Gritman Medical Center

Ben WoodTessa Scholl

Marc BoisvertMimi Sproul

Darren Schnider

Ben WoodTessa Scholl

Marc BoisvertMimi Sproul

Darren Schnider

Problems

DelaysInternal

Common among users of manual systemsEvery time someone comes in contact with a process, there is a 5% chance that an error will occur within the step

Unneeded queues build up

Charts are not taken by staff frequently because it reduces productivity

Every process that has a 95% chance of success (1- 5% of error) requires additional time in auditing to fix

Up to 10 minutes hands on time in system

Days out of system if returned by payee

ExternalPeople do not pay

Problems (continued)

Faster collections from insurance and payeeProblems:

Extended time for bill insurances

Non clean bills

Ideal scenario Collections would take place immediately post treatment

Problems solvedPossible error processing claims

Delay before Final DRG can be sent

Improved personnel allocation

Can be done with automated coding and billing system

Scope Statement

Modeling current billing process to determine accounts receivable days and chart processing times

Examining possible reengineering and mistake proofing of system

Determining NPV’s of implementing new systems

Objectives

Findings

Apparent long wait times in 6.5 day window processes

Enough errors in billing to make AR age 57.37 days average

Industry findings that AR can be reduced dramatically, to at most 30 days

Recommendations

Automate billing system

Add a new financial councilor Decrease self-pay time

If the system is unable to be automated, use improved business rules

Able to reduce queue times and improve throughput

Road map of remaining presentation

Model Description

Model Inputs

Sensitivity Analysis

Additional improvements

Emergency roomCurrent process and improvement

New billing program example

Accounts to concentrate on

Model Description

Gathered Information and assumptionsInputs

Hours worked, chart processing times, staffing schedules, average payee payment periods and 90 patient types

Information collected from actual Gritman medical staff member

Model PurposeAccurately model current billing cycle through Gritman medical center

Sensitivity AnalysisIndividual changes made and reviewed for improvement

Sensitivity Analysis

Our purpose is to reduce Gritman’s AR by 40% to improve costs

Changed general business rules reducing process time while keeping old system

We are also investigating 30%, 20%, 10% and comparing each NPV to find the break even point

Model Inputs

5 Types of PatientsOut-patient Sleep Study: OP Sleep Study

Out-patient Laboratory/Out-patient Radiology: OPL/OPR

In-patient/Out-patient Surgery/Observation: IP/OPS/Observation

Emergency Room: ER

Therapy/Series/Adult Day Health: Therapy/Series/ADH

3 Categories of Payment Amounts>$1,500

$1,500 - $7,500

<$7,500

6 Payment OptionsMedicare

Medicaid

Blue Cross

Commercial

Self-Pay

Charity

Current Emergency Room Process

Proposed Emergency Room process

Comparison of Processes

This new process reduces both time and error increasing revenue

Sage Intergy EHR system

Largest AR issues

Average % of AR

1-Jan-09 0.91% 12.54% 0.87% 0.00% 3.71% 8.05% 1.31% 6.17% 1.52% 10.45% 0.00% 9.97% 0.00% 2.86% 0.00% 1.61% 8.90% 1.89% 0.46% 10.68% 2.21% 1.89% 14.00% 100.00%

1-Feb-09 1.27% 10.28% 1.11% 0.00% 4.26% 7.88% 1.30% 7.52% 1.76% 10.28% 0.00% 7.68% 0.00% 2.40% 0.00% 1.94% 9.50% 2.16% 0.44% 11.29% 1.56% 1.71% 15.66% 100.00%

1-Mar-09 0.82% 6.95% 0.82% 0.00% 4.15% 8.37% 1.08% 7.50% 1.73% 8.22% 0.00% 8.57% 0.00% 1.39% 0.00% 2.09% 8.66% 2.20% 0.41% 11.55% 2.00% 2.15% 21.34% 100.00%

1-Apr-09 0.79% 7.57% 0.56% 0.00% 4.54% 9.67% 1.11% 4.87% 1.59% 13.24% 0.00% 7.51% 0.00% 2.54% 0.00% 2.09% 7.94% 2.35% 0.41% 11.79% 1.56% 2.39% 17.47% 100.00%

1-May-09 0.68% 6.16% 1.24% 0.00% 4.47% 6.59% 0.90% 7.30% 2.82% 8.74% 0.00% 7.15% 0.00% 2.56% 0.00% 2.44% 9.01% 2.56% 0.44% 10.82% 0.92% 1.64% 23.54% 100.00%

1-Jun-09 0.71% 10.23% 1.20% 0.00% 5.73% 7.24% 0.80% 7.02% 3.77% 9.37% 0.00% 7.39% 0.00% 2.06% 0.00% 2.72% 8.70% 2.44% 0.41% 10.31% 1.47% 0.93% 17.51% 100.00%

1-Jul-09 0.64% 7.74% 0.73% 0.00% 4.97% 5.82% 0.53% 7.30% 3.86% 8.49% 0.00% 7.26% 0.00% 2.28% 0.00% 2.68% 9.59% 2.55% 0.31% 11.74% 1.32% 1.17% 21.02% 100.00%

1-Aug-09 1.01% 6.20% 1.17% 0.00% 4.61% 4.30% 0.95% 10.13% 4.38% 7.07% 0.00% 8.37% 0.00% 1.94% 0.00% 2.21% 9.96% 2.63% 0.33% 12.30% 2.09% 1.50% 18.88% 100.00%

1-Sep-09 0.94% 8.76% 0.86% 0.00% 4.37% 4.36% 0.93% 8.14% 3.03% 7.21% 0.00% 8.05% 0.00% 1.66% 0.00% 2.37% 10.79% 2.67% 0.36% 11.24% 2.23% 1.74% 20.29% 100.00%

1-Oct-09 0.51% 7.48% 1.14% 0.00% 4.46% 4.12% 0.87% 7.49% 2.53% 8.27% 0.00% 6.79% 0.00% 1.31% 0.00% 2.12% 9.89% 2.74% 0.30% 10.95% 1.48% 2.36% 25.19% 100.00%

1-Nov-09 0.64% 7.78% 1.27% 0.00% 3.57% 6.17% 0.85% 7.31% 2.78% 8.46% 0.00% 8.43% 0.00% 1.18% 0.00% 2.14% 11.68% 2.95% 0.34% 9.60% 2.76% 1.90% 20.20% 100.00%

2-Dec-09 0.62% 12.39% 0.70% 0.00% 5.06% 3.81% 1.08% 7.28% 2.38% 12.12% 0.00% 8.31% 0.00% 0.82% 0.00% 2.05% 10.96% 2.92% 0.31% 8.97% 2.90% 2.14% 15.18% 100.00%

1-Jan-10 0.77% 8.74% 1.31% 0.00% 4.21% 4.55% 1.14% 5.58% 2.32% 6.58% 0.00% 9.44% 0.00% 1.85% 0.00% 2.30% 11.85% 3.26% 0.32% 11.27% 3.00% 2.91% 18.62% 100.00%

average % of AR 0.79% 8.68% 1.00% 0.00% 4.47% 6.23% 0.99% 7.20% 2.65% 9.12% 0.00% 8.07% 0.00% 1.91% 0.00% 2.21% 9.80% 2.56% 0.37% 10.96% 1.96% 1.88% 19.15% 100.00%

Largest AR issues

The highlighted percentages are how many more days each of the corresponding insurances are taking over the average

% above or below average AR days

1-Jan-09 -13.17% -43.49% -17.61% 0.00% -36.14% 36.60% 47.47% -48.85% 29.40% -66.62% 0.00% 32.47% 0.00% 14.40% -100.00% -74.43% 41.96% -69.83% -92.65% 70.29% -14.09% 27.87% -86.06% 0.00%

1-Feb-09 2.96% -52.93% -2.33% 0.00% -32.33% 37.75% 53.69% -33.66% 36.53% -68.42% 0.00% 1.58% 0.00% 3.40% -100.00% -69.95% 46.91% -66.63% -93.17% 74.73% -22.49% 21.33% -84.34% 0.00%

1-Mar-09 6.27% -65.19% -26.77% 0.00% -40.16% 23.21% 58.30% -32.21% 39.89% -75.38% 0.00% 8.47% 0.00% -39.10% -100.00% -67.32% 35.25% -65.67% -93.60% 80.53% 27.14% 44.52% -78.66% 0.00%

1-Apr-09 1.28% -57.12% -46.28% 0.00% -36.44% 19.02% 62.85% -54.69% 42.79% -60.76% 0.00% -5.39% 0.00% 6.42% -100.00% -70.04% 13.71% -66.30% -94.15% 68.91% 0.42% 48.01% -82.53% 0.00%

1-May-09 11.21% -64.11% 4.67% 0.00% -40.56% -25.23% 56.45% -34.39% 61.31% -73.83% 0.00% -10.09% 0.00% 1.31% -100.00% -62.80% 37.01% -61.12% -93.27% 64.67% -23.93% 6.73% -76.45% 0.00%

1-Jun-09 -2.99% -40.49% -9.68% 0.00% -30.28% -19.37% 42.61% -35.56% 47.71% -71.48% 0.00% -5.99% 0.00% -20.60% -100.00% -57.57% 35.39% -62.15% -93.66% 60.56% 2.64% -23.42% -82.39% 0.00%

1-Jul-09 1.99% -56.55% -50.62% 0.00% -38.95% -27.46% -23.69% -38.48% 35.99% -73.25% 0.00% -4.78% 0.00% -10.68% -100.00% -60.40% 41.72% -62.28% -95.44% 73.44% -5.13% -3.59% -78.98% 0.00%

1-Aug-09 -22.12% -66.77% -8.16% 0.00% -40.36% -42.45% 20.93% -13.69% 39.26% -76.45% 0.00% 6.32% 0.00% -30.63% -100.00% -68.91% 40.35% -62.98% -95.40% 73.25% 4.71% 1.78% -81.12% 0.00%

1-Sep-09 -20.08% -54.97% -26.10% 0.00% -39.25% -38.44% -7.21% -27.87% 33.19% -76.06% 0.00% 1.61% 0.00% -34.28% -100.00% -68.77% 42.03% -64.79% -95.32% 48.02% 14.50% 6.89% -79.71% 0.00%

1-Oct-09 -23.06% -62.13% -14.05% 0.00% -40.30% -46.05% 2.91% -31.11% 19.14% -71.72% 0.00% -13.88% 0.00% -31.86% -100.00% -74.35% 19.51% -66.92% -96.34% 32.34% -28.57% 49.99% -74.81% 0.00%

1-Nov-09 -21.26% -58.83% 4.15% 0.00% -50.75% -26.85% 5.99% -33.13% 9.66% -71.89% 0.00% 7.57% 0.00% -24.39% -100.00% -74.38% 40.00% -64.67% -95.97% 15.06% 27.89% 42.36% -79.80% 0.00%

2-Dec-09 28.19% -34.04% -46.66% 0.00% -33.83% -54.00% 61.74% -32.34% 13.99% -60.15% 0.00% -3.12% 0.00% -35.04% -100.00% -73.19% 43.42% -61.83% -95.94% 17.33% 21.04% 76.44% -84.82% 0.00%

1-Jan-10 42.15% -56.12% -7.12% 0.00% -47.81% -40.83% 93.63% -45.24% 35.74% -78.09% 0.00% 12.24% 0.00% 3.72% -100.00% -67.72% 66.16% -54.23% -95.52% 58.07% 26.75% 83.41% -81.38% 0.00%

average % of deviation -0.66% -54.83% -18.97% 0.00% -39.01% -15.70% 36.59% -35.48% 34.20% -71.08% 0.00% 2.08% 0.00% -15.18% 0.00% -68.45% 38.72% -63.80% -94.65% 56.71% 2.38% 29.41% -80.85% 0.00%

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A/R Totals

1-Jan-09 0.91% 12.54% 0.87% 0.00% 3.71% 8.05% 1.31% 6.17% 1.52% 10.45% 0.00% 9.97% 0.00% 2.86% 0.00% 1.61% 8.90% 1.89% 0.46% 10.68% 2.21% 1.89% 14.00% 100.00%

1-Feb-09 1.27% 10.28% 1.11% 0.00% 4.26% 7.88% 1.30% 7.52% 1.76% 10.28% 0.00% 7.68% 0.00% 2.40% 0.00% 1.94% 9.50% 2.16% 0.44% 11.29% 1.56% 1.71% 15.66% 100.00%

1-Mar-09 0.82% 6.95% 0.82% 0.00% 4.15% 8.37% 1.08% 7.50% 1.73% 8.22% 0.00% 8.57% 0.00% 1.39% 0.00% 2.09% 8.66% 2.20% 0.41% 11.55% 2.00% 2.15% 21.34% 100.00%

1-Apr-09 0.79% 7.57% 0.56% 0.00% 4.54% 9.67% 1.11% 4.87% 1.59% 13.24% 0.00% 7.51% 0.00% 2.54% 0.00% 2.09% 7.94% 2.35% 0.41% 11.79% 1.56% 2.39% 17.47% 100.00%

1-May-09 0.68% 6.16% 1.24% 0.00% 4.47% 6.59% 0.90% 7.30% 2.82% 8.74% 0.00% 7.15% 0.00% 2.56% 0.00% 2.44% 9.01% 2.56% 0.44% 10.82% 0.92% 1.64% 23.54% 100.00%

1-Jun-09 0.71% 10.23% 1.20% 0.00% 5.73% 7.24% 0.80% 7.02% 3.77% 9.37% 0.00% 7.39% 0.00% 2.06% 0.00% 2.72% 8.70% 2.44% 0.41% 10.31% 1.47% 0.93% 17.51% 100.00%

1-Jul-09 0.64% 7.74% 0.73% 0.00% 4.97% 5.82% 0.53% 7.30% 3.86% 8.49% 0.00% 7.26% 0.00% 2.28% 0.00% 2.68% 9.59% 2.55% 0.31% 11.74% 1.32% 1.17% 21.02% 100.00%

1-Aug-09 1.01% 6.20% 1.17% 0.00% 4.61% 4.30% 0.95% 10.13% 4.38% 7.07% 0.00% 8.37% 0.00% 1.94% 0.00% 2.21% 9.96% 2.63% 0.33% 12.30% 2.09% 1.50% 18.88% 100.00%

1-Sep-09 0.94% 8.76% 0.86% 0.00% 4.37% 4.36% 0.93% 8.14% 3.03% 7.21% 0.00% 8.05% 0.00% 1.66% 0.00% 2.37% 10.79% 2.67% 0.36% 11.24% 2.23% 1.74% 20.29% 100.00%

1-Oct-09 0.51% 7.48% 1.14% 0.00% 4.46% 4.12% 0.87% 7.49% 2.53% 8.27% 0.00% 6.79% 0.00% 1.31% 0.00% 2.12% 9.89% 2.74% 0.30% 10.95% 1.48% 2.36% 25.19% 100.00%

1-Nov-09 0.64% 7.78% 1.27% 0.00% 3.57% 6.17% 0.85% 7.31% 2.78% 8.46% 0.00% 8.43% 0.00% 1.18% 0.00% 2.14% 11.68% 2.95% 0.34% 9.60% 2.76% 1.90% 20.20% 100.00%

2-Dec-09 0.62% 12.39% 0.70% 0.00% 5.06% 3.81% 1.08% 7.28% 2.38% 12.12% 0.00% 8.31% 0.00% 0.82% 0.00% 2.05% 10.96% 2.92% 0.31% 8.97% 2.90% 2.14% 15.18% 100.00%

1-Jan-10 0.77% 8.74% 1.31% 0.00% 4.21% 4.55% 1.14% 5.58% 2.32% 6.58% 0.00% 9.44% 0.00% 1.85% 0.00% 2.30% 11.85% 3.26% 0.32% 11.27% 3.00% 2.91% 18.62% 100.00%

average % of AR 0.79% 8.68% 1.00% 0.00% 4.47% 6.23% 0.99% 7.20% 2.65% 9.12% 0.00% 8.07% 0.00% 1.91% 0.00% 2.21% 9.80% 2.56% 0.37% 10.96% 1.96% 1.88% 19.15% 100.00%

% above or below average AR days

1-Jan-09 -13.17% -43.49% -17.61% 0.00% -36.14% 36.60% 47.47% -48.85% 29.40% -66.62% 0.00% 32.47% 0.00% 14.40% -100.00% -74.43% 41.96% -69.83% -92.65% 70.29% -14.09% 27.87% -86.06% 0.00%

1-Feb-09 2.96% -52.93% -2.33% 0.00% -32.33% 37.75% 53.69% -33.66% 36.53% -68.42% 0.00% 1.58% 0.00% 3.40% -100.00% -69.95% 46.91% -66.63% -93.17% 74.73% -22.49% 21.33% -84.34% 0.00%

1-Mar-09 6.27% -65.19% -26.77% 0.00% -40.16% 23.21% 58.30% -32.21% 39.89% -75.38% 0.00% 8.47% 0.00% -39.10% -100.00% -67.32% 35.25% -65.67% -93.60% 80.53% 27.14% 44.52% -78.66% 0.00%

1-Apr-09 1.28% -57.12% -46.28% 0.00% -36.44% 19.02% 62.85% -54.69% 42.79% -60.76% 0.00% -5.39% 0.00% 6.42% -100.00% -70.04% 13.71% -66.30% -94.15% 68.91% 0.42% 48.01% -82.53% 0.00%

1-May-09 11.21% -64.11% 4.67% 0.00% -40.56% -25.23% 56.45% -34.39% 61.31% -73.83% 0.00% -10.09% 0.00% 1.31% -100.00% -62.80% 37.01% -61.12% -93.27% 64.67% -23.93% 6.73% -76.45% 0.00%

1-Jun-09 -2.99% -40.49% -9.68% 0.00% -30.28% -19.37% 42.61% -35.56% 47.71% -71.48% 0.00% -5.99% 0.00% -20.60% -100.00% -57.57% 35.39% -62.15% -93.66% 60.56% 2.64% -23.42% -82.39% 0.00%

1-Jul-09 1.99% -56.55% -50.62% 0.00% -38.95% -27.46% -23.69% -38.48% 35.99% -73.25% 0.00% -4.78% 0.00% -10.68% -100.00% -60.40% 41.72% -62.28% -95.44% 73.44% -5.13% -3.59% -78.98% 0.00%

1-Aug-09 -22.12% -66.77% -8.16% 0.00% -40.36% -42.45% 20.93% -13.69% 39.26% -76.45% 0.00% 6.32% 0.00% -30.63% -100.00% -68.91% 40.35% -62.98% -95.40% 73.25% 4.71% 1.78% -81.12% 0.00%

1-Sep-09 -20.08% -54.97% -26.10% 0.00% -39.25% -38.44% -7.21% -27.87% 33.19% -76.06% 0.00% 1.61% 0.00% -34.28% -100.00% -68.77% 42.03% -64.79% -95.32% 48.02% 14.50% 6.89% -79.71% 0.00%

1-Oct-09 -23.06% -62.13% -14.05% 0.00% -40.30% -46.05% 2.91% -31.11% 19.14% -71.72% 0.00% -13.88% 0.00% -31.86% -100.00% -74.35% 19.51% -66.92% -96.34% 32.34% -28.57% 49.99% -74.81% 0.00%

1-Nov-09 -21.26% -58.83% 4.15% 0.00% -50.75% -26.85% 5.99% -33.13% 9.66% -71.89% 0.00% 7.57% 0.00% -24.39% -100.00% -74.38% 40.00% -64.67% -95.97% 15.06% 27.89% 42.36% -79.80% 0.00%

2-Dec-09 28.19% -34.04% -46.66% 0.00% -33.83% -54.00% 61.74% -32.34% 13.99% -60.15% 0.00% -3.12% 0.00% -35.04% -100.00% -73.19% 43.42% -61.83% -95.94% 17.33% 21.04% 76.44% -84.82% 0.00%

1-Jan-10 42.15% -56.12% -7.12% 0.00% -47.81% -40.83% 93.63% -45.24% 35.74% -78.09% 0.00% 12.24% 0.00% 3.72% -100.00% -67.72% 66.16% -54.23% -95.52% 58.07% 26.75% 83.41% -81.38% 0.00%

average % of deviation -0.66% -54.83% -18.97% 0.00% -39.01% -15.70% 36.59% -35.48% 34.20% -71.08% 0.00% 2.08% 0.00% -15.18% 0.00% -68.45% 38.72% -63.80% -94.65% 56.71% 2.38% 29.41% -80.85% 0.00%

Pro-Active Bill Collection Example

Different communication forms will reduce collection time of accounts

Increase the likely-hood of collection on a Self-pay Account

Students are less likely to receive/respond to letters

Should collect email at admissions

Send out an email on day 15 reiterating the 15% bill reduction if paid within the 20 days

On day 18 call and remindAsk if bill can be paid by credit/debit card

Automated Solution Example

XactiMed Revenue Cycle SolutionsMedAssets’ SolutionsAutomated System

*DHMC: Dartmouth-Hitchcock Medical Center; NH**JPS: John Peter Smith Hospital; Fort worth, TX

Decreased A/R Times

Medical Facility Original Now Reduction

*DHMC: Medicare 27 19 30%

**JPS: third party AR 30 22 27%

**JPS: Commercial AR Fell an average of 90.4 days 44%

Fox Chase Cancer Center 73.1 40.8 56%

Average: 39%

Target for Gritman: 40%

5 Day Window Reduction

Current Process for IP/OP Surgery

Admission Patient Documentation Manual Discharge On Site or Off Site Coder if Off Site: Hold Charge Entry . Auditing Final DRG AR Queue Billed to Payee

Steps: 10 Time: 6+ days

New Process with automated billing and coding

Admission Patient Documentation Manual Discharge Billed to Payee

Steps: 4 Time: 3 days**This minimum time is designated by Federal regulation and is out of the scope of this project to reduce

NPV

Present Value with 40% reduction$980,000

NPV of -$1.89 million

About $400,000 per year reduction in costs

Factors to considerDoesn’t account for savings of reducing employee costs

Reduction of employee time for billing none value added for other processes

Doesn’t account for additional financial counselor