Revenue Cycle Improvement

Laurie Daigle, CPC

Bureau of Primary Care and Rural Health Annual Rural Health Clinic Workshop

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Agenda

Create an environment of continuous quality improvement

Maintain a regular and consistent schedule of auditing

Implement process change and support accountability by tracking responsibilities and results

Develop consistent CDM review process

Create and implement internal denial audits

Identify and report internal denial trends

Find and use data on industry-wide denial trends

Move cash collection to the front end

Address increasing patient liabilities

PATIENT ACCESS

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The Trend The Goal

Patient Access Goals

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The Reality: Collections

• Healthcare is becoming a retail business

• Pharmacy and insurance owned Retail walk-ins

• Walmart clinics

• Virtual Doctors

• Apple

RETAILERS EXPECT PAYMENT

IN ADVANCE!!!

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Subscriber Deductibles Outstrip Earnings,Inflation

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Current State

• Per federal government, the average cost of a “surprise emergency” is $400.00

• A poll of hospitals indicate average health emergency is $2782.00

• 63% of Americans are not prepared for a $500.00 “surprise emergency”

• 36% polled indicate they have had a health emergency

https://www.cbsnews.com/news/most-americans-cant-afford-a-500-emergency-expense/https://www.federalreserve.gov/2015-report-economic-well-being-us-households-201605.pdf

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Over half of providers (51%) polled say it takes their average patient more than three months to pay their full balance

Only 18 percent of patients claim it took them longer than three months to pay their last balance

Patient payment method preference ranked

• Credit card on file (+/- 40%)

• Patient portal/provider website (34%)

• Automated payment plans (9%)

Provider preferred methods

• On line bill pay (22%)

• Credit card on file (20%)

https://www.businesswire.com/news/home/20170217005407/en/Navicure-Survey-Reveals-Patient-Provider-Attitudes-Patient

Current State

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The Good News

Most people will pay when they expect to pay

Assistance will still be available for those who need it

Give Patient Access the tools they need to be successful

Hospitals and practice staff are extremely adverse to asking

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Front End Collections Improvements

• Within the first two years of adding new processes and tools, a midsize hospital increased POS collections by 37 percent

• The hospital also reduced surgery cancellations and improved its relations with physician offices

• A small community hospital reported increasing POS collections 300%

• Added necessary technology

• Moved Collections from back-end to front-end

• Changed culture and mindset – asking for payment

https://www.hfma.org/Content.aspx?id=50307&pagesid=2https://revcycleintelligence.com/news/how-a-small-hospital-increased-patient-collections-by-300

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Front End Collections

• Gain buy-in from the administration

• Add necessary technology and tools

• Prepare the workforce for the transition as early as possible

• Allow plenty of time for IT

• Use collections reports to identify staff who need additional support

• Embrace scripting and prescribed workflows

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Front End Collections

• How much will patient truly owe?Contract

management

• Copay

• Deductible remaining

• Coinsurance

• Out of pocket max remaining

Identify eligibility including patient

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Patient Access Training

• Navigation of software

• Understanding downstream implications

• Medical Necessity checks

• HIPAA concerns

• Customer service

• Ask for ID

• Identify by two indicators, not name first

• Take photo if technology is available

• Review triage nurse process if applicable

• Double check all information during down time

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Patient Access Training

• Incorrect patient ID resulting in combined records requires review of all involved records. Patients and/or providers do not have access until the error is corrected.

• Duplicate medical record results in fragmented, incomplete information and poses patient risk

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Roadblocks to Success

• Slow response for Medical Necessity or Eligibility checks

• Training

• Time management

• Medicare questionnaire

• Organizational skills

• Software vs. paper

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Invest in Training

• Teach staff proper patient interaction

• Acknowledge the culture change of front end collections

• Reinforce behaviors

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Registration / Bedside Registration

• Always greet patients with eye contact and a smile: “Hello, I’m <your name> and I will be completing your registration today.”

• “It will take us about 5 minutes.”

• “Is there anything else I can do for you?” If no, end with “If you have any questions, or need further assistance, please let any one of our team know.”

• “Is there anything else I can do for you today, <Mr./Ms. patient last name>?”

17Source: The Studer Group

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Quick Registration

• Always greet patients with eye contact, a smile, an expression of empathy: “I’m sorry you are not feeling well,” “I am sorry you are hurting” and a commitment to care: “I will get you moving in this process very quickly,” “I want to get you to the doctor as soon as possible.”

• Introduce yourself by name and your role: “I am Karen and I will start your registration this morning. I will be collecting just enough information for the rest of our team to begin caring for you. It will take us about 3 minutes. We will complete your registration later after you have seen your doctor or nurse.”

• When completed, tell patient the next step in their care and when they can expect that step to take place.

Source: The Studer Group

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Role Play

• Training should include role play sessions

• Periodic audits

• Audit in person if possible, or in role play sessions

• Score results

• Mentor if necessary

• Identify super-users that can be trained to mentor, train, and facilitate role playing sessions or audits

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Quality Audit

GUARANTOR LISTED AS EMPLOYER - HOW WAS THIS VERIFIED?

PATIENT DOES HAVE PEACHSTATE I RAN BY SSN AND BD PUT THIS BACK IN SYSTEM

GROUP NAME WRONG, MISSING GROUP NUMBER,EMP STATUS,EMP NAME AND EMP LOCATION SSN ADDED AS POLICY #

ELIGIBILITY NOT CHECKED - MEDICAID NOT UPDATED INCORRECT INSURANCE PRODUCT

MISSING EMP NAME AND EMP LOCATION MALE ENTERED FOR FEMALE

NAME MUST MATCH PHOTO IDVERIFICATION RUN UNDER UNDER THE SPOUSE

NOT THE PATIENT

POLICY NUMBER AND SUB POLICY NUM DOES NOT MATCH W/C OCCURRENCE CODE IS 04 NOT 01

NAME ON INSURANCE VERIFICATION DOES NOT MATCH NAME ON INSURANCE PAGE W/C OCCURRENCE CODE IS 04 NOT 05

NEED MAILING ADDRESS ON GUARANTOR PAGEAUTO INSURANCE PROVIDED BUT NOT

ENTERED

NO INSURANCE VERIFICATION NO REVISED ER FRONT SHEET SCANNED

20

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Monthly Audit Tracking

MONTH 1 MONTH 2 MONTH 3 MONTH 4 MONTH 5

emp 1 85% 90% 90% 85% 100%

emp 2 45% 70% 80% 65% 90%

emp 3 45% 95% 95% 95% 100%

emp 4 70% 75% 90% 95% 80%

emp 5 70% 60% 90% 90% 85%

emp 6 90% 100% 95% 85% 90%

emp 7 95% 95% 95%

emp 8 50% 85% 90% 90% 95%

emp 9 25% 70% 85% 50% 65%

emp 10 90% 90% 80% 95% 85%

emp 11 75% 90% 85% 50% 70%

emp 12 90% 80% 95% 100% 95%

emp 13 70% 80% 80% 70% 85%

emp 14 60% 80% 60% 75% 50%

emp 15 95% 85% 95% 85% 70%

emp 16 100% 100% 80% 95%

emp 17 65% 50%

Average 70% 84% 88% 80% 82%

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Track Overall Improvement

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

WEEK 1 WEEK 2 WEEK 3 WEEK 4 WEEK 5

Registration Audit Monthly Average

DENIAL TRENDS

No.

No.

No.

No.

No.

No.

YES!

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Business Office Training

• Utilize available resources to identify issues to research• Top Claim Submission / Reason Code Errors for Louisiana - March 2018• Common Submission Errors• Known Claim Issues Log• General Billing and Payment Articles• May 2018 - Education Opportunities

• Novitasphere Hot Topics - Register• Credit Balance Overview - Register

• Medicare Fee for Service Recovery Audit Program• Recent Updates• Program Reports• Provider Resources• Historical Programs

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Business Office Training

• Newsletters

• Updates

• Common error lists

Commercial payers

• Reports

• Warning editsClearinghouse

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Denial Management

• If no formal denial reports exist, clean up rejection and adjustment codes and use data to track denials

• Utilize summary reports of Clearinghouse edits

• Always focus on fixing the trends. Rework is extremely costly and redundant errors commonly occur in services such as lab where there is little benefit to fix claim by claim, but huge benefit to correct the trend.

• Root cause to the inception of the problem:

• Registration in ED can cause lab/radiology errors

• Primary care can cause lab/radiology medical necessity errors

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Adjustment Codes

• Are adjustment codes specific to payor?

• Are adjustment codes detailed enough to use as denial trending data?

• Does distribution of adjustment codes used, compared to adjustment codes available, seem reasonable?

• Update codes if necessary to capture cleaner, more accurate data

• Review staff posting practices

• Usage and understanding of available adjustment codes

• Consistency of understanding and usage across departments

• Posting, follow up, customer service

• Incorrect usage of adjustment codes commonly skews denial data

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Identify Trends

Review claims adjusted at 100%

Customer Service: Track and trend common complaints for registration and coverage denials

The Business Office should report external and internal denial trends to the Revenue Cycle/Revenue Integrity Team:

• External, e.g., Medicare and commercial

• Internal identified through scrubber reviews, denial management, individually identified denials and customer service complaints

Denial rends

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Develop Internal Review of Services

• Analyze services

• Perform random audits

• Revenue Cycle teams should choose one type of service to audit each month for denial and reimbursement trends

• Share results across disciplines. Is one department responsible for denials in other areas? Examples:

• ER registration process driving denials in radiology, lab

• PT denials driven by improper/incomplete orders or referrals

• Endoscopic department denials caused by registration or ordering departments

• Respiratory Therapy denials driven by “protocol orders”

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Analyze Root Cause

Insurance denied - can’t ID patient

• Does facility have Eligibility Software?

• Is insurance information updated at every visit?

• Is patient identified using two pieces of information?

• Free Text Fields to recognize payor

Preventative services denied for frequency

• Is ordering provider properly tracking frequency?

• Does follow up department report frequency denials by ordering provider?

Denied for lack of preauthorization

• Are providers required to preauthorize before booking tests?

• Do department order intake processes include obtaining preauthorization verification before scheduling?

• Does facility have Referral Management or Preauthorization Teams?

• Are exams booked too closely to DOS to verify and correct authorization?

Medical necessity denial

• Is service denied appropriately?

• Does follow-up maintain an online library of payor-specific policies?

• Does follow-up understand available payor-specific medical policies?

• Are denials reported back to ordering and servicing departments for education?

• Are HIM and Coding performing proper review?

Billing process

• Are procedures reviewed by coding prior to submission?

• Were proper services and diagnosis codes billed?

• Do Billers change claim to satisfy Clearinghouse edit?

Denial Trends

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Analyze Root Cause

• File or Appeal limits exhausted

• Timely filing appeal denial

• How was deadline missed?

• DNFB report?

• Bylaws for provider record completion?

• Tickler files?

• Exhausted Appeals

• Was service denied appropriately?

• What lessons can be learned?

• Incomplete Appeals

• Did follow-up staff request proper information of HIM?

• Did HIM provide enough information to support payment?

• Was requested information reviewed prior to submission?

Denial Trends

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Look at the Rejection Summary by Group

GROUP AETNA ANTHEM BCBS CIGNA COMMERCIAL MCRMCR

OTHER MEDICAID TRICAREUNITED

HEALTHCARE Totals

CDM 0 0 46 0 0 0 1 547 0 0 594

Credentialing 3 0 81 12 6 0 26 0 0 14 142

Eligibility 12 31 3612 38 48 2873 89 1117 0 33 7853

File Limit 0 0 413 18 42 18 12 231 0 12 746Medical Necessity 0 47 1651 0 4 4,103 112 0 0 8 5925Medical Records 1 1 402 0 116 3,318 12 1,397 0 4 5251Non-covered Service 0 160 6,874 4 87 1,249 207 68 0 3 8652

Other 44 408 1,842 37 421 1,568 1,071 4,661 0 42 10094Pre-Authorization 1 17 6 2 18 0 64 2,314 0 7 2429

Referral 17 0 1,946 6 42 0 27 3 0 0 2041

Registration 60 12 180 16 0 0 1 1,414 0 1 1684UR-Level of Care 0 0 380 0 1 1,617 0 0 0 0 1998

Totals 138 676 17433 133 785 14746 1622 11752 0 124 47409

Step 1

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Select a Category for Review

• Random Review showed non-covered category contained mostly correctable accounts

• The Business Office (revenue cycle analyst) reviewed denials and applied largest 10% rule to determine which service to isolate and address

• Service was further isolated by denials by payor to determine most affective process improvement opportunity

GROUP

AETNA ANTHEM BCBS CIGNA COMMERCIAL MCRMCR

OTHERMEDICAID TRICARE

UNITED

HEALTHCARETotals

Non-covered

Service 0 160 6,874 4 87 1,249 207 68 0 3 8652

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Select an Area for Drill Down

• Incorrect Posting Code!!

• MUE errors

• Reviewed CO (Contractual Obligation) and remark codes

• Identify opportunity to address

• Identify root cause and develop education

• $59,480.00 recouped

• Process change eliminated future denials

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DOSORDERING PROVIDER CPT DESCRIPTION

UNITS BILLED MUE

CODER CORRECTION

UNITS/MODIFIER COMMENT

12/27/2017 PROV 1 10060DRAINAGE OF SKIN ABSCES SIMP 2 1 1

REMOVE MODIFIERS APPENDED BY BO UPDATE CDM TO I & D ABSCESS SGL, SIMP

1/15/2018 PROV 2 10120

INCISION AND REMOVAL FOREIGN BODY 7 4 1

REMOVE MODIFIERS APPENDED BY BO CODE UNIT REPRESENTS INCISIONS NOT FB REMOVED

1/28/2018 PROV 2 29505APPLICATION LONG LEG SPLINT 2 1 1

REMOVE MODIFIERS APPENDED BY BO APPEND MOD 50, UNITS 1

1/7/2018 PROV 3 29581APPLY MULTLAY COMPRS LWR LEG 2 1 1

REMOVE MODIFIERS APPENDED BY BO APPEND MOD 50, UNITS 1

1/7/2018 PROV 1 29550 STRAPPING OF TOES 3 1 1

REMOVE MODIFIERS APPENDED BY BO CODE REPRESENTS TOE(S) NOT TOE

1/30/2018 PROV 6 70190X-RAY EXAM OF EYE SOCKETS 2 1 1

REMOVE MODIFIERS APPENDED BY BO CODE IS PLURAL

1/20/2018 PROV 6 74177CT ABD & PELV W/CONTRAST 2 1 2

REMOVE MODIFIERS APPENDED BY BO SPLIT TO 2 LINES AND APPEND MODIFIER 76

1/12/2018 PROV 1 81025URINE PREGNANCY TEST 2 1 1 ONLY ONE TEST PERFORMED

Tracking and Process Improvement Table

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Root Cause Results

• Coding did not review prior to submission

• The Business Office was allowed to “correct” to override edits

• Lacked proper training

• Split to multiple lines

• Append modifiers

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Analyze Improvement Plan

Objectives achieved

• Why was process successful, and which changes can be transferred to other areas?

• Are changes likely to be permanent or should audit/oversight period be extended?

• Can process be improved for greater success?

• Unexpected consequences: good or bad realized?

Objectives not met

• Was improvement plan followed?

• Were goals realistic or achievable?

• How should plan be modified?

• Establish re-audit period

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Choose New Audit

• Team should always have audit items in queue

• Revenue Cycle agenda should always include option to expand on previous audit or choose new process to analyze

• Refine and improve the process

• Keep looking!

Repeat

CHARGE DATA MASTER REVIEW

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CDM Review

AMA updates CPT codes annually, effective January 1 of each year

CMS updates HCPCS quarterly, with major updates also effective every January 1

• Changes include

• Deleted and replacement codes

• Revised codes

• May change the intent as well as units applicable per reportable code.

• APC changes represent revisions, composite changes and comprehensive payment changes

• Changes to inpatient-only code assignments

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CDM Review

• Quarterly high-level review

• Verify code descriptions

• Deleted codes

• multiple occurrences of the same CPT – verify descriptions make sense

• Pricing

• Revenue Code assignment

• Annual review

• Deleted/Replaced codes

• Revised codes

• APC changes

• Check Errata

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CDM Annual Review

• Compare to Medicare

• APC changes

• Status Indicator changes

• Price changes

• Plan fee expectations based on Medicare review

• CMS changed to incidental

• What fees increased?

• How are commercial payors responding?

• CMS migrated APC

• Are more services included?

• Did code description change?

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CDM Annual Review

Determine the appropriate service component

Professional

Hospital

Evaluate revised codes

Compare proposed fee to the acceptable multiplier within the department, and to any information available for competitor pricing

Assign fee

Review all occurrences of the code within the service component in the CDM (pro to pro, tech to tech, etc.)

Update all for consistency

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Data Driven Decisions

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Choose Data Elements

• Too much data becomes white noise

• Assign responsibilities

• Expect results

• Establish regular report-outs

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Data Driven Decisions

• High-level snapshot of data elements that affect cash flow

• Look for possible root causes and corrective actions

• What drives unfavorable trends?

• What can be done to improve?

• Compare to previous months and identify reasons for variances

• Are variances correct?

• Can errors be corrected and resubmitted?

• Were they known?

• Were you prepared in advance?

• What can be done better to communicate and prepare in the future?

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Patient

Financial

Services

Hospital

Report

Report-

November

Previou

s Fiscal

YR

195,756,1

57.60

Avg

Daily

Revenu

e 536,318

AR Total AR

Credit

Balances Collections POS

Late

Charges Denials

Claims

Generated-

Meditech Held Accounts Unbilled Accounts

Total

Unbilled +

Held

Wee

kda

y

Da

te

Gros

s AR

Days

Total

AR

(Exclud

ing S/P

and

Pendin

g

Medicai

d Self Pay

Pending

Medicai

d $ #

Total

Collectio

ns

Posted

Blue

Cross

Comme

rcial

Medica

re

Medica

id

Medica

id HMO

Medica

re

HMO

Manag

ed

Care

Self

Pay

Tricar

e

Worker

s

Comp

Total

POS $ # $ # Billed $ #

Medi

care

RTP

($)

Held/F

ailed

($)

ePrem

is

Held

($)

Total

($)

Medi

care

RTP

(#)

Held/

Faile

d (#)

ePr

emi

s

Hel

d (#)

Tot

al

(#)

Total

Un-

Billed

($)

0-7

Days

($)

>7

Days

($)

Total

Un-

Bille

d (#)

0-7

Days

(#)

>7

Day

s

(#) $ #

Tue 1 74.41

41,730,

884

##

##

#

4,104,3

01

17,586,5

18

20,040,0

66

1,823,0

72

2,38

1 -

4,214,5

74

3,486,6

01

727,97

3 1,394 1,210 184 48,287 19,203 13,775 77 674 (541) 2

384,85

1 211

565,81

3 201

36,59

3

573,34

2

318,39

4 928,329 6 68 61 134

4,214,5

74

3,486,6

01

727,97

3

1,39

4

1,21

0 184

5,142,9

03

1,52

8

Wed 2 74.67

41,875,

272

##

##

#

4,104,4

33

17,776,5

52

19,994,2

87

1,829,5

86

2,38

6 -

4,121,4

59

3,444,1

70

677,28

9 1,386 1,223 163 1,191 5,241 75,615 8,674 387 1,311 9 50,448 51

750,12

2 254 3,126

561,86

4

510,26

6

1,075,2

56 2 70 78 149

4,121,4

59

3,444,1

70

677,28

9

1,38

6

1,22

3 163

5,196,7

15

1,53

5

Thur 3 74.86

41,982,

531

##

##

#

4,092,7

25

17,885,4

89

20,004,3

17

1,831,4

58

2,39

0 -

4,134,2

10

3,419,1

18

715,09

2 1,384 1,219 165 28,458 7,320 8,102 352 458 (870) 70 34,074 41

709,49

2 260

20,57

1

543,26

1

527,84

3

1,091,6

75 1 61 88 149

4,134,2

10

3,419,1

18

715,09

2

1,38

4

1,21

9 165

5,225,8

86

1,53

3

Fri 4 74.17

41,636,

243

##

##

#

4,092,7

25

17,595,8

62

19,947,6

56

1,855,3

25

2,40

6 -

4,050,6

45

3,291,2

84

759,36

2 1,359 1,221 138 - 17,243 6,751 8 411 2,880 11 49,799 62

685,94

9 223

21,06

2

681,17

4

512,39

5

1,214,6

31 2 69 94 164

4,050,6

45

3,291,2

84

759,36

2

1,35

9

1,22

1 138

5,265,2

76

1,52

3

Mon 7 75.04

42,090,

399

##

##

#

4,092,6

20

18,097,5

46

19,900,2

34

1,842,4

59

2,41

0 -

4,351,9

89

3,594,6

68

757,32

1 1,332 1,223 110 29,923 16,397 5,514 - 305 7,586 12 32,839 38

932,30

1 343

20,89

4

556,48

0

460,43

8

1,037,8

12 1 61 81 143

4,351,9

89

3,594,6

68

757,32

1

1,33

2

1,22

3 110

5,389,8

01

1,47

5

Tue 8 74.11

41,610,

072

##

##

#

4,091,9

34

17,618,9

68

19,899,1

70

1,863,9

30

2,40

0 -

4,279,8

79

3,531,2

55

748,62

4 1,351 1,220 132 22,160 6,265 8,524 - 777 - -

566,39

9 192

592,51

7 249

21,67

9

531,88

4

464,75

1

1,018,3

14 2 61 84 146

4,279,8

79

3,531,2

55

748,62

4

1,35

1

1,22

0 132

5,298,1

93

1,49

7

Wed 9 74.52

41,778,

757

##

##

#

4,091,9

32

17,808,3

95

19,878,4

30

1,814,7

00

2,39

2 -

4,279,3

06

3,585,0

89

694,21

7 1,340 1,212 129 44,934 - 11,723 26 356 (686) 1 73,082 48

756,31

5 215

20,40

4

537,04

8

401,67

2 959,123 1 54 66 120

4,279,3

06

3,585,0

89

694,21

7

1,34

0

1,21

2 129

5,238,4

29

1,46

0

Thur 10 74.70

41,814,

156

##

##

#

4,091,9

27

17,851,4

98

19,870,7

30

1,751,2

25

2,36

8 -

4,306,4

78

3,613,3

91

693,08

7 1,278 1,205 73 178 - 7,034 1,227 221 (171) 1 69,245 48

885,55

1 249

20,40

4

553,20

0

356,90

8 930,512 1 58 55 113

4,306,4

78

3,613,3

91

693,08

7

1,27

8

1,20

5 73

5,236,9

90

1,39

1

Mon 14 76.67

42,773,

539

##

##

#

4,091,9

27

18,771,7

38

19,909,8

74

1,653,0

04

2,32

1 -

4,240,1

74

3,563,9

30

676,24

3 1,304 1,222 83

153,02

8 22,744 11,005 341 217 1,172 16 - -

1,966,9

66 571

20,40

4

716,65

3

439,02

2

1,176,0

78 1 71 76 148

4,240,1

74

3,563,9

30

676,24

3

1,30

4

1,22

2 83

5,416,2

52

1,45

2

Tue 15 75.54

42,126,

042

##

##

#

4,095,4

30

18,109,0

83

19,921,5

29

1,615,1

49

2,30

1 -

4,144,4

17

3,503,6

58

640,75

8 1,372 1,229 143 - 26,721 10,454 6,146 63 - -

427,72

4 329

847,63

4 237

20,40

4

513,85

5

392,80

5 927,063 1 57 63 120

4,144,4

17

3,503,6

58

640,75

8

1,37

2

1,22

9 143

5,071,4

80

1,49

1

Wed 16 75.81

42,314,

384

##

##

#

4,077,9

15

18,301,4

16

19,935,0

53

1,657,3

17

2,27

5 -

4,046,4

41

3,406,8

89

639,55

3 1,333 1,249 84 8 28,086 5,790 - 50 338 2 18,186 36

799,42

7 176

20,40

4

431,97

4

410,01

6 862,394 1 52 60 112

4,046,4

41

3,406,8

89

639,55

3

1,33

3

1,24

9 84

4,908,8

35

1,44

5

Thur 17 76.42

42,545,

125

##

##

#

4,077,9

15

18,493,5

94

19,973,6

16

1,561,4

01

2,24

3 -

3,929,8

41

3,279,8

00

650,04

0 1,312 1,227 85 - - 6,658 5,603 104 107 2 44,927 47

964,07

5 290

20,40

4

411,14

5

479,00

7 910,555 1 49 71 120

3,929,8

41

3,279,8

00

650,04

0

1,31

2

1,22

7 85

4,840,3

96

1,43

2

Fri 18 76.05

42,300,

787

##

##

#

4,077,3

54

18,241,7

81

19,981,6

53

1,515,2

82

2,21

9 -

3,941,7

10

3,265,2

12

676,49

9 1,314 1,230 85 57,636 20,949 8,794 - 229 69 1 38,931 47

837,01

4 202

20,40

4

495,33

8

438,80

5 954,546 1 50 71 121

3,941,7

10

3,265,2

12

676,49

9

1,31

4

1,23

0 85

4,896,2

57

1,43

5

Mon 21 - - - - - - - -

Tue 22 - - - - - - - -

Wed 23 - - - - - - - -

Fri 25 - - - -

Mon 28 - - - - - - - -

Tue 29 - - - - - - - -

Wed 30 - - - - - - - -

Act on the Data

• Are daily, weekly, monthly reports distributed?

• Are follow-up questions sent to changemakers?

• Does the team notice detail and act on it?

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Daily Flash Report

Gross A/R

A/R Days

Credit Balance

Clean Claim Rate

Denial Gross Revenue

By Payor

By Reason

Failed (Held) accounts

Revenue

Units

Cash Deposited

Average Daily Deposit

Average Daily Deposit Required To Meet Goal

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A/R Days

Patient Financial Services

Hospital Report Report-NovemberPrevious Fiscal YR 195,756,157.60

Avg. Daily Revenue 536,318

AR Total AR Credit Balances

Weekday Date Gross AR Days Total AR(Excluding S/P and Pending Medicaid) Self Pay Pending Medicaid $ #

Tue 1 74.41 41,730,884 4,104,301 17,586,518 20,040,066 1,823,072 2,381 Wed 2 74.67 41,875,272 4,104,433 17,776,552 19,994,287 1,829,586 2,386 Thur 3 74.86 41,982,531 4,092,725 17,885,489 20,004,317 1,831,458 2,390 Fri 4 74.17 41,636,243 4,092,725 17,595,862 19,947,656 1,855,325 2,406

Mon 7 75.04 42,090,399 4,092,620 18,097,546 19,900,234 1,842,459 2,410 Tue 8 74.11 41,610,072 4,091,934 17,618,968 19,899,170 1,863,930 2,400 Wed 9 74.52 41,778,757 4,091,932 17,808,395 19,878,430 1,814,700 2,392 Thur 10 74.70 41,814,156 4,091,927 17,851,498 19,870,730 1,751,225 2,368 Mon 14 76.67 42,773,539 4,091,927 18,771,738 19,909,874 1,653,004 2,321 Tue 15 75.54 42,126,042 4,095,430 18,109,083 19,921,529 1,615,149 2,301 Wed 16 75.81 42,314,384 4,077,915 18,301,416 19,935,053 1,657,317 2,275 Thur 17 76.42 42,545,125 4,077,915 18,493,594 19,973,616 1,561,401 2,243 Fri 18 76.05 42,300,787 4,077,354 18,241,781 19,981,653 1,515,282 2,219

A/R

days

trending

up!

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Collections

Total Collections

Posted Blue Cross Commercial Medicare Medicaid Medicaid HMO Medicare HMO Managed Care Self Pay

134,602.25 2,246.70 95,811.59 - - 14,815.36 - 12,076.98 9,327.99

573,419.60 210,492.24 20,315.33 282,651.60 81.73 - 29,938.42 20,552.56 9,042.16

474,111.70 142,095.84 98,744.16 143,907.57 - - 32,386.48 26,456.65 22,038.45

754,468.68 98,023.05 110,362.29 119,538.60 174,644.64 1,302.99 188,688.93 27,885.55 25,149.98

323,851.18 127,382.65 19,441.12 139,059.46 - - - 23,016.48 13,881.37

307,716.58 221,906.55 42,538.56 3,880.48 - 21,151.46 - 625.00 15,643.12

268,760.63 10,575.09 38,217.25 145,909.46 - - 25,305.69 38,790.11 9,848.29

550,661.55 1,288.00 237,391.79 10,803.76 - - 242,397.08 32,834.48 15,720.17

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Gross Revenue

• Forecast goals

• Identify trends

• Assign resources to investigate

Revenue TODAY MTD TOTAL PRIOR YEAR Prior

Actual Budget Actual MTD TOTAL % Variance YTD % Variance

I/P-HOSPITAL 493,998 10,403,322 9,681,550

7%

146,081,94

9

-5%

O/P-HOSPITAL 801,418 15,030,905 15,275,557

-2%

259,887,75

9

0%

CLINIC REVENUE 366,283 3,616,456 4,362,275

-17%

67,283,462

-9%

NURSING HOME REVENUE 96,821 2,012,274 1,827,691

10%

30,637,064

8%

TOTAL GROSS REVENUE

1,758,52

1 38,828,696 38,933,842

-0%

511,677,00

2

-2%

17% drop

in Clinic

Revenue?

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Investigate Outliers

• What happened here?

• Root causes

• What can be corrected?

• What is the future action plan?

Other Metrics TODAY MTD DAILY AVG

ACTUAL ACTUAL

AVAILABLE BED OCCUPANCY % 76.51%

OUTPATIENT REGISTRATIONS 187 129

ER VISITS 132 116

ER ADMISSIONS 15 20

ER LWBS 15 8

OBSERVATION HOURS 85 277

OBSERVATION PATIENTS 6 19

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Trend by Month

• Compare to previous month, and previous year

• Peak seasons not identified in averages of previous months

• Fine tune goals and expectations

June July August September October November DecemberTOTAL GROSS REVENUE CURRENT FY 38,683,672.02 41,647,144.92 42,890,423.66 39,042,037.42 38,279,634.04 41,136,855.87 38,828,695.60TOTAL GROSS REVENUE PREVIOUS FY 45,123,526.07 43,013,252.35 43,742,823.49 39,858,962.82 40,008,618.00 40,370,371.03 38,933,841.81TOTAL CASH COLLECTIONS CURRENT FY 14,510,321.91 12,247,219.35 15,811,125.52 13,416,884.57 14,190,453.81 12,211,326.55 11,903,517 TOTAL CASH COLLECTIONS PREVIOUS FY 13,393,414.29 14,901,173.46 13,741,003.98 12,393,465.72 12,430,944.94 12,584,230.18 12,164,563 Total Procedures CURRENT FY 14064 13131 13131 12769 15206 13317 13747Total Procedures PREVIOUS FY 14979 15469 15469 14763 16944 14981 12456

TOTAL HOSPITAL DISCHARGES CURRENT FY 682 718 708 642 680 630 534TOTAL HOSPITAL DISCHARGES PREVIOUS FY 789 811 767 722 780 676 543

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38,683,672.02

41,647,144.92

42,890,423.66

39,042,037.42

38,279,634.04

41,136,855.87

38,828,695.60

45,123,526.07

43,013,252.35

43,742,823.49

39,858,962.82 40,008,618.0040,370,371.03

38,933,841.81

34,000,000.00

36,000,000.00

38,000,000.00

40,000,000.00

42,000,000.00

44,000,000.00

46,000,000.00

June July August September October November December

TOTAL GROSS REVENUE CURRENT FY

TOTAL GROSS REVENUE PREVIOUS FY

Gross Charge Current Year Vs. Previous Year

Exceeded

previous year!!!

Pay Attention to Data Trends

What

happened

here?

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14064

13131 1313112769

15206

1331713747

1497915469 15469

14763

16944

14981

12456

0

2000

4000

6000

8000

10000

12000

14000

16000

18000

June July August September October November December

Total Procedures CURRENT FY

Total Procedures PREVIOUS FY

Total Procedures Current FY Vs. Previous FY

Exceeded

previous

year!!

Pay Attention to Data Trends

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Track Cash

• Posted vs. deposited

• Goals

• Average three months

• Previous period Revenue

SUMMARY MONTH -TO-DATE-CASH PERFORMANCE

Monthly Cash

Goal: 4,245,609*

* Based Upon Last 3 Months Average of

Net Revenues

MTD Actual Cash Collections

(Posted): 929,838

MTD Variance to Monthly

Goal: 3,315,770

MONTH-TO-DATE CASH DETAIL

Cash Collections (Posted): 929,838

Current Day's Receipts

(Unposted): 92,321

MTD Receipts (Unposted): 165,282

MTD Actual Cash Collections

(Deposited) 999,929

MTD Cash Goal 4,245,609

MTD Variance to Goal 3,315,770

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14,510,321.91

12,247,219.35

15,811,125.52

13,416,884.57

14,190,453.81

12,211,326.5511,903,517

0.00

2,000,000.00

4,000,000.00

6,000,000.00

8,000,000.00

10,000,000.00

12,000,000.00

14,000,000.00

16,000,000.00

18,000,000.00

June July August September October November December

TOTAL CASH COLLECTIONS CURRENT FY TOTAL CASH COLLECTIONS PREVIOUS FY

Total Cash Fiscal Year 2016

Reimbursement

fell below

previous year

Pay Attention to Data Trends

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Sample Monthly Number Snapshot Report

FY 2017 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17

Departmental Visits

EMROP - EMERGENCY ROOM OP B 2,397 2,439 2,472 2,413 2,247 2506 2,500 2,739 2,673 2,662 2,605 2,460

MNROP - EMERGENCY ROOM MINO 615 590 530 484 457 450 479 522 596 625 665 632

EMROP2 - EMERGENCY ROOM OP L 1,387 1,376 1,215 1,241 1,098 1250 1,243 1,319 1,385 1,377 1,399 1,267

Lag Days

Emergency Room 5.81 8.04 8.29 9.96 8.898.70 6.53 9.30 9.65 8.87 9.64 8.35

Supplies Emergency 5.07 6.13 6.89 8.20 9.666.81 5.86 8.94 9.65 8.41 7.98 7.04

Emergency Room 2 3.91 5.33 4.98 4.95 4.493.89 4.01 5.57 6.72 6.48 5.21 4.22

Supplies Emergency 2 3.96 7.05 4.93 5.26 4.353.52 4.61 5.54 6.74 5.98 5.02 4.00

Late Charges

Emergency Room $31,879.78 $200,832.00 $180,480.00 $200,387.00 $107,317.00 $136,432.00 $118,045.00 $137,446.00 $183,307.00 $142,034.00 $179,561.00

Supplies Emergency $33.87 $287.07 $270.90 $539.25 $167.05 $325.23 $126.24 $381.60 $924.65 $353.56 $503.57

Late GL

Emergency Room $55,586.12 $695,512.00 $593,736.00 $722,733.00 $475,958.78 $435,449.00 $313,232.00 $386,365.00 $831,707.00 $483,144.00 $619,602.00 $547,328.00

Supplies Emergency $74.52 $1,607.51 $1,255.34 $1,949.23 $1,795.30 $1,345.46 $929.39 $2,034.47 $3,340.25 $1,488.39 $1,968.66 $1,258.60

Emergency Room 2 $19,578.00 $114,639.00 $109,365.00 $40,977.00 $44,774.00 $50,683.00 $41,480.00 $15,445.00 $121,623.00 $54,757.00 $70,090.00 $29,278.00

Supplies Emergency 2 $11.10 $991.76 $146.41 $313.32 $579.13 $356.60 $283.15 $69.87 $1,035.56 $383.89 $973.11 $69.19

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Detail by Chargecode

• Look for variance from previous month

• Does variance make sense?

• Was change properly communicated and prepared for in advance?

• Can errors be corrected?

• Identify root cause and implement changes to ensure future success

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Detail by Charge Code Report

Jan 15 Feb 15Bill

CodeItem # Proc's DescriptionUNITS BILLED

GROSS REVENUE

UNIT VARIANCE

REVENUE VARIANCE UNITS BILLED

GROSS REVENUE

UNIT VARIANCE

REVENUE VARIANCE

CATH COUDE 5CC 14FR 0 $0.00 0 $0.00 0 $0.00 0 $0.00SURGICEL 4X8 0 $0.00 0 $0.00 0 $0.00 0 $0.00

STOCKINETTE ORTHOPEDIC 3 0 $0.00 0 $0.00 0 $0.00 0 $0.00

STOCKINETTE ORTHOPEDIC 6 0 $0.00 0 $0.00 0 $0.00 0 $0.00

GAUZE STERILE 36 X 36 FLUFF 0 $0.00 0 $0.00 0 $0.00 0 $0.00

SURGIFOAM SPONGE 100CM 0 $0.00 0 $0.00 1 $41.50 1 $41.50

GELFOAM POWDER 0 $0.00 0 $0.00 0 $0.00 0 $0.00

CATH COUDE 5CC 16FR 0 $0.00 0 $0.00 0 $0.00 0 $0.00

CATH FOLEY 3CC 10FR 0 $0.00 0 $0.00 0 $0.00 0 $0.00

CATH 3 WAY 30CC 16FR 1 $16.72 1 $16.72 0 $0.00 -1 -$16.72

CATH KIT FOLEY 16FR W BAG 7 $120.54 3 $51.66 10 $172.20 3 $51.66

CATH 3 WAY 30CC 18 FR 0 $0.00 0 $0.00 0 $0.00 0 $0.00

CATH 3 WAY 5CC 18FR 0 $0.00 0 $0.00 0 $0.00 0 $0.00

CATH 3 WAY 30CC 20FR 0 $0.00 0 $0.00 0 $0.00 0 $0.00

CENTRAL VEIN KIT SINGLE LUMEN 0 $0.00 0 $0.00 0 $0.00 0 $0.00

KNEE IMMOBILIZER 12 UNIV 0 $0.00 -1 -$14.50 0 $0.00 0 $0.00

SET TUR Y SPIKE 0 $0.00 0 $0.00 0 $0.00 0 $0.00

IV VENOSET STERILE W CLAMP 12 $438.84 4 $146.28 4 $146.28 -8 -$292.56

CATH COUDE 5CC 18FR 0 $0.00 0 $0.00 1 $20.87 1 $20.87

CATH 3 WAY 5CC 22FR 0 $0.00 0 $0.00 0 $0.00 0 $0.00

BAG DRAINAGE URETERAL 0 $0.00 -1 -$27.04 3 $81.12 3 $81.12

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Discharge not Final Billed

Top 20 Providers by Oldest Accounts

Physician Oldest Acct (Days)

FLAREU 359

JOHWIL 197

BOLTI 50

BORYO 42

PENJOH 39

JOHKEN 37

CHEDA 34

POPOV 30

COCAR 25

SHIWI 25

HARLI 24

MORWI 24

PENRA 24

DYEJA 21

NEHJU 18

URBVI 18

KISJA 17

Discharge not Final Billed

Top 20 Providers by Revenue

Provider Sum of Charges Number of Accts

PENJOH 1,095,499.99 48

COCAR 792,121.59 47

NEHJU 344,025.60 15

LOPROB 246,591.89 15

KISJA 244,578.82 7

URBVI 177,064.38 6

HARLI 151,438.68 9

TONTH 109,349.05 105

KAPJOS 83,546.70 95

POPOV 75,044.99 6

HEDHA 73,359.46 60

LEESI 69,100.12 2

BRISU 63,926.81 6

BORYO 63,011.01 18

PENRA 31,437.85 2

SHIWI 27,740.05 1

WYKDA 27,143.00 3

CHEDA 25,387.65 3

FERCA 20,761.40 2

BOLTI 13,614.28 3

3,734,743.32 453

Discharge not Final Billed

Top 20 Providers by # Accounts

Provider Sum of Charges Number of Accts

TONTH 109,349.05 105

KAPJOS 83,546.70 95

HEDHA 73,359.46 60

PENJOH 1,095,499.99 48

COCAR 792,121.59 47

BORYO 63,011.01 18

NEHJU 344,025.60 15

LOPROB 246,591.89 15

CAMTH 12,790.20 10

HARLI 151,438.68 9

KISJA 244,578.82 7

URBVI 177,064.38 6

POPOV 75,044.99 6

BRISU 63,926.81 6

WHEGE 1,629.00 6

ERPHYS 631.00 6

GUTRA 7,932.85 4

TAPWI 2,541.20 4

MORWI 3,942.15 4

PURRU 2,348.10 4

3,551,373.47 475

Discharge not Final BilledSummary by Department

Department#

Accounts Sum of ChgsOldest Account

(Days)

?? Vet 1 26.00 359

Cardiology 1 1,622.00 9

COMMUNITY 16 185,787.23 24

ED 18 47,009.70 34

ER 112 110,807.05 197General Surgeon 7 29,491.10 7

HemOnc 8 71,899.72 37

HOSPITALIST 142 2,902,423.47 39

LOCUM 212 276,402.58 21

OB/GYN 28 151,711.28 50

Psych 1 27,740.05 25

546 3804920.18

How do you

define DNFB?

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Other Reports

• Audits in process, completed and planned• Standard benchmarks should be published daily and distributed to department leadership • Final reports should be discussed at Revenue Cycle meetings for process improvement

• Clean claim rate• Where can we improve? • How do we compare to industry standard?

• Coding backlog• How is this communicated to billing on a daily basis for preparation and

scheduling?• How can we improve?

• Provider behavior• Coding education• System checks: too few or too many

• A/R• Revenue month to date• Monthly target• Days cash on hand

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Expectation and Responsibilities

Department leaders must take charge and

drive progress

Understand the intent of the data

Review timely (daily, weekly, monthly as

distributed)

Assign research or improvement projects

for outliers

Ensure that all duties, responsibilities and

due dates are clearly stated

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Keep Additional Goals in the Pipeline

Promote a culture of Continuous Quality Improvement

Items may be preempted by more important issues, but should not be disregarded

Even audits demonstrating success after an education initiative should be rescheduled to ensure that learned behaviors are reinforced and staff does not revert to previous habits

Keep learning, keep growing, keep striving!