connect the dots: contracts to revenue...

Connect the Dots: Contracts to Revenue Cycle

SIM/TCPi Webinar Series:Moving Into Value-Based Models

April 24th 201912pm – 1pm MT

Copyright 2016. Medical Group Management Association® (MGMA®) . All rights reserved.

All information contained in this presentation is the intellectual property of Prosper Beyond.

Doral Jacobsen, MBA, FACMPECEO, Prosper Beyond, Inc.

Pamela Ballou-Nelson, RN, MSPH, PhDPrincipal Consultant, MGMA Health Care Consulting Group

Learning Objectives

Determine contracting foundationUnderstand how contracts impact the revenue cycleLearn how to create a plan to optimize contract

performance

Agenda

1. Payer Contracting Foundation2. Revenue Cycle Implications 3. Best Practices: Optimize Contract

Performance4. Summary

Indicates Tool =

1. Payer Contracting Foundation

2. Revenue Cycle Implications

3. Best Practices: Optimize Contract Performance

4. Summary

Contracting Principle 1

Why participate? Supply and demand Discount in exchange for referralMarket share Do you need this relationship?

Quadruple Aim

Ideal Care System

Source: Adapted from Don Berwick 2008

Satisfied Patients

Best Quality

Care

Reduced Cost of Care

Satisfied Providers

Catalogue Contracts

Steps:1. Identify payer contracts

a. Where do you take discounts?b. Billing team can assistc. Are all providers credentialed?

2. Request copy from payer (usually via email)3. Request current fee schedule4. Complete contract grid5. Complete contract quick reference guide6. Create a system for easy access to contracts and fee schedules

a. Binder with quick reference guideb. Electronic storage

Catalogue Contracts

PayerCopy of Executed Contract?

Products Covered

Through a Network?

Next Negotiation Start Date

Contact

1. Payer Contracting Foundation

2. Revenue Cycle Implications

3. Best Practices: Optimize Contract Performance

4. Summary

Connecting the Dots

Scheduling

Ask about insurance carrier – contracted? Gather information to verify

Can you pull out your card?Can you please read me your subscriber ID?

Document detailsCommunicate with patient regarding next steps

New patient packetOnline access/tools

Pre-Visit Clearance

Verify insurance coverage – deep diveProduct? Are you participating?Deductibles? Copay?

Document the details AND the plan for next stepsCommunicate with patientEstablish payment expectations as appropriateFinancial counseling?

Time-of-Service Collections

Understand what is due at time of serviceEnsure appropriate staff are available to address issuesFace-to-face collections before the visitStaff education and training

Do you have the right skills at the front?Do they have policies and procedures?Who can they turn to for challenging conversations?

Any other service considerations (i.e., lab, facility)?Dealing with different types of patients Allowable = insurance carrier payment + patient responsibility

Charge Entry and Coding

Workflow Are all charges captured? How do you know?What is your charge lag time?Any plan specific considerations (i.e., modifiers)?

Coding accuracyAny outside assessments?What is your education plan? Staff training?Compliance plan?Some major payer contracts penalize for errors

Claim Submission

WorkflowValidation process

Did all charges move through to the payer?What documentation do you keep?Are you up to speed on clearing house tools?

Timely filingPay-for-performance programs – electronic submission

Payment Posting

Allowables loadedTop 80% revenue generating CPT codesAll contracted payers

VariationHow are inaccurate payments flagged?Who works those and how is the loop closed?Contract parameters – time limits for reporting discrepancies

Accounts Receivable Follow Up

Are accounts receivable (AR) worked by payer?Relationships…Payer tools and websites

Payer edit systemsDo you understand them? Very impactful….How does your team keep up to date?Ever find discrepancies? How do you handle?

Contract Management

Understand payers agreementsExecuted copy?Products?Narrow networks?

Provider credentialing, and linking and websiteTransparency informationContract performanceMarket shareRenegotiation schedule

1. Payer Contracting Foundation

2. Revenue Cycle Implications

3. Best Practices: Optimize Contract Performance

4. Summary

Optimize Performance

1) Consider implications throughout the entire revenue cycle2) Proactive management - renegotiations3) Monitor performance – collections, payer mix, products4) Load allowables5) Ensure charges are above allowables6) Cultivate relationships = collaborate7) Ensure staff has the right tools and adequate training8) Open lines of communication – front office/back office

Sample Analysis - Contract Relevance

Sample Analysis – Payer Mix/Gross CollectionsClinic Charges Est Payments Gross CollectionsSAMPLE PRACTICE Aetna 87,521$ 46,033$ 53%BCBS 1,101,886$ 803,671$ 73%Cigna 121,415$ 64,733$ 53%Commercial 169,994$ 24,036$ 14%Crescent 23,897$ 15,711$ 66%Government 57,042$ 19,523$ 34%Humana 87,735$ 49,187$ 56%Medcost 149,069$ 99,009$ 66%Medicaid 200,643$ 91,643$ 46%Medicare 617,134$ 284,083$ 46%Medicare Advantage 1,380$ 933$ 68%UHC 392,748$ 236,945$ 60%Total 3,010,465$ 1,735,506$ 58%

Sample Analysis – Aggregate Medicare %

1. Payer Contracting Foundation

2. Revenue Cycle Implications

3. Best Practices: Optimize Contract Performance

4. Summary

Total Cost of Care

Summary

PAMELA BALLOU-NELSON RN, MSPH, PHD630.294.1072 CELLPBALLOUNELSON@MGMA.ORG

DORAL JACOBSEN, MBA FACMPECEO - PROSPER BEYOND, INC.828.231.1479 CELLDORALDJ@PROSPERBEYOND.COM

Questions? Contact

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Copyright 2017. Medical Group Management Association® (MGMA®) . All rights reserved.