Practical Information for Your Practical Information for Your Revenue CycleRevenue Cycle

• Discover HFMA Website’s InformationDiscover HFMA Website’s Information• Demonstrate Practical Application of Demonstrate Practical Application of

the informationthe information• Challenge - Do!Challenge - Do!

• The Site Layout Includes the following:The Site Layout Includes the following:– Knowledge Center *Knowledge Center *– Education & Events *Education & Events *– Publications *Publications *– HFMA Initiatives &*HFMA Initiatives &*– Career Center *Career Center *– New & Opinion *New & Opinion *– Marketplace *Marketplace *– Communities *Communities *– About HFMAAbout HFMA

• The Knowledge Center has a plethora of The Knowledge Center has a plethora of information in the following categories:information in the following categories:– Accounting and Financial ReportingAccounting and Financial Reporting– Finance and Business StrategyFinance and Business Strategy– Legal and Regulatory ComplianceLegal and Regulatory Compliance– Operations ManagementOperations Management– Payment, Reimbursement, and Managed Payment, Reimbursement, and Managed

Care *Care *– Revenue Cycle *Revenue Cycle *– Technology *Technology *

• There are areas that relate to There are areas that relate to Revenue Cycle in Knowledge Center, Revenue Cycle in Knowledge Center, but the the HOT ones are:but the the HOT ones are:– Legal and Regulatory ComplianceLegal and Regulatory Compliance– Payment, Reimbursement, and Managed Payment, Reimbursement, and Managed

CareCare– TechnologyTechnology

• The Area of Greatest Interest for The Area of Greatest Interest for Revenue Cycle Leaders?Revenue Cycle Leaders?

The Revenue Cycle The Revenue Cycle Category!!!Category!!!

• Bad DebtBad Debt• Billings and CollectionsBillings and Collections• Charity Care and Financial CounselingCharity Care and Financial Counseling• CDM, Charge Capture and CodingCDM, Charge Capture and Coding• Consumer-Directed Health CareConsumer-Directed Health Care• Denials ManagementDenials Management• Patient AccessPatient Access• Self-Payment CollectionSelf-Payment Collection

• Key pieces to this part of the site:Key pieces to this part of the site:• There are virtual conference trainings There are virtual conference trainings

that are free.that are free.• Certification information is availableCertification information is available• Credentialing for your Revenue Cycle Credentialing for your Revenue Cycle

Staff is availableStaff is available• Training Products (Mastering Customer Training Products (Mastering Customer

Service and Revenue Cycle)Service and Revenue Cycle)

• HFM Magazine *HFM Magazine *• Healthcare Cost Containment Healthcare Cost Containment

NewsletterNewsletter• Revenue Cycle Strategist Newsletter *Revenue Cycle Strategist Newsletter *• Strategic Financial Planning NewsletterStrategic Financial Planning Newsletter• LeadershipLeadership• Healthcare Finance Strategies E-BulletinHealthcare Finance Strategies E-Bulletin• Career Opportunities E-BulletinCareer Opportunities E-Bulletin• Patient Friendly Billing E-BulletinPatient Friendly Billing E-Bulletin• Business of Caring ArchivesBusiness of Caring Archives

• HFMA’s MAP *HFMA’s MAP *• The Value ProjectThe Value Project• Principles and Practices BoardPrinciples and Practices Board• Healthcare ReformHealthcare Reform• Patient Friendly Billing *Patient Friendly Billing *• Healthcare Financial PulseHealthcare Financial Pulse• Research and TrendsResearch and Trends• Financing the FutureFinancing the Future• CoalitionsCoalitions

• Job Bank *Job Bank *• Careers at HFMACareers at HFMA• CertificationCertification• Subscribe to Career OpportunitiesSubscribe to Career Opportunities

• It has Healthcare Finance NewsIt has Healthcare Finance News• From the Chair and PresidentFrom the Chair and President• HFMA NewsHFMA News• My favorite is the News Roundup My favorite is the News Roundup

(News from various sources talking (News from various sources talking about things that can impact about things that can impact Revenue Cycle)Revenue Cycle)

• Revenue Cycle Forum *Revenue Cycle Forum *– More Article AccessMore Article Access– More Tool AccessMore Tool Access– Ask Experts QuestionsAsk Experts Questions– Participate in List Serve and Message Participate in List Serve and Message

BoardBoard

• Your Revenue Cycle is a Mess Your Revenue Cycle is a Mess • You can’t fix it RESISTANCE IS You can’t fix it RESISTANCE IS

FUTILE!!!FUTILE!!!

• Net Days in A/RNet Days in A/R• Aged A/R as a Percentage of billed A/RAged A/R as a Percentage of billed A/R• Point-of-Service CollectionsPoint-of-Service Collections• Cost to CollectCost to Collect• Cash Collections as a Percentage of Cash Collections as a Percentage of

Adjusted Patient Net Service RevenueAdjusted Patient Net Service Revenue• Bad DebtBad Debt• Charity CareCharity Care• Days in Total Discharged Not Final Billed Days in Total Discharged Not Final Billed

(DNFB)(DNFB)

• Aged A/R as a % of Billed A/R by Payer Aged A/R as a % of Billed A/R by Payer GroupGroup

• Day in Final Billed Not Submitted to Day in Final Billed Not Submitted to PayerPayer

• Days in Total Discharged Not Submitted Days in Total Discharged Not Submitted to Payerto Payer

• Late Charges as % of Total ChargesLate Charges as % of Total Charges• Initial Denial Rate – Zero PayInitial Denial Rate – Zero Pay• Initial Denial Rate – Partial PayInitial Denial Rate – Partial Pay

• Denial Overturned by AppealDenial Overturned by Appeal• Net Days Revenue in Credit BalanceNet Days Revenue in Credit Balance• Pre-Registration RatePre-Registration Rate• Insurance Verification RateInsurance Verification Rate• Service Authorization RateService Authorization Rate

• Effective 12/01/10 MAP Application Effective 12/01/10 MAP Application was made available.was made available.

• Cost is based on sizeCost is based on size– Solo Facility Solo Facility – SystemSystem

• Not Necessary to Participate in MAP Not Necessary to Participate in MAP AwardAward

• MAP Keys bring standard definitions MAP Keys bring standard definitions and purpose to enable providers to and purpose to enable providers to compare with like facilitiescompare with like facilities

• New KPI’s New KPI’s • Days in Final Billed Not Submitted to Days in Final Billed Not Submitted to

Payer (FBNS) tracks claims held by Payer (FBNS) tracks claims held by edits in claims processing system or edits in claims processing system or secondary bills not sent outsecondary bills not sent out

• Days in Total Discharged Not Days in Total Discharged Not Submitted to Payer (DNSP) – Includes Submitted to Payer (DNSP) – Includes FBNS and DNFBFBNS and DNFB

• Ecclesiastes 1:9 NIVEcclesiastes 1:9 NIV

““What has been will be again, What has been will be again,    what has been done will be done    what has been done will be done again; again;    there is nothing new under the sun.”   there is nothing new under the sun.”

Jason’s Translation: Don’t recreate the Jason’s Translation: Don’t recreate the wheel…Steal !!!wheel…Steal !!!

• Average Registration Time – unknown, but Average Registration Time – unknown, but patient’s are complainingpatient’s are complaining

• Average Patient Wait Time – unknown. But Average Patient Wait Time – unknown. But patients and departments complainingpatients and departments complaining

• Average patient registrations per shift – Average patient registrations per shift – UnknownUnknown

• Registration Data Quality – Unknown but a Registration Data Quality – Unknown but a lot of patient and business office complaintslot of patient and business office complaints

• MSPQs obtained – Accidentally eliminatedMSPQs obtained – Accidentally eliminated

• Average registration interview duration Average registration interview duration << 10 minutes 10 minutes

• Average patient Wait time Average patient Wait time << 10 Minutes 10 Minutes• Average Registrations per shift (Varies Average Registrations per shift (Varies

by department and system - 35 by department and system - 35 inpatient 40 outpatient is Hammer’s KPI)inpatient 40 outpatient is Hammer’s KPI)

• Data Quality 99% or better Data Quality 99% or better • ABN and MSPQ when Required 100%ABN and MSPQ when Required 100%

• Requested Productivity Reports with Requested Productivity Reports with Detailed Registration Start and Stop TimesDetailed Registration Start and Stop Times– The times seemed reasonable 80% of the timeThe times seemed reasonable 80% of the time– 20% of the time there were significant waits20% of the time there were significant waits

• Worked with Staff and found that Incomplete Worked with Staff and found that Incomplete Orders shut the process downOrders shut the process down

• Designated an office individual to handle those Designated an office individual to handle those situations with patient, physician and departmentsituations with patient, physician and department

• Increased percentage to 98%Increased percentage to 98%

• Still had complaints Still had complaints – Volume of Accounts didn’t work due to rush Volume of Accounts didn’t work due to rush

periods and lulls after doing a traffic study. It periods and lulls after doing a traffic study. It wasn’t a productivity issuewasn’t a productivity issue

– Implemented a inexpensive check-in system Implemented a inexpensive check-in system • Patients were waiting a long time for lab services and Patients were waiting a long time for lab services and

surgical servicessurgical services

– Implemented direct lab registration processImplemented direct lab registration process– Implemented Quick-Registration for Surgical Implemented Quick-Registration for Surgical

PatientsPatients• Significant improvement (except for lab patients at Significant improvement (except for lab patients at

peak times)peak times)• Patient Access Perception Improved (Press Ganey)Patient Access Perception Improved (Press Ganey)

• Complaints from Patient and Complaints from Patient and Business OfficeBusiness Office– Implemented Individual AuditingImplemented Individual Auditing– Scanned Cards and IDs for Identity Scanned Cards and IDs for Identity

Protection and to Audit AccuracyProtection and to Audit Accuracy

Expect Expect Staff to Staff to “Bomb” “Bomb” the first the first audits. audits. They need They need to fully to fully understanunderstand d expectatioexpectations.ns.

Scores will Scores will improve improve over time over time as staff see as staff see that that quality is quality is being being monitored monitored seriouslyseriously

• If you don’t ask the question, you If you don’t ask the question, you don’t know what is going on.don’t know what is going on.

• MSPQ’s were accidentally MSPQ’s were accidentally discontinued when an eligibility discontinued when an eligibility verification was implemented a year verification was implemented a year before.before.

• Training occurred and the MSPQ was Training occurred and the MSPQ was initiated immediately following. initiated immediately following.

• Hospital Scenario Hospital Scenario –Cash flow diminishingCash flow diminishing–HIM days at 10HIM days at 10–Coder productivity unknownCoder productivity unknown–Un-coded charts > 30 unknownUn-coded charts > 30 unknown

• All coding done is in descending balance order, not first All coding done is in descending balance order, not first in/first out. in/first out.

• Consistently monitor and control Discharged-Not-Final-Billed Consistently monitor and control Discharged-Not-Final-Billed A/R due to HIM.A/R due to HIM.

• HIM “DRG development” D-N-F-B A/R days greater than the HIM “DRG development” D-N-F-B A/R days greater than the late charge hold ≤ 2 A/R days late charge hold ≤ 2 A/R days

• Inpatient charts coded, per coder per day Inpatient charts coded, per coder per day • 23 - 26 23 - 26 • Outpatient charts coded, per coder per day Outpatient charts coded, per coder per day • 150 - 230 150 - 230 • Emergency room charts coded, per coder per day Emergency room charts coded, per coder per day • 190 - 250 190 - 250 • All coding is done by employees who report to the HIM All coding is done by employees who report to the HIM

director.director.

• Discovered that completed coding was Discovered that completed coding was being tracked by a paper report generated being tracked by a paper report generated weekly.weekly.

• Employee manually noted issues on paper.Employee manually noted issues on paper.• High Balances were worked like low High Balances were worked like low

balances (No Pareto Principle gains)balances (No Pareto Principle gains)– Discovered a software add-on not used by Discovered a software add-on not used by

hospital and created queues for each coderhospital and created queues for each coder– Productivity Reports createdProductivity Reports created– Coding Days began to drop except for Coding Days began to drop except for

outpatientoutpatient

• Discovered that Facility-Based Urgent Discovered that Facility-Based Urgent Care coding happened on-siteCare coding happened on-site

• Coder position was vacant and lead was Coder position was vacant and lead was coding when had timecoding when had time

• Coding was 6 months behindCoding was 6 months behind– Used Scanning Technology to scan charts Used Scanning Technology to scan charts

at site dailyat site daily– Urgent Care coding position moved under Urgent Care coding position moved under

HIMHIM– Coding caught upCoding caught up– Increase Revenue due to coder put in Increase Revenue due to coder put in

charge for E/M codescharge for E/M codes

• Bill hold 6 daysBill hold 6 days• CDM duplicates - UnknownCDM duplicates - Unknown• Incorrect CDM items – UnknownIncorrect CDM items – Unknown• Item price less than HOPPS APC rate Item price less than HOPPS APC rate

– Unknown– Unknown

• Late Charge Hold Period 2-4 daysLate Charge Hold Period 2-4 days• CDM Duplicate 0CDM Duplicate 0• CDM Codes Incorrect/Missing CPT CDM Codes Incorrect/Missing CPT

HCPCS 0HCPCS 0• CDM item price less than HOPPS APC CDM item price less than HOPPS APC

raterate

• Worked with Departments and taught Worked with Departments and taught department directors how to review rejected department directors how to review rejected charge reports, revenue reports, and enforced charge reports, revenue reports, and enforced late charge policylate charge policy– Increase revenue and reduced late charges for Increase revenue and reduced late charges for

many departments other lost their revenue many departments other lost their revenue already not being billedalready not being billed

• Discovered duplicate and incorrect CDM codes Discovered duplicate and incorrect CDM codes and prices below APC rate –Some rates hadn’t and prices below APC rate –Some rates hadn’t been updated since going on the system 2 been updated since going on the system 2 years prioryears prior– Updated CDM and improved revenue, payment, Updated CDM and improved revenue, payment,

and billing complianceand billing compliance

• Discharge Not Final Billed (DNFB) 11.1Discharge Not Final Billed (DNFB) 11.1• A/R Days 58.5 Gross (67 Net)A/R Days 58.5 Gross (67 Net)• Days in Total Discharge Not Submitted Days in Total Discharge Not Submitted

to Payer (DNSP) – Not Trackedto Payer (DNSP) – Not Tracked• Days Final Billed Not Submitted to Payer Days Final Billed Not Submitted to Payer

(FBNS)(FBNS)• Insurance A/R aged more than 90 days Insurance A/R aged more than 90 days

from service/discharge 31% (w/o Self-from service/discharge 31% (w/o Self-Pay 19%)Pay 19%)

• DNFB A/R days - 4-6 A/R daysDNFB A/R days - 4-6 A/R days• Net A/R days - 55 A/R daysNet A/R days - 55 A/R days• Insurance A/R aged more than 90 Insurance A/R aged more than 90

days from service/discharge 15-20%days from service/discharge 15-20%

• Focused on reducing HIM unbilled daysFocused on reducing HIM unbilled days• Started Tracking Unbilled in Electronic Started Tracking Unbilled in Electronic

Claims SystemClaims System– Discovered Electronic Claims were not Discovered Electronic Claims were not

counted in unbilled numberscounted in unbilled numbers– Discovered Secondary and printed claims Discovered Secondary and printed claims

not mailed were not counted in any not mailed were not counted in any numbers numbers

– Months of paper billing had been Months of paper billing had been backlogged and some reaching filing limitsbacklogged and some reaching filing limits

• HIM Days Started Going Down with HIM Focus HIM Days Started Going Down with HIM Focus and Toolsand Tools

• All Paper Claims starting going through All Paper Claims starting going through Electronic Claims system for TrackingElectronic Claims system for Tracking– Initially DNFB Days in PFS went up because of Initially DNFB Days in PFS went up because of

the new trackingthe new tracking– Additional Biller Training occurred to ensure Additional Biller Training occurred to ensure

billers knew how to get claims out the door.billers knew how to get claims out the door.– OCR Remit scanning for paper remits began to OCR Remit scanning for paper remits began to

assist with secondary billingassist with secondary billing– Cash increased due to bills starting to go out Cash increased due to bills starting to go out

that were not going out previouslythat were not going out previously– Instituted Collection Tool, Auditing, and Instituted Collection Tool, Auditing, and

ProductivityProductivity

• Over 90 Aging is now below 20% Over 90 Aging is now below 20% including Self-Payincluding Self-Pay

• Over 90 excluding self-pay is below Over 90 excluding self-pay is below 6%6%

• Total DNFB averages under 5 daysTotal DNFB averages under 5 days• FBNS is under 1 dayFBNS is under 1 day• DNSP is under 6 days on averageDNSP is under 6 days on average• 7% Cash increase in FY 20097% Cash increase in FY 2009

• 1. Visits without charges as % of 1. Visits without charges as % of total total visits 0%visits 0%

• 2. Co-pay collections as % of 2. Co-pay collections as % of total copay total copay office visits $ 95%office visits $ 95%

• 3. EDI claims as % of total claims $ 3. EDI claims as % of total claims $ 90%90%

• 4. Charge-entry 4. Charge-entry lag period - 1 business lag period - 1 business dayday

• 5. Claims passing claim edits 5. Claims passing claim edits as % of as % of total claims $ 98%total claims $ 98%

• 6. Appointment no-show rate - 2-3%6. Appointment no-show rate - 2-3%• 7. Appointment bumped rate - 2-3%7. Appointment bumped rate - 2-3%• 8. Net A/R days (non-specialty 8. Net A/R days (non-specialty

practices) -40 dayspractices) -40 days• 9. Collections as % of net 9. Collections as % of net revenue revenue

$100%$100%• 10. Collections as % of gross 10. Collections as % of gross revenue revenue

(non-specialty practices) $ 60%(non-specialty practices) $ 60%

• 11. Third-party A/R aging 11. Third-party A/R aging 90 days 90 days from service date - 10%from service date - 10%

• 12. Denials as % of net revenue 12. Denials as % of net revenue (including “incidental to” services) - 2%(including “incidental to” services) - 2%

• 13. Claims with no activity 13. Claims with no activity 90 days 90 days from last activity date 0%from last activity date 0%

• 14. Credit balances - 2 A/R days14. Credit balances - 2 A/R days• 15.Average patient wait 15.Average patient wait time after time after

office arrival - 15 minutesoffice arrival - 15 minutes

• Received a Grant in 2010 to do LEAN Received a Grant in 2010 to do LEAN Training and CRCRTraining and CRCR

• 50% of staff that took the test 50% of staff that took the test certifiedcertified

• 90% of Patient Financial Services90% of Patient Financial Services• Staff are more involved in fixing Staff are more involved in fixing

problems problems

• Choose a topic to research on HFMA Choose a topic to research on HFMA site or take the MAP journeysite or take the MAP journey

• Prioritize Issues Discovered Prioritize Issues Discovered (Compliance/Care/Cost Savings)(Compliance/Care/Cost Savings)

• Study the topic or MAP KeysStudy the topic or MAP Keys• Implement ChangesImplement Changes– Set SMART GoalsSet SMART Goals– Involve Staff (Devil is in the details) Involve Staff (Devil is in the details)

• Teach others (Leaders and staff)Teach others (Leaders and staff)• Celebrate your success and tell your Celebrate your success and tell your

storystory