Show Me the Numbers!

1. Show Me the Numbers! How Strategic Planning Can Pay Off for Your Health Center

2. What Are the Numbers? • Key indicators chosen to measure a basic level of success • 14 Sites w/ completed evaluation results assessed by SNS 2006-2008 • Where located: Massachusetts, Maine, Connecticut • 10 FQHCs • 4 Non-FQHC CHCs • Key indicators measured: • Net revenue • Number of patient visits • Gross charges • Number of unduplicated patients

3. Aggregate Data – 14 Health Centers

4. Average Increase Per Site – 14 Health Centers

5. How Did They Get There?

6. Common Strategies Employed • Education of dental and administrative team related to opportunities to maximize access and productivity • Improved scheduling systems to maximize productivity and make best use of chairs given current staffing • Created or refined policies designed to reduce or eliminate chaos (eg, emergencies, no-shows) • Tweaked patient mix to improve access for priority populations (such as children) which also aided the practice financially • Developed clinical protocols to standardize services provided to patients at each visit, which fostered the completion of treatment plans, ensured the avoidance of churning and maximized revenue opportunities

7. Common Strategies Employed (cont.) • Adjusted fee schedules to be more in line with Usual and Customary Rates • Revised encounter forms to enhance their functionality • Established access and productivity goals for the practice, ensuring elimination of disease and creation of financial sustainability • Met with dental and administrative staff to review current situation and present the action steps recommended for practice enhancement and/or recovery • Showed the practice how to monitor success or lack thereof in achieving action plan goals • Promoted the development of a process to reward and celebrate success on a regular basis

8. Common Strategies Employed (cont.) • Reviewed monthly progress reports with dental leadership related to progress in accomplishing each action step according to the agreed upon timeline • Adjusted action steps when needed • Reviewed SNS key data reports with practice at 6,12,18, and 24 months

9. Case Study Six-Chair Federally Qualified Health Center

10. About This Program • Six-chair clinic located in Boston suburb (FQHC) • Six FTE dentists, each seeing an average of 13 patients per day • Fee-for-service reimbursement for Medicaid • Practice located in an area of enormous need and demand for care • Only FQHC in service area • As a result of moving from red to black, this practice is in the process of expanding from 6 to 12 chairs!

11. Case Study: How Did They Increase Visits?

12. Strategies for Increasing Visits • Managing Emergencies • Managing No-Shows • Scheduling

13. Managing Emergencies • Define what constitutes a true emergency • Create an emergency management system that meets the level of need, but preserves regularly scheduled appointments • Develop and implement an emergency policy, and stick to it • Provide training for registration and reception staff in the triage of emergency walk-ins and calls

14. Managing No-Shows • Create and distribute no-show policy to patients and staff • Post the no-show policy in several areas • Have patients read, sign and insert signed policy in chart • Enforce the no-show policy consistently across the practice • Track: • No-shows • Cancellations • Fill-ins • Scheduled visits vs. actual appointments

15. Managing No-Shows (cont.) • Provide reminder messages for upcoming appointments • Schedule appointments no further out than 30-45 days • Schedule one follow-up appointment at a time

16. Improving Scheduling System Some factors that affect scheduling policies: • Demographics of the patient population • Typical needs of the patient population • How far in advance appointments are scheduled • Appointment lengths • Number of appointments available

17. Improving Scheduling (cont.) • Schedule appointments no further out than 30-45 days • Schedule appointments one at a time Exception: patients undergoing complex procedures that require multiple visits to complete • Determine basic appointment length by type of service provided: 30-45-60 minutes Allocate10-15 minute increments for procedures requiring additional time

18. Case Study: How Did They Increase Net Revenue?

19. Case Study: Increasing Net Revenue

20. Strategies That Increase Revenue Documentation of Eligibility • Flow charting and establishing accountability for every step of the eligibility process through staff orientation and training Management of Self-Pay Patients • Define the responsibilities of patients and staff • Communicate expectations for payment at the time of the visit • Support front desk staff to perform this crucial task through training and scripting; use objective performance measures to evaluate staff success Billing Efficiencies • Flow charting and establishing accountability for each step in the process from patient registration through reconciliation • Identify barriers to successful billing and develop strategies to resolve • Staff training to increase probability of success through the billing process

21. Strategies That Increase Revenue Cross-train staff (receptionists, registration staff, dental assistants) to fill in as needed, according to priority • The consideration of incentive programs to reward the dental team (not just providers) • Use of DAs and RDHs for expanded duty to maximize availability of dentists for treatment Staff are regularly educated and trained relative to the rules and regulations of the practice’s primary third-party payers (especially Medicaid) • Determination of a defined scope of service fostering elimination of disease, yet preserving financial viability

22. Strategies That Increase Revenue Establishment of a fee schedule, sliding fee scale and nominal fees that sustain the practice yet do not pose barriers to care Non-emergent procedures requiring prior authorization should not be initiated until PA is received or patient agrees to self-pay status Verification of patient’s eligibility before and at each visit Skillful utilization of IT systems to maximize clinical effectiveness and enable the practice to obtain the data needed to evaluate program performance

23. Policies That Increase Revenue Self-pay patients and those with insurance co-payments need to pay at the time of the visit Patients should be educated about the true value of the services they are receiving and the discounts they are eligible for

24. Developing a Sliding Fee Scale • Slide fees from full charges (set at 75-80th percentile of UCR) based upon household income and Federal Poverty Guidelines • Slide categories are typically 100% FPL and below; 101-150% FPL, 151-200% FPL, with percentage discounts offered for each category (patients above 200% FPL pay full charges) • In setting sliding fee scale, need to create a balance between compassion and financial sustainability • FQHCs – set a nominal fee for patients 100% of FPL and below • Can be determined by setting a dollar amount (e.g. $30), a percentage of 20% of full fee, or the Medicaid adult fee for same service • Make every effort to collect, but those 100% of FPL and below who are unable to pay are subsidized by the practice [330 funds?]

25. Strategies for Creating an Effective Billing System • Utilization of an up-to-date, practice-friendly encounter form • A policy that all staff responsible for any part of the billing process be trained and held accountable • A policy guiding the transfer of information from dental to billing with built-in accountability • The creation of a flow chart that defines each step in the billing process and assigns accountability for each step

26. Creating an Effective Billing System • A policy that guides the reconciliation of remittances and the resubmission of denials with designated accountability • A prior approval policy and process • A billing manual and orientation/training process for accountable staff

27. Sample Billing Flow Chart Patient calls for appointment; registration documents eligibility and schedules appointment Patient comes in for appointment; eligibility is checked again; patient is asked to pay any co-pays due at the time of the visit Encounter form (or routing slip) is generated; patient sits in chair; provider sees patient and documents services on encounter form or on routing slip For patients covered by Medicaid or other third-party insurers, DA takes encounter form and puts it in holding cart Patients with co-payments (self-pay or commercial insurance) take encounter form to registration and check out Encounter form goes to billing, where it is reviewed by dental specialist Patient meets with patient accounts specialist to review follow-up care needed and estimated costs

28. Sample Billing Flow Chart (cont.) Third Party insurance Self-Pay If patient agrees to care plan, next appointment is made Encounter form goes to billing, where it is reviewed by dental specialist Patient accounts specialist takes encounter form Claim is filed Encounter form goes to billing, where it is reviewed and patient invoice is generated for balance due, if any Claim is paid or denied Patient gets bill and pays or continues to get billed Paid Denied Reconciled against patient account Investigated, corrected and rebilled Paid Hopeless Reconciled against patient account Written off Claim is paid or denied Paid Still Hope Hopeless Reconciled against patient account Written off Submitted for payment again

29. Strategic Planning • After establishing where it is (through practice analysis), the practice needs to decide where it wants to go and how it will get there • Define the practice’s mission and explore scope of service • Develop an action plan to get the practice to achieve the goals of: • The dental practice’s mission (access and services) • The overall health center mission • Financial sustainability • Quality dental health indicators • Completion of Phase 1 Treatments • Develop policies, procedures, and operations that foster the attainment of the dental practice’s goals • Develop long- and short-term goals and action steps • Regularly review practice data to monitor performance of dental program

30. What Data Should We Gather?

31. Partnering to Strengthen and Preserve the Oral Health Safety Net A PROGRAM OF THE 2400 Computer Drive, Westborough, MA 01581 Tel: 508-329-2280 Fax: 508-329-2285www.dentaquestinstitute.org