareorganizations that achieve excellence in therevenue cycle and serve as models for thehealthcare industry32

SUCCESSFUL PRACTICES

SUCCESSFUL tion34

CULTURE

SUPPORT FOR REVENUECYCLE7 Extremely high to 1 None at allHigh PerformingAll Other86%76%36

PEOPLE37

DAYS OF INITIAL REVENUECYCLE TRAINING REQUIREDHigh Performers 10 days5-10days3-5 days2-3 days1 dayor ollectors50%21%21%7%0%Financial Counselors64%14%14%7%0%All Others 10 days5-10days3-5 days2-3 days1 dayor llectors47%30%10%9%5%Financial Counselors52%26%10%7%5%38

STRATEGIES TO MOTIVATE,RECRUIT, AND RETAIN STAFFProvide incentives for staffwho meet goals86%44%Increase front-line staffsalaries (beyond averageorganizational increase)64%31%Increase back-office staffsalaries (beyond averageorganizational increase)43%19%0%50%100%High PerformingAll Others39

PROCESSES40

FREQUENCY OF REVENUECYCLE TEAM MEETINGSRevenue cycle staff team meet atleast monthly71%84%Process centered improvementteam(s) meet at least weekly50%26%Cross-functional team meet atleast monthly (including repsfrom clinical, IT, HIM, . . . )57%51%Metric triggered leadership teams(triggered by revenue cycle metricoutside defined parameters)50%25%Other (responses generally includemore frequent, targeted meetings)21%3%0%20%40%High Performing60%80%100%All Others41

USE OF PATIENT FOCUSGROUPSHigh PerformingAll Others43%20%42

COLLABORATION WITHPAYERSRoutinely meet to review & discuss issuesregarding patient satisfaction57%21%Routinely meet to discuss & implementprocess streamlining initiatives64%25%Routinely meet to discuss & implementtechnology improvements and interfaces64%26%Routinely meet to review & discusspayment discrepancies86%57%7%Do not routinely collaboratewith payers35%0%20%40%High Performing60%80%100%All Other43

SIGNIFICANT CHANGES TO THEFOLLOWING AREAS WITHIN THE PAST 3YEARS1 no improvement to 7 complete overhaulFinancial 9%31%Billing50%Collections27%0%20%40%High Performing60%80%100%All Other44

TECHNOLOGY

TECHNOLOGY SUPPORT FORTHE REVENUE CYCLE7 Extremely high to 1 None at allIT support forrevenue cycle79%55%71%IT collaborationwith revenue cycle51%0%20%40%High Performing60%80%100%All Other46

COMMUNICATION

AVAILABILITY OF ESTIMATES FORPATIENT OUT-OF-POCKET LIABILITYWe provide estimates to nearlyevery patient21%16%36%At scheduling, upon request53%57%At registration, upon request40%43%At time of service, upon request33%7%10%We do not provide estimates0%20%40%High Performing60%80%100%All Others48

WHO HAS ABILITY TO APPROVEPROVISION OF CHARITY CAREManagers, Directors, CFO71%Financial Counselors64%48%No approval needed if patientmeets organizational CharityCare igh Performing60%80%100%All Other49

Spectrum Health SystemSuccessful Practices

Automated Eligibility, AddressChecking and Propensity toPay Revenue Cycle Strategy combiningPeople, Process and Technology.March 10, 20112Prepared and presented for:association of IllinoisPatient Access Management

Tracey McKnight, RN,MM,CMACSenior Director – Revenue Cycle ManagementSpectrum Health Hospital GroupAmi KihnSenior Director – Patient Financial OperationsSpectrum Health System3

MAP Case Study4

About Spectrum HealthSpectrum Health is a not-for-profit system of care dedicated toimproving the health of families and individuals. Ourorganization includes a medical center, regional communityhospitals (7), a dedicated children’s hospital, a multispecialtymedical group, affiliated physicians and a nationally recognizedhealth plan, Priority Health.Spectrum Health has over 16,700 employees and 1,500physicians

Mission, Vision, ValuesMISSION: To improve the health of the communities we serveVISION: To be the nation’s highest quality and most successfulhealthcare enterpriseVALUES: Compassion, Excellence, Innovation, Integrity,Respect, Teamwork,6

Revenue CycleOverviewRevenue Cycle Technology Systems Planning, Integration, Deployment, StabilizationRevenue Cycle Education and TrainingRevenue Cycle Policy and ProcedureCompliance and Payer RelationsRevenue Cycle Leadership and DirectionAccessRegistration/CheckPre-ArrivalInTime of Service gibilityMSPSchedulingAddress Counseling MySpectrum EnrollRequestPhys RelationshipPre-RegistrationID CardsFinancial ClearanceScanningPatient ReadinessWayfindingClinical PrepOrder Follow Up7Clinical EncounterClinical TreatmentCCAPPatient PlacementSocial WorkDischarge PlanningCodingHIMPatient FinanceClaim SubmissionPatient Bil ingCheck-out/DischargeRevenueIntegrityAcct. Follow Up/Mgt.Charge CaptureCare Management/UMChargeCaptureCustomer Svce Call Ctr.DenialCash ApplicationManagement

Project Methodology

AgendaInitiate Idea Project Sponsor Identified Vision and Business Objectives Resource Estimates Leadership Support/Project StructureDevelop Concept Resource Estimates Defined and Resources Committed Project Plan Developed Project Plan Approval and Project Funding9

Agenda continuedPlan & DO Project Overview Project Inclusions Integration Development Process Flow Changes Education and TrainingImplement & Evaluate Go-Live Decision Documented Go-Live Statistics Criteria to Measure Success (Dashboard)Questions

Project Vision and Business ObjectivesProject Vision To provide tools and resources to the front-end/first patientcontact areas to identify correct and accurate patientdemographic and insuranceBusiness Objectives Decrease number of Self Pay designations at the time ofservice/registration due to valid insurance Decrease Self Pay referrals made to Financial Counselingbecause truly has insurance Decrease customer service phone calls Increase clean claims submissions Reduce front end edits for incorrect subscribers

Project StructureOversight Committee- Representation Includes Leadershipsupporting: Patient Access- Facility, Patient FinancialServices- Facility, Professional Business Office, TIS,United/Kelsey, Reed CityWork Group Structure- Several Workgroups throughout projectto include personnel from all areas as indicated above- workitems included: Address Checking, Credit Checking, Propensityto Pay, Eligibility, Pre-EncounterRevRunner Utilization Work group – established after go-live(s) to continue to monitor activities, questions, enhancements,reports, quality activities, etc of the RevRunner users andsystem12

Project OverviewAutomated 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 CheckingPatient ID:This functionality will allow for us to verify and validateguarantor address to ensure accuracy of the information in ourcore systems. This will improve identification of the patient;assisting with response to compliance with Red FlagRegulations, as well as decrease the rate of returned mail;improving the length of the billing and collection cycle with thepatient.14

Overview- Eligibility CheckingVerifier:Verifier allows us to verify and validate the accuracy of theinsurance information in our core systems. With thisfunctionality we can assure that the patient is still eligible for theidentified insurance and, as provided by the insurance plan, weare also able to gather benefit levels, co-payments, anddeductibles to determine the patient’s out-of-pocket obligation.This functionality will prevent unnecessary re-submission ofbills due to inaccurate or ineligible insurance information, aswell as, improve our ability to collect prior to and at the point ofservice.15

Overview- Propensity to PayPropensity to Pay Scoring:Through utilization of the Propensity to Pay module we will beable to identify a patient’s ability to pay for their healthcareservices either prior to or at the time of service, depending onthe nature of their visit. This will enable us to focus ourcollection efforts, providing education on potential Medicaideligibility or assistance with determining payment options orfinancial assistance as necessary.16

Scope InclusionsLocations:Technology: Horizon’s Practice Plus Misys Cerner HealthquestGrand Rapids Hospitals Butterworth Blodgett HDVCH United Hospital Kelsey Hospital Reed City Hospital Kent Long Term Acute CareHospital17

Integration270/271 Transactions: Allows for checking insurance eligibility real-time during theregistration 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/NoIndicator (Cerner) Allows us to pre-populate fields to cut down on manual entryduring the credit checking inquiryTesting Unique - Live patient testing required given nature of workBatch File Reports – CCL out of Cerner, Healthquest or queried out ofEnsemble (can set up when to run and how often)18

Stand Alone versus Integration Staff may elect to utilize as a stand alone system inappropriate circumstances Education and Training developed scenarios to guidestaff when to utilize in stand alone environment Once data is entered into the technology system,integration is forced through the 270/271 transaction sets19

Integration Diagram

Process Flow ChangesCreated new process flows for the use of automated eligibilityand 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 paperbased education completed as well. Specific Modulesbelow: Integrated Version Standalone Version Administrative Functions ModuleIncluding education to support scripting and links toprocedures and processProvided on-site training to each individual area23

Examples of Education Materials

Go-Live Statistics/SuccessesRolled Out Verifier and Patient ID to over 68 departmentlocations (October 2009 – July 2010) Began Propensity to Pay roll out October 2010 (anticipatecompletion 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 gonedown from around 9% to 7.9% on average Self pay/NA designation at registration changed toanother insurance in Finance has decreased from 23% to6% 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?

Propensity to Pay Evaluation –A patient friendly process to supportthe growing shift of financialresponsibility.32

AgendaWhat and WhyPropensity to Pay Validation/Scoring MatrixTarget Process ChangesPilot PhaseTimelineNext Steps33

Propensity to PayWhat is it?An individual’s ability and likelihood to payfor their healthcare servicesWhy Consider it?. financial liability to theTo be able to communicatepatientas early in the Revenue Cycle Process as possible.34

Example: Propensity to Pay ScoringColor and Score AssignedRed 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 AssistanceApplication Process Fewer Touch points along Revenue Cycle- predeterminedaccounts 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 Group36

Phase 1: ValidationTarget Goal at least 85% of the validation accounts match P2PRecommendationP2P pilot .3%Self-pay pilot accountsFinancial counseling pilot accountsTotal pilot accountsP2P score matches37P2P score discrepancies

Validation ResultsThe majority of the time the tool produced thePropensity to Pay score that we expectedFor the accounts with discrepancies SH found thetool was more conservative in scoring than what wewould have been in our determination process38

Phase 2: PilotDecember 22, 2010 – March 1, 2011 Butterworth Campus Emergency Dept Financial Counselors Self Pay Patients Out39Patient Accounts (not admitted from ED visit)

Next Steps Run Batch file of existing Self Pay Accounts Receivable toidentify Presumptive Charity Accounts – Complete by03/01/11 Identify where in current collection process ongoing batchfiles will be sent for scoring. Develop deployment Calendar for go live sites. Develop and Deliver Education materials to targeted staff tocoincide with go live planning. Update Financial Assistance Policy and Procedures40

Next Steps (cont.) Increase awareness for all Revenue Cycle Staff Partnership and Communication with Medical Group onFinancial Assistance Determination Partnership and Communication with Care Management onFinancial Assistance Determination41

42Questions?42

43

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