MAP KeysMAP Keys The Keys to Revenue ClSCycle Success · 15: Analysis of HFMAs MAP ... Total...

MAP Keys℠MAP KeysThe Keys to Revenue C l SCycle Success

Sandra Wolfskill, FHFMADirector, Healthcare Finance PolicyRevenue Cycle MAPHealthcare Financial Management Association

hfmamap.org

Spring Institute 2014May 19, 2014

OVERVIEWBackground to the MAP InitiativesMAP Keys℠MAP KeysMAP App – the ToolsMAP AwardsMAP AwardsMAP EventMAP ResearchImplementing Metrics for revenue cycle improvementQuestions …

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Q

2

C-Suite Focus Shift to Revenue CycleIncreased attention to revenue cycle management y g– Cash flow– Revenues

Focus on specific process improvementFocus on specific process improvement– Cash collection– Work flow

Customer satisfaction– Customer satisfaction– Reduction in process variation

Use of metrics to track performance

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EVIDENCE-BASED IMPROVEMENT

MeasuringComponents

g

– What are consensus measures of revenue cycle excellence?

Comparing

– How are peers performing and what are valid performance targets?

Improving

– How do high performers achieve and maintain success?

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Evidence from High Performing Revenue CyclesRevenue Cycles

Not All Revenue Cycles Are Created Equal…

80100%

Days in Accounts Receivable Patient Satisfaction Patients Would “Definitely Recommend” Hospital

V i +17%

51.3

37.540

60

80

71%80%

60%

80%Variance = +17%

Variance = -38%

37.5

20

40

0%

20%

40%

0 0%Average “High Performing”

Source: 2013 Medicare HCAHPS Scores

Median “High Performing”Source: HFMA’s MAPAPP June 2013

Source: HFMA’s

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Fundamentals for Successful ComparisonComparison

• Standardization

Timeliness• Timeliness

• Well-defined customized “peer”Well defined, customized peer

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Why Is Measuring Performance Important?Important?

Creates a framework for analyzing dataCreates a framework for analyzing data

Understand your performance progress

– Internally throughout the organization

– Externally with peers and high performers

Identify resource needs

– Allocate labor, technology, and other resources to areas where they

will have greatest impact

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Timeliness Affects Relevance

Performance can shift rapidly in response to such

Current data is needed to set appropriate performance targets

Performance can shift rapidly in response to such factors as:

– Economyy

– Regulatory environment

– Shifts in insurance coverage/self payShifts in insurance coverage/self pay

– Industry rate of technology adoption, such as EHRs

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Peer Definition Affects Usefulness

Are You Comparing Performance With That of True Peers?

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*Source: HFMA's MAP App for July 2012

Why Prioritize Revenue C l M t?Cycle Management?

“Good” is no longer good enoughg g g

– Payment trends demand efficiency and effectiveness

– Regulatory change is adding complexity to the paymentRegulatory change is adding complexity to the payment processes

– Consumers expect high levels of revenue cycle service• Patient financial communication• Transparent pricing • Prompt and accurate billing – Patient-Friendly Billing™ • Seamless payment experience• Seamless payment experience

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The Right Data Guide Performance ImprovementImprovement

Internal view– Quantifying performance change across key areas of your

revenue cycle, will position you to effectively:

• Set organizational goals and objectives

• Improve organizational effectiveness and efficiencies

• Use data to change behaviors

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Industry Expectations

External view

– Moody’s looks for:

• Comparison against a carefully selected set of peers• Comparison against a carefully selected set of peers

• Frequency and depth with which senior leadership and board

members review comparative datap

• Leadership actions based on hospital performance relative to

key indicators

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Just How Above “Good” D Y N d t B ?Do You Need to Be?

To Optimize Improvement Efforts, You Need to First Understand What A Change in Performance Will Mean

d d

Understand What A Change in Performance Will Mean.

You need

Industry accepted

You need targets that are:

Measurable and quantifiable

Defined by true “peer groups”

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Example: Days in A/R

Consider a Hospital Where Days in A/R Improved to 38.7, and p y p ,Performance has been Sustained Most Months for the Past Year

Days in

JANFEBMARAPR Days in

A/R

38.7

APRMAYJUNJUL

IMPROVED & SUSTAINED

AUGSEPTOCT

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Example: Days in A/RMeanwhile, Days in A/R for the Organization’s Peers Have Dropped Even More

DAYS IN A/R AMONG PEER GROUPS OF SIMILAR REVENUEDAYS IN A/R AMONG PEER GROUPS OF SIMILAR REVENUE, PAYER MIX

38.7Case Example Hospital

38.0Peer 1

35 5Peer 3

38.1Peer 2

Source: Analysis of HFMA's MAP AppSM ,

33.0 34.0 35.0 36.0 37.0 38.0 39.0

35.5Peer 3

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Source: Analysis of HFMA s MAP App ,

How HFMA RespondedHow HFMA Responded …

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Defining the Industry’s Standards

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Task Force Purpose

Leading industry representativesLeading industry representatives Supported by HFMA staffCharged to identify a common set of revenueCharged to identify a common set of revenue cycle performance indicators that will allow hospitals to measure in a consistent way for p ythe purpose of peer to peer comparison

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Task Force Charge

Review current KPIs and other industryReview current KPIs and other industry definition sources for completeness, validity and relevancyIdentify and prioritize the top KPIsFinalize and approve KPI definitionsppReview work product with NACsPrepare recommendations for HFMA Board epa e eco e dat o s o oa dapproval

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Process Steps – Then and NowOriginal process still in place for revisions and recommendations for new keysResearch and internal reviewResearch and internal reviewResults submitted to KPI Task Forces (Hospital/Physician)Definitions and measure drafted or updated– Initial determination of most relevant KPIs– Draft concise definition statement and measurement for each

KPI– Task force consensus

Recommendations submitted to the NACNAC comments considered and definitions finalizedNAC comments considered and definitions finalizedFinal work product submitted to HFMA Board for approvalImplementation!

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p

21

And the Results Are …

Objective industry-standard metricsClear, consistent and unbiased terms to define the essentials of revenue cycle performanceperformanceGateway to valid peer comparisons through HFMA’s MAP App toolHFMAs MAP App toolTool for identifying high performing and improving revenue cycles across aimproving revenue cycles across a standardized set of KPIs

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Hospital Keys

25 Individual Keys– Task Force reviewing for 2014 additions and– Task Force reviewing for 2014 additions and

clarifications4 Categoriesg– Patient Access – 5 keys– Revenue Integrity – 4 keys– Claims Adjudication – 6 keys– Management – 10 keys

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List of all 25 Hospital MAP Keys℠1. Net Days in Accounts Receivable (A/R)2. Aged A/R as a percentage of Billed A/R3. Point-of-Service (POS) Cash Collections4. Cost to Collect5. Cash Collection as a Percent of Adjusted Net Patient Services Revenue6 B d D bt6. Bad Debt7. Charity Care8 D i T t l Di h d N t Fi l Bill d8. Days in Total Discharged Not Final Billed (DNFB)9 Aged A/R as a % of Billed A/R by Payer Group

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9. Aged A/R as a % of Billed A/R by Payer Group

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List of all 25 Hospital MAP Keys℠10. Days in Final Billed Not Submitted to Payer (FBNS)11. Days in Total Discharged Not Submitted to Payer (DNSP)12 L t Ch % f T t l Ch12. Late Charges as % of Total Charges13. Initial Denial Rate – Zero Pay14 Initial Denial Rate Partial Pay14. Initial Denial Rate - Partial Pay15. Denials Overturned by Appeal16 Net Days Revenue in Credit Balance16. Net Days Revenue in Credit Balance17. Pre-registration Rate

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List of all 25 Hospital MAP Keys℠

18. Insurance Verification Rate19 Service Authorization Rate19. Service Authorization Rate20. Denial write-offs as a percent of net revenue21. Charity as a Percent of Uncompensated Care21. Charity as a Percent of Uncompensated Care22. Case Mix Index23. Cost to Collect by Functional Area3 Cos o Co ec by u c o a ea24. UB04 (837I) Clean Claim Rate25.Conversion rate of uninsured Inpatient to ppayer source

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Patient Access Key: Insurance Verification Measure: Insurance verification rate

Purpose: Trending indicator that patient access functions are timely accurate and efficienttimely, accurate and efficient

Value: Indicates revenue cycle process efficiency and effectiveness

Variable Notes:Metric Calculation: Numerator: Includes all scheduled

Total number of verified encountersTotal number of registered encounters

encounters prior to service and non-scheduled accounts verified within one day of service or date of admissionadmissionDenominator: Total registered IP and OP encounters in same reporting period as numerator

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Revenue Integrity Key: Late Charges

Measure: Late charges as % of total charges

Purpose: Measure of revenue capture efficiency

Value: Identify opportunities to improve revenue captureValue: Identify opportunities to improve revenue capture, reduce unnecessary cost, enhance compliance, and accelerate cash flow

Metric Calculation: Variable Notes:

Ch ith tNumerator: charges must come from the

Charges with postdate >3 days from DOS

Total gross charges

same reporting period monthly; based on last posting date of month; transaction level detaildebits + credits reported as absolute valueDenominator: No note

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g g Denominator: No note

Claims Adjudication Key: Days in FBNSMeasure: Days in final billed not submitted to the payer

Purpose: Trending indicator of claims impacted by payer/Purpose: Trending indicator of claims impacted by payer/regulatory edits within claims processing system

V l T k i t f i t l/ t l i t t lValue: Track impact of internal/external requirements to clean claim production which impacts positive cash flow


Gross dollars in FBNSNumerator: Excludes In-house and DNFB;Excludes rebills and late charge bills

Average Daily Gross RevenueDenominator: No notes

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Management Key: Net Days in A/R

Measure: Net Days in Accounts Receivable (A/R)

Purpose: Trending indicator of overall A/R performance

Value: Indicates revenue cycle efficiencyValue: Indicates revenue cycle efficiency


Net A/RNet Patient Service Revenue

Numerator: Excludes credit balances, non-patient A/R related 3rd party settlements & non-patient A/R

Denominator: most recent threemonth daily average

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Cash flow – Point of service collections

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Cash flow – Cash collections as % of net PSR

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Cash flow –Days in discharged not final billed (DNFB)

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Cash flow – Final billed not submitted to payer (FBNS)

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Components of net patient service revenue – Bad debt

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Components of net patient service revenue – Charity

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Expense – Revenue cycle operations – Cost to collect w/o IT

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Physician Practice Management Keys14 Individual Keys14 Individual Keys4 Categories – Patient Access – 2 keysPatient Access 2 keys– Revenue Integrity – 1 keys– Claims Adjudication – 2 keys– Management – 9 keys

Similar concept to hospital side with other keys unique to physician practice management

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14 Physician Practice Management ℠MAP Keys℠

1a. Primary Physician Practice Operating Margin y y g gRatio1b. Specialty Physician Practice Operating Margin R tiRatio1c.Net Income/Loss per Primary FTE§ Physician1d N t I /L S i lt FTE§ Ph i i1d.Net Income/Loss per Specialty FTE§ Physician2. Practice Net Days in Accounts Receivable (A/R)3 Practice Cash Collection Percentage3. Practice Cash Collection Percentage4a.Total Primary Physician Compensation as a Percentage of Net Revenue

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Percentage of Net Revenue

39

14 Physician Practice Management ℠

4b. Total Specialty Physician Compensation as a P f N R

MAP Keys℠

Percentage of Net Revenue5. Percent of Patient Schedule Occupied6 P f i l S i D i l P t6. Professional Services Denial Percentage7. Point-of Service (POS) Collection Rate8 T t l Ch L D8. Total Charge Lag Days9.Aged Accounts Receivable (A/R) by Payer Group as a Percentage of Outstanding Total A/RGroup as a Percentage of Outstanding Total A/R10.Aged Accounts Receivable (A/R) as a Percentage of Outstanding Accounts Receivable

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g g

40

% Patient Schedule OccupiedPeer Group: Nationwide

0.94

0.9

0.92

0 84

0.86

0.88

0.8

0.82

0.84

0.78Aug‐12 Sep‐12 Oct‐12 Nov‐12 Dec‐12 Jan‐13 Feb‐13 Mar‐13 Apr‐13 May‐13 Jun‐13 Jul‐13

A/B MAC 5 & 6 Median Performance 90th Decile 75th Percentile

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POS Collection RatePeer Group: Nationwide

80.0%

60.0%

70.0%

30 0%

40.0%

50.0%

10.0%

20.0%

30.0%

0.0%Aug‐12 Sep‐12 Oct‐12 Nov‐12 Dec‐12 Jan‐13 Feb‐13 Mar‐13 Apr‐13 May‐13 Jun‐13 Jul‐13


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Charge Lag DaysPeer Group: Nationwide

7

5

6

3

4

1

2

0Aug‐12 Sep‐12 Oct‐12 Nov‐12 Dec‐12 Jan‐13 Feb‐13 Mar‐13 Apr‐13 May‐13 Jun‐13 Jul‐13


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Practice Cash Collection PercentagePeer Group: Nationwide

160.0%

120.0%

140.0%

60 0%

80.0%

100.0%

20.0%

40.0%

60.0%



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Practice Net Days in A/RPeer Group: Nationwide

70

50

60

30

40

10

20

0Aug‐12 Sep‐12 Oct‐12 Nov‐12 Dec‐12 Jan‐13 Feb‐13 Mar‐13 Apr‐13 May‐13 Jun‐13 Jul‐13


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Aged A/R 90+Peer Group: Nationwide

20.0%

14.0%

16.0%

18.0%

8.0%

10.0%

12.0%

2 0%

4.0%

6.0%

0.0%

2.0%

Aug‐12 Sep‐12 Oct‐12 Nov‐12 Dec‐12 Jan‐13 Feb‐13 Mar‐13 Apr‐13 May‐13 Jun‐13 Jul‐13


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A/R: Medicare Traditional 90+Peer Group: Nationwide

4.5%

3 0%

3.5%

4.0%

2.0%

2.5%

3.0%

0 5%

1.0%

1.5%

0.0%

0.5%

Aug‐12 Sep‐12 Oct‐12 Nov‐12 Dec‐12 Jan‐13 Feb‐13 Mar‐13 Apr‐13 May‐13 Jun‐13 Jul‐13


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Payment Denial RatePeer Group: Nationwide

16.0%

12.0%

14.0%

6 0%

8.0%

10.0%

2.0%

4.0%

6.0%



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MAP App – The ToolMAP App The Tool

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Better than ever and growing fast

More than 500 hospitals and health systems = rich peer p y pcomparisons continually improved to reflect industry trends

hfmamap.org 2014 HFMA

MAP AwardsMAP Awards

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MAP Awards: High Performance and Performance Improvement

High Performance – Individual hospital or System level– Scope – total revenue cyclep y– Deadline – February 28, 2014– On-line application form

Performance improvement – individual provider levelPerformance improvement individual provider level– Scope – one up to five specific metrics– Deadline – Application opens March 1; deadline May 16, 2014

On line application form– On-line application form

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Data from 2013 High Performing Revenue Cycle Award Submissions:

Net Days in A/R

Aged A/R 90 days and

greater DNFB FBNS DNSPBad Debt

Write Off %Cash

CollectionPOS Cash Collection

Charity Care Write

Off %M di 40 55 23 0% 5 90 60 6 50 2 2% M di 99 2% 11 7% 3 0%Median 40.55 23.0% 5.90 .60 6.50 2.2% Median 99.2% 11.7% 3.0%Percentile 90 27.15 10.7% 2.80 .00 4.17 0.5% Percentile 90 104.8% 38.5% 6.4%

75 34.03 16.4% 4.50 .00 5.34 1.3% 75 102.8% 24.4% 5.2%50 40.55 23.0% 5.90 .60 6.50 2.2% 50 99.2% 11.7% 3.0%25 47.60 29.6% 8.95 1.78 10.56 2.9% 25 95.9% 2.6% 1.4%10 52.45 41.3% 15.00 3.95 20.43 5.0% 10 87.7% 0.3% 0.6%

D f 2012 Hi h P f i R C l A d S b i iData from 2012 High Performing Revenue Cycle Award Submissions:

Net Days in A/R

Aged A/R 90 days and


Write Off %Cash


Charity Care Write

Off %Median 39.02 22.9% 6.03 .77 6.87 2.1% Median 97.7% 13.6% 2.8%Percentile 90 27.22 6.8% 4.08 .08 4.60 0.6% Percentile 90 102.8% 41.4% 8.1%

75 33.23 11.3% 4.92 .37 5.50 1.3% 75 100.5% 22.0% 5.3%50 39.02 22.9% 6.03 .77 6.87 2.1% 50 97.7% 13.6% 2.8%25 44 00 29 5% 8 01 1 29 9 25 3 3% 25 95 2% 5 4% 1 7%25 44.00 29.5% 8.01 1.29 9.25 3.3% 25 95.2% 5.4% 1.7%10 57.20 39.0% 10.82 3.22 13.03 5.4% 10 91.3% 1.4% 1.1%

Data from 2011 High Performing Revenue Cycle Award Submissions:Aged A/R Charity

Net Days in A/R

ged /90 days and


Write Off %Cash


C a tyCare Write

Off %Median 40.33 24.0% 5.73 .85 6.73 2.0% Median 100.0% 20.0% 3.0%Percentile 90 31.64 10.4% 3.73 .10 4.69 1.0% Percentile 90 105.0% 53.0% 6.5%

75 35.63 16.0% 4.65 .39 5.68 1.0% 75 101.8% 36.0% 4.8%50 40.33 24.0% 5.73 .85 6.73 2.0% 50 100.0% 20.0% 3.0%25 46.59 28.0% 6.98 1.53 8.40 3.0% 25 96.3% 7.0% 2.0%10 54.01 35.0% 9.97 2.41 10.22 5.7% 10 91.0% 5.0% 1.0%

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MAP EventMAP Event

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MAP EventOpen to all revenue cycle professionalsEducation focus on measure, apply, perform

tconceptsHighlights innovation in revenue cycle operationsBrings together providers physicians and payers toBrings together providers, physicians and payers to demonstrate winning strategiesProvides opportunities to learn from high performing revenue cycle professionalsPeer reviewed vendors provide additional sessions

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Your Challenges

Organizations must continue to do more with lessOrganizations must continue to do more with less

Greatest opportunity is the value of your data

Don’t keep sticking your toe in the water to check the

temperature….do something about it….jump in

The way to achieving high performance is through

benchmarking and performance trackingbenchmarking and performance tracking

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The Secret Sauce: Begin With the Keys!Calculate the potential improvement valueCalculate the potential improvement value to the organizationUse KPIs that are standardized and includeUse KPIs that are standardized and include peer comparison of validated data to provide “best practice”p pSelect measurements that are meaningful to your organizationy gUse data to change behaviors

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MAP Research: SuccessfulMAP Research: Successful Practices

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Highly Effective HabitsResearch Has Shown that High-Performing Revenue Cycles Focus on SixResearch Has Shown that High-Performing Revenue Cycles Focus on Six Key AreasPatient Friendly Billing Project Research Report Key Revenue Cycle CompetenciesResearch Report

People

y y p

Processes Technology Metrics Communication Culture

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Patient Friendly Billing® StrategiesPeople Processes Technology Metrics Communication Culture

C‐Suite Set high Develop & Appreciate Encourage improved Support organizational DemonstrateC Suite Set highexpectations for revenue cycle positions

Devote organizational

Develop & participate in intraorg. teams around revenue cycle

Use patient

Appreciate community dynamics and those with greatest impact to the organization when prioritizing tech

Encourage improved monitoring of rev cycle processes through use of traditional and non‐traditional metrics

Support organizational alignment around clear, correct and patient‐friendly messaging

Set clear and

Demonstrate value for the revenue cycle through significant commitment of time andorganizational

resources to improved training and compensation

Use patient experience as cornerstone for setting revenue cycle strategy

prioritizing tech needs Develop & enforce

systems of accountability around monitoring and reporting

Set clear and transparent financial assistance policies & procedures

time and resources

Establish systems to reward high revenue cyclerevenue cycle performance

Revenue Cycle Leadership

Apply high standards to hiring

Emphasize

Use formal structures to obtain stakeholder input

Selectively use technology for interactions with customers

Measure and report frequently

Look beyond

Drive a positive sched/reg experience

Provide estimates of

Support rev cycle at highest level

Emphasize education

Take a career approach to revenue cycle positions

input

Target revenue cycle improvements around the consumer’s

customers

Manage for investment value

Dedicate IT staff to the revenue cycle

Look beyond traditional metrics for success

Seek the consumers perspective

Provide estimates of financial obligations

Promote financial assistance

Support clear & simple

Garner appreciation for rev cycle from nonfin staff

Find purposepositions

Leverage compensation and work arrangements for employee satisfaction

consumer s experience

Adopt established improvement methodologies incl. those not

the revenue cycle Support clear & simple billing & collection materials

Recognize importance of external communications

Find purpose through the patient

Demand high performance

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satisfaction those not traditionally used in healthcare

communicationsMake innovation a priority

Source: Strategies for a High-Performing Revenue Cycle, HFMA, 2009, p4

Designing Operational MetricsMultiple levels from macro (Map Keys) to detailed to vendorsFi t l l KFirst level Keys:• Cash by major payer category daily and month-end• Cash to Net %• Discharged not final billed – Days in A/R (include failed claims)• Accounts receivable aging• Self pay A/R (include % of total A/R)p y ( )• Gross A/R days and Net AR days• Bad debt write-offs as % of GPR• Charity write-offs as % of GPR• Charity write-offs as % of GPR• Denial write-offs as % of GPR• Denial A/R

P t V i A/R

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• Payment Variance A/R

62

Designing Operational MetricsLevel 2: Departmental Performance – Example –Patient Access– POS Collections– Customer service scores– Registration error rate– Pre-registration of scheduled procedures and services– Conversion of self pay to insurance– Central Scheduling – Call abandonment rate

Level 2: Department Performance – Example – HIM• $ delayed in HIM• DNFB days >3 daysy y• Transcription turnaround time• Clinical chart turnaround time

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Applying the MAP Strategies: Measure

Payer Performance Scorecards:y• Anonymous comparative data by payer• Denial rates as a % of visits/admissions

T f d i l• Types of denials• Overturn rates• Appeal turn around time• Average days to pay• A/R Aging • # and $ Outstanding appeals over X days old• # and $ Outstanding appeals over X days old• # and $ Outstanding overturn denials over X days old

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MAP Strategy: Apply

Sharing performance with payersComparing denial rates among payersDriving improvement in appeals resolution daysComparing average days to payComparing average days to payUsing scorecard data to change managed care contract terms

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MAP Strategy: Perform

Use data to reduce days in A/RUse data to improve denial resolution rates and timesLower denial rates equates to $X increase in cash collectionsReduce bad debtsReduce bad debts

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Finding Your Opportunities …

Identify segments of the revenue cycle where performance is laggingPrepare a Gap Analysis to confirm specific target areasUse the ideal revenue cycle steps from the Gap Analysis and y p p ybest practices from industry sources to redesign for the futureSet performance expectations over reasonable period of timeTrain staffTrain staffImplement and continue to track the relevant KPIs to demonstrate progress on a routine basis

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Gap Analysis…SampleBest Practice Activity: Facility – Current Activity Gap Narrative Metrics

Pre‐serviceTotally integrated electronic scheduling system used for all scheduled services; single database used to allow

100% of services which should be scheduled are electronically scheduled

scheduling to view all system resources and enterprise‐wide MPIElectronic scheduling option available to physician offices

100% of services which should be scheduled areavailable to physician offices

through secure networkshould be scheduled are electronically initiated by the physician offices

ABN process integrated into scheduling and completed at

100% screened prior to provision of service

earliest opportunity based on written order and coded diagnosisRules‐based work distribution and delinquency monitoring

100% of scheduled and pre‐registered cases monitored to q y g

tool used to route accounts for processing and to identify processing requirements for scheduling and pre‐service work

gidentify processing requirements for scheduling and pre‐service work

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work

68

In Closing…What is Your Approach to Metrics?

CFO

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QuestionsQuestions

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Appendix: Gap Analysis WorksheetAppendix: Gap Analysis Worksheet

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Best Practice Activity: Pre‐service

Facility – Current Activity Gap Narrative Metrics

Totally integrated electronic scheduling system used for all scheduled services; single database used to allow scheduling to view all system resources and enterprise‐wide MPI

100% of services which should be scheduled are electronically scheduled

Electronic scheduling option available to physician offices through secure network

100% of services which should be scheduled are electronically initiated by the physician offices

ABN process integrated into scheduling and completed at earliest opportunity based on written order and coded diagnosis

100% screened prior to provision of service

Rules‐based work distribution and delinquency monitoring tool used to route accounts for processing and to identify processing requirements for scheduling and pre‐service work

100% of scheduled and pre‐registered cases monitored to identify processing requirements for scheduling and pre‐service work



Standard data set required for all scheduling transactions; pre‐registration record electronically created

97% of scheduled cases pre‐registered

Scheduling integrated into pre‐registration system

Yes

Orders received electronically; prep instructions provided at earliest opportunity

100% of orders received no later than time of service; 100% of current prep instructions supplied to patient prior to service

All insurances verified electronically; all private pay patients screened vs. state Medicaid files; MSP screening requirements identified and resolved at the earliest opportunity

100% of scheduled cases

Managed care requirements identified based on verified insurance and resolved prior to service

100% resolved prior to date of service



Charges anticipated using electronically stored database that reflects payer‐specific contract terms

100% for non Medicare, non‐Medicaid patients

Patient liabilities identified and explained prior to DOS; cash collected or appropriately resolved, including charity or other financial assistance processing no later than DOS

>95% of scheduled patients financially educated and counseled

Patient qualifies for express arrival processing at point of service or centralized location

97% of scheduled cases

Patient reminder contact completed for high dollar or other targeted services one day prior to scheduled date of service

97% of high dollar and targeted cases

Best Practice Activity: Time of Service


Expedited patient arrival processing at point of service or convenient centralized area completed for all scheduled patients, including account activation upon arrival; insurance cards and other documents scanned directly into patient’s electronic folder

97% of scheduled patients qualified for expedited processing

Comprehensive patient access processing completed for unscheduled ancillary patients; insurance cards and other documents scanned directly into patient’s electronic folder

100%

Point of service collections or account resolution completed for all patients

>95% of patients with identified patient liability; 100% cash posted electronically

Service provided; charges posted concurrently on day services provided; exceptional situations immediately identified and appropriate system controls used to eliminate late charge posting

98% accurate and timely charge capture



Charge master updating and user education provided on a routine basis

Yes, no less than monthly

Ongoing patient financial liabilities monitored for high dollar accounts; account resolution options updated and revisited with patient, as appropriate

100% when required

Ongoing case management (Utilization Review) and discharge planning is completed, as appropriate

95% payer acceptance of clinical treatment plans; 95% clinical denial overturn rate

Concurrent coding completed at earliest opportunity; coding completed no later than three days after completion of service

<0.5 day in AR held for coding; 0.5 day in AR held for dictation; coding completed <3 days from DOS

Medical Records coding is completed by credentialed individuals and coding quality is routinely monitored by HIM management

Audit schedule completed monthly



Census activity completed and balanced daily

100% of the time

Courtesy discharge completed for all patients except ED

100%

ED patients processed prior to or at time of discharge for information verification and co‐payment or account resolution

100% of ED patients electronically verified no later than discharge

Billing edits fully resolved no later than date of discharge/completion of service; account qualifies for billing at the end of the 3 day suspense period

100% resolved within 3 days of discharge/DOS

Best Practice Activity: Post Service


Electronic billing system used to complete compliance checking

100% clean claims released without manual intervention; all claims edited electronically

All contractual adjustments applied at time of billing

At time of billing, or <24 hours from receipt of payment

Payer and patient liabilities correctly pro‐rated at time of billing

97% accuracy rate

Clean claims released daily to payers without intervention

97% of all claims clean

Self Pay statements formatting in accordance with HFMA Patient Friendly Billing Project guidelines

Follow PFB project guidelines

Processing of Medicare supplemental insurance claims expedited

0 days from receipt of Medicare adjudication

Follow‐up queues automatically created based on specific payers’ clean claim payment cycles

No more than 20% of AR >90 days from discharge; no more than 10% of AR >120 days from discharge



Patient friendly billing pursued, including telephone contacts for self pay accounts.

No more than 20% of AR >90 days from discharge; no more than 10% of AR>120 days from discharge

All payment processing is electronic: EFT, ERA, electronic posting

75‐80% of all payments received and posted electronically

Use of bank lock box and electronic processing for all other AR payments (patients, other third party payers)

Lock Box processing has become the industry standard

Payment review automated and variances electronically routed for processing

100%

System generated reports provide denial inventory tracking and trending at the service line level

Denial overturn ratio: 95% of denials overturned; 95% of underpayments overturned

Delinquent self pay accounts transferred electronically to collection agencies; payments received electronically from collection agencies

Bad debt <4% gross revenue; <2% net revenue [does not include charity dollars]



Medicare bad debt log produced automatically by collection agencies as accounts deemed uncollectible

100% of eligible accounts logged correctly

Zero balance accounts archived electronically

Sandra J Wolfskill, FHFMA Director Healthcare Finance Policy Revenue Cycle MAPDirector, Healthcare Finance Policy, Revenue Cycle MAPHFMA

Ms Wolfskill is responsible for revenue cycle and MAP initiatives at HFMA. Herextensive experience in revenue cycle management includes leading engagements with clients engaged in process mapping and analysis project management staffingclients engaged in process mapping and analysis, project management, staffing analyses, using contemporary metrics to identify improvement opportunities, staff education, interim management and system implementation testing and training. Prior to joining HFMA, she worked closely with HFMA in supporting the task force work which lead to the CRCR study guide and certification process.

Background and AffiliationsMs. Wolfskill received a BA cum laude from Wittenberg University and a Master of Arts degree from The University of Delaware. Prior to founding her consulting firm, Sandra had extensive revenue cycle experience and provider management experience in a variety of positions including serving as the chief financial officer for a smalla variety of positions, including serving as the chief financial officer for a small community hospital.

When not engaged in revenue cycle opportunities, Sandra, along with her best friend Donna, can be found breeding and showing their Dandie Dinmont Terriers and judging dog shows in the United States Europe Canada China and Russiadog shows in the United States, Europe, Canada, China and Russia.

Contact InformationMs. Wolfskill can be reached by telephone at (708) 492-3419 and/or by e-mail at [email protected].

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