POST ACA
REVENUE CYCLE
TRANSFORMATION
• Intro
• Revenue cycle features
• ACA impact areas
• What did we expect?
• UDS and PMG data analytics
• Top “to-do” items
• Summary
• Encounters with DOS post 10/1/2015 need to use ICD 10 Codes
• Largest change in coding in 20+ years
• Potential of significant cash flow issues
• Daily update suggested from billing - # Denials
• Significantly more time needed to fight denials
* Caresource Medicaid (OH) paid 29,674 FQHC claims & 11 ICD10
denials. Medicare Intermediary in OH paid 2,340+ ICD 10 claims
• Demographics
• Charge Entry
• Transmit Claims
– Patient Statements
• Post Payments
Revenue Cycle Features
ALL MISSION CRITICAL ACTIVITIES PRE- AND POST-ACA!!
• Manage Denials
• Unpaids & Appeals
• General Management
• Close & Reporting
• Decrease in self-pay volume
• Increase in Medicaid enrollees
– Medicaid represents 64.3% (2013) & 66.9% (2014) of total payments
• Elevated “blended encounter rate” – CHCs make more money
• Expanded healthcare exchanges
• RCM/Billing staff feeling more burdened
• Over-burdened outcome: – Elevated AR
– Lower performance around KPI
CY13 vs. CY14
• Mix of insured vs. uninsured
– Uninsured decrease, -7% (7.6M to 6.4M) – Insured increase, +7% (14.1M to 16.5M)
• Patient visit volume
– Increase, +5.3% (+21.7M to 22.9M)
**Possible $100+ per visit swing from slide patient vs. Medicaid
UDS Data - Insurance & Visits
Source: Geiger Gibson & RCHN Community Health Foundation Research Collaborative; Policy Research Brief # 42
Source: Geiger Gibson & RCHN Community Health Foundation Research Collaborative; Policy Research Brief # 42
Source: Geiger Gibson & RCHN Community Health Foundation Research Collaborative; Policy Research Brief # 42
Source: Geiger Gibson & RCHN Community Health Foundation Research Collaborative; Policy Research Brief # 42
Source: www.bphc.gov
UDS Data – National 2012
47% 9% 4% 13% 27% 2012 National Charges medicaid medicare public private self pay 64% 10% 4% 12% 10% 2012 National Payments medicaid medicare public private self pay
UDS Data – AK 2012
Source: www.bphc.gov 34% 13% 1% 26% 26% 2012 AK Charges medicaid medicare public private self pay 51% 12% 1% 26% 10% 2012 AK Payments medicaid medicare public private self payUDS Data – 2014 National
Source: www.bphc.gov 47% 10% 4% 13% 26% 2014 National Charges medicaid medicare public private self pay 64% 10% 4% 12% 10% 2014 National Payments medicaid medicare public private self payUDS Data – 2014 AK
Source: www.bphc.gov 34% 13% 1% 24% 28% AK 2014 Charges medicaid medicare public private self pay 51% 11% 1% 26% 11% AK 2014 Payments medicaid medicare public private self pay– Trends
• Less self pay in 2014, should continue in 2015
• More insurance visits – higher reimbursement per encounter
• Splintering of payer mix - Credentialing/enrollment needs
• Additional patient visits in 2014, right size billing staff
• Increase in self pay/slide payment per encounter
• AK Expanded Medicaid – effect for FQHCs
• 20 states, no state expansion program
• 28% still uninsured (indefinite?)
• Data integrity, suspect
• Sustainable trend?
• Premium payments continued?
UDS Data – Thoughts II
Source: Geiger Gibson & RCHN Community Health Foundation Research Collaborative; Policy Research Brief # 42
• Average payment per visit/encounter
• How to calculate:
Blended Encounter Rate - What is it?
Total Payments ÷ Total Visits* = Blended Encounter Rate
vs. (different than knowing) Medicaid or Medicare Rate
• Average payment per visit/encounter • How to calculate:
– 2012 National UDS 5 Line 34 (Grand Total Visits) 83,766,153* – 2012 National UDS 9D Line 14 B Collection $9,024,236,793* – 2012 National Blended Encounter Rate: $107.73/visit*
– 2012 AK UDS 5 Line 34 (Grand Total Visits) 515,046** – 2012 AK UDS 9D Line 14 Collection $80,042,598** – 2012 AK Blended Encounter Rate: $155.41/visit**
Blended Encounter Rate
2012 UDS Data.. Pre-ACA
* http://bphc.hrsa.gov/uds/datacenter.aspx?q=tall&year=2012&state= **http://bphc.hrsa.gov/uds/datacenter.aspx?q=tall&year=2012&state=AK
Alaska Only…
• Average payment per visit/encounter • How to calculate:
– 2014 National UDS 5 Line 34 (Grand Total Visits) 90,379,441* – 2014 National UDS 9D Line 14 B Collection $11,416,470,097* – 2014 National Blended Encounter Rate: $126.32/visit*
– 2014 AK UDS 5 Line 34 (Grand Total Visits) 537,310** – 2014 AK UDS 9D Line 14 Collection $97,682,138** – 2014 AK Blended Encounter Rate: $181.79/visit**
Blended Encounter Rate
2014 UDS Data: Post-ACA
* http://bphc.hrsa.gov/uds/datacenter.aspx?q=tall&year=2014&state= **http://bphc.hrsa.gov/uds/datacenter.aspx?q=tall&year=2014&state=AK
Alaska Only…
• Average payment per visit/encounter
• Average AK community health center reimbursement per encounter
• 2012 $ 155.41
• 2014 $ 181.79
$ 26.38
UDS Data: Payer Mix Shift 2014
Uninsured Delta: -7.57% (Decrease) Medicaid Delta: +8.16% (Increase)
• RCM = Revenue Cycle Management
• Get paid as much as able on first claim submission
– Clean Claim
• Get paid as much as you are able (legally entitled) when you can, so
you can give it away when you want to
• RCM Expert??? – CFO – Billing Manager – Outside Firm
Post-ACA RCM Focus
Item #1…
Billing 101
• Expense as percent of payments: < 9% • Cost per claim: < $8
• Electronic claim transmission: 90%+ • Clearinghouse utilization: Yes
• Certified staff: At least one
• RVU/Medicare based charges: Yes • < 30 DAR
• ICD 10 denials reported and fixed • AR over 90 Days, < 20%
• Net AR: As close to $0 as possible
Post ACA RCM Focus
• Medicaid encounter rate rocks
• Took ACA $ or not… get patients enrolled
• Expand Medicaid patient base
• Teach all staff to recognize opportunity to enroll
• Volunteer staff focus on outreach
• Room on CHC website explaining:
– Plan options with benefit detail in plain language – Open enrollment deadlines
Post-ACA RCM Focus
Item #3…
Enrollment
• “Battle is won or lost at the front desk.”
• Eligibility… check every patient every time
– Check every patient every time
– 15-20% of ACA beneficiaries, no premium paid
• TOS payment
– SFS… Slide deductibles and copayments
– No insurance verified… pay cash (NO EXCEPTION)
• Start “Triangle of Communication” with regular meetings
– RCM (Billing) to Front Desk to Providers
Post-ACA RCM Focus
• Share understandable data
• Picture worth a 1,000 words
• Again, “Triangle of Communication”
• Who are in-house experts & accountable??
– Target charges/payments…. CFO
– Acceptable denials… Billing Manager – System optimization… IT Lead
– Provider productivity… Medical Director (other?)
Post ACA CHC Focus
Post ACA CHC Focus
• USE RCM Data Analytics – Look for trends
• ICD 10 – Review and plan of attack
• Regular and persistent review
• Defined/Targeted performance expectations
• Control what is controllable
• Hold people accountable
