FernAaronZagor,LCSW-RRoseMarieBelfini

April1,2020

Finance/BillingWebinar

Agenda:TheWholeisGreaterThantheSumofIsParts

• QuickReviewofSessions1and2• ComponentsofFiscalManagement• AccountingSystem• RevenueCycle• KeyPerformanceIndicators• FinancialReporting• InternalControls• In-HouseorOut-Sourced?

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Session1Review– IntroductiontoBusinessPractices

• RoleofLeadership AgencyCultureandValues• Leadersmustgeneratestaff,board,andcommunitystakeholderbuy-in.• Theymustalignthebusinessandstrategicplanwithbusinessoperationsandafundraisingplanreflectingmissionandneedforsustainabilityandgrowth.

• ResponsibleforEffectiveCommunicationwithAgencyStakeholders!• DevelopingaBusinessPlanisanessentialtool!• Laysoutaplanofoperationthatidentifieshowanorganizationwillreachitsgoals.• InHealthcare,thebusinessplanshouldalignwiththetripleaim:Improvepatientexperience,Improveoutcomes,Reducecost.

• TheStrategicPlantakeswhatthebusinessplanhasidentifiedandanswershowdesiredresultswillbeachieved.• Identifyworkflow.Useatracermethodology.

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Session2Review– InformationTechnologyandData

• Therightdataisanasset.• Essentialforcompetitiveadvantageandstrategicsuccess.• InformationTechnology– Stores,retrievesandmanipulatesdata• Therighthardwareandsoftwarearecritical– EHR,FinancialAccounting.

• Technologyanddatamusttieintoorganization’smission,goals,andbusinessandstrategicplans.• Understandingandmanagingdataeffectively:• Organized,consistent,andaccuratedataleadstobetterdecisions.• Datacanincreaseefficiency,quantifyvalue,evaluateperformance(VBP,ROI).

• CreateaDataInformedOrganization

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WhatareComponentsofFinancialManagement?

• FinancialPlanning• BudgetingProcess• UnitCost• RevenueCycle• InsuranceContracts/Billing• KeyPerformanceIndicators

• AccountingSystem• Payroll• AccountsReceivable/Payable• Purchasing&FixedAssets• GrantsManagement• Reporting

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FinancialPlanning&BudgetingProcess

• FinancialPlanningistheprocessthatidentifiestheresourcesneededtoimplementyourbusinessandstrategicplans.AFinancialPlanusuallycoversa3to5yearperiodandshouldultimatelydetermineifyourplanisviable.FinancialplanningisfundamentalpartofanyBusinessorStrategicPlan.Itdoesnotstandalone.

• ABudgetingProcessis thesystemfordeveloping,approvingandmanagingabudget.Budgetdevelopmentshouldnotbedoneinavacuum.Managerandkeystaffshouldbepartoftheprocesswhichwillfortifytheir“buyin”tothemission.Adetailedprogrambudgetisessentialtocalculatingunitcost.

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WhatisUnitCost?• Thesimplestwaytodescribe unitcost istheamountofmoneyittakestoprovideoneservice.Tocalculateunitcostyouneedtotalcostsofprovidingservicesdividedbytotalnumberofservicesforthetimeperiod.Thereare3typesofcoststhatwillgointothecalculations:fixedcosts,directlaborcosts,anddirectmaterialcosts.• Fixedcosts areallcoststhatgointoprovidingtheservicethatdonotvarywiththenumberofservicesprovided.Rentisacommonfixedcost.Thesamereasoningappliestothecostofequipment,propertytaxes,salariedworkersnotdirectlyinvolvedwithproduction(suchasaccountantsandmanagementstaff),mortgagepayments,andinsurancepayments.• Directlaborcosts arelimitedtothewagespaidtoworkersdirectlyinvolvedwithprovidingtheservices.• Directmaterialcosts arealsolimitedtomaterialspurchasedandusedinprovidingtheservice.Directlaborandmaterialsarealsoreferredtoasvariablecosts,becausetheymaychangefrommonthtomonthandwiththenumberofservicesprovided.

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SampleofUnitCostAnalysis

MonthlyCosts FactorsthatimpactServicesVariableClinicalSalaries 5,417 1SocialWorkerFringeBenefits 1,733 35hourworkweek 1,820Equipment&Supplies 75 with4weeksvacation&2personal (154)Telephone 50 10daysofsicktime (70)Travel 25 10Holidays (70)TotalVariableCosts 7,300 Totalannualservicehours 1,526

Fixed Avg#ofworkdayspermonth 18M&GSalaries 2,571AdminSalaries 1,550 Numberofservicesprovidedperday 6FringeBenefits 1,319 Maximum#ofservicespermonth 109Utilities 38 Discountfor"MissedAppointments" 15%Rent 100 Estimated#ofservices 93Utilities 38

TotalFixedCosts 5,615 UnitCost=TotalCost/NumberofServices 139.40$TotalCosts 12,915

WhyisUnitCostImportant?

• Itprovidesabenchmarkforcomparison.• Itprovidesforprofitmarginanalysis.• Itprovidesusefulinformationtoidentifywaste,lossandinefficiencies.• Itactsasaguidetomanagementandhelpstoformulateaproductivitypolicy.

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WhatisRevenueCycleManagement?

• Revenuecyclemanagementisthefinancialprocessthatorganizationsusetomanagetheadministrativeandclinicalfunctionsassociatedwithclaimsprocessing,payment,andrevenuegeneration.Theprocessencompassestheidentification,management,andcollectionofclientservicerevenue.• Arevenuecycleincludestwocomponents:front-end andback-end.Thefront-endmanagestheclient-facingaspects,whereastheback-endhandlesclaimsmanagementandreimbursement.Eachcomponentincludesitsowndepartments,staff,andpoliciestodriverevenuethroughthecycle.• EHRsystemshavehelpedtostreamlineandprovidemoreaccuracytohealthcarerevenuecyclemanagement strategies.Manyorganizationsusetechnologytotrackclaimsthroughouttheirlifecycles,collectpayments,andaddressclaimdenials.Ultimately,thesetechnologiesfacilitateasteadystreamofrevenue.

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REVENUECYCLE

BillingProcess

• ClientRegistration• ConfirmFinancialResponsibility• ClientCheck-InCheck-Out• PrepareClaims• TransmitClaims• MonitorAdjudication• GenerateClientStatement• FollowuponClientPayments&Collections

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MCO&OtherInsuranceContracts

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• Payercontractsdefineandexplaina provider's reimbursementarrangementfordelivering servicestoclientscoveredbyaspecific health plan.Thecontractscoverseverythingfromreimbursementratesand provider networksto medical necessityand provider credentialing.• ManagingInsurancecontractsisvitaltosupportingyourrevenuecycle.Understandingandcommunicatingthefollowing:• Whatistheagreeduponpaymentrateperservice?• Whatisrequiredtoensuretimelyreimbursementofclaims?• Arepriorauthorizationsrequired?

WhatareKeyPerformanceIndicators?AKeyPerformanceIndicator(KPI)isameasurablevaluethatdemonstrateshoweffectivelyyourorganizationisachievingkeybusinessobjectives.HerearesomeexamplesofKPImeasures:

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• TotalChargeLag• PointofServiceCollectionRate• DaysinReceivablesOutstanding(DRO)• DenialResolveRate• CosttoCollect

HowareKPIsUsed?Theseindicatorscanprovidethefollowinginsights:• Patienteligibility andrequiredauthorizations havelostrevenueduetolackoffrontdeskprocesses.

• Cancellationandno-showrates canbedetrimentaltoahealthcareprovider.Withoutthecancellationorno-showreasons,yourpracticecannotpinpointtherootcausesofthislostrevenue.• Doesyourschedulingsystemhavethecapabilitytonotewhyappointmentsarebeingcanceled?

• Areyourno-showsthosepatientsthathaveahistoryfornotshowingup?• Billing lagtime canleadtomoneylost.Lostchargescanbearesultoflaggingdocumentationandbilling.

• InsurancedenialpercentagesDenialsnotonlydelayrevenuecomingintoyourpractice,butdenialsalsouseupadministrativetimethatcanbeworkingonrevenue-producingactivities.Findoutthereasonsfordenials.

• Accountsreceivables shouldbe"within30days."Whenyouhaveahighpercentageover30days,itiscriticaltoanalyzewhatisdelayingrevenuefromcomingintothepractice.

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AccountingSystem&Payroll

• TheAccountingSystem:asystemthatconformstofiscalpoliciesandprocedures.Theaccounting/generalledger(GL)systemoperateswithachartofaccountsthatmatchesrevenueandexpensestofundingsources,organizationalunitsand/ormultiplesites.• Payroll:theoperationofcompensationofemployees.Itincludescontrolsonhiring,firingandsalaryadjustments.Payrollrequiresdocumentationoftimeandeffort.Payrollaccountsforemployeetimeoff,employees’withholdingtaxesandemployertaxes.

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AccountsReceivable(A/R)

• A/RistheseriesofGLaccountsusedtomanagetheamountsowedtotheorganizationbyitsclients,fundersandgrantors.TheaccountsreceivableprocessincludesbillingtothirdpartypayerssuchasMedicaid,Medicare,andcommercialinsurances.

• Accountsreceivableisalsopartofthebackendofthe“RevenueCycle”.TheagingofaccountsreceivableisanimportantKPImeasure.

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Purchasing&FixedAssets• Purchasingandfixedassets:theprocessthatcontrolsthebuyingofandaccountingforassetsorequipment.Aperiodicinventoryofassetsshouldbeperformed.• DepreciationisthedeclineinthevalueofanassetovertimethatistrackedintheGLaccountsforfixedassets.

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AccountsPayable• Accountspayable:theGLaccountsmanagingtheamountspaidouttotheorganization’svendors.Accountspayableusuallyrequiresapprovalofpurchaseordersoremployeetravelreimbursementandtheco-signingofchecks.

FinancialReporting

YourGLsystemshouldgeneratereportsthatshowtheorganization’smonetaryactivityandnetworth.Themosthelpfulreportsarethebalancesheet,thestatementoffinancialactivities(income&expense),andcashflow.• TheBalanceSheetshowsanorganization'sassets,liabilities,andnetassets.• TheStatementofFinancialActivities(SOA)showsthenonprofitorganization’sincomeandexpensesforaspecificperiodoftime.• ACashFlowreportprovidesaggregatedataregardingall cash inflowsanorganizationreceivesfromitsongoingoperationsandexternalinvestmentsources.Italsoincludesall cash outflowsthatpayforbusinessactivitiesandinvestmentsduringagivenperiod.

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SampleBalanceSheet

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SampleStatementofFinancialActivity

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Revenue Budget Actual VarianceSTATE&CITYCONRACTS 3,060,000 3,100,000 40,000PATIENTFEES&PRIVATEINS 270,000 250,000 (20,000)MEDICAIDINCOME 5,300,000 5,400,000 100,000MISCELLANEOUSINCOME 100,000 130,000 30,000PRIVATEGRANTS&CONTRACTS 400,000 500,000 100,000

TotalRevenue 9,130,000 9,380,000 250,000

Expense Budget Actual VariancePERSONNELSERVICES 7,420,000 7,157,600 (262,400)CONSULTANT&PROFESSIONALFEES 363,668 303,668 (60,000)FACILITYCOSTS 556,716 556,716 -SUPPLIES&EQUIPMENT 150,000 120,000 (30,000)POSTAGE&PRINTING 25,000 22,000 (3,000)TELEPHONE 80,000 81,000 1,000TRAVEL 70,000 73,000 3,000LEASEDSERVICES 80,000 80,046 46OTHEREXPENSE 55,592 50,592 (5,000)LEGAL 25,000 20,000 (5,000)DEPRECIATION 25,000 25,000 -INSURANCES 150,000 145,000 (5,000)ORGANIZATIONALFEES 20,000 15,000 (5,000)AUDIT 100,000 80,000 (20,000)

TotalExpense 9,120,976 8,729,622 (391,354)NetSurplus(Deficit) 9,024 650,378 641,354

StatementofFinancialActivityForPeriodEndingJune30,2019

StatementofCashFlow

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Cashflowsfromoperatingactivities:Cashreceivedfromservices 100,000Cashreceivedfromcontributors 25,000Proceedsonsaleofequipment 500Miscellaneousreceipts 100Cashpaidtoemployees (75,000)Cashpaidtosuppliers (20,000)Purchaseofequipment -

Netcashusedbyoperatingactivities 30,600

Cashflowsfrominvestingactivities:Interestanddividendsreceived 5,000Proceedsfromsaleofinvestments 70,000Purchaseofinvestments (65,000)

Netcashprovidedbyinvestingactivities 10,000

Cashflowsfromfinancingactivities:Paymentsofinterest (1,000)Paymentsofnotespayable (5,000)Paymentsoflong-termdebt (10,000)

Netcashusedbyfinancingactivities (16,000)Netincrease(decrease)incashandcashequivalents 24,600Cashandcashequivalentsatthebeginningoftheyear 100,000Cashandcashequivalentsattheendoftheyear 124,000

XYZNon-ProfitStatementofCashFlow

MonthEndingApril30,2020

• Grantsmanagementensurescompliancewithrequirementsofgrantsorcontracts.Usually,thegrantorcontractspecifiesexpenditureorlineitemcontrols,performancemeasures,deliverablesandreportingrequirements.• On-goingcommunicationwithprogrammanagementandstaffisthebestapproachtomeetgrantgoalsandrequirements.Thisincludes:

• Staffing• LevelsofService• Acceptableexpenditures• Reviewofbudgetvsactualperformance

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ProgramGrantsManagement

WhatareInternalControls?

• InternalControlsarethepoliciesandproceduresimplementedthatsafeguardtheassetsoftheagency,andmitigateriskandfraud.Thisiscommonlyknownas“checksandbalances”.• SegregationofDuties• AuthorizationofAgencyTransactions• MaintainDocumentationandRecords• InternalAudits

• EffectiveinternalcontrolsandinternalauditsreducetheriskoffindingsoffraudwasteandabusewhenundergoingregulatoryauditsbyentitiessuchastheOfficeoftheMedicaidInspectorGeneral(OMIG).

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WhoNeedstoKnowtheFinancePlan?• ExecutiveLeadership• Allagencydepartments:• ProgramManagersandSupervisors• ContractManagers,Fiscalstaff,HR• ITandcompliancestaff

• BoardMembers• Grantors• Regulators• LegislatorsandLocalGovernmentUnits

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In-houseorOutsourceAccountingfunction

ProstoOutsourcing

• Savingsinsalariesandbenefits• Moretimetofocusonexpansionandgrowthprospects• MitigationofFraud• Moreexperiencedguidance

ConstoOutsourcing

• Lesscontrol• Lesscommunication• Lossofoversightandbudgetdevelopmentifallfiscalfunctionsareoutsourced• Canbeamoreexpensivealternative

Therearesomeagenciesthathavedecidedtooutsourcethebillingand/oraccountingfunctions.Herearesomeconsiderations:

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Summary

• Todaywereviewed:• ThesignificanceofFinancialPlanninganditsconnectiontoyourbusinessandstrategicplans.• Thebudgetingprocessandwhymanagementandstaffshouldbeinvolved.• Howunitcostcanbeusedabenchmarkandtodetermineprofitability.• Componentsoftherevenuecycle.• HowKPIscandemonstrateifyouaremeetingorganizationalobjectives.• AccountingSystemandfunctions• FinancialReporting• Theoverallimportanceofcommunicatingwithyourmanagersandstaff.

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FeelFreetoContactUs

FernAaronZagor,LCSW-R• FernZagorConsultingLLC• Zagor.consulting@gmail.com

RoseMarieBelfini• Roebelfini@aol.com

MCTACTeam• mctac.info@nyu.edu

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