Post on 27-Dec-2015
IMPLEMENTING A MEDICAL BILLING MODEL:STUDENT HEALTH CENTER REVENUE POTENTIAL
Donna Hash & Merry Lawrence
Presentation Overview• Background
• Getting Started• Terms & Definitions
• Fee Schedule
• Planning Process
• Operational Changes• Key Considerations
• Implementing the Process
• Evaluation• Monitoring & Reporting
• Lessons Learned
• Next Steps
Background: Motivating Factors
• Our Previous Approach
• Financial Considerations• University Administrative Charges
• Student Fees
• Organizational Aims• Improve Services to Students
• Recruit & Retain Quality Clinicians
• Data• In 2008, ~90% of students surveyed were insured*
*Based on spring 2010 NCHA data (1,632 student respondents)
Getting Started: Exploring New Opportunities
• Health Services Fee• Ongoing cost increases and budget/resources decreases
• Medical Billing Model (old vs. new)• Provide cost-effective services & generate revenue
• Consistent with industry billing standards
• Establish a Fee Schedule• What to charge? How much?
• Conversion factor
2007-2008 2008-2009 2009-2010 2010-2011 2011-2012 2012-2013$0
$100,000
$200,000
$300,000
$400,000
$500,000
$600,000
$700,000
$800,000
$900,000
$1,000,000
Gross Revenue
Gross Revenue
Getting Started: Learning the Lingo
• In-house Billing vs. Billing Service• EMR/EHR
• Establishing a Fee Schedule• Conversion factor
• CPT, E&M Codes
• RBRVS
Operational Changes: Preliminary Decisions
Code DescriptionWork Value
Non Fac PE
FAC PE Malpractice
Non Fac Total
Fac Total
Global Gap
15952
Excision, trochanteric pressure ulcer, w/ skin flap closure;
12.31 12.03 12.03 2.63 26.97 26.97 090
15953
with ostectomy 13.57 13.29 13.29 2.67 29.53 29.53 090
15956
Excision, trochanteric pressure ulcer, in preparation for muscle or myocutaneous flap or skin graft closure;
16.79 14.05 14.05 3.42 34.26 34.26 090
15958
with ostectomy 16.75 14.83 14.83 3.39 34.97 34.97 090
16000
Initial treatment, first degree burn, when no more than local treatment is required
.89 1.01 .34 .12 2.02 1.35 000
16020
Dressings and/or debridement of partial-thickness burns, initial or subsequent; small (less than 5% total body surface area)
.71 1.56 .77 0.10 2.37 1.58 000
16025
Medium (eg, whole face or whole extremity or 5% to 10% total body surface area)
1.74 2.27 1.26 0.29 4.30 3.29 000
16030
Large (eg, more than 1 extremity., or greater than 10% total body surface area)
2.08 2.86 1.45 0.37 5.31 3.90 000
16035
Escharotomy; initial incision 3.74 1.53 1.53 0.63 5.90 5.90 000
16036
Each additional incision (list separately in addition to code for primary procedure)
1.50 0.69 0.69 0.27 2.46 2.46 zzz
17000
Destruction (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), premalignant lesions(eg, actinic keratoses), first lesion
0.65 1.65 0.92 0.08 2.38 1.65 010
Code DescriptionWork Value
Non Fac PE
FAC PE Malpractice
Non Fac Total
Fac Total
Global Gap
17110
Deconstruction (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), of benign lesions other thank skin tags or cutaneous vasular proliferative lesions; up to 14 lesions
0.70 2.48 1.27 0.08 3.26 2.05 010
Fee for Service Example:
Non FAC Total (code value) = 3.26
Sample Conversion Factor = $50.00
Code Value x Conversion Factor 3.26 x 50 = $163.00
• Contracting with insurance plans • Top 3
• Clearinghouses• Electronic medical claim submission (ERA)
• Staffing• Billing Manager
• Payment processing• Check ICD/CPT codes
• Create billable claim forms
• Submit claims (electronically)
• Correct/re-bill claims
• Post payments
• Manage accounts receivables
• Patient responsibility charges to patient accounts
Operational Changes: Key Considerations
• Utilize Practice Management Software/EMR• Document patient information (e.g., store ID cards)
• Use reporting tools
• 3 Primary Reports:• Accounts Receivable Aging Report
• Payer Mix Analysis
• Summary of Charges • Analyze by transaction code
Operational Changes: Insurance Aging A/R
A/R Report:
• Patient charges detailed by plan
• Aging “buckets”
• Focus on oldest claims
• Analysis of aging conducted by the Billing Manager
Evaluation: Monitoring & Reporting
Evaluation: Payer Mix Analysis
Evaluation: Summary of Charges
• Provider Cooperation & Coordination• Clinical staff buy-in
• Management support
• Billing Office Staff• Professional development
• Reporting Process • Payment codes, adjustment codes, charting system, missed charges etc.
• Monitor reimbursements for errors
• Annual Technology Upgrades
• Plan for changes & train staff
Lessons Learned
Next Steps• Adapt to ACA• Contract with additional insurers
• Adjust fee schedule
• Consider the value of an in-house patient advocate• Student advisory board
• Financial assistance plan
• Prepare for ICD 10• October 1, 2015 expected implementation
• Continue to support the health & well-being of students
Contacts & Resources
Contacts at WSU:Donna Hash, Administrative ManagerHealth & Wellness Services509.335.6759donna.hash@wsu.edu
Merry Lawrence, Billing Office ManagerHealth & Wellness Services509.335.5293mklawrence@wsu.edu
Online Resources:Resource-Based Relative Value Scalewww.ama-assn.org//ama/pub/physician-resources/solutions-managing-your-practice/coding-billing-insurance/medicare/the-resource-based-relative-value-scale.page
Medical Group Management Association www.mgma.com
American Medical Associationwww.ama-assn.org/ama/pub/physicians/physicians.page
Credentialing & Contracting Articlewww.articlesbase.com/business-articles/improve-your-practice039s-financial-health-focus-on-the-four-ps-in-a-pod-patients-payers-payments-and-productivity-2003088.html