Fall 2016 • vol 63 • num 1

new jersey chapter

Celebrating the40th Anniversary Annual Institute

Special Edition:

NJHFMA Annual Institutein Atlantic City

October 5-7, 2016

metropolitan philadelphia chapter

NJ & Metro Philly HFMA 40th Anniversary Annual InstituteThe Borgata Casino & Spa

October 5-7, 2016

17 HOURS OF CPEsFor more information visit our website: http://www.njhfmainstitute.org/

Featured Speakers:Connie Merritt, Nancy J. Ham and Steve Adubato

Steve Adubato, Ph.D., enjoys a distinguished career as a broadcaster, author, syndicated columnist, university professor and motivational speaker. A trainer and coach in the areas of leadership and communication skills, Steve also served in the mid 1980’s as New Jersey’s youngest state legislator at the age of 26.

Steve currently anchors three public television broadcasts produced by the Caucus Educational Corporation (CEC) — Caucus: New Jersey, an Emmy Award-winning public affairs television series; New Jersey Capitol Report, a weekly program covering New Jersey’s most pressing policy issues; and One-on-One with Steve Adubato, CEC’s nightly public television series that brings viewers in-depth interviews with some of the region’s most compelling personalities, including artists, authors, health experts, politicians, and sports icons, as well as “ordinary” people who accomplish extraordinary things. Steve has also anchored many high-profile television specials including an

exclusive, live primetime interview with Governor Chris Christie and a primetime special with US Senators, Bob Menendez and Cory Booker.

Connie Merritt, RN, BSN, PHN, is an established information agent to leaders – and their teams – since she un-derstands what they are facing as they press forward in this diverse, multi-generational, mobile, high-tech world…on deadline, at every turn.

A seasoned professional with more than 20 years experience of speaking nationally with leading companies, orga-nizations and associations, Connie understands people, the processes and dynamic influences at our doorstep today. She has an established reputation of connecting with audiences and providing essential content with step-by-step tactical teachings and motivation to learn the best practice skills and strategies to thrive now and continue to excel in managing tasks and relationships.

Nancy J. Ham is the CEO of Medicity, Nancy Ham brings more than 20 years of experience in health care finance, population health management, enterprise software, and transaction processing. She has led companies through all phases of corporate growth, most recently as president and CEO of MedVentive, a provider of performance analytics to accountable care organizations and payers.

Nancy draws inspiration from her father, great leaders, and women pioneers like Beryl Markham and Amelia Earhart. She is passionately mission-driven to tackle the hardest problems in health care, but at the same time, never takes herself too seriously. Fueled by Diet Coke, she enjoys promoting a fun and quirky culture, mentoring staff, and delighting the customer.

Prior to MedVentive, Nancy served as president of Sentillion, Inc., a leading innovator of identity and access management solutions and president of ProxyMed, Inc., the industry’s second-largest medical claims clearinghouse. Nancy was also senior vice president of Business Development and CFO at ActaMed Corporation and spent five years in leveraged finance at GE Capital. She holds a bachelor’s degree in economics from Duke University and a master’s in International Business Studies (MIBS) from the University of South Carolina.

PLUS:6 General Sessions

28 Breakout Session andNot to be Missed Panel Discussions

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focus• advertisers•focus• features•

ARMC & BPS Strategies

Besler

CBIZ KA Consulting Services, LLC

Fox Rothschild

McBee Associates, Inc.

William H. Connolly & Assoc.

focus• cover•

Photo Courtesy ofBorgata

focus• points•

Who’s Who in the Chapter ...... 2

The President’s View by Dan Willis ................................ 3

From the Editor by Elizabeth G. Litten, Esq. ........... 4

Who’s Who in NJ Chapter Committees ........... 11

Mark Your Calendar ................ 19

Focus on Finance .................... 20

Job Bank Summary ................ 27

New Members .......................... 34

Industry News .......................... 37

Co-Chair’s CornerWelcome to the 40th Anniversary Annual Institute by Michael P. McKeever, CPA, FHFMA ..................................................................................... 6

Epic Conversion – Revenue Cycle Lessons Learned by Kathy Ruggieri and Mary Devine ........................................................................................ 9

American Healthcare – Worst Value in the Developed World?Part 2 by John J. Dalton, FHFMA . .................................................................................................... 13

Optimizing Care Coordination Within Referral Management Centers by Lillian Lee-Chun, Jennifer McCraw, & Sarah Wirth............................................................... 18

Implementing CJR: How CentraState Healthcare System Builds on its Gainsharing Experience to Engage Physicians by Dr. Cheryl Lyn Hayne, Ph.D., M.Sc., M.P.H. and Jo Surpin .................................................... 21

Transforming Your Revenue Cycle by Kristin Greenstreet ............................................................................................................ 28

We Turn and Face the ChangesThe S-10 Emerges as a Proxy for Payment by Fred Fisher and Scott Besler ............................................................................................. 30

Revenue Integrity Forum Hosts Successful June 2016 Conference by Betsy Weiss, RN, MPH ...................................................................................................... 35

Q&A: A Sound Investment Management Program is Imperative for Healthcare Organizations by Craig Standen .................................................................................................................. 38

2016 Institute Schedule at a Glance .................................................................. 40-41

Chapter Awards ............................................................................................................ 43

Chapter Year-end Financials .................................................................................. 44-46

Institute Sponsor Guide ............................................................................................ 47-55

Sponsors .......................................................................................................................... 56-59

Our 2016-17 NJHFMA Board .................................................................................. 60

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focus/hfmaWho’s Who in the Chapter 2016-2017Chapter Website …………………………………..www.hfmanj.org

Communications CommitteeBrian Herdman, Director ......................................................................CBIZ KA ConsultingElizabeth G. Litten, Esq., Chair ........................................................... Fox Rothschild LLPAl Rottkamp, MBA, Vice Chair, Website ............................... Princeton Healthcare SystemRhonda Maraziti, Vice Chair, Advertising ................................WithumSmith + Brown, P.C.Mark P. Dougherty, FACHE......................................................................... Blue Pillar, Inc.Laura Hess, FHFMA ............................................................................................ NJHFMAJohn Manzi ................................................................ Panacea Healthcare Solutions, LLCNicole K. Martin, MPH, Esq. ..................................................................... Martin Law, LLCWilliam McCann ................................................................................................HealthfirstDavid A. Mills ..............................................................................Hinduja Global SolutionsAmina Razanica .............................................................New Jersey Hospital AssociationJames A. Robertson, Esq. ..........................McElroy, Deutsch, Mulvaney & Carpenter, LLPRoger D. Sarao, CHFP ................................................... New Jersey Hospital Association

NJ HFMA Chapter OfficersPresident, Dan Willis ...................................................... Sutherland Healthcare SolutionsPresident-Elect, Scott Mariani ................................................. WithumSmith + Brown, P.C. Treasurer, Erica Waller ...........................................................Princeton Healthcare SystemSecretary, Michael McKeever ........................................... Saint Peter’s University Hospital

Advertising Policy/Annual RatesThe Garden State “FOCUS” reaches over 1,000 healthcare professionals in various fields. If you have a product or service you would like the healthcare financial industry to know

about, please take advantage of this great opportunity!Contact Laura Hess at 888-652-4362 to place your ad or receive a copy of the Chapter’s advertising policy. The Publications Committee reserves the right to refuse any ad not consistent

with the overall mission of the Chapter. Inclusion of an ad in this Newsmagazine does not infer endorsement of the product or service by the Healthcare Financial Management Association or the Publications Committee. Neither the Healthcare Financial Management Association nor the Publications Committee shall be responsible for slight variations in production quality of published advertisements. Effective July 2015 Rates for 4 quarterly issues are as follows:

Ads should be submitted as print ready (CMYK) PDF files along with hard copy. Payment must accompany the ad. Deadline dates are published for the Newsmagazine. Checks must be payable to the New Jersey Chapter - Healthcare Financial Management Association.

DEADLINE FOR SUBMISSION OF MATERIAL Issue Date Submission Deadline Fall August 15 Winter November 1 Spring February 1 Summer May 1

IDENTIFICATION STATEMENTGarden State “FOCUS” (ISSN#1078-7038; USPS #003-208) is published bimonthly by the New

Jersey Chapter of the Healthcare Financial Management Association, c/o Elizabeth G. Litten, Esq., Fox Rothschild, LLP, 997 Lenox Drive, Building 3, Lawrenceville, NJ 08648-2311

Periodical postage paid at Trenton, NJ 08650. POSTMASTER: Send address change to Garden State “FOCUS” c/o Laura A. Hess, FHFMA, Chapter Administrator, Healthcare Financial Management Association, NJ Chapter, P.O. Box 6422, Bridgewater, NJ 08807

OBJECTIVEOur objective is to provide members with information regarding Chapter and national activities, with

current and useful news of both national and local significance to healthcare financial professionals and as to serve as a forum for the exchange of ideas and information.

EDITORIAL POLICY Opinions expressed in articles or features are those of the author(s) and do not necessarily reflect the view of the New Jersey Chapter of the Healthcare Financial Management Association, or the Communications Committee. Questions regarding articles or features should be addressed to the author(s). The Healthcare Financial Management Association and Communications Committee assume no responsibility for the accuracy or content of any articles or features published in the Newsmagazine. The Communications Committee reserves the right to accept or reject contributions whether solicited or not. All correspondence is assumed to be a release for publication unless otherwise indicated. All article submissions must be typed, double-spaced, and submitted as a Microsoft Word document. Please email your submission to:Elizabeth G. Litten, Esq. elitten@foxrothschild.com

REPRINT POLICY The New Jersey Chapter of the HFMA will not reprint articles published in Garden State FOCUS Newsmagazine. Individuals wishing to obtain reprint authorization must obtain it directly from the author(s) of the article. The cover of the FOCUS may not be used in the reprint; however, the reprint may note that the article was published in a specific issue. The reprint may not imply endorsement by the HFMA, directly or indirectly.

Per issue/Total Per issue/Total Per issue/Total Per issue/TotalBlack & White 1x 2x (10% off) 3x (15% off) Full Run (20% off)Full Page $ 675 $ 607 / $ 1,214 $ 573 / $ 1,719 $ 540 / $ 2,160Half Page $ 450 $ 405 / $ 810 $ 382 / $ 1,146 $ 360 / $ 1,440Quarter Page $ 275 $ 247 / $ 494 $ 233 / $ 699 $ 220 / $ 880

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NJ HFMA Board MembersScott Besler ..............................................................................................Besler ConsultingStacey Bigos ....................................................................New Jersey Hospital AssociationMegan Byrne ..................................................................................................Ernst & YoungDeborah Carlino ........................................................................................................RutgersPeter Demos – Associate Board Member ...................................................Meridian HealthBrian Herdman ...................................................................................... CBIZ KA Consulting Kevin Joyce .....................................................................................................QualCare Inc.Michael McKeever .............................................................Saint Peter’s University Hospital Anthony J. Panico, CPA, MS......................................................WithumSmith + Brown, P.C.Brittany Pickell – Associate Board Member .......................................................ConvergentJosette Portalatin ...................................................................................The Valley Hospital Belinda Doyle Puglisi ...........................................................Children’s Specialized HospitalRoger Sarao, CHFP – Ex-Officio .......................................New Jersey Hospital AssociationHealther Stanisci – Associate Board Member ............................ Arcadia Recovery BureauJill Squires ........................................................................................................ AmeriHealth

NJ HFMA Advisory CouncilHeather Weber ........................................................................................... Baker Tilly LLPTracy Davison-DiCanto, MBA , FHFMA ...................................Princeton Healthcare System David J. Wiessel ................................................................................... Ernst & Young, LLPJohn Brault, FHFMA ................................................................................................ Aetna

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The President’s View . . .

Dan Willis

As President of the HFMA New Jersey Chapter, I would like to welcome you to the 40th Annual Institute Edition of the Garden State Focus. Yes, time flies and we are about to begin the 40th Anniversary of the New Jersey Chapter’s Annual Institute. Hopefully, I will see a good number of you in Atlantic City! As anyone who has attended in the past can validate, it is an excellent event, full of great education sessions and great networking events, with some fun thrown in, as well.

I would like to thank the Institute Committee for all their hard work preparing; they actually begin preparation on the closing day of the prior year’s Institute. We have such a great group of volunteers. Many come back every year, but there is always room for more. I want to especially thank and congratulate Jennifer Vanegas for preparing the groundwork for this Institute prior to moving on to her new position and Michael McKeever for his dedication to and leadership of the committee. The team has outdone themselves in putting together what is sure to be another extraordinary event.

I would be also like to thank the Sponsors, without whose support HFMA NJ would not be able to continue to provide the quality education we are known for and certainly not an event of this size. Our success as a chapter is directly related to the Institute, which drives our ability to continue educational and networking events throughout the year. Thank you!

We are following what seems to be an HFMA tradition and once again have selected the Make-A-Wish Foundation as our sponsored Charity. On Wednesday, October 5th, between 5:30 and 8:00 pm during the networking trade show we will be having some fun playing “Minute to Win IT” games, while hopefully raising enough funds to grant at least two children their wishes. We have met that goal in the past and look forward to meeting the challenge once again.

If you haven’t registered yet, this is an event not to be missed, registration can be completed online at www.njhfmainstitute.org and it runs from October 5th to 8th at the Borgata in Atlantic City.

I look forward to seeing you there; please enjoy this issue of the award-winning Garden State Focus.

Dan Willis

I look forward to seeing you there; please enjoy this issue of the award-winning Garden State Focus.I look forward to seeing you there; please enjoy this issue of the award-winning Garden State Focus.

Dan WillisDan Willis

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Hello everyone,

Welcome to the HFMA Annual Institute issue of the focus! Perhaps some of you are leafing through this issue while attending the Annual Institute at the Borgata in Atlantic City (if so, lucky you – the Institute provides a wonderful opportunity for both learning and socializing). Others may be reading it in the office or at home, and I can picture some readers pulling out the magazine to read while sitting on the sidelines at a kid’s soccer game or waiting in a carpool line.

This autumn, I find myself reminiscing about the days when “back to school” involved coordinating after-school activities and frantic last-minute runs to Target or Staples for an elusive school supply, rather than coordinating college tuition payments and last-minute texts (to reassure me that “everything’s fine, Mom!” after a day or two of radio silence). I think I will always associate autumn with the start of a new school year and the excitement and worries that go along with it, long after my youngest graduates from college.

Many parents worry about peer pressure as kids go back to school, and while the term typically has a negative connotation, a couple of articles in this issue demonstrate that peer pressure can be useful and part of an improvement process. Dr. Cheryl Lyn Hayne and Jo Surpin’s article, “Implementing CJR: How CentraState Healthcare System Builds on its Gainsharing Experience to Engage Physicians”, points out that “being able to show physicians how they fare against their peers helps to engage them.” I attended a conference in Chicago over the summer at which the VP/CIO of Butler Health System in Pennsylvania presented very compelling data proving the same point: physicians (like many of us) tend to be competitive, and sharing specific peer data is an effective means of changing behavior.

John Dalton’s article, “American Healthcare – Worst Value in the Developed World? Part 2” continues the comparison of the U.S. health care system with those of other countries in the Organization for Economic Cooperation and Development (OECD) peer group. The more we understand about what works well in other countries in terms of health care value and why, the more likely we are to develop system improvements here at home. John points out that “the British spend less than the U.S. to achieve a life expectancy two years higher than the U.S. and infant and child mortality rates about one-third lower than ours.” Our competitive American spirit should be sparked by this article. I am already looking forward to Part 3.

Thank you to these authors and to each person and organization who has contributed an article or supported this issue (and the Institute) by advertising. For those of you who haven’t contributed or advertised, maybe a little peer pressure will do the trick!

Happy Reading,

Elizabeth G. LittenEditor

From The Editor . . .

Elizabeth G. Litten

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Co-Chair’s CornerWelcome to the 40th Anniversary Annual Institute

by Michael P. McKeever, CPA, FHFMA, CHA, CHRC

Mike McKeeverSo here we are at the 40th Anniversary Annual Institute. Quite a bit has changed in healthcare over those 40 years, but the Annual Institute has always been where the NJ Chap-ter comes to celebrate our role in managing those changes. There’s been a lot of great education, a lot of fantastic net-working opportunities, a lot of unforgettable fun, and of course a lot of jumbo shrimp! Those of us on the Annual Institute Committee and on the Board welcome you to this year’s event, and are looking forward to continuing the tradi-tion for another 40 years, although many of us hope to be retired by then.

I recently attended as a speaker the inaugural Region 3 Summit at the Mohegan Sun in Wilkes-Barre, Pa. It was a great opportunity to network with the other Chapters with-in our region, which is comprised of New Jersey and Penn-sylvania. And while the Metropolitan Philadelphia Chapter has participated in our Annual Institute for a number of years, it was nice to meet our colleagues from the Northeastern, Central and Western Pennsylvania Chapters, as well as old friends from across the river. Here’s hoping that many of them are here with us in Atlantic City as we celebrate our 40th Anniversary.

So there have been a few changes to the AI this year, the most noticeable which will be the location of the Vendor Hall. We’ve moved it back to the front of the Conference Center, directly across from the Registration Desk. The Keynote Ad-dresses and General Sessions will be held in Salon D, which is directly behind the Vendor Hall. We have used this con-figuration in the past, and hope that the attendees will enjoy the change. And this year we’re replacing the Bingo Card with a Scavenger Hunt, whereby attendees who visit each Vendor Booth and answer (or at least try to answer) that sponsor’s question will have the chance to win 1 of 2 complimentary registrations to the 2017 Annual Institute. A special thanks goes to Bill Giovanni for preparing the questions that we’ll be using. Most of them are relatively simple, but there are a few brain stumpers in there!

Wednesday Night’s Net-working Activities

On Wednesday night we’ll once again be raising money for the Make-A-Wish Foundation of New Jersey. This year’s fundraiser will be a Charity Auction, with many exciting prizes that were donated by our sponsors and one grand prize winner, which was purchased with funds donated by the NJ Chapter membership for this specific purpose. Thanks to Fred Molinari and his team for procuring the prizes. Auction tickets will be available up until the selection of the winners, so look for AI Committee members selling them in the Vendor Hall, or visit the Make-A-Wish booth. For the past several years the funds raised at the Annual Institute have paid to fulfill the wishes for 2 deserving youngsters, so make sure you give from the heart (and the wallet) to this outstanding local charity.

Also on Wednesday night we’ll be playing a special ver-sion of the Minute To Win It game, with challenges set up throughout the Vendor Hall. Although we won’t have a top prize of $1,000,000, we anticipate at least that much in fun and laughs. Our Wednesday night networking event will end at 8:00 pm, allowing plenty of time to relax with friends and colleagues, and perhaps try your luck in the Borgata Casino.

Thursday EveningThe President’s Reception this year will be held in the Sig-

nature Room, which is off the casino floor and adjacent to the main entrance to the Borgata. This is the premier networking event of the Chapter year, and the highlight of the Annual In-stitute. As always, there will be plenty of great networking op-portunities, engrossing conversations on any and all imaginable topics, and shrimp. But a word of warning, as it is a month out from the presidential election please leave the politics outside when you enter the room. The President’s Reception is sched-uled to run from 6:00 pm until 8:00 pm, with a 2 hour break before the Late Night Gathering begins at 10:00 pm at Premier Nightclub, Atlantic City’s newest and most exciting club. The

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Premier is located where Mixx formerly stood, but after $14 million in renovations you won’t recognize the place. But don’t stay out too late, because you won’t want to miss the fabulous sessions and panel discussion on Friday!

Vendor DemosOnce again this year we’ll be having the Vendor Demos,

which allow our sponsors to showcase their products and ser-vices in a more relaxed atmosphere to both current and poten-tial clients. The sessions will be held in the Boardrooms this year, during the lunch breaks on Wednesday and Thursday. Lunch will be set up outside the rooms, so that attendees can pick up something to eat and drink and bring it in with them. Some of the sponsors who will be participating, along with their offerings, are:

TransunionWith the advent of insurance marketplaces and expansion

of Medicaid, rising uncompensated care costs make capturing reimbursements more important than ever. During this work-shop, they will demonstrate a TransUnion healthcare technol-ogy called eScan. eScan is a no-risk, contingency based, post-service insurance eligibility solution that locates previously unknown coverage on an average of 1-5% of a provider’s un-compensated care accounts.

A few highlights of the eScan platform:

➣ Runs all accounts against the Medicare Common Working File and state Medicaid databases.

➣ Delivers commercial coverage from its proprietary database.

➣ Identifies patient demographic discrepancies between the hospital and payer data.

➣ Identifies commercial policy ID numbers for patients believed to be uninsured.

In addition, TransUnion will be giving away an Apple iWatch to one lucky person in the audience.

MediTract/MD BuylineThe complexity of Purchased Services can present major

obstacles for Supply Chain teams. And the level of expertise, tenacity, and commitment necessary for reigning in the cost of Purchased Services can be daunting. MD Buyline and Medi-Tract can ease your challenges by providing your health system with Purchased Services consulting and a turn-key solution, Purchased Services Manager.

Purchased Services Manager can help you identify, bench-mark, and track savings opportunities. Components include:

• Current state visibility and planning

• Project definition and scope• RFP preparation and execution• Efficient and accurate contract development• Iterative benchmarking and negotiations• Contract storage, analysis, and monitoring

AdreimaIn the world of changing reimbursement models, hospi-

tals need to find new and innovative ways to collect patient payments, while ensuring that patients are satisfied with their overall hospital experience.

Through a combination of proprietary technology and one-on-one support, the Adreima Patient Advocacy service helps patients manage the financial and administrative aspects of their healthcare, beginning pre-admission and continuing throughout the revenue cycle. Each patient is assigned an ad-vocate who reviews all of their medical bills and follows up on any billing issues or claim denials that arise. Patients are at ease knowing that an expert advocate will guide them through the entire process leading to increased patient satisfaction within the hospital revenue cycle.

Quality Asset RecoveryPlease join Quality Asset Recovery for a presentation about

some simple steps for every Revenue Cycle Management office who assigns inventory to a vendor.

The US Department of Health and Human Services (HHS) Office for Civil Rights (OCR) has sent a very expensive re-minder to the hospital industry in the first quarter of 2016. Hospitals should heed the warning and make sure their facility is protected whenever a vendor is involved.

The presentation will be conducted by Larry Steller, CEO of Quality Asset Recovery and President of the New Jersey Chapter of the American Collectors Association. QAR is ap-proaching our 15th anniversary handling the full spectrum of challenges presented in medical receivables.

About the authorMichael P. McKeever is currently the Director of Internal Audit at Saint Peter’s Healthcare System. He has over 25 years’ experience in healthcare finance, compliance and audit in acute care hospitals, long term care settings, ambulatory surgery centers, physician practices and a health sciences university. A graduate of Rider College, he is a member of the AICPA, NJSCPA, HCCA and NJ HFMA, where he is the Chapter Secretary and the Co-Chair of the Annual Institute Committee. He is a Certified Public Accountant, an HFMA Fellow, and certified in Healthcare Compliance and Healthcare Research Compliance. Mike can be reached at m.mckeever2@verizon.net.

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Epic Conversion – Revenue Cycle Lessons Learned

Kathy Ruggieri

by Kathy Ruggieri and Mary Devine

Electronic health record (EHR) implementations can be operationally invasive and can have significant financial im-plications. Organizations may see a reduction in net revenue, an increase in accounts receivable days and a slowdown in cash collections. With several NJ providers in the process of moving to an Epic HIS and EHR environment, preserving net revenue, maintaining consistent cash and ensuring ac-curate financial reporting should be among the provider’s primary conversion goals. We have worked with several pro-viders throughout the country who have undergone a recent Epic conversion and thought it would be beneficial to share conversion lessons learned from these providers.

A consistent phrase in the Epic conversion world is ”Big Bang,” indicating that every module that’s been purchased is implemented at the same time. The conversion timeline is an eighteen month journey and has been described as a con-version like no other. More and more providers are moving towards the “Single Billing Office” (SBO) solution, mean-ing hospital, physician and potentially other entities such as home health appear on a single statement. This alone is a sig-nificant change for hospital providers.

Lessons Learned1. Don’t underestimate the implementation

Do not treat the Epic implementation like a project. Some providers felt they did not initially dedicate enough re- sources to the conversion. The conversion to Epic is a stra-tegic commitment that may require partnership with an ex-ternal consulting group to assist with the implementation.

2. Understand your baselines / metricsEpic provides user-friendly dashboards to analyze key per-formance indicators (KPIs) and metrics. However, com-paring pre-conversion metrics to post-conversion metrics is critical in identifying conversion disconnects. Metrics that are consistent and trended over time illustrate the best historical picture. Therefore, a full complement of com-parative pre- and post-conversion KPIs allows providers to know where they should be at system cutover. Since the conversion timeline extends over eighteen months, there is time to fine tune or implement KPIs to effectively monitor

post-conversion trends. Ex-ample essential metrics are:

• Charges by cost center • Visits by cost center • Late charges • DNFB trends • Claim accuracy • EDI claim edits • Denials • Payer payment trends

(specifically, how fast you are paid)

These are just a few recom-mended metrics. Every pro-vider we have spoken with can’t stress enough the importance of monitoring comparative metrics daily, at time of cutover and going forward. This was a deal breaker for many facilities.

Some examples of conversion disconnects identified through the analysis of comparative metrics:

• Increase in Self Pay ED Claims Post-cutover – Pre-con- version self-pay visits compared to post-conversion visits revealed a significant increase in self-pay ED visits. The analytics platform identified the trend im- mediately and an error had occurred with the appropri- ate mapping of the insurance plan. The ability to com- pare ED visits by payer, pre and post conversion, facili- tated the ability to promptly correct the disconnect.

• Decrease in IME Revenue – Historical revenue reports revealed a 40 percent reduction in IME revenue post conversion. This was unexpected since Epic automati- cally generates a shadow bill when the Medicare Advantage claim is billed. It was later identified that not all plans were flagged as Medicare Advantage during the build.

• Charge Capture – The ability to timely identify charge capture disconnects is essential. For example, if there is a 1% difference in historical gross charges within 24

Mary Devine

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continued from page 9

hours from cutover, the issues must be identified and resolved immediately. These types of issues can spiral into much larger problems. It is important to remem- ber that an EHR implementation is life-changing for your clinical areas and errors can and will occur. 3. Perform a Full Revenue Cycle Assessment

Some providers invest in a full assessment to review the en-tire revenue cycle continuum prior to conversion, in order to assess revenue cycle workflow efficiency. With a goal of optimal efficiency and collection, work flows are changed to prevent revenue leakage prior to conversion. There are others who might take the opportunity to incorporate the approach of looking at the revenue cycle from the patient experience perspective.

4. TestingThe common response we heard with regard to testing is “Test, test and test some more, you can’t test enough!” Paral-lel testing was a common practice, running claims through the legacy system and Epic to ensure the outcome was the same. Parallel testing also allows for the creation of addi-tional upfront edits to improve the overall clean claim rate.

5. TrainingWith regard to training we also heard a common response of “you can’t train enough.” Some providers went the route of appointing a credentialed trainer which was over and above the vendor training. Several providers felt it was es-sential to not only provide system training on the new func-tionality but to also include training around the workflow processes so the staff understood the workflow mechanics and not just the tasks themselves. Since the new system was significantly different than the legacy system, this was a critical piece. It was certainly more time-consuming, but a worthwhile investment as the users were ultimately more well-rounded to the system function and design.

6. On-site Presence at Cutover It is beneficial to plan to include a few billing staff on-site when the system converts. Granted, this will require some juggling of schedules to staff at midnight but it is well worth the effort. Billing staff are able to concurrently identify in-terface and charging issues within the first few hours of the conversion.

7. Go-live DateYou might avoid glitches by going live with your conver-sion on the first day of the calendar month. Otherwise, for example, be prepared to address the potential financial re-porting disconnects resulting from your recurring accounts.

8. Backlog ReductionReduce all backlogs prior to conversion. This would in-clude denials, unbilled accounts in the EDI platform,

unapplied cash, coding, etc. Some providers dedicated ad-ditional resources to the overall reduction of the DNFB.

9. Legacy AR Wind DownMany providers utilize an outsourcing partner post conver-sion. However the timing of the outsourcing varies. Some multi-entity system providers who outsourced at ninety days felt it was too late, others outsourcing at day one felt it was too early. It is important to determine the best out-sourcing timeline utilizing historical “days to pay” metrics and volumes.

10. “Release of Information”Coordinate with HIM to ensure special attention is givento “Release of Information” when setting up the bills.Scenarios can occur where an entire patient’s record is print-ed versus a sole visit or vice versa.

11. CommunicationIt is imperative that post-cutover issues are acted upon im-mediately. An effective communication plan should also be a component of the conversion plan.

ConclusionConversion planning, testing, training, monitoring and

communication are the critical components to minimizing financial impact.

About the AuthorsKathy is responsible for BESLER’s Revenue Cycle service line and has been a member of the Revenue Cycle team for over fifteen years. Kathy has over 25 years of experience in healthcare financial management and has extensive knowledge of all components within the revenue cycle. Her background is very diverse, with experience in acute care hospitals in addition to skilled nursing facilities, psychiatric facilities and home healthcare. Kathy created the Medicare Transfer DRG Revenue Recovery Service in 2007 and expand-ed the service to include Medicare Advantage and other payers in 2011. Kathy has selected and mentored our multi-disciplinary team and guided the creation of our proprietary software solution that has positioned BESLER as a national transfer recovery partner. She has managed and participated in numerous client projects related to patient access, accounts receivable reduc-tion, interim patient accounting management, central business office devel-opment and implementation, cash acceleration and charity care evaluations. Kathy can be reached at kruggieri@besler.com.

Mary is responsible for the Transfer DRG service and has been a member of our Revenue Cycle team for over eight years. Mary applies her clinical ex-pertise to our underpayment decision making. She is involved in all of our engagements and provides mentorship to our validation team. Mary also has extensive background in appeals, which includes working with hospitals on inpatient and outpatient appeals for managed care and Medicare. She also has experience with Medicare at the Provider Reimbursement Review Board level. Mary is an RN with clinical experience in acute care and long term care, as well as for large teaching institutions. Mary is also an expert in the Revenue Cycle and was an Assistant Vice President of Revenue Cycle for a large health system in New Jersey. Mary can be reached at MDevine@Besler.com.

If you would like additional information regarding this article, please contact Kathy Ruggieri at kruggieri@besler.com or Mary Devine at mdevine@besler.com

Fall 2 0 1 6

Focus 11

• Who’s Who in NJ Chapter Committees•2016-2017 Chapter Committees and Scheduled Meeting Dates

*NOTE: Committees have use of the NJ HFMA Conference Call line. The Call in number is (712) 432-1212If the committee uses the conference call line, their respective attendee codes are listed with the meeting date.

PLEASE NOTE THAT THIS IS A PRELIMINARY LIST - CONFIRM MEETINGS WTH COMMITTEE CHAIRS BEFORE ATTENDING.

COMMITTEE PHONE DATES/TIME/ ACCESS CODE MEETING LOCATION

CARE (Compliance, Audit, Risk, & Ethics) Chairman: Susan Hatch – shatch@virtua.org (856) 355-0723 First Thursday of the Month Conference Calls Co-Chair(s): Lisa Hartman Weinstein – lisarhartman@hotmail.com (609) 718-9982 9:00 AM Deborah Carlino – carlindl@ca.rutgers.edu (973) 972-3260 Access Code: 274-926-602 Board Liason: Tony Panico – apanico@withum.com (973) 532-8847

Communications Chairman: Elizabeth Litten – ELitten@foxrothschild.com (609) 896-3600 First Thursday of each month Fox Rothschild offices Co-Chair(s): Al Rottkamp – ajcr123@aol.com (201) 821-8705 Access Code: 549-853-204 9:30 AM 997 Lenox Dr Bldg 3 Board Liason: Brian Herdman – bherdman@cbiz.com (609) 918-0990 x131 No June or July Meetings Lawrenceville, NJ

Education Chairman: Stacey Bigos – Sbigos@njha.com (609) 275-4017 First Friday of each month Conference Calls Co-Chair(s): Mary Cronin – mmcronin@aol.com (732) 589-9613 10:00 AM Sandra Gubbine – Sandra.Gubbine@atlanticare.org (609) 484-6407 Access Code: 207-716-687 Board Liason: Mike McKeever – mmckeever@saintpetersuh.com (732) 745-8600 x5089

Certification (Sub-committee of Education) Chairman: Rita Romeu – Romeur@comcast.net (973) 418-6071 First Friday of each month Conference Calls Board Liason: Mike McKeever – mmckeever@saintpetersuh.com (732) 745-8600 x5089 10:00 AM

FACT (Finance, Accounting, Capital & Taxes) Chairman: Tony Palmerio – apalmerio@barnabashealth.org (732) 923-8638 Second Wednesday of each Month Co-Chair(s): Karen Henderson – khenderson@withum.com (973) 532-8879 8:00 AM Conference Calls Board Liason: Scott Mariani – smariani@withum.com (973) 532-8835 Access Code: 587-991-674

Institute 2016 Chairman: Dan Willis – dkwillis6@gmail.com (201) 803-4067 Third Wednesday of each Month Co-Chair(s): Mike McKeever – mmckeever@saintpetersuh.com (732) 745-8600 x5089 8:00 AM Conference Calls Board Liason: Dan Willis – dkwillis6@gmail.com (201) 803-4067 Access Code: 207-716-687

Membership Services/Networking Chairman: Brittany Pickell – BPickell@ConvergentUSA.com (732) 221-0785 8/12, 8/26, 9/9, 9/23, 10/4 Conference Calls Co-Chair(s): Peter Demos – pdemos@hackensackmeridian.org (732) 751-3378 9:30 AM In-person Meetings Maria Facciponti – mfacciponti@adreima.com (973) 614-9100 Access Code: 808-053-2866 by Notification Board Liason: Megan Byrne – megan.byrne@ey.com

Patient Access Services Chairman: Maria Lopes-Tyburczy – MLopes-Tyburczy@palisadesmedical.org (201) 295-4028 / C: (201) 744-8505 6/9/16, 9/8/16, 11/10/16, RWJBarnabus Corporate Co-Chair(s): Dara Derrick – dara.derrick@atlantichealth.org (908) 850-6870 1/12/17, 3/9/17, 5/11/17 379 Campus Drive 2nd Floor Conf Room Andrew Webber – awebber@medixteam.com (201) 406-1097 2:30 PM Somerset, NJ 08873 Board Liason: Belinda Puglisi – BPuglisi@childrens-specialized.org O: (908) 301-5458 / C: (862) 251-0753 Access code: 542-364-749

Patient Financial Services Besler Office 3 Independence Way, Chairman: Steven Stadtmauer – sstadtmauer@csandw-llp.com (973) 778-1771 x146 Second Friday of each Month Suite 201 Princeton – June - Nov. 2016 Co-Chair(s): Marie Smith – msmith1@rbmc.org (732) 324-5053 10:00 AM CBIZ Office 50 Millstone Road BLDG 200, Board Liason: Josette Portalatin – jportal@valleyhealth.com (201) 291-6017 Access Code: 714-898-796 STE 230 – Dec. 2016 - May 2017 East Windsor, NJ 08520

Payer and Provider Collaboration Chairman: Thomas Barnes – barnest@sjhmc.org (973) 754-2136 Third Wednesday of each Month alternating locations each month Co-Chair(s): Ruth Fritsky – Ruth.fritsky@amerihealth.com (609) 662-2503 2:00 PM United Healthcare, Iselin, NJ Board Liason: Jill Squiers – Jill.Squiers@AmeriHealth.com (609) 662-2533 No conference calling Horizon BCBS, Wall Township, NJ

Physician Practice Issues Form Chairman: Dara Quinn – DaraQ@villagecare.org (908) 247-9165 7/14/16, 9/8/16, 11/10/16 Conference Calls Co-Chair(s): Melody Hsiou – mhsiou@kpmg.com (818) 451-3580 1/12/17, 3/9/17, 5/11/17 9:00 AM Board Liason: Deborah Carlino – carlindl@ca.rutgers.edu (973) 972-3260 Access Code: 703-211-177

Regulatory & Reimbursement Chairman: Peter Demos – pdemos@hackensackmeridian.org (732) 751-3378 Third Tuesday of each Month Monmouth Shores Corp. Park Co-Chair(s): Rachel Simms – rsimms@ubhc.rutgers.edu (732) 235-3420 9:00 AM Meridian Conf. Room 1C Board Liason: Scott Besler – sbesler@besler.com (732) 598-9608 Access Code: 175-802-794 1350 Campus Pkwy, Neptune

Revenue Integrity Chairman: Edlynn Lewis – edlynn.lewis@rwjuh.edu (732) 418-8077 First Wednesday of each Month Co-Chair(s): Jay Mullaney – jmullaney@barnabashealth.org (732) 923-8435 9:00 AM Princeton HealthCare System Board Liason: Tracy Davison-Dicanto – Tdavison-dicanto@princetonhcs.org (609) 529-9461 Access Code: 351-605-588

CPE Designation Chairman: Lew Bivona – ldbcpa@verizon.net (609) 254-8141

n Financial Modelingn Clinical Benchmarkingn Revenue Integrity

n Eligibility and DSH Servicesn Charge Evaluationn Risk Reduction (RAC)

The Devil Opportunity is in the Detail.

You have data. You need insight.CBIZ KA Consulting Services, LLC

Information. Not Intuition.

1-800-957-6900 www.kaconsults.com

Fall 2 0 1 6

Focus 13

American Healthcare – Worst Value in the Developed World?Part 2

John J. Daltonby John J. Dalton, FHFMA

Part 1 of this series reviewed the progress made on key health indicators over the past quarter century by 22 members of the Organization for Economic Cooperation and Develop-ment (OECD) including the United States (U.S.). The other 21 countries all have some type of universal healthcare, either:

• Insurance Mandate: Government mandates that all citizens purchase insurance, whether from private, pub- lic or not-for-profit insurers (five countries including Austria, Germany and Switzerland).• Single Payer: Government provides insurance for all. Pays all expenses except for copays/coinsurance. (Eleven countries including Canada, Italy, Japan, and the United Kingdom).• Two-Tier: Government provides or mandates catastro- phic or minimum coverage for all, while allowing sup- plemental voluntary insur- ance or fee-for-service care when desired (five countries, including France, Israel and the Netherlands).

Four key health indicators were reviewed: 1. life expectancy at birth, both sexes; 2. infant mortality rate (the probability of dying between birth and 1 year of age); 3. under-five mortality rate (the probability of dying between 1 year of age and before 5 years of age); and 4. adult mortality rate (the probability of dying between 15 and 60 years of age). America has the best-equipped hospitals and most thoroughly trained physicians in the world, yet lags the developed world on all four indicators. Key conclusions included:

• Despite its massive expenditures ($9,086 per capita and 16.4% of GDP in 2013), the U.S. healthcare system fails to deliver reasonable value for the money, and the gap

between the U.S. and other OECD countries on key health indicators is widening.

• The eleven countries with Single Payer systems consume the lowest percentage of GDP on healthcare (9.2% in 2013) while achieving the best results on each of the four key health indicators.

• American healthcare is the worst value in the developed world.

• It will take a huge paradigm shift to close the gap with other OECD countries on the key health indicators.

Part 2 of the series will compare the different approaches taken by France, Germany and the United Kingdom (UK), and then explore some of the underlying reasons for the dis-parity between America and its OECD counterparts. With a

combined population of 214.6 million and GDP of $9.1 trillion, France, Germany and the United Kingdom are roughly two-thirds of the U.S. population of 318.9 million and half the U.S. GDP of $18.6 trillion. There are key lessons to be learned from their experience. Table 1, on page 14, displays healthcare spending and

key health indicators for the four countries.

Why the Disparity?With the best-equipped hospitals and most thoroughly

trained physicians in the world, America excels at diagnosing, treating and curing illnesses. However, curing illness is not synonymous with health, and the reality of health lies outside hospital walls and physician offices, in the communities we serve. The World Health Organization’s definition of health

With the best-equipped hospitals and most thoroughly trained physicians

in the world, America excels atdiagnosing, treating and

curing illnesses.

continued on page 14

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14 Focus

is “a state of complete physical, mental and social well-being” (emphasis added).

America’s healthcare system has made enormous invest-ments in technology and training to ease pain and cure illness, but has underinvested in the support systems, networks and services vital to attaining health. Let’s look at how three major industrialized countries with characteristics similar to the Unit-ed States – Germany, France and the United Kingdom (UK) – have implemented universal health care, and then broaden our view to consider the effect of social support systems and services on their better outcomes. Much of the on-the-ground knowledge of their health care systems was gleaned from T.R. Reid’s excellent 2009 book, “The Healing of America: a Global Quest for Better, Cheaper, and Fairer Health Care.”

Part 3 of this series will conclude by examining the feasibil-ity of implementing approaches that have succeeded in other OECD countries and, the author hopes, to provide a clearer understanding of why it’s essential that not-for-profit health care leaders go beyond our traditional roles to make a positive difference in the health status of the populations that we serve.

Two Tier – the French ApproachIn addition to being Amer-

ica’s key ally in our War of Independence, France has a remarkable record of medical innovation. The world’s first man-made joint, a shoulder re-

placement, was implanted by Dr. Jules Pean in March 1892. Other noted French innovators include Louis Pasteur, whose work with vaccines in the 1870s has saved countless lives, and Marie and Pierre Curie, discoverers of radium. More recently, the French were the first to achieve complete interoperability and do away with paper medical records, replacing them in 1998 with the carte vitale (see Exhibit 1). This green plastic credit card with an embedded memory chip is the central ad-

ministrative tool of French medicine. Issued to all of France’s 66.7 million citizens and legal residents, the encrypted card contains the owner’s complete medical history (a child’s medi-cal record is maintained on the mother’s card until age 15).

France’s health care system is based on private doctors treating patients who buy health insur-ance to cover most of the cost. Most French doctors are in the private sector and charge patients on a fee-for-service basis. Like

the German model, health insurance is purchased through work, with the employer and the worker splitting the cost and the monthly premium withheld from the paycheck. The caisses

d’assurance maladie (“sickness insurance funds”) are not-for-profit entities whose primary concern is paying for people’s health care, not on marketing, reviewing and denying claims, or paying dividends to stockholders and bonuses to executives. As a result, they are much more efficient than their American counterparts, keeping administrative costs below 5 percent, comparable to Medicare, which spends 97 cents of every pre-mium dollar on health care.

Everyone must belong to a health insurance fund, even the unemployed (the government pays their premium). Premi-ums are relatively inexpensive, with the lion’s share paid by the employer. As in Germany, the funds can’t deny a claim; once a doctor submits a bill, insurance has to pay it. The French don’t use a “gatekeeper” system, so French patients can see any specialist, anytime. Doctors do make house calls, and receive a higher payment for doing so. There are no deductibles, but there are co-pays. The French system expects patients to pay when treatment is provided, and then get reimbursed by their insurance fund for 75-80 percent of the fee. People living below the poverty level and receiving welfare payments have lower co-pays. Only the poorest of the poor and patients cer-tified to be suffering from a chronic illness pay nothing. In

continued from page 13

Table 1 - Healthcare Spending and Key Health Indicators, France, Germany, UK and U.S.

Healthcare % Health Spending Country Type of Universal Life Expectancy @ Birth Infant Mortality Child Mortality of GDP per Capita, Health Care (1) both sexes 2012 (4) Rate per 1000, Rate, per 1000, - 2013 (2) 2011 (3) 2012 (4) 2012 (4) 10.9 $4,111 France Two-Tier 82 3 4 11.0 $4,495 Germany Insurance Mandate 81 3 4 8.5 $3,405 United Kingdom Single Payer 81 4 5 16.4 $8,508 United States None 79 6 71. Modern Healthcare, February 8, 2016, p. 342. OECD Health Statistics, 2015, FOCU.S. on Health Spending, July 20153. Commonwealth Fund, 2014, "Mirror, Mirror on the Wall: How the U.S. Health Care System Compares Internationally"4. World Health Statistics, 2014, PART III, Global Health Indicators, WHO

Fall 2 0 1 6

Focus 15

continued on page 16

the aggregate, roughly 77 percent of health expenditures are covered by government-funded agencies.

Not all procedures or treatments are covered by the sickness funds, but the French can buy supplemental health insurance and the vast majority do so. This private insurance also helps cover the co-pays that the sickness funds don’t reimburse, much like “Me-digap” policies in the U.S., as well as procedures that are not included in the mandated benefits package.

With 14 different sickness funds and a cluster of supplemen-tal plans, France looks like a mul-tipayer health care system. In reality, France functions more like a single-payer system: the National Health Ministry ne-gotiates with doctors, hospitals and drug companies. It then dictates what providers can charge for treatment and what price will be paid for prescriptions.

What’s the downside? Among others, French physicians earn far less than their U.S. peers. This is partially offset by their tuition-free attendance at college and medical school. So French physicians enter practice without the student loan debt burden facing most new American M.D.s. As a result, many more enter general practice than do their American peers. With freedom of choice, skillful doctors and well-equipped hospitals with little or no waiting at bargain prices, the French live 3 years longer than their American counterparts while spending less than half per capita on health care.

Insurance Mandate – the German WayGermany is the birthplace

of Wilhelm Roentgen who, in 1895, discovered X-rays, won the first ever Nobel Prize in Physics, and is considered the “Father of Diagnostic Radiol-ogy.” The German health care

system is the work of the “Iron Chancellor,” Otto von Bis-marck, best known for his unification of a dozen fiefdoms and principalities into the German nation to create an industrial and military powerhouse in central Europe. Less well known is his innovative origination of many programs that make up the modern welfare state. Although an aristocrat, he also was a skillful politician and saw this as a way to gain working class support for unification. Enacted by the Reichstag in 1883, his Sickness Insurance Law was the world’s first national health care system. Medical insurance became mandatory. Premi-ums are paid jointly by employers and workers, with the workers share withheld from their paycheck. Bismarck also created an old age pension system.

Germans have a choice among 200 different private insur-ance plans (Krankenkassen – sickness funds). Even though prices for coverage are fixed, these private entities compete vigorously for business. As not-for-profit entities, the sickness

funds exist to pay medical bills, not to pay dividends to stockhold-ers. They are required to accept all applicants and to pay any claims submitted by a recognized doctor or hospital. Coverage includes millions of “guest workers,” legal or not, who live in the country.

Patients can choose any doctor or hospital. The bulk of medical

professionals are general practitioners (GPs) working in pri-vate clinics. Most German hospitals are either municipal or charity operations, although there are some for-profit hospital chains. Extensive negotiations between the sickness funds and the doctors’ union determine what procedures and treatments are covered. These are available in an on-line directory used by GPs (Germany’s gatekeepers) to guide them in prescribing treatments for their patients.

Patients never see a bill, but are subject to a small co-pay. Their insurance premiums are a percentage of income; thus, high earners pay more for their coverage. Premiums average about 15 percent of income, split between the employee and the employer. With less government control of medical prac-tice than in the United States, it’s clear that countries utilizing the Bismarck approach are not practicing “socialized medi-cine,” even though roughly 77 percent of aggregate health ex-penditures are government funded.

What’s the downside? Complete freedom of choice in a sys-tem with minimal waiting times and high quality costs a lot of money, $4,495 per capita in 2011, compared with $4,118 in France and $3,405 in the UK. Payments to doctors and hospitals are strictly controlled, and the 2008 implementa-tion of a digital health card has kept administrative costs much lower than in the U.S. Physicians earn less than their American counterparts, but as the beneficiaries of a free medical educa-tion, they are not burdened with student loan debt.

Single Payer – the National Health ServiceBuilding on the Pasteur’s

work, in 1865 British surgeon Joseph Lister developed “anti-septic” techniques for wounds, pioneered sterile surgery and is generally considered as the “Fa-

ther of Modern Surgery.” Britain was later to the game in implementing universal health care, and took a distinctly dif-ferent approach.

the French were the first to achieve complete interoperability and do away with paper medical records, replacing

them in 1998 with the carte vitale

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16 Focus

Its National Health Service (NHS) was created by two opposites, Lord William Beveridge, an aristocratic social reformer raised in India, and Aneuryn (Nye) Bevan, a miner from South Wales. Unveiled in 1942, the Beveridge Report (Social Insurance and Allied Services) promised free health care to all at the doctor’s office or hospital, with payment coming from general taxation, not from medical fees or insurance companies. It was well received in war-torn England and achieved great popularity. However, converting his bold policy proposal into legal reality fell to the cunning Nye Bevan, appointed in 1945 by Labour Prime Minister Clement Attlee as Minister of Health. Faced with enormous opposition from the British Medical Association and existing health insurance programs, Bevan forged a compromise that allowed GPs to remain private

operators and insurers to market policies to customers who chose not to use the NHS.

Unlike the German and French systems, there are no insur-ance premiums to pay and no co-payments since the system is

funded through general taxation. The British income and social security taxes are higher than the U.S. in every income bracket. The result is a system with minimal paperwork and no billing that is a highly cost-efficient way to provide quality health care to all. Roughly 98.8 percent of aggregate health expenditures are government funded. Administrative costs are

about one-fifth of those in the U.S. There are private insurance plans in the UK, but they are not widely used. The Indian Health Service and the Veterans Administration are examples of the Beveridge model at work in America, but they are not nearly as cost efficient as the NHS.

continued from page 15

Are there lessons to be learned that could help the U.S. get more value

for its expenditures and movefrom paradox to paragon?

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Focus 17

The nationwide network of general practitioners (GPs) plays a powerful gatekeeper role. They are not government employees, but independent business people paid on a capi-tation basis. Everyone who wants access to NHS treatment must be registered with a GP. The capitated payment sys-tem provides a strong incentive for GPs to practice preventive medicine. If patients want to see a specialist (“consultant”), they must be referred by a GP. Since many conditions can be managed well by a GP in the local doctor’s office (“sur-gery”), many non-essential visits to hospital-based specialists are avoided. GPs also make house calls. About 60 percent of British doctors are GPs, compared with 35 percent in the U.S. Surprisingly, British GPs earn more than the specialists, and enjoy income levels comparable to primary care practi-tioners in the U.S.

The NHS controls the range of medications, tests and pro-cedures covered through its National Institute for Health and Clinical Excellence (NICE). This type of rationing is not un-like that practiced in the U.S. by private insurance companies and by Medicare’s coverage determinations. The British pro-cess is transparent and, given that all have a common stake in the NHS, there’s a political will to accept the harsh decisions that NICE occasionally has to make.

What are the downsides? The most notorious is the dreaded “queue,” or waiting list. Even when the GP agrees to refer the patient to a consultant, it can take weeks or months to get an appointment if the problem is deemed non-urgent or elective (e.g., hernia repair, varicose veins). However, for suspected cancers or cardiac issues, the queue is bypassed. In its “Health at a Glance 2015,” the OECD noted that “Wait-ing times for planned interventions such as hip and knee re-placements are now lower than in most other OECD coun-tries reporting data.” The upside is that, despite Americans negative perceptions of “the National Health,” the British deliver the best value for the money of any healthcare system in the developed world.

From “Health Care” to “Health”In their well-researched 2013 book, “The American Health

Care Paradox – Why Spending More Is Getting U.S. Less,” co-authors Elizabeth Bradley and Lauren Taylor make a compel-ling case that when spending on both social services and health care services were taken into account, the U.S. is not a high spender. Social services expenditures include public and pri-vate spending on old age pension and support services for older adults, survivor’s benefits, disability and sickness cash benefits, family supports, employment programs and other social ser-vices that exclude health expenditures.

Comparing the same 11 OECD countries as the Com-monwealth Fund did in its 2014 “Mirror, Mirror on the Wall, How the U.S. Healthcare System Compares Internationally,”

the U.S. is at the median, spending a combined 25 percent of GDP on health and social care (see their Exhibit 8, Health and Social Care Spending as a Percentage of GDP). Their research also found that countries with high health care spending rela-tive to social service spending (like the U.S.) had significantly lower life expectancy and higher rates of infant mortality than did countries that favored social spending (like France, Ger-many and the UK).

France devotes fully one-third of its GDP to health care and social services spending; Germany 29 percent; the U.S. 25 percent and the United Kingdom 23 percent. However, the U.S. spends only 9 percent of GDP on social services compared with 21 percent in France, 18 percent in Germa-ny and 15 percent in the United Kingdom. Despite spend-ing the lowest aggregate percentage of GDP on health care and social services, the British produce the best results on the four key health indicators. When it comes to providing value for the money, the UK is at the paragon of the devel-oped world.

France’s enormous investment in health and social services pro-duces an average life expectancy of three years more than the U.S. and infant and child mortality rates that are half ours. Should the U.S. try to match French spending levels to try and narrow the gap? On the other hand, the

British spend less than the U.S. to achieve a life expectancy two years higher than the U.S. and infant and child mortal-ity rates about one-third lower than ours. Are there lessons to be learned that could help the U.S. get more value for its expenditures and move from paradox to paragon? Or, must the approach be uniquely American? Unfortunately, there are no easy answers. The final article in this series will ex-plore the options and opportunities and attempt to propose an approach that, the author hopes, will bend the cost curve and produce better health for the communities we serve. After all, that is the Triple Aim!

About the authorJohn J. Dalton, FHFMA, is Senior Advisor Emeritus at BESLER Consulting, a former Chapter President, National Board member, and HFMA’s 2001 Morgan Award winner for lifetime achieve-ment in healthcare financial management, the only New Jersey Chapter leader to receive that honor. He remains involved in healthcare as Trustee and Chair of the Strategic Planning Com-mittee at the St. Joseph’s Healthcare System and as Honorary Trustee at Children’s Specialized Hospital where he serves on the Audit & Compliance Committee.

Fall 2 0 1 6

18 Focus

Optimizing Care Coordination Within Referral Management Centers

by Lillian Lee-Chun, Jennifer McCraw, & Sarah Wirth Lillian Lee-Chun

As payment reform accelerates through new mandatory bundled payment programs, MACRA, and other initiatives, the savviest health systems are zeroing in on care coordination as a critical tool for success in the value-based era. Good care co-ordination requires a tightly integrated provider network that makes it easy for patients to navigate their healthcare needs across providers and care settings. Referral management, when supported by the right infrastructure, can assist integrated net-works in delivering on the cost and quality requirements of value-based programs while simultaneously enhancing patient satisfaction and quality of care. This article positions the referral management center (RMC) as the optimal approach to support the transition of care between providers within an integrated network of employed and independent physicians. Further, we explain how a high-performing RMC can increase patient re-tention, visit volumes, and revenue; improve provider, staff, and patient satisfaction; lower costs; and reduce the logistical and administrative burdens for patients.

How the RMC Model WorksMany organizations rely on frontline clinic staff to manage the

referral process. However, with clinic staff responsible for count-less patient-facing and non–patient facing tasks, the referral-man-agement function may fall through the cracks. By moving this task from the clinic environment to the RMC, both small and large organizations can achieve positive—and profitable—results.

An RMC acts as a central connecting point between self-referring patients or referring providers and receiving providers. It enables a bidirectional flow of information—such as patient history, previous services provided, reason for specialist consult, and scheduling information—to facilitate a more accurate and efficient referral process.

RMCs vary in look and feel. The model can be customized to accommodate both small and large organizations as well as varying levels of centralization. Generally speaking, requests made by a referring provider are routed or submitted directly

to the RMC. The RMC then processes the request, either manually or aided by an EHR or technology platform specifi-cally designed for referral man-agement. After the patient’s financial clearance has been achieved, customized protocols are applied to the referral to ensure the patient is matched with the right provider in the appropriate setting. If the RMC is not responsible for scheduling the appointment, the receiving provider’s office will be contacted and given the appropriate information to appoint the patient. Lastly, following the patient’s visit, post-visit care notes are routed back to the referring provider to close the loop.

Although most organiza-tions use an existing EHR to manage and track provider referrals, some have invested in additional technologies that offer better work-queue orga-nization and reporting and that can apply automated provider-match algorithms, instead of relying on a manual process. As the size and complexity of the referral network grows, these tech-nologies can deliver greater functionality and efficiency.

Implementing the RMCWhile referring providers are eager for dedicated resources to

manage their patient care transitions, receiving providers can be more reluctant to engage in the process, particularly when the

Jennifer McCraw

Sarah Wirth

Fall 2 0 1 6

Focus 19

RMC schedules directly into their calendar. Without their trust and participation in the design and development of RMC pro-cesses, the referral center will not succeed. The implementation of an RMC hinges on the ability to create standard algorithms that match conditions, symptoms, and diagnoses with the appropriate providers and ensure that providers’ schedules are structured to allow for easy scheduling of consults. Without these two compo-nents, RMCs function merely as patient tracking centers.

We recommend a phased approach when developing and implementing a new RMC. Often, organizations begin with a large and engaged primary care clinic that can spare the staff, thus making the effort budget neutral. From there, best practice work flows can be developed for coordinating referrals with pi-lot specialties, which should include relatively simple rules for patient assignment and appointment scheduling. As the work flows are vetted and the proof of concept is validated, the pro-cesses can be expanded and scaled throughout the health system or integrated network.

Quantitative and Qualitative ResultsCentralization of referral management has proven to be a

cost-effective way to reduce referral leakage. For example, one large health system in Tennessee was able to decrease referral leakage by almost one-third in the first year its RMC was up and running. Further, there is anecdotal evidence to suggest that the centralized model has increased provider and patient satisfac-tion. Providers experience a reduced administrative burden and no longer need to track and collect data pertaining to the refer-ral visit, while patients experience improved outcomes because they are seen by the right provider in the right setting at the right time.

Looking ahead, a centralized RMC can become more than a referral-management system. The same pipelines the RMC uses to manage referrals can be further developed to support the coordination of care. Envision an RMC with added care management components. Patients who are being referred to a cardiologist because they have indicators for heart failure also

speak with a care manager who enrolls them in a heart failure program and connects them with other educational and clinical resources. Staff responsible for following up with patients who missed their referral appointments also reach out to patients who need to be scheduled for a visit to address gaps in care.

TakeawaysThere is no question that healthcare organizations must

evolve to succeed under MACRA and other value-based man-dates. But they don’t have to jump in head first—in fact, many would argue that experimentation with lower-risk points of en-try is the smarter approach to developing the new competen-cies required in the evolving healthcare landscape. Building an RMC is one such low-risk strategy, and it’s one with the poten-tial to pay high dividends for care coordination efforts.

About the authorsJennifer McCraw is a manager within ECG’s healthcare practice and specializes in operational performance improvement. She has exten-sive experience in strategic planning and medical group development, patient access strategy implementation, clinical referral process im-provement, and hospital/physician employment transactions. Jennifer can be reached at jmccraw@gmail.com. Lillian Lee-Chun is a Manager in ECG’s contracting and reimburse-ment practice. She specializes in developing strategies to transition integrated networks and health systems to value-based reimbursement and success under alternative payment models. Lillian can be reached at LLee-Chun@ecgmc.com. Sarah Wirth works in ECG’s healthcare practice. She has experience in optimizing large physician group practice operations, as well as improving financial performance through physician- and hospital-based revenue cycles. Over the past several years, Sarah has focused her career on planning, implementing, and optimizing centralized refer-ral management and patient contact centers. Sarah can be reached at SWirth@ecgmc.com.

mark your calendar . . .

PLEASE NOTE: NJ HFMA offers a discount for those members who wish to attend Chapter events and who are currently seeking employment. For more information or to take advantage of this discount contact Laura Hess at NJHFMA@aol.com or 888-652-4362. The policy may be viewed at: http://hfmanj.orbius.com/public.assets/A02-Unemployed-Discount/file_168.pdf

September 13, 2016 All dayAPA Hotel Bi-monthly Educational MeetingWoodbridge Regulatory & Reimbursement Committee

October 5-7, 2016 Annual InstituteThe Borgata, Atlantic City

November 8, 2016 All day APA Hotel Bi-monthly Educational MeetingWoodbridge FACT Committee

Fall 2 0 1 6

20 Focus

For an effective cybersecurity program, a business needs to coordinate efforts throughout its entire information system, all of which likely has an impact on the organization’s account-ing function. As such, involving the accounting department as well as a CPA firm can be incredibly productive.

The most difficult challenge in cybersecurity is the ever-evolving nature of security risks themselves. As a result, na-tional organizations are recommending more proactive and adaptive approaches to cybersecurity. The National Institute of Standards and Technology (“NIST”) recommends a shift toward detection, continuous monitoring and real-time as-sessments. The National Cyber Security Alliance (“NCSA”) recommends a top-down approach and focuses cyber-risk as-sessments on five key areas:

• Identifying the most valuable information requiring pro- tection;

• Identifying threats and risks facing that information and their likelihood of occurrence;

• Assessing impact on your business should data be com- promised;

• Assessing ability to recover from such an event;

• Detecting nefarious activities (i.e. breach) on your net- work.

While specialized skills and in-depth knowledge of latest technologies and trends in cybersecurity can be critical, your accounting firm likely understands the nuances of your busi-ness, as well as the processes and controls in place regarding your assets. Your accounting firm can provide valuable infor-mation as you begin to address the activities above.

For years, accounting firms have been drafting manage-ment letter comments related to internal controls. Internal controls are not just about technology, they are also heavily rooted in people and process. The threat of a cyber event (or

being hacked) expands the scope and significance of those internal controls as well as es-calates the related risks if they are not working properly.

And what happens if your business is not as prepared as you think? Recently, a compa-ny experienced a cyber-attack only to find out that the cyber insurance claim was denied for failure to meet policy re-quirements around internal controls.

Security is only one piece of the puzzle. Assessing your ability to identify, protect, detect, respond and recover from a security incident and to take action to achieve your targeted level of readiness going forward is important to your bottom line. So yes, an account-ing firm can help with cybersecurity. Do you know how pre-pared your organization really is? Visit http://www.withum.com/kc/prepared-event-cybersecurity-attack/ to access a pre-paredness checklist you can use to advance the conversation.

About the authorsJoseph Riccie, CPA, is the Practice Leader of WithumSmith+Brown, PC's Cloud Solutions & Management Consulting Services Group. Joe can be reached at jriccie@withum.com.

Meghan Watson is Team Leader of Management Consulting Ser-vices with WithumSmith+Brown, PC. Meghan can be reached at mwatson@withum.com.

Can an Accounting Firm Help with Cybersecurity?

Joe Riccie

• Focus on Finance•

By Joe Riccie, CPA and Meghan Watson

Meghan Watson

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Focus 21

continued on page 22

Implementing CJR: How CentraState Healthcare System Builds on its Gainsharing Experience to Engage Physicians

Dr. Cheryl Lyn Hayne

by Dr. Cheryl Lyn Hayne, Ph.D., M.Sc., M.P.H. and Jo Surpin

Jo Surpin

It has been several months since the Comprehensive Care for Joint Replacement Program (CJR) went into effect. This bundled payment program is the first mandatory program of its kind and represents a significant step in the larger paradigm shift from traditional fee-for-service to value-based reimburse-ment, as well CMS’ strategic goal of moving 50% of tradition-al Medicare payments to alternate payment methods (APMs) by the end of 2018. Currently 30% of payments are under an APM and it is clear that CMS is evaluating CJR and other bun-dling models with a view for national expansion. It has been estimated that as much as 60% of the hospitals participating in the CJR Program might be facing penalties based on their cost performance. The program carries financial incentives for pro-viders to better coordinate care and keep costs down. While only 4 orthopedic MS DRGs are currently included, there are indications that there will be expansion to include additional MS DRGs and other service lines in the near future.

With the 5 year CJR pilot- program, Medicare will be look-ing at lower extremity joint replacements (LEJR) through the ocular of an Episode of Care, tracking the cumulative cost of care incurred over a 90 day period. The basic modus operandi of CJR is that designated hospitals have a target episode price for LEJR which are primarily hip and knee replacements, as-signed by Medicare based on historical data. The interim pay-ment for care provided during episodes is provided through traditional fee-for-service payments to all providers, but at the end of the performance year, all payments are reconciled against an established, quality-adjusted target episode price. If the care provided to the beneficiary is lower than the target episode price, the savings are kept by the episode-initiating hospital provider. Beginning in Year 2, hospitals assume the risk that should the cost of care provided exceed Medicare’s tar-get, any difference must be repaid to Medicare by the hospital

who performed the initial joint replacement.

In addition, hospitals are as-signed a composite quality score that is assessed at each perfor-mance year’s reconciliation. A hospital’s composite quality score is based on their performance on three quality measures (HCAHPS Survey, Complications and Pa-tient Reported Outcomes) and impacts the percentage discount that Medicare takes from the episode target price, in addition to a compulsory reduction. Hospitals must receive a composite quality score of at least ‘acceptable’ or higher to be eligible for any reconciliation payments they have otherwise earned through cost reductions. Unlike other demonstrations, where the focus was on one provider type or another, with this program hospitals assume the financial risk for the cost of all care provided within a 90 day period, requiring coordination of care across the con-tinuum and that all providers involved in the delivery of care for a patient undergoing a hip or knee replacement work together.

Where the fee-for-service environment has enabled systems to often operate in silos, CJR requires patient care to extend beyond the hospital’s boundaries and requires physicians, hos-pitals, and post-acute providers, such as skilled nursing facili-ties, inpatient rehab, and home health agencies, to work to-gether in collaboration.

In preparing for CJR, CentraState Medical Center drew upon its experience in the New Jersey Hospital Association’s Medicare Gainsharing Demonstration. The Gainsharing Dem-onstration began in July 2009 and continued until April 2013 when it expanded into the BPCI Model 1 initiative. That ex-

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22 Focus

continued from page 21

perience allowed the hospital to structure a successful gainshar-ing program, emphasizing the importance of good, detailed data as a tool for engaging physicians. In addition, the gainshar-ing demonstration provided a foundation for the alignment of hospital and physician goals, which will be vital in succeeding under CJR. The Gainsharing Demonstration was limited to in-ternal cost savings and did not focus on an episode of care, but the hospital was allowed to work with other shared savings pro-grams at that time.

The Importance and Use of DataOne of the key factors that CentraState recognized during

the Gainsharing Demonstration was that physicians are scien-tists and, as such, they respond to data. Regular reports were utilized through the Gainsharing Demonstration that showed physicians how they measured up against their peers, as well as with internal goals and industry-established benchmarks. Data identified areas for improvement, both internal cost re-ductions and quality, and drove change. Therefore, it was vital to provide accurate, timely data that provided physicians with information on their performance and encouraged a change in behavior. Using data showing the potential incentive if the physician was able to reach the best practice level (a statewide norm established at the 25th percentile of lowest cost for a severity adjusted DRG) versus the potential if there was no change in practice assisted in the identification of physicians that could benefit from the initiative, and possibly become leaders in the hospital’s efforts, as seen below.

The data was also summarized by severity adjusted DRG (i.e. APR DRG), so that analysis of particular case types could be considered. In this illustration (top right), the example phy-sician has cost overages in hip and knee replacements. A higher length of stay, medical surgical supplies (MSS) and operat-ing room costs (ORR), contributed to the overages. This data was then summarized into an individual physician dashboard,

Par Status

Responsible Physician

RP First Name

RP Last Name Specialty

Total Eligible

Admissions

Average LOS

Average BP LOS

Average Simulated

LOS

Average LOS

OpportunityActual Cost BP Cost

Cost Reduction Opportunities (No Change)

Maximum Improvement

Incentive

Maximum Performance

Incentive

Maximum Total Incentive

Actual Physician

Incentive (at BP)

Actual Physician

Incentive (No Change)

Difference in Incentive

PAR 198266 Family Practice 135 4.8 3.3 3.2 1.6 $1,047,849.14 $700,023.82 $387,384.18 $19,978.70 $25,031.56 $45,010.26 $45,010.28 $18,137.05 $26,873.23PAR 162908 Internal Medicine 114 5.2 3.3 3.1 2.1 $875,614.40 $573,493.79 $342,667.06 $19,437.03 $20,582.45 $40,019.48 $40,019.52 $15,215.69 $24,803.83PAR 193213 Internal Medicine 84 4.7 3.2 2.9 1.8 $640,014.70 $393,585.82 $273,980.58 $19,537.06 $14,082.77 $33,619.83 $33,619.84 $17,232.36 $16,387.48PAR 125539 Internal Medicine 108 4.0 3.3 3.0 1.1 $696,452.63 $542,640.76 $198,103.33 $18,770.72 $19,666.60 $38,437.32 $38,437.34 $22,439.36 $15,997.98PAR 118468 Internal Medicine 70 4.3 2.8 2.6 1.7 $447,541.81 $300,465.57 $165,496.83 $12,713.54 $10,567.97 $23,281.51 $23,281.48 $8,883.66 $14,397.82PAR 119480 Orthopedic Surgery 55 4.1 3.8 3.5 0.5 $740,908.60 $627,994.56 $162,219.99 $11,169.63 $13,335.78 $24,505.41 $24,505.44 $10,536.03 $13,969.41PAR 184127 Orthopedic Surgery 55 4.6 3.6 3.5 1.2 $782,863.93 $600,615.73 $198,492.11 $12,492.48 $12,513.52 $25,006.00 $25,006.08 $11,159.12 $13,846.96PAR 161998 Internal Medicine 115 4.8 3.0 2.8 2.0 $900,321.86 $524,087.26 $396,283.25 $0.00 $18,816.45 $18,816.45 $18,816.50 $6,515.06 $12,301.44PAR 100380 General Surgery 32 7.2 4.2 3.9 3.3 $455,860.95 $310,279.95 $156,826.76 $7,972.75 $8,447.91 $16,420.67 $16,420.66 $5,910.67 $10,510.00PAR 127560 Internal Medicine 44 5.5 3.4 3.2 2.3 $358,187.97 $234,617.51 $136,444.68 $7,527.39 $8,148.82 $15,676.21 $15,676.22 $5,893.29 $9,782.93PAR 107356 Vascular Peripheral Surgery 48 6.2 4.1 3.8 2.4 $674,385.66 $605,766.18 $130,164.94 $13,585.94 $16,691.61 $30,277.55 $30,277.56 $20,654.94 $9,622.62…… ………. ………. ………. ………. ………. ………. ………. ………. ………. ………. ………. ………. ………. ………. ………. ………. ………. ……….

Non PAR 162907 1 2.0 3.0 2.0 0.0 $2,959.81 $3,813.28 $0.00 $46.69 $132.60 $179.29 $179.29 $179.29 $0.00PAR 172019 Pulmonary 1 3.0 3.0 3.0 0.0 $3,741.74 $4,215.56 $0.00 $133.08 $138.29 $271.37 $271.37 $271.37 $0.00PAR 175035 IM/Cardiology 2 1.0 1.5 1.0 0.0 $3,346.42 $5,629.30 $0.00 $188.21 $189.80 $378.01 $378.01 $378.01 $0.00Non PAR 182120 1 2.0 3.0 2.0 0.0 $3,653.97 $5,281.74 $0.00 $0.00 $169.15 $169.15 $169.15 $169.15 $0.00Non PAR 195237 2 4.0 5.5 4.0 0.0 $12,563.54 $19,469.27 $0.00 $0.00 $394.65 $394.65 $394.65 $394.65 $0.00

2,473 $21,239,940.43 $15,268,934.79 $7,106,934.49 $283,701.51 $484,955.95 $768,657.46 $768,657.92 $365,102.12 $403,555.80

AMS: NJHA (20xxq4b 10% Var) - Program: diff_simltn1c

75th Percentile of Spread for Surgical Improvement and Uncapped Medical Improvement Incentives

Incentive Simulation ReportPerformance Based Incentives

Total Incentive by Physician (Ranked High to Low difference in Incentives)Non PAR - NPI Accuracy not Verified

July 20xx through December 20xx; Medicare Only ClaimsProvider: 100000 - General Medical Center

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Focus 23

continued on page 24

shown on previous page, bottom, which allowed the hospital to have an in-depth discussion with the physician about their costs, the potential incentive to be earned, and which areas might hold these opportunities. Through these conversations, CentraState was able to expand the physician’s knowledge of how their performance impacted the hospital’s performance and allowed them to share in the internal cost savings achieved, contributing to the success of the program.

The Gainsharing Program required that each hospital estab-lish a Steering Committee to review data, identify areas for care redesign and other interventions, and approve incentive payouts. In order to ensure that quality under the program was enhanced, the Steering Committee established a set of standards that physi-cians had to meet in order to achieve the full payment. Examples of these standards included active participation in care redesign initiatives, meeting guidelines for completion of operative sum-maries and reducing readmission rates. In summary, the analy-sis of data, open conversations with physicians and the actions of the Steering Committee provided the hospital with a solid structure for a successful gainsharing program. The insights and experience gained through CentraState’s initial Gainsharing ex-perience encouraged them to utilize a similar strategy for CJR, one that rewards alignment with the program’s goals for quality and efficiency, while simultaneously creating physician leaders for the program. Despite programmatic differences, the founda-tion to success remains the same: reliable, accurate data.

The CJR Program is no different – accurate and timely data is required in order to make the appropriate decisions neces-sary to achieve care coordination and reduce costs. While CMS does provide every CJR hospital with historical data on care, the raw claims data must be transformed into a meaningful format in order to be utilized as a catalyst for change. The data, unlike in the Gainsharing Demonstration, spans the entire 90-day episode so it is a very comprehensive data set. Getting data beyond the initial hospitalization is a wealth of information. For this reason, hospitals may find they need to engage a data analytic partner to assist them in translating the data into reports that can easily be used within the hospital, with physi-cians and with post-acute providers. CentraState, in partner-ship with NJHA and AMS, is using the data set provided by CMS (samples shown below), which has proved useful in ana-lyzing the utilization of services provided to CJR cases:

1. Identify where the hospital is above or below the target price:

Exceeding the target price set for your hospital exposes the institution to the risk of having to repay CMS during the recon-ciliation. But, as this report shows, CentraState had actual costs that were less than the target price on 3 of 4 diagnoses. On the 4th, actual costs exceeded the target by 15%. Focusing on just one APR DRG can help to concentrate the hospital’s efforts.

2. Where are payments going?

For the first time, hospital staff has to be concerned with both the care delivered within its walls and what is provided after discharge. While the majority of the episode payment arises from the inpatient stay, understanding what payments are made to which post-acute providers is crucial to the hospi-tal’s plan. On the inpatient side, the DRG payment is fixed and internal cost savings is the key. On the post-acute side, devel-oping/enhancing relationships with providers that can deliver quality care at low cost, and avoid readmissions, is the key.

3. How is the hospital faring against the region?In the early stages of the CJR Program, hospitals are given a

target price based on a blend of the hospital’s historical perfor- mance (2/3) and that of the regions (1/3). But in subsequent periods, the historical to regional blend of the target price will evolve to be based exclusively on regional data. CentraState found that 29% of the episode payments for their patients was-going to Skilled Nursing Facilities while the regional average was 15%. This clearly illustrated an area of opportunity. See chart 3 on page 24.

Chart 1

Chart 2

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24 Focus

4. What the reconciliation might look like?

Projecting what the reconciliation might look like is also a key aspect of the data analysis. This can jolt the hospital into understanding what their risk is and help motivate efforts to develop and implement a plan. In CentraState’s case, while 3 of the diagnoses were showing savings, the fourth offset these, which could have resulted in a net loss (i.e. CMS repayment) had similar costs been incurred in the 2nd year of the program. However, with repayment to Medicare not required in the ini-tial program year, CentraState could expect a positive net pay-ment reconciliation based on their historical data.

Sharing the Savings and PenaltiesPrevious CMS programs included either shared savings or

gainsharing (internal cost savings). The CJR Program has re-defined gainsharing to incorporate both concepts. Upon meet-

ing minimal quality requirements, participating hospitals are able to keep, and share, a percentage of the positive reconcilia-tion payment by falling below CMS’s target price. In addition, hospitals may track internal cost savings. Internal savings, real-ized through CJR programming measures, can be added to the overall savings pool, comprised of both any positive net pay-ment reconciliation and internal cost savings. How this savings pool is spent is at the purview of the hospital (subject to CMS caps) –and may include internal programs, and/or sharing with post-acute partners with whom they have engaged. In addi-tion, hospitals can share with their physicians a portion of the savings generated internally through care redesign. The data provided by CMS can be crucial in analyzing key components that can impact savings. In particular, readmissions and indi-vidual post-acute providers are a good starting point.

1. What is the impact of readmissions?

Understanding readmissions remains a critical quality issue. Payments for cases that are readmitted can skew the total episode payment. As seen on this chart, episodes with a readmission have an average payment that is almost twice that of a non-readmitted case. CentraState was fortunate that most of the readmissions came back to their facility, thereby providing better opportunity to implement care redesign plans to change this trend.

2. How are individual physicians doing compared with each other?

As mentioned earlier, being able to show physicians how they fare against their peers helps to engage them. It also provides a basis for determining what physicians with lower

Chart 3

Chart 4

continued from page 23

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Focus 25

continued on page 26

lengths of stay, lower episode costs and lower readmission rates are doing, or not doing, differently than other physicians. CentraState found that while some physicians had a length of stay below the average, they had higher episode payments.

3. Where are patients being sent post-discharge and what do those costs look like?

Appreciating the patterns of post discharge care is key to controlling episode payments. Where patients are going and the related average payments are critical. These charts show that the bulk (70%) of patients are going to inpatient rehab or skilled nursing facilities. Average payments for these locations are high. If care redesign can change the pattern of discharge destination or the care provided at the post-acute provider, to-tal episode cost can be reduced.

4. Do individual physicians have different patterns for post discharge care?

Again, being able to look at all physicians in the CJR Program and determine what one is doing versus another can provideintegral clues to potential care changes. Some CentraStatephysicians sent most or all of their patients to Skilled NursingFacilities while others discharged patients to home (i.e. com-munity). The distribution of destinations was shown to have an impact on cost and became a place to start conversations with physicians.

5. Are there particular PAC facilities that the hospital should develop relationships with?

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26 Focus

Using the data on ALOS, payments and readmission rates specific to individual facilities can highlight those with better outcomes with whom the hospital might want to further de-velop a relationship. In some cases, there were clear winners with several facilities.

6. How can cost savings be earned by engaged physicians through gainsharing?

With the analytics described above, CentraState is able to focus its efforts on both the reduction of post-acute costs, as well as identify hospital-level internal cost savings oppor-tunities. Having engaged physicians remains integral to the planning and improvement processes. As was learned through CentraState’s participation in the Gainsharing Demonstra-tion, quality data and analytics not only serve to direct the hospital’s attempt and energy, but also to reward the effort and leadership required for revision. Since the savings to make incentive payments possible are generated through ef-ficient hospital performance, the hospital may condition in-centive payments on:

• The realization of internal cost savings and receipt of a positive reconciliation payment from CMS

• The successful support in design and implementation of specific care redesign initiatives (i.e. care maps)

• Individual attainment of various quality indicators (in addition to those established by CMS)

• Individual cost savings contributions as compared to both peer group performance and individual improve- ment.

Final WordCMS has signaled that bundled payment programs are

here to stay, and in fact more to come with coordinated cardiac bundles to start in 2017. Hospitals must be able to weather the transition from traditional fee-for-service pay-ments to value-based payments. The key to this effort is to take the data provided by CMS combined with hospital data and transform it into a usable format that allows in-depth analysis of internal costs, as well as payments related to post-acute providers.

On the inpatient side, efforts to reduce costs through en-hanced supply control and care redesign can be focused on the CJR DRGs. However, many of these activities may also affect costs associated with other orthopedic procedures, as well as non-Medicare patients, which may enhance overall cost reduc-tion. CentraState found that effective and open communica-tion with physicians engages them. For instance, if they under-

stand how more efficient scheduling in the Operating Room benefits the hospital, they become more interested in finding ways to contribute to the effort. To further communication, the provision of reliable data to engaged physicians identifies individual cost savings contribution earnings and opportuni-ties; sharing a portion of the savings achieved with the physi-cians can foster positive long-term relationships between the hospital and its physicians.

Reducing the episode payments by Medicare primarily af-fects the post-acute side of the equation. Medicare pays for the inpatient stay with DRG payments; this payment is fixed so cost savings do not affect the payment by Medicare. Rather, the payments to the various post-acute providers must be as-sessed and reductions made based on lower utilization (e.g. ALOS), lower costs, and/or redistribution within the post-acute providers.

This all leads to the conclusion that success may very well depend on the quality and quantity of the data available. Hospitals must be able to use the data provided by CMS to properly assess the inpatient stay, post-acute providers and physicians involved. This can be integrated into a compre-hensive plan that rewards the provision of quality care in the right setting at the right price.

About the Authors:Dr. Cheryl Lyn Hayne, Ph.D., M.Sc., M.P.H. is Manager of Managed Care and responsible for the implementation of CJR at CentraState Healthcare System, Freehold, NJ. Cheryl can be reached at chhayne@centrastate.com.

Jo Surpin is President of Applied Medical Software, Inc. Collin-gswood, NJ and a member of HFMA. Jo can be reached at jsur-pin@appliedmedicalsoftware.com.

continued from page 25

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Focus 27

• Focus on...New Jobs in New Jersey•

JOB BANK SUMMARY LISTINGHFMA-NJ’s Publications Committee strives to bring New Jersey Chapter members timely and useful information in a convenient, accessible manner. Thus, this Job Bank Summary listing provides just the key components of each recently-posted position in an easy-to-read format, helping employers reach the most qualified pool of potential candidates, and helping our readers find the best new job opportunities. For more detailed information on any position and the most complete, up-to-date listing, go to HFMA-NJ’s Job Bank Online at www.hfmanj.org.

[Note to employers: please allow five business days for ads to appear on the Web site.]

Job Position and Organization

Budget/Cost Analyst Children’s Specialized Hospital – Somerset NJ

Budget Analyst III Meridian Health

Controller ID CARE, P.A.

Manager, Accounting Atlantic Health

Medicare Account Representative Valley Health System

Coding – HIM Opportunities Cooper University Health Care

Revenue Accounts Manager, Health Services, FT Days AtlantiCare, Egg Harbor Township, NJ

Coordinator Atlantic Health System

CDM Coordinator Atlantic Health System

Compliance Manager & Tax Compliance Officer NJ Health Care Facilities Financing Authority

Budget and Reimbursement Coordinator CentraState Healthcare System

Controller Pocono Medical Center

Decision Support Financial Analyst Atlanticare

Insurance Specialist ABS Cooper University Health Care

Senior Auditor The Valley Health System

Senior Internal Auditor Kennedy Health System

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28 Focus

Transforming Your Revenue Cycle

Kristin Greenstreet

by Kristin Greenstreet

The rapidly changing healthcare environment has required healthcare providers to put a new focus on patients, transparency and the choices consumers now have at their fingertips. This combined with the upcoming changes related to value based care and Population Health have put great pressure on areas such as Revenue Cycle to focus on how to optimize current operations while effectively preparing for upcoming change. The truth is that we are still reeling from changes that took place two years ago. Complex managed care contracts, the Healthcare Exchange, changes to Medicaid and CHIP (Children’s Health Insurance Program) as a response to the Affordable Care Act, and the evolution of accountable care organizations and population health have created reimbursement challenges across the healthcare industry that are still problematic for most providers.

The need for changeWith an unprecedented focus on reduced costs and capital

needs, more hospital and health system leaders are looking at their information technology systems and are realizing that they are not prepared for the changes that are underway. Additionally, CMS regulatory changes, managed care guidelines, rising administrative costs, and the competitive retail health market are putting more pressure on financial stability than ever before.

Positioning for the future is difficult when we don’t know what is on the horizon. Much has been written about moving from “Curve One” to “Curve Two” -- essentially, the move from volume to value. How billing is handled during that transition and knowing the different billing nuances from acute care to home health, or skilled nursing, outpatient/inpatient rehabilitation, assisted living, or the physician office is key to healthy reimbursements. The “bottom line” is that our Revenue Cycle infrastructure is not adequately prepared to effectively pivot for some of the upcoming changes.

What does this mean to revenue cycle?

What is clear is that maintaining the “status quo” is not an option. In fact, it is important to note that even leading practice Revenue Cycle organizations must be prepared to change

now to avoid risk and revenue degradation in the future. The changing payment models, new system implementations and performance metrics, and the rise of population health has made it imperative for healthcare organizations to evolve with the industry. The new view of revenue cycle includes:

• A focus on the patient as a customer• Financial and clinical integrity and integration• Population health & care/revenue-driving campaigns• Integrated IT solutions with heavy focus on EMR

optimization• Organizational development and shared services• Data analytics• Strategic partnerships

Where to start?The transformation begins with a focus on what changes

need to be made to the revenue cycle to provide improves financial performance in the short-term. Simultaneously, providers need to be preparing for the shift to Curve Two.

The key to success is infrastructure. The revenue cycle strategy must evaluate the people, processes and technology needed to effectively support payment model shifts. Population health, referral management, and patient-focused customer service options must also be reviewed. And critical to the process is a comprehensive revenue cycle information technology and strategic partnership strategy. It is critical that organizations truly optimize the EMR systems that are being implemented and the power they can bring to the Revenue Cycle.

Another key area of focus is shared service consolidation and establishing a synergy between Acute and Physician services. This will be vital to the success in transitioning from Curve 1 to Curve 2 and there will need to be strong emphasis on your Pre-Service and Access services for patients to access care.

Finally, organizations must be prepared to shift their traditional thinking about Revenue Cycle. Revenue Cycle is not a department or a function. Instead it should be viewed as the key to Revenue Optimization for your organization. The key to sustaining transformational change will be to engage and

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Focus 29

hold accountable ALL key stakeholders that impact revenue. This stretches far beyond the resources that report directly under Revenue Cycle. It is imperative that Revenue Cycle accountability bridges together the Departments, Physicians, Clinicians, Case Management, UR, Managed Care, Finance, IT, Office Managers, Revenue Cycle and every other person that has a responsibility for impacting the financial health of your organization.

Once the infrastructure is in place, the strategic plan can be implemented. This will only be successful if the focus is on services that will provide the greatest impact.

Establishing key metrics and tracking during the process will provide leaders with the data to make changes as trends develop and market conditions change. Prioritizing short-term and long-term goals keeps teams on track and forward-thinking, while allowing for flexibility for adaptations during the process.

It can be doneThe most successful healthcare providers

have been able to find synergies between acute, physician, and post-acute revenue cycle func-tions. Processes were defined, standardized and consolidated, where appropriate. Once cen-tralized, they established metrics and expecta-tions for all functions, clinical documentation improvement was implemented, information technology updated and EMR optimized.

When all systems come together with a patient-focus and proper support is given to the physicians and clinicians partnering within the healthcare organization, revenue cycle management -- even in a transformational era – is possible. About the authorKristin Greenstreet is a managing director and the national business leader for revenue cycle with the healthcare team at Navigant Consulting, Inc. She has extensive experience in the management and the completion of revenue cycle improvement initiatives including financial and operational as-sessments, prioritization of strategic revenue cycle initiatives, and process/tool implementation. Ms. Greenstreet’s experience spans acute, physician practice and post-acute services. As a black belt in Lean Sigma, Ms. Greenstreet also focuses on the strategic design and implementation of leading

practice models that encompass improved efficiency, financial perfor-mance and customer satisfaction. Ms. Greenstreet also has extensive project management office experience with large health systems and has served as the leader for the design and implementation of shared service models, mergers/acquisitions, ICD-10 preparation and the impact of upcoming reform on revenue cycle approaches. She has been asked to speak nationally on all of these projects and serves as a strategic business advisor for some of the largest organizations across the country.

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30 Focus

We Turn and Face the ChangesThe S-10 Emerges as a Proxy for Payment

Fred Fisherby Fred Fisher and Scott Besler

We are all a few inches taller thanks to CMS keeping us on our toes. The Federal Fiscal Year (FFY) 2017 Hospital Inpatient Prospective Payment System (IPPS) final rule issued a postpone-ment for using data from Worksheet (WS) S-10 of the Medi-care cost report to determine Medicare Disproportionate Share (DSH) Uncompensated Care (UC) payments. The Centers for Medicare and Medicaid Services (CMS) originally intended to incorporate WS S-10 in the methodology beginning next Oc-tober (FFY 2018). However, due to copious and thoughtful ob-servations from commenters, CMS has again put WS S-10 on hold while a number of issues surrounding fairness, consistency and accuracy are deliberated. The hospital community will be engaged in future rulemaking and CMS anticipates WS S-10 will be used for UC payments no later than FFY 2021 (using WS S-10 from cost reports beginning in FFY 2017).

The Medicare cost report is similar to a tax return. Both re-ports are subject to hard deadlines, submitted annually, and are reviewed by a third party to determine the amount due from or owed to the federal government. If you like filing your taxes, you’ll love making the commitment to complete a cost report. Even though you know your hospital’s deadline well in advance, it still feels like the deadline creeps closer each year.

Similar to the process of taxation, the cost report contains sets of “base data” to determine the allotment of funding for specific programs. One of these programs is Medicare DSH, whereby 75% of all DSH funding is a fixed amount and set aside in the national UC pool.

Currently, and in the foreseeable future, CMS utilizes Medic-aid and Supplemental Security Income (SSI) days to determine each DSH eligible hospital’s UC payment. CMS notes its inten-tion to explore if other reliable data exists to use as a proxy for future UC payments. In the FFY 2017 proposed rule, CMS had endorsed a glide path so that “cost” associated with charity care and non-Medicare bad debt would be used as the basis UC pay-ments beginning in FFY 2018. This likely would have resulted in

huge swings in reimbursement for hospitals across the nation. Many providers look at this change with zest but also apprehension. What is the true impact to revenue and is it fair? These are practical questions that must be examined before any meaningful change can take place.

So join us as we take a look at the S-10’s key issues and what could have been if the S-10 was employed to determine UC payments sooner rather than later.

BackgroundIn order to pay for expanded coverage, the Affordable Care

Act (ACA) mandated CMS to reduce DSH payments. Starting in FFY 2014, CMS adjusted Medicare DSH payments so that 75% of the total funding would be applied to eligible DSH hos-pitals for patients newly insured through the ACA. Therefore, since FFY 2014, a hospital’s Medicare DSH payment has been split into two parts: 1) empirically justified Medicare DSH at 25% (we like to refer to this as “DSH classic”); and 2) the UC pool at 75%. The empirically justified Medicare DSH payment is simply 25% of the DSH payment a qualifying hospital would have received prior to the ACA. The UC payment is the result of three separate factors, “strategically” labeled, Factor 1, Factor 2, and Factor 3. We’d have to dive another 5,000 feet to explore the detail behind each of these factors, but simply stated, they represent the following:

Factor 1: Unadjusted UC Pool – The remaining 75% of DSH payments that CMS would have paid prior to the ACA. In the FFY 2017 Final Rule, CMS estimates this amount to be $10.797 billion ($14.397 billion x’s 75%)

Factor 2: Adjusted UC Pool – This reduces the UC pool, as mentioned above in Factor 1, to correlate with the change

Scott Besler

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continued on page 32

in folks that now have health insurance. CMS estimates, in the Final Rule that there will be a reduction, from FFY 2016 to FFY 2017, in the percent of uninsured from 63.69% to 55.36% ($10.797 billion x’s 55.36% = $5.977 billion).

Factor 3: Hospital’s Portion of Adjusted UC Pool – This factor is used to determine each DSH hospital’s portion of the adjusted UC pool. From FFY 2014 to FFY 2016, this factor represented each qualifying DSH hospital’s Medicaid and SSI days (referred together as “low income”, or L.I., days) from one cost report year (i.e., 2012). Factor 3 represents each DSH hos-pitals’ L.I. days as a percentage of all DSH hospitals’ L.I. days. For FFY 2017, in an effort to address data anomalies, CMS is using a three-year average of L.I. days to determine Factor 3.

This largest change would have begun in FFY 2018, whereby CMS proposed to phase in charity care and non-Medicare cost from WS S-10 as a part of the three year aver-age. Many in the provider community agree it is entirely too soon for this change. CMS, now aims to make modifications to the cost report instructions for WS S-10, as well as imple-ment review protocol for Medicare Administrative Contractors (MACs) to use in reviewing Worksheet S-10. This is a strong step in the right direction as the current data proved to be un-reliable at this time.

The Medicare cost report WS S-10 description reads “Hos-pital Uncompensated and Indigent Care Data”. The fact that this information is listed in the “S” series of the cost report is interesting. The “S” series represents data used by CMS as sta-tistical and informational. However, it is also noted that data from the “S” series flows to other sections of the cost report, which impacts settlement and should be carefully analyzed.

At present, for payment purposes, WS S-10 is used for de-termining Health Information Technology (“HIT”) reimburse-ment but CMS has bigger plans for this schedule. Although it has been discussed for over five years, CMS strongly indicated in the FFY 2016 proposed and final rules, that “costs” related to charity care and bad debt from the S-10 may be used in the “new” Medicare DSH UC distribution. In the Proposed Rule for FFY 2017 (FFY 2017 IPPS Proposed Rule 04.27.16), CMS outlined how WS S-10 would be incorporated for UC payments.

Additionally, the Medicare Payment Advisory Commission (“MedPAC”) has long supported the use of WS S-10 (Med-PAC March 2007). For the past three years, MedPAC has com-

mented to CMS that they believe data from WS S-10 is getting better, and should eventually be used as an improved source for UC payments. However “getting better” is not good enough. One commenter to the FFY 2017 proposed rule points out that due to the “zero-sum” nature of UC payments, any inac-curacy and lack of uniformity in data reporting can have an unfair and very large impact on hospital payments. Before WS S-10 is used for UC payment, data reporting for all hospitals must be better.

Change is Never Easy – Outstanding Issues RemainCMS remains eager to use WS S-10 in determining UC

payments. However, in order to lead in an environment where transparency and fairness are key, CMS, by its postponement of the use of WS S-10, acknowledged that there is still work that needs to be done and issues that must be addressed. Listed below are three major issues that CMS must address before the S-10 is used for hospital UC payments. 1. Establish a National Standard Review of S-10 Data – A $6 billion program deserves this level of attention. CMS re-quires independent audits for other programs (i.e., wage index) to ensure consistency in reporting across all hospitals. Without a thorough audit process, hospitals can be affected by inadver-

tent data entry errors or misinterpretations of cost report instructions.

CMS has already started to address issuesof consistency through recognizing new cost report instructions are required sothat charity care and bad debt claims on WS S-10 are recorded based on when the claim was written off as charity care or bad debt (as opposed to current instruc-

tions stating that these claims reflect care delivered during the cost reporting period). This is a good start, but a national standardized review is still needed across all DSH hospitals to ensure providers are accurately reporting WS S-10 data.

CMS will not likely roll out a “desk review” process, like the one used for wage index, rather CMS looks to pro- vide MACs with uniform work-plans and procedures to re- view and identify aberrant WS S-10 data. One of the largest issues CMS looks to address is the definition of “cost”. For instance, All Inclusive Rate Providers (AIRP) and other government owned hospitals can have unique charge struc- tures allowing for alternative methods of apportioning cost for Medicare and non-Medicare patients. This anomaly re- quires a unique work-plan for MAC review. Amongst other issues, when revising WS S-10 instructions and creating MAC work-plans, CMS must also consider a) states with varying policies on determining charity care costs; b) charges

As Proposed but NOT ADOPTED by CMS 33% 33% 33%

FFY 2017 2011 L.I. Days 2012 L.I. Days 2013 L.I. Days

FFY 2018 2012 L.I. Days 2013 L.I. Days 2014 MCR S-10

FFY 2019 2013 L.I. Days 2014 MCR S-10 2015 MCR S-10

FFY 2020 2014 MCR S-10 2015 MCR S-10 2016 MCR S-10

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32 Focus

associated with non-covered services to commercial and/or Medicaid beneficiaries; c) the reduction in charges for certain patients qualifying for charity care based on IRS 501(r) and the hospital’s financial assistance policy; and d) deductibles and co-pays that are recorded as bad debt but documented at a discount from hospital charges.

2. S-10 Public Use File is Incomplete and Should Con- sider Other Costs – Like any organization, hospitals must be prepared and budget for all impending changes. Pro- viders need to fully understand the implications of transi- tioning to a new methodology, as well as the impact of including other data reflecting care to the entire low income population, which CMS has previously considered. This in- cludes understanding the impact of incorporating costs associ- ated with graduate medical education (“GME”) as well as Medicaid shortfalls. Based on the CMS’ responses to comments in the FFY 2017 final rule, it does not look promising that Medicaid shortfalls or GME will be included in the definition of uncompensated care. CMS intends to “re-propose” a defi-nition of uncompensated care only to include the cost of charity care and non-Medicare bad debt. Although Med-icaid losses are included as “community benefit” in the eyes of the IRS, CMS believes it is best to exclude these losses in order to target UC payments to hospitals with the highest levels of uninsured patients. CMS also states in the FFY 2017 final rule that it believes UC payments are not for costs associated with training residents. There still remain grey areas in identifying all costs. For instance, DSH hospitals incur additional costs associated with subsidizing physicians for access to care in low-income communities. These costs are not captured on WS S-10, but should be considered so that we understand the true cost of care. Last, but not least, the S-10’s cost-to-charge ra-tio, which is used to net charges down to cost, is a universal ratio for the entire hospital. In order to arrive at a more ac-curate statement of cost, department-specific cost-to-charge ratios could be utilized for WS S-10. Notably, CMS has not provided a complete public use file for assessing the true impact of using WS S-10. The current S-10 public use file is unable to identify the “Factor 3” for approximately 10% of all DSH hospitals. This is indicative of not only an issue regarding the completeness of cost re-port data, but also points other probable issues of missing and inaccurate data.

3. Consider the Impact to the Healthcare Delivery System – So far, 31 states (as well as Washington DC) have expanded the Medicaid program under the ACA. If CMS only looks

at the cost of charity care and bad debt for UC payments, in theory the agency may be implying that non-expansion

states are “rewarded” for not expanding Medicaid. In other words, these states will report higher levels of charity care, thereby shifting federal DSH dollars away from states that expanded Medicaid. The intent of Medicare DSH is to ac- knowledge the higher costs associated with all low-income patients who are more severely ill than average. Transition- ing to a methodology that recognizes charity care, and not Medicaid and SSI, could create a dangerous trend and provide states another reason not to expand their Medicaid programs.

If WS S-10 Was Used Today - Potential Impact to DSH Hospitals

Of the 3,336 hospitals listed in the Medicare DSH Supple-mental data, 2,432 hospitals (72.9%) are listed as “Projected to Receive DSH for FFY 2017” and will share in the distribution of approximately $6 billion.

So what would have happened to UC payments if and when charity care and non-Medicare bad debt from S-10 is the sole source? We’ve pulled the available data and have arrived at the estimates in the charts below. Before you set your eyes on these impacts, it is extremely important to note that these estimates were developed using the best data available at the time of crafting this article. The data is incomplete and likely in-cludes reporting errors for hospitals across the country. This is the most compelling reason supporting the position that it is too soon to rely on WS S-10 data for UC funding. The data sets used to arrive at these estimates include the CMS FFY 2017 proposed rule S-10 public use file, hard copy cost reports for NJ hospitals, and national cost report data from the Healthcare Cost Report Information System (“HCRIS”).

If you would like any additional detail regarding the es-timates above, please contact Scott Besler at sbesler@besler.com or Fred Fisher at fred@hospitalalliance.org.

Conclusion We’ve investigated the data and have determined there re-

mains too much missing information and apparent reporting errors across the country for WS S-10 to be a reliable source in determining UC payments. For now, CMS has come to the

continued from page 31

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continued on page 34

same conclusion. We appreciate CMS’ efforts to get this right before WS S-10 is used as the basis for UC payments. Going forward, CMS must be clear in its instruction to the MACs in establishing a consistent review, so that billions of UC dollars are distributed in a dependable manner. Too many DSH hos-pitals desperately rely on this funding to provide access to care and jobs for their communities.

In the meantime, hospitals should remain diligent in their review of all of the components involved in current and future calculations of their UC payment. This includes ensuring that low-income days from 2012 and forward are accurate, and to file amended cost reports if necessary.

Instructions for Revising WS S-10On Friday, July 15, 2016 CMS posted guidance in Trans-

mittal number 1681 for accepting WS S-10 revisions related to Medicare cost reports submitted on/after October 1, 2013 and prior to October 1, 2014. Providers were instructed to submit their amended WS S-10 data by Friday, September 30, 2016. Now with the release of the FFY 2017 final rule will are wait-ing to see if there are any changes to these instructions and/or deadline. Additionally, with the 2014 WS S-10 being put into the “uncompensated care payment queue”, it is still critical to verify that each line of the S-10 is accurately reported so that proper checks are in place by FFY 2017 (the first cost report year CMS intents to use WS S-10 for UC payments).

Current Cost Report Instructions and ReferencesFor your reference, the current instructions for worksheet

S-10 are restated below as per S-10 Instructions:

4012. Worksheet S-10 - Hospital Uncompensated and In-digent Care Data

Section 112(b) of the Balanced Budget Refinement Act (BBRA) requires that short-term acute care hospitals (§1886(d) of the Act) submit cost reports containing data on the cost incurred by the hospital for providing inpatient and outpatient hospital services for which the hospital is not com-pensated. Charity care charge data, as referenced in section 4102 of American Recovery and Reinvestment Act of 2009, may be used to calculate the EHR technology incentive pay-

ments made to §1886(d) hospitals and critical access hospitals (CAHs). CAHs, as well as §1886(d) hospitals, are required to complete this worksheet. Note that this worksheet does not produce the estimate of the cost of treating uninsured patients required for disproportionate share payments under the Med-icaid program.

Definitions Uncompensated care--Defined as charity care and bad

debt which includes non-Medicare bad debt and non-reim-bursable Medicare bad debt. Uncompensated care does not in-clude courtesy allowances or discounts given to patients.

Charity care--Health services for which a hospital demon-strates that the patient is unable to pay. Charity care results from a hospital's policy to provide all or a portion of services free of charge to patients who meet certain financial criteria. For Medicare purposes, charity care is not reimbursable and unpaid amounts associated with charity care are not consid-ered as an allowable Medicare bad debt. (Additional guidance provided in the instruction for line 20.)

Non-Medicare bad debt--Health services for which a hos-pital determines the non-Medicare patient has the financial capacity to pay, but the non-Medicare patient is unwilling to settle the claim. (Additional guidance provided in the instruc-tion for line 25.)

Non-reimbursable Medicare bad debt--The amount of allowable Medicare coinsurance and deductibles considered to be uncollectible but are not reimbursed by Medicare under the requirements of §413.89 of the regulations and of Chapter 3 of the Provider Reimbursement Manual Part 1. (Additional guidance provided in the instruction for line 25.)

Net revenue--Actual payments received or expected to be received from a payer (including co-insurance payments from the patient) for services delivered during this cost reporting pe-riod. Net revenue will typically be charges (gross revenue) less contractual allowance. (Applies to lines 2, 9, and 13.)

About the authorsFred Fisher, Vice President, Finance and Strategy of the Hospi-tal Alliance of New Jersey, has 15 years of experience identifying, managing and compliantly reporting on reimbursement policies resulting in hundreds of millions of dollars in improved revenue for hospitals across the United States. Recently, Fred has engaged with hospitals, as well as state and federal legislators on changes in policy related to the ACA and population health initiatives. Fred graduated from Rider University with a Bachelor of Science degree and is a member of the New Jersey HFMA and its Reimbursement Committee. Fred can be reached at fred@hospitalalliance.org.

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continued from page 33

Scott Besler has over 25 years of progressively responsible ex-perience in hospital reimbursement. He has been responsible for a myriad of areas relating to healthcare facility reim-bursement while working at BESLER Consulting. Scott is a Medicare Cost Report expert including DSH, IME/ GME and wage index areas. He has participated in detailed au-dit reviews of the wage index for acute care hospitals and hospital associations as well as chiefly responsible for unique

reclassification strategies. Scott received a Bachelor of Sci-ence degree in Accounting from LaSalle University. He is a member of the New Jersey and Philadelphia HFMA and their respective Reimbursement Committees. He also served on the Institute as well as Education Committee for the New Jersey chapter and is currently a director and board liaison to the New Jersey chapter reimbursement committee. Scott can be reached at SBesler@Besler.com.

Clinton J. BoydSamaritan Healthcare & HospiceController(856) 552-3233cboyd@SamaritanNJ.org

Stephanie R. FernandezAdreimaPatient Access Manager(609) 815-7332stephanie.fernandez@adreima.com

Dina L. RiceCBIZ KA Consulting, LLCSenior Manager(908) 994-8659drice@cbiz.com

Jason SiedmanDirectorRevenue Integrity(856) 412-5196jsiedman@hotmail.com

Varun Singh Bajaj(973) 668-1220vsb2115@columbia.edu

James WilsonAVC Bank(646) 355-2900jwilson@avcbank.org

Graham J. Hughes MDSutherland Healthcare SolutionsChief Medical Officer & Head Global Analytice(973) 405-5123graham.hughes@sutherlandglobal.com

Yingying Lu(415) 969-6890joicy.lu@dignityhealth.org

Diane J. WarrenBacharach Institute For RehabilitationBusiness Office Manager(609) 652-7000dwarren@bacharach.org

Elizabeth MillerRobert Wood Johnson Univ HospitalCompliance Manager(732) 729-7662elizabeth.miller@rwjuh.edu

Tina Zarro, CHFPSt. Joseph's Regional Medical CenterManager PFS(973) 754-2152tinaz13@hotmail.com

Heather A. MurrayBacharach Institute for RehabilitationAccounting Manager(609) 748-5378hmurray@bacharach.org

Jefrrey HorowitzAmedisys(516) 987-7585Shabtai92@gmail.com

Sean CapwellO’Conco Healthcare Consultants(732) 292-0840scapwell@oconco.com

Matthew MielczarekSummit Health Management, LLCInterim Controller(908) 790-6544matthew.mielczarek@gmail.com

Erin SturmSummit Health ManagementAssistant Controller(908) 273-4300 x2954esturm@smgnj.com

Chenda DuongSonja Kill Memorial HospitalFinance Manager(077) 666-7510chendaduong815@gmail.com

Robert R. RoldanRSL Management, LLC(646) 779-9754rroldan@rslmanagement.com

Jason CooperHorizon Blue Cross Blue Shield of New JerseyVice President & Chief Analytics Officer(973) 466-4621Jason_Cooper@horizonblue.com

Dan FoleyFirst American HealthcareAssistant Vice President(585) 643-3353dan.foley@fahf.com

Krishna VelagaSunray Healthcare IncChief Technology Officer(732) 465-1411krishna@sunrayinformatics.com

Arthur SweeneyProfessional Receivables Network, LLC(856) 773-3300asweeney@prnhs.net

Sheryl MillerAdvanced Data Systems Corp.Vice President(800) 899-4237sheryl.miller@adsc.com

Charlie CastigliaRevSpring, Inc.Northeast Sales Executive(201) 841-5770ccastiglia@revspringinc.com

Amanda Maria CajigasLillyPatient Access ManagerCajigasam@gmail.com

Matthew W. ReighnInspira Health Network, Inc.Assistant Controller(856) 575-4775reighnm@ihn.org

Dan CapelaAtlantic Health SystemsManager Financial Systems (PFS)(973) 656-6928dan.capela@atlantichealth.org

Andrea SigismondiRevenue Guard Medical Claims ManagementVP IT(866) 624-0900andrea@revenue-guard.com

Laurie ClaytonPrinceton HealthCare SystemManager, Revenue Cycle Technology(609) 620-8369lclayton@princetonhcs.org

Kathleen M. DempseyCentraState Medical CenterSupervisor Revenue Integrity(732) 294-7051kdempsey@centrastate.com

Raina M. HarrellRowan UniversityDirector of Administration(856) 566-2707harrelrm@rowan.edu

Yolanda VirellaRowan University(856) 566-6744virellyo@rowan.edu

Lorenzo GarciaCommerce BankVP - National Account Exec(212) 786-2450lorenzo.garcia@commercebank.com

Tyler A. VergaPrinceton ProcureAccountant(732) 357-2607tylerverga@gmail.com

New Members

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Focus 35

Revenue Integrity Forum Hosts Successful June 2016 Conference

by Betsy Weiss, RN, MPH

Red, white and blue were the colors of the day on June 14th at the Renaissance Woodbridge Hotel for the Revenue Integ-rity Forum’s annual conference. The date of the conference fell on Flag Day and provided a backdrop to the day’s sessions.

The conference, entitled “Keeping the Beat in Today’s Chang-ing Healthcare Environment,” was designed to inform partici-pants of how the changing landscape from fee-for-service to value-based models will impact the fundamental components of the revenue cycle. The conference also provided strategies for hospital systems to remain viable in a value-based world.

In a return performance Helene O’Donnell of Capio Partners served as emcee. She kept the audience entertained between sessions and rallied support towards a collection for veterans. The Revenue Integrity Forum felt it was important to include a philanthropic component to the event and part-nered with the Metuchen Elks Lodge #1914 for this year’s event. All donations went to the Elks Veterans Service Com-mission which provides events and services for veterans in Middlesex County. The attendees of the session raised $534 for the organization exceeding the Forum’s goal of $500.

The induction of NJ HFMA officers for the 2016-2017 season kicked off the day, followed by a regulatory update by

Roger Sarao of NJHA. The formal education sessions included four informative presentations and an interactive panel discus-sion on bundled payment programs.

The first presenters, Govi Goyal and Kelly Pompea, both Regional Directors of Enterprise Solutions at ZirMed, dis-cussed “Life, Liberty & the Future of the Chargemaster (CDM)” and how in a value-based world the power to drill down and capture the true cost of supplies and procedures will be in-credibly advantageous. This was followed by a presentation by Sandy Piersol, Compliance Officer at Mc Bee Associates, who addressed key strategies to improve documentation and billing compliance for high cost drugs and devices.

There were a number of valuable take-away messages:• Embrace change as we move into a value-based reim-

bursement environment• Ensure your hospital system remains viable in a value-

based model by accurately capturing costs for services rendered

• Scrutinize costs for high-volume supplies such as screws and pins as hospitals need the ability to consider less ex- pensive alternatives while still maintaining quality stan- dards

• Create supply specific charge codes and move away from miscellaneous codes representing multiple items

• Ensure your chargemaster has the correct billing codes for high cost drugs and devices

• Understand when to apply the JW modifier and the documentation requirements that need to be followed

• Educate physicians on the need for detailed, specific and accurate documentation as these impact coding and ulti- mately hospital reimbursement

• Understand the dosage of drugs purchased and report drug units based on the full HCPCS billing descrip- tions, not based on packages/stocked vial size

Dr. Ronald Hirsch, noted author and VP of Education and Regulations Group from Accretive Physician Advisory Services,

Betsy Weiss, RN, MPH

continued on page 36

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36 Focus

changed gears and kept the audience engaged with his wit and case examples as he focused on how to avoid take backs and increased audit activity related to Medicare and Medicare Ad-vantage plans.

Some sage advice from Dr. Hirsch: • While CMS has put the short stay audits on hiatus to

provide more education to the auditors, expect them to resume soon. It is unclear which charts they will audit so continue to be vigilant to ensure all patients are placed in the right status.

• All one day admissions should be reviewed for compli- ance with the Two Midnight Rule prior to dropping the bill. Poor compliance with the Rule on the audits may lead to a referral to the Recovery Auditor.

• Medicare Advantage plans continue to create roadblocks to proper payment of admissions and proper care for your patients. Ask your case management staff to review any contracts to determine the effect on their work and the patients. Ask the plan for their rule book; you cannot play their game properly unless you know the rules.

• Physicians receive no compliance training. Hospitals that acquire physician practices assume responsibility for those physician billing practices. Ensure your doctors are educated on compliance, perform regular audits of their billing, and query the publically available databases on physician billing patterns to look for red flags.

• Medical necessity for all services, especially elective surgery and drug infusions, should be documented in every chart prior to the service being provided. If the documentation is not present, the service should not be provided.

After lunch, David Wagner, Market Manager of Remedy Partners, provided an overview of the CMS Bundled Pay-ment for Care Improvement program (BPCI) and warmed up the crowd for the panel discussion on bundled payment programs. He then became a panelist along with hospital rep-resentatives Robin Brown-Stovall of Jefferson Health (Senior Director, Revenue Integrity and Claims Processing) and Tracy Davison-Dicanto of Princeton HealthCare System (Executive Director or Network Development), and consultant, Caroline Rader Znaniec, (owner, Luna Health Care Advisors, LLC). Dr. Hirsch moderated and effectively engaged the panelists to share their perspectives and experiences with bundled payment programs. Recommendations from the panelists included:

• Ensure accuracy of patient identification and the account- able provider by encouraging collaboration between Case Management, Coding and Revenue Integrity. It is imper- ative that this coordination takes place while the patient and family are within reach of your hospital team.

• Using Coding resources, identify which cases are appli- cable for bundling as soon as possible so you can impact

the discharge planning at the beginning of the hospital stay rather than at discharge or even post discharge.

• Establish a Steering Committee with representation from key areas of the revenue cycle in order to ensure collabo- ration and prevent the bundling payment initiative from being managed in silos.

• Realize the importance of data analytics in managing initiatives like bundles, gainsharing and attribution re- lated deals.

• Encourage transparency as much as possible with physi- cians and other facilities while staying within the con- straints of confidentiality. The more that those partner- ing with you have confidence in what you are telling them, the better the relationship will be.

The final session of the day, “The Wave of the Future: Under- standing the Impact of Quality Reporting on the Revenue Cycle,” by Kim Charland, Editor of VBPmonitor and Senior VP of Clinical Innovation for Panacea Healthcare Solutions, tied to-gether the sessions to show the larger picture of how quality reporting continues to expand in all patient care settings and is becoming increasingly linked to payment for services.

The last food for thought:• Revenue Cycle staff need to determine where in their

roles they can begin to participate and impact changes that will help their organizations succeed in this new en- vironment.

• The move from fee-for-service to value-based payments is here and everyone in the revenue cycle needs to begin to educate themselves if they haven’t started.

Following the educational component, there were raffle drawings sponsored by Arcadia Recovery Bureau, FBCS, Inc. and Health Republic Insurance. The day culminated with a networking event sponsored by Craneware. We would like to

continued from page 35

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Focus 37

thank all of the vendors who generously supported the event as they are an integral part of the event and chapter. They in-clude: Accelerated Claims, Inc., Advanced Data Systems Cor-poration, Arcadia Recovery Bureau, Craneware, FBCS, Inc., GetixHealth, Panacea, Health Republic Insurance, PATHS and Trans-Continental Credit and Collection Corporation.

The Revenue Integrity Forum’s 2015-2016 season was chaired by Betsy Weiss, and Eric Shubin, co-chair, led the Edu-cation Sub-Committee for this successful event. The Educa-tion Sub-Committee included Nora Burdi, Jen Gillooly, Don-na Heringes, Jane Hoffman, Pam Hoon, Jay Mullaney, Helene

O’Donnell, Christine Putterman, Heather Stanisci, Justine Sponziello, and Kate Walsh, as well as Tracy Davison-Dicanto, our Board Liaison.

For a slide show of the highlights of the day, go to the home page of www.hfmanj.org.

About the authorBetsy Weiss, RN, MPH is the Director, Revenue Cycle at St. Francis Medical Center in Trenton, NJ. She was Chair of the Revenue In-tegrity Forum’s 2015-2016 season. Betsy can be reached at BWeiss@stfrancismedical.org.

CDS Software, makers of CollectOne andDorado Systems Inc., announced the two companies

will be partnering to offer Dorado Systems’ doradoRecover solution to CollectOne users.

Approximately 25% of all healthcare claims are denied. Nearly half of these are due to eligibility issues, including accounts incorrectly labeled as “self-pay”, when valid insurance coverage is actually available. doradoRecover will help CollectOne clients identify this coverage and reclaim millions of dollars from insurance companies for claims at risk of being, or having already been written off as bad debt.

“While searching for vendor partners that could address the growing healthcare collections vertical in the ARM industry we discovered Dorado’s solution” said Brett Menzie, Director of Sales at CDS. He continued “the success of our clients is our success. Giving our clients another avenue to reduce collection costs and recover more revenue naturally made sense, thus the partnership with Dorado Systems.”

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Industry News...

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38 Focus

Q&A: A Sound Investment Management Program is Imperative for Healthcare Organizations

by Craig Standen Craig Standen

Earlier this year, Cerulli Associates released a report1 on the invest-ment needs and concerns of the healthcare sector. The report high-lighted the increased focus on effective management of investable assets in an increasingly complex operating environment. Because healthcare providers tend to have multiple pools of assets–such as balance sheet pools, endowments and defined benefit pensions–finance professionals responsible for overseeing these investments must have a clear understanding of how decisions in one pool can and do impact other pools and the broader organization.

Why do you think there’s been an increased focus on in-vestment management for healthcare finance executives?

Over the past decade or so, hospitals and health systems have seen margins come under increasing pressure, and investment returns continue to play a critical role in maintaining financial stability. Favorable investment mar-kets over the longer term have helped to grow asset val-ues, strengthen balance sheets and provide hospitals and systems with financial flexibility to make strategic invest-ments.

Last year, healthcare sector outlooks from all three rating agencies highlighted the role of investment returns and the importance of how unrestricted assets are managed mov-ing forward. Beyond those operating assets, many health-care providers also oversee other investment pools including endowments, self-insurance, defined benefit and defined contribution plans. Each asset pool has a unique purpose, return objective and risk profile, which makes the strategic asset allocation for the entire investment program much more complex and important.

To effectively manage the portfolio, the organization must make investment decisions that take into account all asset pools and make sure that the strategic allocation aligns with and supports long-term goals and objectives. With so many moving parts, investment management

has become a major component of the broader financial strategy and risk management approach within healthcare organizations.

What components should be considered when trying to maximize investment management success?

The key to long-term success of any investment program is putting the appropriate strategic asset allocation in place and understanding the potential impact that investment performance across all organizational portfolios may have on the financial condition of a healthcare system. Each investment pool may have a specific goal or purpose; how-ever, from an enterprise wide perspective, a cohesive strat-egy is necessary to control the impact of these portfolios on broader organizational goals and objectives.

It’s also important to identify, quantify and prioritize risks. The financial profile of health systems can be vol-atile due to their high levels of exposure to the capital markets. Profitability and overall stability can also be im-pacted by variables that are largely out of management’s control. Therefore, it’s important to evaluate portfolios based not only on traditional comparisons to a predeter-mined benchmark or peer group, but also on the impact that portfolio construction has on important financial and credit metrics (such as days cash on hand, unrestrict-ed cash/debt, debt to capitalization and debt service cov-erage). Once the key risk factors are identified and quanti-fied, healthcare providers are in a better position to make decisions regarding the level and types of risk factors they are willing to accept in various asset pools and across the broader strategic allocation.

Also, it’s important to monitor performance relative to objectives at the portfolio level and progress toward stated goals at the organizational level.

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Alternative investments have piqued the interest of many healthcare executives, but they undoubtedly bring ad-ditional complexity to the portfolio. How should these strategies be viewed or used?

We believe alternative strategies have a role in a well-diversified portfolio, historically providing uncorrelated sources of returns and, depending upon the strategy, re-ducing volatility. When healthcare executives consider adding alternatives to an asset allocation, the executives and board governance should examine a number of fac-tors, including:› The purpose of the particular pool› The risk/return objectives for the pool and the broader investment program› The organizational liquidity requirements and/or con- straints that might be impacted by the illiquidity associ- ated with a range of alternative strategies

While alternatives might be viewed as only being ap-propriate for larger healthcare organizations, many pro-viders across the size spectrum use alternative strategies within their various asset pools. Ultimately, the growing number and complexity of alternative investments avail-able to institutional investors—including healthcare pro-viders—requires that they have the staff and expertise able to evaluate the options and clearly understand the risk/return trade-offs of the alternative investments they might include in their strategic allocation. The Cerulli report specifically mentions using outside expertise, such as an outsourced chief investment officer (OCIO), when considering adding alternatives to any portfolio.

With regard to outside expertise, how are healthcare or-ganizations building a process that uses the right mix of partners and internal resources?

Since the implementation of the Affordable Care Act, hos-pital and health system finance teams have faced a myriad of challenges adapting to the new operating environment with time and resources stretched pretty thin. Healthcare CFOs are entrenched in daily operations, and finance teams are charged with managing multiple asset pools in a very complex investing environment, while also dedicating time to strategic planning. The recent Cerulli report mentions the challenges and stress that typical healthcare finance pro-fessionals face. “Regardless of who oversees the responsibili-ties of asset allocation, manager selection, etc., it is not an easy endeavor. As one consultant explained to Cerulli, ‘I feel bad for finance people in the healthcare systems; they’re just getting destroyed. When meeting a treasurer, their desk is completely covered and they’re constantly fighting fires.’”1

Some healthcare organizations maintain full-time staff dedicated to managing the investment pools. However, primarily due to cost constraints, the vast majority of hospitals and health systems either rely on internal staff members with multiple job responsibilities (in addition to monitoring investments), or on external investment man-agers that can provide additional expertise and resources.

To overcome time management and lack of inter-nal expertise issues, as well as satisfy the need for greater customization, investment outsourcing continues to be a growing trend in the healthcare sector. Discretionary man-agers allow healthcare organizations to delegate part of the investment management decision-making process to ex-ternal experts. Plus, this delegation also frees up time for finance executives to focus on strategic issues and makes the overall investment management process more efficient and nimble.

About the authorCraig serves as the healthcare director for the Advisory Team, where he is responsible for implementing SEI’s healthcare solution to our institutional client base. His team provides advice and analysis that integrates multiple asset pools, including operating, founda-tion, endowment and pension plan assets, with corporate finances into a cohesive investment strategy.

Craig has extensive experience delivering customized financing and balance sheet management solutions to institutional clients in the nonprofit healthcare sector. He regularly speaks at industry conferences and served as a guest lecturer on healthcare finance at Loyola University in Chicago. Also, publications, such as Crain’s Chicago Business, The Bond Buyer and Investor’s Business Daily have interviewed Craig.

He earned his B.A. in economics from Cornell University and his MBA from the Weatherhead School of Management at Case Western Reserve University. He also maintains FINRA Series 7 and 66 licenses. Craig can be reached at CStanden@seic.com

Footnote1Cerulli Associates, The Cerulli Edge, U.S. Institutional Edition: Health And Hospitals, 2Q 2016

This information is provided by SEI Investments Management Corporation (SIMC), a registered investment adviser and wholly owned subsidiary of SEI Investments Company. The material included herein is based on the views of SIMC. Statements that are not factual in nature, including opinions, projec-tions and estimates, assume certain economic conditions and industry de-velopments and constitute only current opinions that are subject to change without notice. Nothing herein is intended to be a forecast of future events, or a guarantee of future results. This information should not be relied upon by the reader as research or investment advice (unless SIMC has otherwise separately entered into a written agreement for the provision of investment advice).

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Wednesday, October 5, 2016

9:45–10:00 Welcome Ballroom Dan Willis Annual Institute Chair Welcome to the 40th Annual Institute General10:00–10:50 General Session #1 Ballroom Day Egusquiza AR Systems, Inc. Attacking the 2 Midnight Rule - General Finding Your Lost Inpatients10:50–11:05 Break Vendor Hall Break11:05–11:30 Chapter Awards Ballroom Heather Weber Baker Tilly Virchow Krause, LLP General11:30–12:40 Lunch Vendor Hall Lunch11:40–12:30 Lunch & Learn Studio 1 57 Kim Charland / Greg Adams Panacea Healthcare Solutions, Inc. Preparing and Navigating Through the Payer Issues/ Bundled Payment Maze Managed Care11:30–12:30 Board Meeting Studio 3 Board Meeting11:30–12:00 Vendor Demo 1 Boardroom 1 Transunion eScan Eligibility Solution Vendor Demo11:30–12:00 Vendor Demo 2 Boardroom 2 Vendor Demo12:10–12:40 Vendor Demo 3 Boardroom 1 Adreima Increasing Satisfaction in the Hospital Vendor Demo Revenue Cycle 12:10–12:40 Vendor Demo 4 Boardroom 2 Vendor Demo12:45–2:00 Keynote Ballroom Connie Merritt General2:00–2:15 Break Vendor Hall Break2:15–3:05 Breakout #1 Studio 1 09 John S. Budd / ECG Management Changing Care Delivery Through Payer Issues/ Asif Shah Mohammed Consultants Retail Partnerships Managed Care2:15–3:05 Breakout #1 Studio 2 31 Scott Besler / Fred Fisher BESLER Consulting Uncompensated Care & Worksheet S-10 Financial in the Regulatory Environment Reporting/Tax2:15–3:05 Breakout #1 Studio 3 64 Brian Gale / Richard Friedland SaferMD, LLC / DRA Imaging Failure to Communicate: High Stakes Compliance/ Problem and High Performance Solutions Revenue Integrity2:15–3:05 Breakout #1 Studio 4 08 Howard Tepper Barnabas Health Physician Hospital Integration - Your Revenue Cycle Practice Has Been Purchased - Now What?2:15–3:05 Breakout #1 Boardroom 1 6 Sandy Gubbine AtlantiCare How To Build A Career Path For Revenue Revenue Cycle Cycle Staff 3:05–3:20 Break Vendor Hall Break3:20–4:10 Breakout #2 Studio 1 26 Frank Lonardo Cammack Health Trends in Commercial Plans and Their Payer Issues/ Impact on Your Financial Health Managed Care3:20–4:10 Breakout #2 Studio 2 49 Maria Facciponti / Julie Capra Adreima Transform Patient Satisfaction while Revenue Cycle Accelerating Cash Flow 3:20–4:10 Breakout #2 Studio 3 34 Bret S. Bissey MediTract What Every Compliance Officer Needs Compliance/ in Their Toolkit Revenue Integrity3:20–4:10 Breakout #2 Studio 4 44 Jack Byrnes/Robert Guadagno The PFM Group Overview of Taxable Financing Options for Financial Christine Doyle Non Profit Hospitals and Health Systems Reporting/Tax4:10–4:20 Break Vendor Hall Break4:20–5:10 Breakout #3 Studio 1 67 Heather Hagan/Ryan Haggerty Deloitte Advisory Getting Ahead of MACRA and its Implications Revenue Cycle4:20–5:10 Breakout #3 Studio 2 61 Lou Feuerstein / Grant Thornton LLP FASB & AICPA Update Financial Crispin Hildebrand Reporting/Tax4:20–5:10 Breakout #3 Studio 3 53 Stella Visaggio/ Atlantic Health System Optimizing Reimbursement with Pay Payer Issues/ Stephen Moran for Performance Managed Care4:20–5:10 Breakout #3 Studio 4 58 Rita Romeu / Gerry Blass / ComplyAssistant / How to Effectively and Compliantly Work Compliance/ Helen Oscislawski / Attorneys at Oscislawski LLC / With Your BA's: Hear It From Both Sides Revenue Integrity Donna Michael-Ziereis AtlantiCare5:10–5:30 Break Vendor Hall Break5:30–8:00 Charity Event Vendor Hall

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Thursday, October October 6, 20169:00–9:50 General Session #1 Ballroom 45 John Dalton BESLER Consulting American Healthcare - Worst Value in the General Developed World?9:50–10:40 General Session #2 Ballroom 51 Edward Anselm / QualCare Inc. / Health Republic of NJ / HRINJ/Qualcare - A Healthcare Exchange General Kevin Joyce / Tim Ford / Health-Lynx Success Story Tom Dwyer10:40–10:50 Break Vendor Hall Break10:50–11:40 General Session #3 Ballroom 38 Michael J. McLafferty EisnerAmper LLP 2017 Annual Healthcare Update General11:40–12:50 Lunch Vendor Hall Lunch11:50–12:40 Lunch & Learn Studio 1 37 Dr. Cheryl Lyn Hayne CentraState Healthcare/ Bundled Payments & Other Emerging Models Payer Issues/ Jo Surpin Applied Medical Software Managed Care11:40–12:10 Vendor Demo 1 Boardroom 1 Quality Asset Recovery Challenges Presented in Medical Receivables Vendor Demo11:40–12:10 Vendor Demo 2 Boardroom 2 Vendor Demo12:20–12:50 Vendor Demo 3 Boardroom 1 MediTract/MD Buyline Purchased Services manager Vendor Demo12:20–12:50 Vendor Demo 4 Boardroom 2 Vendor Demo1:00–2:15 Keynote Ballroom Nancy Ham Medicity Value Based Contracting General2:15–2:30 Break Vendor Hall Break2:30–3:20 Breakout #1 Studio 1 32 Kate S. Gillespie / Virtua Navigating Bundled Payments: Payer Issues/ Christine Gordon One HealthSystem's Success Story Managed Care2:30–3:20 Breakout #1 Studio 2 47 Dr. Raj Lakhanpal SpectraMedix Powering Quality and Operations Compliance/ Improvement Initiatives with Financial Revenue Integrity Implications Through Integrated Data Consolidation and Self Service Analysis2:30–3:20 Breakout #1 Studio 3 14 Kristin Greenstreet Navigant Consulting, Inc. Transforming Your Revenue Cycle Revenue Cycle2:30–3:20 Breakout #1 Studio 4 46 Kathy Ruggieri / BESLER Consulting EPIC Conversion - Revenue Cycle Revenue Cycle Mary Devine Lessons Learned 3:20–3:35 Break Vendor Hall Break3:35–4:25 Breakout #2 Studio 1 55 Joseph Partain Convergent Revenue Cycle Management, Inc. Using Legal Education to Build a Successful Payer Issues/ Denial Management Team Managed Care3:35–4:25 Breakout #2 Studio 2 21 Jim Boswell / IKS Health / ECG Management Consultants Supporting the Transition from Volume Compliance/ Jennifer McGraw / to Value Revenue Integrity Lillian Lee-Chun3:35–4:25 Breakout #2 Studio 3 11 Kurt Mosley Merritt Hawkins Doctor, Dollars and Health Reform: Revenue Cycle Physician Reimbursement From Fee-For-Service to MIPS3:35–4:25 Breakout #2 Studio 4 68 Craig Dolan/Thomas Perry Pharmatek Systems / St. Joseph Panel Discussion: Transforming the Financial Mitch Sobel Medical Center / Pharmacy Cost center - Profitability Analytics Reporting/Tax Nancy Palamara Holy Name Medical Center & Actions3:35–4:25 Breakout #2 Boardroom 1 54 Gretchen Segado / Ernst & Young Update on Federally Qualified Health Revenue Cycle Sam Cunningham Centers (FQHC) 4:20–4:35 Break Vendor Hall Break4:35–5:25 Breakout #3 Studio 1 62 Terry Brown/David Mistkawi The SSI Group Touch Free Billing: Flipping the Pyramid Revenue Cycle4:35–5:25 Breakout #3 Studio 2 56 Craig Standen SEI Investments Capital Planning: A Changing Approach for a Financial Changing Landscape Reporting/Tax4:35–5:25 Breakout #3 Studio 3 03 Robert F. Bacon University of Pennsylvania Health System Increased Government Scrutiny & Adopting Compliance/ Risk Based Auditing Revenue Integrity4:35–5:25 Breakout #3 Studio 4 36 James S. Ryan / ECG Management Consultants Taking "Advantage of the Changing Market - Payer Issues/ Tyronne Jolly Exploring the Medicare Advantage" Managed Care Opportunity4:35–5:25 Breakout #3 Boardroom 1 18 Idette Elizondo / Veralon Partners Using Data Analytics to Improve Payer Issues/ Amanda Brown ACO Performance Managed Care5:25–6:00 Break Vendor Hall Break6:00–8:00 President's Reception Signature Room Dan Willis, President 10:00–??? Late Night Get Together Premier

Friday, October 7, 20169:00–10:00 Keynote Ballroom Steve Adubato Caucus Educational Corporational Lessons in Leadership General10:00–10:10 Break 10:10–11:00 General Session #1 Ballroom 50 Edward Anselm Health Republic of NJ Health Care Cost Savings Through Improved General Tobacco Control in New Jersey: Challenges and Opportunities

11:00–12:30 Panel Discussion Ballroom Betsy Ryan - Moderator New Jersey Hospital Association Expanding Your Footprint in Today's Market General Tom Baldosaro, CFO Inspira Health Network Phil Okala, Senior VP for University of Business Development Pennsylvania Health System TBD TBD

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New Jersey Healthcare FinancialManagement Association

2015-16 Chapter Awards Listing

YERGER Awards:Awards are presented to Yerger authors and applicable committee chairs

Collaboration with the state hospital association to produce “Finance Education for Clinicians.”Michael McKeeeverStacey BigosJane Kaye

Networking Opportunities Improvement Plan for 2015/2016 Heather WeberMaria FaccipontiPeter Demos Brittany PickellMike Alwell

Utilizing LinkedIn & Star Chapter Email Blasts to Increase Sponsorship and Registration RevenuesJennifer VanegasDeb CarlinoMichael McKeeever

Women’s Event Using Member Feedback to Reinvigorate an All-Day Women Focused Education ProgramHeather StanisciDeb Carlino

Creation of an Assistant Treasurer Position for the NJ ChapterScott Mariani Linda Gnesin

Creation of a Study Group to Assist Members Desiring to Take the New HFMA Certification ExamRita Romeu

Medal of HonorDan WillisDave Wiessel

President’s AwardMichael McKeeeverJennifer VanegasChairs of Institute

Leading the Change AwardSandra GubbineWebinar Guru

Sister Mary Gerald Bronze Awards of Excellence for EducationMichael McKeeeverSandra GubbineStacey BigosMary CroninEducation Committee Chairs

Founders Merit Award - BRONZEDara QuinnRhonda MarazitiSteven Stadtmauer, EsqJill Squiers

Founders Merit Award - SILVER Anthony Panico

Founders Merit Award - GOLDB.J. WelshErica WallerKathryn Gibbons

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44 Focus

2016 Chapter Internal Financial Review

HFMA requires that each chapter conduct either an independent audit or a HFMA Internal Financial Review. The HFMA Internal Financial Review process and reporting was developed by HFMA and must be followed by any chapter opting for this approach instead of an independent audit. Pursuant to HFMA’s requirements, the Internal Financial Review must also be completed by an individual or individuals possessing the appropriate financial experience and who are not involved in the chapter’s bookkeeping activity.

The purpose of the Internal Financial Review is to test and validate the chapter’s fiscal integrity and operating guidelines. Furthermore, the review:

• Addresses whether the chapter’s financial statements correctly reflect its activities for the year.

• Considers whether an adequate level of documentation is maintained for the chapter’s receipt and disbursement transactions in order to reconcile checking and saving account bank statements.

• Considers whether transaction approval guidelines are in place and being observed.

The Internal Financial Review for the 2015-2016 Chapter Year was completed on a voluntary basis by a certified public accountant who is a member of the chapter. The Chapter Treasurer, Assistant Treasurer and Officers provided the necessary documentation required for the Internal Financial Review. The completed Internal Financial Review questionnaire was provided to the chapter’s Audit Committee of the Board of Directors. A meeting of the Committee was held to review the findings and the questionnaire. Upon review, the Audit Committee accepted the Internal Financial Review findings and approved the final financial statements for the 2015-2016 Chapter Year.

The accompanying balance sheets and statements of activities and cash flows for the years ended May 31, 2016, 2015 and 2014 reflect the final financial statements for the NJ Chapter. If you should have any questions, please feel free to reach out to any Board member for assistance.

I extend my congratulations to the chapter on another successful year.

Respectfully submitted,

Tracy A. Davison-DiCanto, FHFMA2015-2016 Audit Committee ChairNJ HFMA

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2016 2015 2014 Assets Current Assets Bank accounts 325,957 301,316 253,136 Accounts receivable, net 13,704 14,153 8,062 Other current assets 30,795 15,783 8,041 Total current assets 370,456 331,252 269,239

Fixed assets - - - Total assets 370,456 331,252 269,239

Liabilities and net assets Liabilities Current liabilities Accounts payable 70,147 80,847 54,969 Deferred revenue 31,480 35,250 41,385 Accrued payroll 4,346 3,591 4,706 Total current liabilities 105,973 119,688 101,060 Total liabilities 105,973 119,688 101,060

Net assets Unrestricted net assets 264,483 211,564 168,179 Total liabilities and net assets 370,456 331,252 269,239

Healthcare Financial Management Association - New Jersey ChapterBalance Sheets

May 31

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46 Focus

2016 2015 2014

Operating activities Net income (loss) 52,919 43,385 21,163 Adjustments to reconcile net income (loss) to net cash provided by (used in) operations: Accounts receivable, net 449 (6,091) 6,528 Other current assets (15,012) (7,742) 14,959 Depreciation - - 1,039 Accounts payable (10,700) 25,878 (37,610) Deferred Revenue (3,770) (6,135) (1,313) Accrued Payroll 755 (1,115) (1,742)Net cash provided by (used in) operating activities 24,641 48,180 3,024

Cash at beginning of period 301,316 253,136 250,112 Cash at end of period 325,957 301,316 253,136

Healthcare Financial Management Association - New Jersey ChapterStatement of Cash Flows

Year ended May 31

2016 2015 2014

Income Meeting and education income 240,672 242,996 239,599 Newsletter income 38,548 42,980 43,062 Golf Outing Income 65,050 60,750 61,835 General sponsorship income 238,866 191,385 189,137 Interest income 249 304 300 Other income 30,190 29,330 29,843 Total income 613,575 567,745 563,776

Expenses Meeting and education expenses 384,667 350,316 360,183 Newsletter expenses 32,251 35,544 43,167 Golf Outing expenses 56,344 59,491 53,780 Member recognition and social event expenses 16,041 7,666 5,175 General and administration expenses 71,363 71,406 78,072 Depreciation - - 1,039 (Recovery of) provision for bad debts (10) (63) 1,197 Total expenses 560,656 524,360 542,613 Net Operating Income 52,919 43,385 21,163 Net (loss) income 52,919 43,385 21,163

Healthcare Financial Management Association - New Jersey ChapterStatements of Activities

Year ended May 31

Focus 47

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INSTITUTE SPONSOR GUIDE

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@Sutherland_HC

2 Brighton Road, Clifton, New Jersey

SUTHERLAND ISHONORED TO SPONSOR

THE 40TH NJ & METROPHILLY HFMA

ANNUAL INSTITUTE

withum.com

IN HEALTHCARE SERVICES

SM

At WithumSmith+Brown, PC, (Withum), our client-focused philosophy and goal-oriented approach delivers expertise, efficiency and innovation to meet the unique needs of the healthcare industry.

Scott J. Mariani, JD, Partner

Has your revenue cycle lost its spark?

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Optimizing purchasing, compliant contracting. The only strategic sourcing application suite deliveringPeace of Mind to those who make healthcare work for all of us.work for all of us.

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INSTITUTE SPONSOR GUIDE

J.P. Morgan is proud to support the HFMA NJ 2016 Institute

© 2016 JPMorgan Chase & Co. All rights reserved. 255078

Education, Learning, Training… Get All Your Continuing Educational Needs in One Place

NJMGMA has a full calendar of educational events including online webinars, face to face seminars and our annual 3-day Practice Management Conference. Scheduled throughout the year and covering all facets of Practice Management, NJMGMA strives to be

Webinar Series

Lunchtime Webinars, 2 Tuesday’s a month,

12:00-1:00

Quarterly Education Seminars

North and South Jersey locations for your

convenience

Annual Practice Management Conference Save the Date:

June 14-16, 2017

Archived Webinars available for members at

NJMGMA.COM

NJMGMA P.O. BOX 3403

HAMILTON, NJ 08619 608-208-3279

WWW.NJMGMA.COM

A Division of

Award Winning Technology Based Revenue Cycle Management for Hospitals and Physicians

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3 9/16” x 4 11/16”Full Color

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Health Plans that Care AboutYour Health Care

732-562-0833www.qualcareinc.com

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Thank you to our 2016 Sponsors

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Maximized & Clean AR

Medicare • Medicaid • Blue Cross • Commercial/Managed Care Appeals & Denials • Customer Service Call Center

libertybilling.com

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NEW JERSEY EXPERTS IN EMS BILLING & COMPLIANCE

REVENUE GUARD

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Our 2016-2017 NJHFMA Board

Our 2016-2017 NJHFMA Board was inducted early in the day at the Revenue Integrity June 14th Meeting at the Renaissance Woodbridge Hotel. Inducted board members were as follows:

Officers:Dan Willis, PresidentErica Waller, Treasurer

Scott Mariani, President-ElectMichael McKeever, Secretary

Board Members:Scott BeslerStacey BigosMegan ByrneDeborah CarlinoPeter DemosBrian HerdmanKevin Joyce

Anthony J. PanicoBrittany PickellJosette PortalatinBelinda Doyle PuglisiRoger Sarao – Ex-OfficioHealther Stanisci Jill Squires

Congratulations to all and best wishes for another fabulous year!

“ There is a single light of science, and to brighten it anywhere is to brighten it everywhere.”

- Isaac Asimov

Fox Rothschild’s health law attorneys are at the cutting edge in helping clients respond to the challenges

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With a reputation as a leading national health law practice, we offer personalized service and practical, cost-effective solutions to the

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(877) 4BESLER | www.besler.com | @BeslerDotComEnhancing and protecting Medicare revenue for hospitals

Visit besler.com/CJR to download a Special Report that explains how CJR works and what your responsibilities are in this new environment.

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