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“Improving Revenue Cycle Management with Clinical and Operational Workflow” PowerPoint Presentation
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“Improving Revenue Cycle Management with Clinical and Operational Workflow”

“Improving Revenue Cycle Management with Clinical and Operational Workflow”

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“Improving Revenue Cycle Management with Clinical and Operational Workflow”

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Presentation Transcript

  1. “Improving Revenue Cycle Management with Clinical and Operational Workflow” Connecting the Dots:

  2. Improving Health Center SustainabilityLearner Objectives • The learner will gain insight into how to utilize Health Information Technology (HIT) to improve financial performance. • Identify the critical success factors related to workflow integration. • Understand the relationship between the role of health information technology, workflow, and revenue cycle management. • Incorporate the principles of workflow integration into revenue cycle management.

  3. Key Discussion Points History/Mission 1 Policy Information Notice 2 Health Information Technology Strategy 3 Sustainability 4

  4. History • In 2015 Health Centers will celebrate 50 years of expanding healthcare access and delivering quality primary to medically underserved and uninsured populations. • The health center model targeted the roots of poverty by combining the resources of local communities with federal funds to establish neighborhood clinics. • Health centers primarily provide health care to patients who are uninsured or covered by Medicaid. • Community health centers rely on a combination of Medicaid payments, grant revenues, and other private and public funding sources to fund their operations. • Health centers have established themselves as mission based healthcare providers that provide care to patients regardless of “ability to pay.”

  5. Mission • Medically underserved populations. • Uninsured • Underinsured • Chronically unemployed • Newly unemployed • Migratory and seasonal agricultural workers. • Homeless populations. • Residents of public housing.

  6. Policy Information Notice • Health centers must assure that any fees or payments required for services will be reduced or waived to enable the center to fulfill the assurance. • The Health Center Program statute also requires “a schedule of fees or payments for services consistent with locally prevailing rates or charges. • The PIN requires health centers to design a fee schedule to cover its reasonable costs of operation. • And “to make every reasonable effort to secure from patients payment for services in accordance with such schedules. • And to collect reimbursement for health services to persons covered by public or private insurance.

  7. Health Centers Margins Mission Sustainability Business Operations

  8. Margins HealthCenter Mission Sustainability Financial Infrastructure • Grant Funds • Primary Health Services • Specialty • Services • Medically • Underserved • Healthcare Access • Preventive Services • Financial Infrastructure • Financial Quality Improvement • Financial Goals • Financial Management • Financial Culture • Business Mindset

  9. Health Center Revenue Cycle Management Leadership Regulatory Compliance Information Technology Quality Mission Sustainability Margins Financial Transformation

  10. Appointment Scheduling • Registration/Certification • Patient Reception • Clinical Visit/Service Delivery • Documentation and Coding of Visit • Charge Processing/Check Out • Patient Statement & Claim Production • Claims & Patient Payments Processing • Denied Claims Management • Accounts Receivable Oversight & Collections Revenue Cycle Management

  11. Financial Operations Revenue Cycle Management Executive Leadership Clinical Operations Operations Revenue Cycle Management: RCM

  12. Current Status of Business Operations and Workflow • What are the health center’s financial policies and procedures? • What is your current understanding of FQHC billing and reimbursement systems? • Who currently manages the complexities of these billing and reimbursement systems? • Who stands as your internal or external finance, billing, coding, and HIT content expert. • How often does leadership assess financial workflow and operations? • All Inclusive Rate • Medicare • Medicaid versus • Managed • Sliding Fee • Self-pay • Wraparound billing

  13. Current Status of Business Operations and Workflow What current HIT workflows are in place to support business operations? • Leadership operations • Finance operations • Billing operations • Operations • Clinical operations

  14. Mission Sustainability Margins Health Center Health Information Technology Optimization • Leadership • Understand operations • Team competence • Cultivate change • Finance/ • Billing • Practice Management • Billing Policies/Procedures • Collections • Operations • Scheduling • Front Desk • Back Office • Clinical • Credentialing Scheduling • Documentation • Coding • Productivity

  15. Health Information Technology Health Information Technology Finance/Billing Operations • Leadership • Transformation • Financial Solvency • Restructure Workflow • Cultivate Financial Culture Clinical Operations

  16. Patient Check-Out Clinical Encounter Registration Scheduling • Begins • RCM • Pt. Access • Appointment Management • Initial Contact • Eligibility • Credentialing • Patient Information • Insurance • Eligibility • Credentialing HIPPA/Compliance • Copayment • Outstanding Balances • Fees for Service • Patient Payments • Charge Retrieval • Appointment • Scheduling • Provider • Accountability • Patient Experience • E&M • Documentation • Coding • Time Management HIT Process Improvement Health Information Technology Workflow

  17. Patient Scheduling Workflow • The revenue cycle starts with scheduling the patient. • Health center staff should use a check sheet or script guide to be sure all pertinent information is collected at the time of scheduling. • Collecting insurance information will help the scheduler know what information to ask from the patient. • Additional items to discuss with the patient include explaining what information the patient should bring to the appointment. • The expectation of payment of co-pays at the time of the visit, and the arrival time of the patient if certain paperwork and registration work needs to be completed.

  18. Patient Registration Workflow

  19. HIT and Practice Management System • Practice Management System – key driver of the RCM process. • Establish mandatory registration data entry points. • Verify patient information at every visit (phone numbers, UDS data points). • Front desk must check insurance eligibility and check patient’s insurance card at every visit. • Collect copayments at the point of registration. (Financial Policy)

  20. Case Study A new uninsured patient walks into the health center and requests a same day visit for a physical examination. Develop a patient centered access friendly workflow for this scenario. What are the major factors to consider? • The patient reports the following: • No current health insurance. • No current primary care provider. • No current history of present illness. • Working part-time at a local farmer’s market. • Patient reports occasional headaches possibly due to stress. “I would like to take better care of myself.”

  21. Workflow Development Considerations • Identify internal and external processes influences that prevent your health center from successful revenue cycle management. • Does your health center currently have a financial policy that serves as the back bone of your RCM processes? • How does your health center utilize your practice management system and electronic health record to optimize operations and workflow processes? • What is your health center’s “WOW” factor? How do you make a memorable first impression? How best can you utilize HIT to develop sound walk-in registration/uninsured patient workflow processes? • What HIT techniques are used to decrease incidences of registration backlog due to processing delays, patient literacy support, and triage needs?

  22. Patient Financial Policy Patient Financial Policy ALL PAYMENT IS EXPECTED AT THE TIME OF SERVICE Payment is required at the time services are rendered unless other arrangements have been made in advance. This includes applicable coinsurance and copayments for participating insurance companies. The Health Center accepts cash, Visa, MasterCard, flexible spending accounts, money orders, and debit cards. Past Due Balances: Unpaid past due balances create a financial burden for both you and the health center. To minimize the burden incurred by both parties, the Health Center will ask you to create a payment plan for all unpaid balances greater than $50. Any payment plan will be strictly associated with past due balances and will not replace charges due for current or future services. Patients will not be denied services based on an inability to pay. The Health Center establishes payment plans as a courtesy to you. The Health Center realizes that financial difficulties may occur. In such circumstances, we advise immediate communication of your financial changes. The Health Center is committed to ensuring all patients have access to quality healthcare. Patients identified through the financial application process as having an ability to pay are expected to honor established payment plan arrangements. Refusal or failure to pay if ability to pay has been established may result in patient dismissal from the Health Center. Patients with an outstanding balance 60 days or more overdue must make arrangements for payment prior to scheduling appointments. Refunds Patient/guarantor credits in amounts less than $20.00 will be retained on account to be credited towards future balances unless written request for refund is received. Amounts $20.00 and greater will be automatically refunded to the patient/guarantor. Insurance: Providing Insurance Information It is your responsibility to provide us with accurate insurance information. You are expected to bring insurance cards to every appointment. It is your responsibility to advise us of any insurance changes prior to scheduling any appointment or requesting any service, such as a medication refill or a referral.

  23. Provider Clinical Operations and Workflow Health Information Technology Your Text Patient Patient Scheduling Front Desk Your Text Clinical Workflow Healthcare Team Integrated Care Workflow Your Text Your Text Check-out Workflow

  24. Margins Sustainability Compliance Provider Mission Clinical Workflow and HIT Electronic Medical Record • Patient • Encounter • Chief Complaint • Examination • Clinical decision Making • Evaluation and Management • CPOE • Documentation • E&M Coding • Plan of Care C

  25. Information Exchange Information Exchange Electronic Health Record Practice Management • Patient Centered Care • Medical Decision Making • CPOE • Documentation/Coding • Patient Accountability • Self-Management • Patient Responsibility • Ability to Pay Financial Responsibility Medical Orders Medical Charges Medical Billing Clinical Workflow and HIT

  26. Sustainability Improved Access Quality Healthcare Delivery Integrated Care Financial Management Patients Health Center Healthcare Teams Financial Infrastructure

  27. Margins Sustainability Mission Health Center Health Information Technology Workflow Mission vs Margins 100 % 65 % 10 % 25%

  28. Questions

  29. Contact Information DPM Healthcare Consulting Stephanie J. Wroten BSN, MS, LNC Debra P. McGrath, President DPM Healthcare Consulting

  30. Thank You! DPM Healthcare Consulting