be prepared for the tsunami of changes affecting your reimbursement by jimmy lewis kathy whitmire n.
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  1. Be Prepared for the Tsunami of Changes Affecting Your ReimbursementbyJimmy Lewis & Kathy Whitmire

  2. ACRONYMS PRE-TEST • RAC = R ____ A ____ C ____ • MAC = M ____ A ____ C ____ • HAC = H ____ A ____ C ____

  3. ACRONYMS TEST • POA = P ____ O ____ A ____ • MUE = M____ U ____ E ____ • MSP = M ____ S ____ P ____

  4. ACRONYMS TEST • HRA = H ____ R ____ A ____ • ABN = A ____ B ____ N ____ • VBP = V ____ B ____ P ____ • CERT = C ____ E ____ R ____ T ____

  5. Why is Change Vital to your Hospitals Survival? Medicaid and Medicare cuts are projected to exceed $60 billion over the next 2 years. Managed care continues to cut payments for procedures & increase complex requirements High Cost of collections on the backend decreases net of claim by 25% The rules have all changed while no one was looking and bad debt has doubled!

  6. Why has Revenue Decreased and Bad Debt Increased? Increased Deductibles & Co-Pays Increase in the Underinsured & The Uninsured Rising Medicare Enrollment Development of the Consumer-Directed Health Plans Reactive vs. Proactive Billing & Collection Practices CMS Medicare Advantage Plans Changing Medicare FFS Requirements RAC’s, HAC’s, MAC, MS-DRG’s (500+ to 700+), POA Lack of technology or knowledge to use technology Fragmented Solutions Changing Interqual Admissions Criteria =Less Admissions

  7. Rising Medicare Enrollment

  8. Increasing Out of Pocket Payments

  9. How to Overcome Obstacles to Change in the Revenue Cycle

  10. Define & Understand the Problems with the Current Processes Increased complexity in the reimbursement system requires ongoing process changes PROCESS CHANGE # 1 Implement Payer Matrix with requirements for payment Medicare FFS with/without supplemental Medicare Advantage FFS, PPO, HMO, HRA, HSA (24 plans) Pre-authorization prior to procedure (24-28 hours) Proof of Eligibility verification at time of service Confirmation that service is Medically Necessary and covered by Medicare If not, ABN Issued with expected cost of service Co-Pays & Deductibles collected (20% Minimum –O/P)

  11. Understand Everyone’s Role in the Revenue Cycle

  12. Redesign the Work Flow New Expectations of the Revenue Cycle

  13. Define & Understand the New Expectations All requirements completed on 100% of scheduled Outpatient procedures Diagnostic Testing performed in ER after patient is stabilized, should be done as stat O/P and all payer requirements completed O/P Lab procedures should be checked for Medical Necessity and for Covered service prior to performing test and ABN issued if necessary. Criteria Checklist is completed by Nurse Case Mgr prior all Inpatient Admissions DRG assigned, LOS noted and related to physician, Condition Code 44 Form completed if patient does not meet criteria and is assigned back to Observation status.

  14. Understand & Address the Obstacles: FOR EXAMPLE: Obstacles to Improving Collections Uneducated Physicians and Board Members Community image Vague or outdated policy & procedure Fears regarding Emtala Insufficient training and follow through

  15. 6 STEPS:Guaranteed to Reduce Bad Debt and A/R Days

  16. Complete Revenue Cycle Assessment Involve your team in developing an action plan for improvement with a timeline. Next - make sure everyone is on board: Educate Your Board Educate Your Community Educate Your Staff 1) Develop Your Revenue Improvement Plan & Educate

  17. FOR EXAMPLE: In the 4th Quarter we will: Reduce accounts receivable days by 15% Increase point-of-service cash collections by 50% Reduce denial write-offs by 30% 2) Set Real Goals

  18. 3) Create a Timeline for Change

  19. 4) Review & Write New Policy & Procedures All Patient Access policies need to be reviewed and revised to reflect the changes made in order to strengthen collections. MAKE SURE – to train all employees on new policy! Have up-to-date policies available in an easy reference manual so that employees can refer to them if needed.

  20. Review performance of all staff w/ HR Plan a Patient Access Dept. upgrade Have staff agree to Performance Improvement program goals Must meet performance goals within 60 days 5) Hire & Train Competent Staff

  21. Implement proven technology to accomplish goals: nTelelagent – Manages Self Pay accounts, verifies eligibilty, confirms address, measures ability to pay, calculates prompt pay discounts & payments, implements standard policy. QUADAX - Verifies eligibility, It catches registration errors on the front-end while providing detailed error trending and edit tracking with an automated bi-directional HL/7 feed interface capability. 6) Evaluate and Implement Proven Technology

  22. Monitor weekly and monthly progress with the following reports: Cash Collection Reports Point-of-Service Cash Collections by Location/Service Cash Collections by Collector Denials Reports Denials by Discharge Date Denied Accounts Receivables by Reason Denied Charges by Month 7) Monitor Progress with Weekly Reports

  23. Monitor weekly and monthly progress with the following reports: Accounts Receivable Reports Outstanding Accounts Receivable by Biller Age from Final Bill Date to Pay Date by Payer Medicare Accounts Older than 180 Days Bad Debt and Self-Pay Reports Bad Debt Write-Offs by Patient Type Charity Care Write-Offs by Patient Type Aged Self-Pay Accounts by Collector Self-Pay Write-Offs by Service Area Cont. - Monitor Progress Weekly

  24. Finally. . .EDUCATIONis the Key to Successful Change

  25. Education – Who is responsible for education? EVERYONE! Each Dept/Clinic Manager is responsible for training their people. Training should be at a set time and place on a minimum of a monthly basis. Evaluate your employees and their performance Identify their weaknesses and then set up a training time to address their needs – Set Goals and reward them when they meet their goals.

  26. Training – What are you Training? POLICY & PROCEDURE Policy and Procedure is the law of the Hospital. It will be easy to measure employee performance based on compliance/non-compliance with policy & procedure. They should be so familiar with P&P, that they can answer with “Our hospital policy on that is ___” Use a standard policy format to identify a new or revised procedure and publish to all people that deal with that Policy.

  27. WHAT IS HTHU? A Virtual University available through any internet connection 24 hours a day / 7 days a week

  28. WHAT ARE BENEFITS OF ONLINE EDUCATION ? • No travel • Less time away from work • Access for all • Timely, Relevant, Up to date • Improved Performance • Pride and Achievement • Validation of Correct Process

  29. “The definition of insanity is doing the same thing and expecting a different result” Embrace Change – empower your people to make the change AND MOST IMPORTANT – Make education a priority!!!! In Summary

  30. When you don’t know what an acronym stands for go to: REMEMBER: DBAOC DON’T BE AFRAID OF CHANGE In Summary