ambulatory surgery scheduling strategies with case · pdf fileambulatory surgery scheduling...

Michigan ASC Association2013

Dawn Q. McLane-Onofrio RN, MSA, CASC, CNORDirector Integration Management

SCA

Ambulatory Surgery Scheduling Strategies

with Case Cost Analysis

2DQM

The Scheduler Who is She?

Knowledge of surgical setting Computer literate Mature Organized and able to prioritize Multi-task (and stay sane!) Attention to detail – accuracy Critical thinking skills Ability to produce reports Marketing skills – interpersonal skills Dedicated and cheerful

3DQM

The Scheduler What She Does

Demographics Schedules procedure(s) Coding (in some organizations) Verifies surgeon’s privileges Verifies equipment availability Assures conflicts are resolved Verifies / communicates special requests of

the surgeon

4DQM

Scheduling FlowsheetAANNYY SSUURRGGEERRYY CCEENNTTEERR

SCHEDULING PROCESS FLOWSHEET

Receive Call from Surgeon Office

Scheduler

Receive Fax from Surgeon Office

Scheduler

Verify Information on Fax and Schedule into

Block or Open Time/ Conflict Checking Scheduler

Notify Materials Manager if Resource Needed

(equipment or implant) Scheduler/Materials Manager

5DQM

Scheduling Flowsheet

Complete Patient Demographics in

Scheduling Program Scheduler

Insurance Verification/ Patient Call if

Necessary regarding Co-Pay AR Specialist

Pre-op Phone Call for Patient History and

Demographic Record Completed Pre-op RN /Admitting Clerk

Pre-op Worksheet to Registration and AR

Scheduler

Patient Chart Completed

Pre-op RN

6DQM

Scheduling Roles

Patient Registration pre-op input demographics review for previous visit(s)

Pre-op Nurse chart complete 24-72 hours pre-op pre-op test review and notification pre-op nurse interview – patient history anesthesia “alerts” ID special needs (interpreter)

7DQM

Scheduling Roles

Surgery RN , Anesthesia, Surgeon live by the schedule availability of equipment, implants, etc room turn-over and on-time schedule

PACU & Phase II RN staffing affected by schedule Post-op Call – assess patient satisfaction

8DQM

Scheduling Roles

Medical Staff assure credentialing and privileging

Materials staff review schedule for availability of supplies and

implants assures materials are available control overnight shipping costs schedule vendor reps

9DQM

Scheduling Roles

Patient Accounts verification of benefits – insurance card billing case & implants documentation of medical necessity

Payables Clerk match documents and pay invoices for supplies

10DQM

Information Systems

Experior “SurgeOn” (formerly Camberly) Source Medical

Vision (Scott Palmer)

Advantix SIS (SurgiCenter Information Systems

HST - Healthcare Systems & Technologies, LLC. (Tom Hui)

Amkai – Medical Record, releasing ASC Program

11DQM

Scheduling Formats

Open Schedule first come first serve

Block Schedule blocks all or most available time

surgeon, practice or specialty

Modified Block Schedule combination of Open and Block

12DQM

Modified Block Schedule

flexibility early release time – 7 days – 72 hrs may make exception for Gen & GYN permits scheduler to fill schedule “holes” (avoid

phantom scheduling) Goal: 70-85% utilization Utilization management quarterly - MEC

13DQM

Modified Block Sample

Room 1 Room 2 Room 3 Procedure Room 1

Monday AM GYN GEN ORTHO PAIN

Monday PM GYN OPEN ORTHO OPEN

Tuesday AM EYE EYE ORTHO PAIN

Tuesday PM EYE EYE OPEN OPEN

WednesdayAM GYN GEN ENT COLON

WednesdayPM OPEN GEN ENT OPEN

Thursday AM EYE EYE ENT COLON

Thursday PM EYE EYE OPEN OPEN

Friday AM HAND OPEN ORTHO PAIN

Friday PM HAND OPEN ORTHO OPEN

14DQM

OR Utilization Management

Number of hours of OR time actually used / number of hours of OR time available (not including turnover time??)

If benchmarking use survey’s definition Permits management of blocks and decisions

about scheduling Goal 70-85%

15DQM

Policies & Procedures Scheduling Procedures describes requirements for scheduling paperwork required means of communication

Pre-surgical worksheet demographic information pre-op orders insurance information schedule request – procedure(s)

16DQM

HIPAA patient communications policy continuum of care getting patient permission what can be communicated

HIPAA Communications Form Pre-operative Testing Guidelines Anesthesia Alerts Aborted Cases Checklist Advanced Directives – policy / form

Policies & Procedures

17DQM

Policies & Procedures

Credentialing and Privileging Observers in the Operating

Room

18DQM

Networking

Schedulers from other ASCs Schedulers from physician offices Attendance at seminars Resources: ASC Association AAAHC

19DQM

Scheduler’s Manual provide to office scheduler scheduling policies and protocols forms / passwords if electronic list of required elements to schedule payor contract information HIPAA Communications form ASC contact information - cards

Scheduler & Marketing

20DQM


Budget for Scheduler Marketing Plan Schedule events Scheduler’s Breakfast or Luncheon

twice annually catered with door prizes educational session hosted by ED, CD, BOM, patient accounts and

scheduler

21DQM


Visit Practice – scheduler, patient accounts and Manager 1-2 times per year take lunch deliver small tokens – candy include all offices – not volume driven

Scheduler is first impression !!

22DQM

Advanced Directives

23DQM

Payor ContractsFrom: Executive Director & Scheduler Update: 10/1/2005

Any Surgery Center Scheduling Information

Financial Class

Type

Description / Comment

Effective Date

7 TeamCare Teamsters Direct Contract 01/01/2005 CIGNA PPO Product 01/01/2005 9 CHAMPUS Standard & TriCare 06/22/2004 23 Partners HMO/PPO/POS 06/26/2004 12 Worker’s Compensation BCBS 10/01/2004 5 Blue Shield

AICI

Traditional Preferred Care Premium Preferred Blue Access (PPO Product)

10/01/2004 10/01/2004

BCBS Auto Workers 08/15/2004 4 Medicaid Risk-based and PCCM 06/22/2004 1 Medicare All 06/22/2004 Choice Care 09/01/2004

15 United Health Care All 03/24/2004 12 Worker’s Compensation All 02/14/2004 9 Commercial All 02/14/2004 8 Self-Pay All 02/14/2004

We will continue to keep your offices updated as changes occur. If you have any questions, issues or concerns or wish to schedule surgeries, please contact the surgery center. The surgery center staff will continue to assist in every way and will continue to confirm insurance coverage and/or limitations of scheduled procedures.

24DQM

Canceled Case Billing?Any Surgery Center

Aborted/Cancelled Case Checklist Patient Name: Patient ID: Physician: I. When was the case aborted/cancelled? Before registration After IV or Med given in Pre-Op After registration/Before IV After admission to surgery

II. What was responsible for the aborted/cancelled case? Patient did not follow instructions

Anesthesia provider

Abnormal Diagnostic

Abnormal Pre-Op Assessment

Other

Equipment

Not available

Malfunction

Specialist/Surgeon

Change in Diagnosis

Pre-Op Assessment

Other

Supply not available

Case open in OR

Other - Explain

25DQM

Canceled Case Billing?

III. Did we treat patient/expend resources? IV started Case open (attach preference card) Medication given Other ________________________

IV. Documentation required to make a decision regarding the billing of this case to a payor? History Diagnostic Physical Lab

X-Ray

EKG

Other Comments:

V. Recommendation of Coder: Meets criteria – Bill Comments____________________________

Does not meet criteria – Do not bill _____________________________________

Signature – Coder Date

26DQM

Canceled Case Billing?VI. Recommendation of Controller: Meets criteria – Bill Comments____________________________

Does not meet criteria – Do not bill _____________________________________

Signature – Controller Date VII. If billed to a payor, the Controller will wait for the EOB. After the EOB is received, the Controller will perform a second review of this case.

Patient responsible amount per primary EOB $ _________________

Patient responsible amount per secondary EOB $ _________________

Paid by Insurance $_____________ Deductible $ ____________ Co-Pay $_____________ Not covered by insurance Co-Insurance $ _____________ $ ____________

VIII. Bill patient $____________ Write off $ __________ to account # __________ Comments:

27DQM

Canceled Case Billing? IX.

Account paid

Payment arrangements Signature Date

Account paid in full Signature Date

To collection Signature Date

Signature Date

_________________________________________________ Signature-Controller Date X. Patient notified Letter

Statement Signature Date

Phone Signature Date

Signature Date Notes:

28DQM

Breakeven Analysis

Any Surgery CenterBreak-even Analysis based on best estimates and a conservative approach

2 OR 3 OR 4 OR

Cash Flow required to fund-Monthly 150,000$ 200,000$ 250,000$

Ave/Receipt/Case 1,000$ 1,000$ 1,000$

# of Cases needed to break Even-Per Month 150 200 250 # of Cases needed to break Even-Per Week 38 50 63 # of Cases needed to break Even-Per Day 8 10 13

# of Cases needed to break Even-Annually 1,950 2,600 3,250

Projected Case Volume at full operation-not full utilization 3500Cases in excess of break Even 250 Potential cash flow @ $1,000/case 250,000$

29DQM

Overhead Calculation Any Surgery CenterOverhead Cost per Case based on 3rd quarter current FYFixed Expenses - 2005 Actual:

Payroll Expense 22,525 12% (NP) budgetMedical Director 6,686Clinical Expense 23,929 Clin Eng/Eqpt Rent/Mtn Cont/MR Con/Stryker/Ph

RM Eqpt/Rad/Credentialing/instrumentsFacility Expense 94,655Admin Expense 44,271Debt Service 79,123

$271,189

650 #cases/mo Multispecialty mix

$417 Fixed cost per case

30DQM

PS Case Cost Analysis

Patient Name ____________________________________ Patient ID ________________

Insurance ______________________________________________________________________

Surgery Date __________________Surgeon ____________________________________

Scheduled Procedure(s) ______________________________________________________________________

CPT code(s) (anticipated) ______________________________________________________________________

Implants (anticipated)

Notes: _____________________________________________________________________________________

___________________________________________________________________________________________

Any Surgery Center Pre-Surgical Case Analysis

31DQM

PS Case Cost AnalysisCost Analysis - Worst Scenario

Estimated Reimbursement Estimated Reimbursement

Projected Expenses Projected Expenses Implants Implants

Staffing Staffing

Medical Supplies Medical Supplies

Marginal Revenue (Loss) 0.00 Marginal Revenue (Loss) 0.00

OR Time (overhead) OR Time (overhead)

Net Income(Loss) $0.00 Net Income (Loss) $0.00

Notes: ________________________________________________________________________________________________________________________________________________________________________________

Analysis By:__________________________Date of Analysis:_____________________

Physician Contacted / Spoke with:________________________________Date/Time of Contact:_______________

Physician Decision Comments:__________________________________Date/Time of Contact:_______________

___________________________________________________________________________________________

___________________________________________________________________________________________

* This above analysis was estimated based on all information available at the time the case was scheduled and benefits were verified.

Cost Analysis - Best Scenario

32DQM

Case Cost Analysis LC

391.50191.00N/A

*see attached preference card from AdvantX 582.50$ Staffing # staff neededposition hours neededAvg rate/hourCost of staff benefits (22%) Total Staff Costs

Registration 1 Registration 0.25 11.86 2.97 0.22 0.65 3.62Pre-op 1 RN 1 24.17 24.17 0.22 5.57 29.74Surgery 1 RN 1 25.32 25.32 0.22 3.25 28.57Surgery 1 Scrub Tech 1 14.78 14.78 0.22 3.25 18.03Rad Tech 0 Rad Tech 0 0.00 0.00 0.22 0.00 0.00Recovery 1 RN 1 24.17 24.17 0.22 5.32 29.49Phase II 1 RN 1 24.17 24.17 0.22 5.32 29.49

Personel Costs $138.94$775.44

hours rate/hour

1 $417.00 $417.00$417.00

$1,192.44

CPT # 47562 Name of Procedure: Lap CholeCost / Expenses: Cost per case

$54.00Depreciation Expense (instrument cost)

Supplies- Surgeon A (436.39) Surgeon B (346.46)Anesthesia -Implants

Supply costs

Marginal costsOverhead / Time in ORAvg OR time Billing Overhead cost

TOTAL COSTS

33DQM

Case Cost Analysis LC$775.44

hours rate/hour

1 $417.00 $417.00$417.00

$1,192.44

%billed to date

Medicare reimbursement / case 035203015

$1,841.86

$649.43

Overhead / Time in ORAvg OR time

CPT # 47562 Lap Chole Marginal cos

Billing Overhead costTOTAL COSTS

Reimbursement Calculation:Contractual or average

reimbursement Total reimbursement0 0

Insurance A 2,590 90,645Insurance B 815 16,291Insurance C 950 28,500Insurance E 3,250 48,750

Net Income

Weighted Avg Reimbursement

34DQM

Scheduling Decisions

Revenue Payor mix – contract status Collections – days in AR Billing protocols – within 24 hours DOS

Expense Preference cards – resource management Materials expense – GPO Inventory management Staffing - management

35DQM

Scheduling Decisions

Maturity of organization Organization Policy: Do Case? perform case cost analysis cover Marginal Cost / cover out of pocket &

contribute to overhead cover Total Cost review reimbursement by payor

36DQM

Case Cost Analysis - EyeCPT # 66984 Cataract with IOL ImplantCost / Expenses: Cost per caseDepreciation 0.00SuppliesPack and MedicationsLensMedications 10.32

Rental Contract 521.61Supply cost 531.93

Staffing # staff needed position hours needed Avg rate/hour Cost of staff benefits (1.25%)

Registration 1 Registration 0.25 13.00 3.25 4.06Pre-op 1 RN 0.75 19.55 14.66 18.33Surgery 1.5 RN 0.25 22.10 8.29 10.36Surgery 1 Scrub Tech 0.25 16.60 4.15 5.19Recovery 0 RN 0.00 19.62 0.00 0.00Phase II 1 RN 0.25 19.55 4.89 6.11

$35.24 Staffing Cost 44.05Marginal cost $575.98

Overhead / Time in ORAvg OR time (IS data) 0.25 $417.00 104.25Billing

Total Cost $680.23

37DQM

Case Cost Analysis Eye

CPT # 66984 Cataract with IOL Implant Marginal cost $575.98Overhead / Time in ORAvg OR time (IS data) 0.25 $417.00 104.25Billing

Total Cost $680.23Reimbursement Calculation:

%billed to date reimbursementInsurance A 100 949.00 $94,900.00Insurance B $0.00Insurance C $0.00Insurance D $0.00Insurance E $0.00

100 WeightAvgReim $949.00

Net Revenue $268.77

38DQM

Case Cost Analysis – OrthoCPT # 23412 Shoulder - Rotator Cuff Repair

Cost / Expenses: Cost per caseDepreciation 450.00SuppliesPre-Op supplies & Anesthesia Drugs 150.00Medical Supplies 423.00Implants (Estimate Anchors/Tacks) 400.00

973.00Staffing # staff needed position hours needed Avg rate/hour Cost of staff benefits (1.25%)

Registration 1 Registration 0.25 13.00 3.25 4.06Pre-op 1 RN 0.50 19.55 9.78 12.22Surgery 1 RN 1.50 22.10 33.15 41.44Surgery 2 Scrub Tech 1.50 16.60 49.80 62.25Recovery 1 RN 1.00 19.62 19.62 24.53Phase II 1 RN 2.00 19.55 39.10 48.88

154.70 193.37

CPT # 23412 Shoulder - Rotator Cuff Repair Marginal cost $1,616.37

Overhead / Time in OR minutes hours rate/hour

Avg OR time (IS data) 0 1.5 $417.00 625.50Billing Total Cost $2,241.87

39DQM

Case Cost Analysis - Ortho

CPT # 23412 Shoulder - Rotator Cuff Repair Marginal cost $1,616.37


Avg OR time (IS data) 0 1.5 $417.00 625.50Billing Total Cost $2,241.87Reimbursement %billed reimbursement

Insurance A 25 $966.00 $24,150.00Insurance B 17 $1,866.00 $31,722.00Insurance C 20 $2,511.00 $50,220.00Insurance D 9 $1,315.00 $11,835.00Insurance E 14 $2,332.50 $32,655.00Insurance F 15 $1,956.00 $29,340.00

100 WeightAvgReim$1,799.22

Net Revenue ($442.65)

40DQM

Case Cost Analysis – OrthoCPT # 64721 Carpal TunnelCost / Expenses: Cost per caseDepreciation 360.00

SuppliesMedical Supplies (includes $90 disposable knife) 180.00Anesthesia 100.00



61.74 77.17

CPT # 64721 Carpal Tunnel Marginal cost $717.17

41DQM

Case Cost Analysis – Ortho

CPT # 64721 Carpal Tunnel Marginal cost $717.17


Avg OR time (IS data) 0.5 $417.00 208.50

Billing Total Cost $925.67

Reimbursement Calculation: %billed to date reimbursementInsurance A 25 433.00 10,825.00Insurance B 1 751.00 751.00Insurance C 18 845.00 15,210.00Insurance D 25 1,451.00 36,275.00Insurance E 11 1,413.00 15,543.00Insurance F 20 1,206.00 24,120.00

100 WeightAvgReimb$1,027.24

Net Revenue $101.57

42DQM

Case Cost Analysis – ColonCPT # 45378 Colonoscopy

Cost / Expenses: Cost per caseDepreciation 360.00

Medical SuppliesSupplies 74.24Anesthesia 12.50



42.15 52.69(staffing cost)

CPT # 45378 Colonoscopy Marginal cost $139.43


Avg OR time (IS data) 0 0.5 $417.00 208.50Billing Total Cost $347.93

43DQM

Case Cost Analysis – Colon

CPT # 45378 Colonoscopy Marginal cost $139.43


Avg OR time (IS data) 0 0.5 $417.00 208.50Billing Total Cost $347.93

Reimbursement Calculation: %billed reimbursementInsurance A 29 $433.00 $12,557.00Insurance B 21 $580.00 $12,180.00Insurance C $0.00Insurance D $0.00Insurance E 20 $720.00 $14,400.00Insurance F 30 $596.00 $17,880.00

100 WeightAvg Reimb $570.17

Net Income $222.24

44DQM

Payor Mix & Contracting It is imperative that you know your case mix

and payor mix Negotiation of payor contracts may be one of

the most difficult and time consuming jobs of an Administrator

Marketing to payors cannot be underestimated –Answer: Why should they contract with your Center?

45DQM

Payor Mix & Contracting

Who are the big players in the industry? Modern Healthcare July 23, 2007:

1. UnitedHealth Group 6.Health Care Service 2. Wellpoint (Anthem) 7. Health Net3. Kaiser Permanent 8. Aflac4. Aetna 9. Independence BC5. Humana 10. Highmark

46DQM


Who are the big players in the industry? Modern Healthcare July 23, 2007:

11. Cigna Corp 16. Horizon Healthcare12. BC and BS of Michigan 17. BC and BS of Mass.13. BS of California 18. Carefirst BC and BS14. BC and BS of Florida 19. Regence Group15. Coventry Health Care 20. Unum Group

47DQM

Payor Contracting Do’s

Market the ASC to the payor – Why they should include you in network

Know your ASC – case mix, payor mix, cost of providing care

Perform modeling studies: how much can you save the payor vs same cases performed at hospital

48DQM


Read the entire contract – every version, to assure changes are not made to the contract (other than the redline items)

Know what the payor’s reimbursement schedule really means – if grouper, is it Medicare or payor defined and get a crosswalk to ID what CPT codes are assigned to what grouper

49DQM


know if and how they pay for multiples know if and how they reimburse for implants

and prosthesis know if the payor will negotiate carve-outs or

move codes to a more appropriate grouper

50DQM


know the payor’s turn around time for clean claims – are you in a state that mandates prompt reimbursement of a clean claim filed electronically

know if the contract evergreens – and the notice required to renegotiate some of the terms

51DQM

Payor Contracting Don’ts

never sign a contract with a “most favored nation clause”

don’t sign a contract without understanding the termination clause – can you terminate without cause and 30 days notice

avoid permitting the payor access to your financial records

52DQM


avoid a contract that says that the payor can make changes to the contract and reimbursement with 30 days notice

avoid payor language that states that you will be paid 100% of the negotiated rate or XX% of your billed charges – unless you are sure all charges will be higher than XX% of your negotiated rates

53DQM


avoid a contract where the payor defines essential components of the contract and reimbursement in the Provider Manual and is allowed to make changes just by changing the Provider Manual (with or without notification

avoid allowing a payor to sell or rent your negotiated contract (silent PPO)

54DQM


PPO – a network of providers who agree to accept a discounted fee schedule to become a preferred provider to a group of payors under a contract the PPO is the contracting intermediary between

the providers and the payors

55DQM

Payor Mix & Contracting Silent PPOs when a PPO allows non-member payors to

“purchase or rent” the contract with providers these payors pay you the PPO’s negotiated

contract rates, even if you are contracted with those other payors

can be very difficult to identify a silent PPO illegal in some states now

56DQM


Silent PPO scenario patient may present with an indemnity insurance

card that doesn’t identify the patient as a member of any network

you bill the usual charge – expecting no discount or your privately negotiated discount

the insurance company runs the claim thru a PPO database or uses a re-pricing agency to handle the claim

57DQM


they apply the lowest reimbursement and pay you

if a large enough claim, you may notice, but this practice often goes unnoticed on smaller claims

58DQM


Contracting language to avoid the Silent PPO specify that contract is in exchange for steerage

of patients require different coverage for in-network and

out-of-network providers require all member ID cards include the PPO

name and that patient must present card at time of service

Ambulatory Surgery Compliance and Reimbursement Insider, Sept 2006

59DQM


require ID of payor’s use of PPO network on the EOB

require that a complete payor list be attached to the contract and updated whenever there is a change

require that PPO will forfeit all discounts that do not comply with the agreement

require PPO to require all payors to comply include a clause that allows the provider to audit

PPO records related to patient activity

60DQM


include language that restricts the plan, and any claims-paying entity the plan affiliates with, from leasing or selling the payment rates

include a clause that restricts the sale, access, or disclosure of the facility’s proprietary discount information to the payors you specify

61DQM

ASC ReimbursementThings to Think About 2013

ASC average payment set at 56% of HOPD (varies greatly by specialty)

ASCs paid for 3,300 procedures (some office procedure)

62DQM

ASC Reimbursement Procedures excluded because:

Poses a significant safety risk to the beneficiary Would result in the beneficiary typically requiring active

medical monitoring and care at midnight following the procedure

Is on the inpatient only list Directly involves major blood vessels Requires major or prolonged invasion of body cavities Generally results in extensive blood loss Is emergent in nature Is life-threatening in nature Commonly requires systemic thrombolytic therapy Can only be reported using an unlisted surgical

procedure codewww.FASA.org

63DQM

Summary Administration break-even analysis case cost analysis payor mix analysis and reimbursement

Physician & office staff – marketing and education

Clinical management of resources Patient accounts – collections Schedule the right cases !!

64DQM

Thank You!

Questions?

65DQM

Scheduling Bibliography

1. McLane, Dawn Q., Ambulatory Scheduling Strategies, HC Pro, 2005.

2. Evaluating and Negotiating Payor Contracts for Success, Today’s Surgicenter Magazine, November 2006, pg 31-34.

3. Protect your reimbursement dollars from a ‘silent killer’, Ambulatory Surgery Compliance and Reimbursement Insider, September 2006, pp 4-7.

4. ASCs: We can’t drive 65, Modern Healthcare, July 23, 2007, pp 6- 7, 16-17.

ambulatory surgery scheduling strategies with case · pdf fileambulatory surgery scheduling...

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