“Improving Health Center Sustainability” Revenue Cycle and Health Information Management.
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Transcript of “Improving Health Center Sustainability” Revenue Cycle and Health Information Management.
“Improving Health Center Sustainability”
Revenue Cycle and Health Information Management
Improving Health Center SustainabilityLearner Objectives
• The learner will gain insight into how to utilize Health Information Technology (HIT) to improve financial performance.
• The learner will learn how to execute health team workflow processes to improve RCM.
• The learner will understand the correlation between employing sound HIT processes, clinical outcomes and RCM.
• The learner will develop strategies to improve margins while expanding mission.
History/Mission
Policy Information Notice
Health Information Technology Strategy
Sustainability4
3
2
1
Key Discussion Points
History • In 2015 Health Centers will celebrate 50 years of
expanding healthcare access and delivering quality primary to medically underserved and uninsured populations.
• The health center model targeted the roots of poverty by combining the resources of local communities with federal funds to establish neighborhood clinics.
• Health centers primarily provide health care to patients who are uninsured or covered by Medicaid.
• Community health centers rely on a combination of Medicaid payments, grant revenues, and other private and public funding sources to fund their operations.
• Health centers have established themselves as mission based healthcare providers that provide care to patients regardless of “ability to pay.”
Mission
• Medically underserved populations.– Uninsured– Underinsured– Chronically unemployed– Newly unemployed
• Migratory and seasonal agricultural workers.
• Homeless populations.• Residents of public housing.
Policy Information Notice
• Health centers must assure that any fees or payments required for services will be reduced or waived to enable the center to fulfill the assurance.
• The Health Center Program statute also requires “a schedule of fees or payments for services consistent with locally prevailing rates or charges.
• The PIN requires health centers to design a fee schedule to cover its reasonable costs of operation.
• And “to make every reasonable effort to secure from patients payment for services in accordance with such schedules.
• And to collect reimbursement for health services to persons covered by public or private insurance.
Health Centers
MissionSustainability
Margins
Business Operations
Financial Management
• Financial Culture
• Business Mindset
MedicallyUnderserved
• Healthcare Access
• Preventive Services
Grant Funds• Primary
Health Services
• SpecialtyServices
Financial Infrastructure
• Financial Quality
Improvement • Financial
Goals
MissionSustainabilityMargins
Health Center
Financial Infrastructure
Revenue Cycle Management
Leadership
Regulatory Compliance
Information Technology
Quality
Mission
SustainabilityHealth
Center
Margins
Financial Transformation
• Appointment Scheduling • Registration/Certification • Patient Reception • Clinical Visit/Service Delivery • Documentation and Coding of Visit • Charge Processing/Check Out • Patient Statement & Claim Production • Claims & Patient Payments Processing• Denied Claims Management • Accounts Receivable Oversight & Collections
Revenue Cycle Management
Revenue Cycle
ManagementExecutive
Leadership
Clinical
Operations
Financial
Operations
Operations
Revenue Cycle Management: RCM
Current Status of Business Operations and Workflow
• What are the health center’s financial policies and procedures?
• What is your current understanding of FQHC billing and reimbursement systems?
• Who currently manages the complexities of these billing and reimbursement systems?
• Who stands as your internal or external finance, billing, coding, and HIT content expert.
• How often does leadership assess financial workflow and operations?
• All Inclusive Rate • Medicare • Medicaid versus • Managed • Sliding Fee• Self-pay• Wraparound billing
• What current HIT workflows are in place to support business operations?– Leadership operations– Finance operations– Billing operations– Operations– Clinical operations
Current Status of Business Operations and Workflow
Leadership• Understand
operations• Team
competence• Cultivate
change
Operations
• Scheduling• Front Desk• Back Office
Finance/Billing
• Practice Management
• Billing Policies/Procedure
s• Collections
Clinical
• Credentialing Scheduling
• Documentation
• Coding• Productivity
Mission
SustainabilityHealth Center
Margins
Health Information Technology Optimization
Health Information Technology
Finance/Billing
Operations
Clinical Operations
Leadership
• Transformation• Financial
Solvency• Restructure
Workflow• Cultivate
Financial Culture
Health Information Technology
BeginsRCM
• Pt. Access• Appointment
Management• Initial Contact
• Eligibility• Credentialing
Patient InformationInsurance• Eligibility
• Credentialing HIPPA/Complianc
e• Copayment• Outstanding
Balances
ProviderAccountability
• Patient Experience• E&M
• Documentation• Coding• Time
Management
Fees for Service
• Patient Payments
• Charge Retrieval
• Appointment• Scheduling
HIT Process Improvement
SchedulingPatient
Check-Out
Registration Clinical
Encounter
Health Information Technology Workflow
Patient Scheduling Workflow
• The revenue cycle starts with scheduling the patient.• Health center staff should use a check sheet or script
guide to be sure all pertinent information is collected at the time of scheduling.
• Collecting insurance information will help the scheduler know what information to ask from the patient.
• Additional items to discuss with the patient include explaining what information the patient should bring to the appointment.
• The expectation of payment of co-pays at the time of the visit, and the arrival time of the patient if certain paperwork and registration work needs to be completed.
Patient Registration Workflow
HIT and Practice Management System
• Practice Management System – key driver of the RCM process.
• Establish mandatory registration data entry points.
• Verify patient information at every visit (phone numbers, UDS data points).
• Front desk must check insurance eligibility and check patient’s insurance card at every visit.
• Collect copayments at the point of registration. (Financial Policy)
Case Study
A new uninsured patient walks into the health center and requests a same day visit for a physical examination.
Develop a patient centered access friendly workflow for this scenario. What are the major factors to consider?
• The patient reports the following:– No current health insurance.– No current primary care provider.– No current history of present illness.– Working part-time at a local farmer’s
market.– Patient reports occasional headaches
possibly due to stress. “I would like to take better care of myself.”
Workflow Development Considerations
• Identify internal and external processes influences that prevent your health center from successful revenue cycle management.
• Does your health center currently have a financial policy that serves as the back bone of your RCM processes?
• How does your health center utilize your practice management system and electronic health record to optimize operations and workflow processes?
• What is your health center’s “WOW” factor? How do you make a memorable first impression? How best can you utilize HIT to develop sound walk-in registration/uninsured patient workflow processes?
• What HIT techniques are used to decrease incidences of registration backlog due to processing delays, patient literacy support, and triage needs?
Patient Financial Policy
Patient
Scheduling
Front Desk
Healthcare Team
Your Text
Your Text
Your Text
Your Text
Health Information Technology
Provider
Patient
Clinical Workflow
Integrated Care
Workflow
Check-out Workflow
Clinical Operations and Workflow
C
PatientEncounter
Chief Complaint
ExaminationClinical decision
Making
Evaluation and Management
• CPOE• Documentation
• E&M Coding• Plan of Care
Electronic Medical Record
Provider
Sustainability
Margins
Mission
Compliance
Clinical Workflow and HIT
Patient Centered Care
• Medical Decision Making
• CPOE• Documentation/Coding
Patient Accountability
• Self-Management• Patient
Responsibility• Ability to Pay
Information
Exchange
Medical
Orders
Medical
Charges
Information
Exchange
Financial
Responsibility
Medical
Billing
Electronic Health
Record
Practice
Management
Clinical Workflow and HIT
Improved Access
Quality Healthcare Delivery
Integrated Care
Financial Management
Financial Infrastructure
Healthcare Teams
Health Center
Patients
Sustainability
65 %
10 %
25%
100 % Mission vs
Margins
Health Center
Mission
Sustainability
Margins
Health Information Technology Workflow
Questions
DPM Healthcare Consulting
Stephanie J. Wroten BSN, MS, [email protected]
Anna Gard RN, [email protected]
Contact Information
DPM Healthcare Consulting