Health Center Revenue and Reimbursement Management Julie M Vlasis Consultant Department of Health and Human Services Health Resources and Services Administration.

Health Center Revenue and Reimbursement Management

Julie M VlasisConsultant

Department of Health and Human ServicesHealth Resources and Services

AdministrationBureau of Primary Health Care

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Learning Objectives

• Understanding components of Revenue Cycle

• Sliding Fee Scale Policy• Fee Schedule Development

Understanding Components of Revenue Cycle

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What Does Real Revenue Cycle Look Like?

Appointment Schedules

Patient Registration

Provision of CareCoding and Billing

of Patient Encounter

Accounts Receivable

Management Payments and

Denials

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Scheduling• Scheduling

• Open Access• Modified Wave• Structured Appointment Type

• Scheduling Guidelines• Information to assist staff in maintaining

adequate scheduling• Staff Training

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Scheduling

• System Monitoring/Reporting• Patient Scheduling Trends

• Morning/Afternoon/Early Evening• Pediatrics vs. Adults

• Provider Productivity

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Patient Registration

• Patient Registration• Demographic and UDS Data Collected

• Patient Insurance Collected• Copies of Insurance Cards• Insurance Eligibility Verified

• Managed Care – PCP Designated• Benefits Reviewed

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Patient Registration

• Patient Application for Sliding Fee Program Initiated• Application completed• Financial Information collected • Family Size Verified

• Copays Collected• Ability vs. Willingness

• Staff Training and Development

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Provision of Care• Provider Coding and Documentation

• Templates• Smart Phrases • Implementation of New Programs

• IPPE – Medicare Initial Preventative Physical Examination

• AWV – Medicare Annual Wellness Visit• Provider Coding Profiles - ICD-10 Implementation• Free Text

• Auditing • QA/QI Inclusion

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Provision of Care

• Annual Coding Update• Implementation Plan and Training for ICD-10• CMS Updates

• Clinical Policies and Procedures• Progress Note Documentation

• Understanding of Required Reporting• UDS Reporting • Other Health Center Gran

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Coding and Billing

Encounter Edit Process 1. Review Evaluation and Management Codes

2. Review Procedure/Other Services Codes

3. Review Diagnosis Codes – Highest Level Of Specificity – Important for ICD-10 Implementation

4. Confirms Insurance Eligibility

5. Posting of encounter within 3 days of service

6. Claim Submitted Electronically

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Accounts Receivable Management

Process Driven • Receipt of Payments and Adjustments• Secondary Insurance Claims Submitted• Denials tracked and worked• Resubmission of claims• Patient Responsibility determined• Patient Statements mailed• Active Collection process completed

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Accounts Receivable Management

• Clear Communication with All Critical Departments

• Scheduling• Registration• Clinical

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Metrics and Measurements

• Registration• Percentage of Accurate Insurance

Verifications - 85%• Percentage Collection of Copays at time

of Service – 90%• Percentage Sliding Fee Applications

Processed Correctly -95%

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Metrics and Measurements• Billing

• Percentage of claims submitted in 3 days from date of service – 95%

• Percentage of Clean Claims – 90% • Days in Accounts Receivable Aging – 45 Days• Percentage of Denials - 5%• Percentage of Underpayment – 5%• Percentage of successful appeals – 90%• Percentage of Claims over 90 days – 20%

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Accounts Receivable Management

• Team Work• Clear Communication

• Scheduling• Registration• Clinical

• Identification of Training Opportunities• Constant Report Analysis

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Policies and Procedures

• Essential Framework for Strong Revenue and Reimbursement Management

• Provides Staff Accountability• Reduces Errors• Increases Reimbursement

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Policies and Procedures to Identify

• Appointment Scheduling• Registration• Sliding Fee Scale• Clinical Encounter Management• Billing Credit and Collections• Finance

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Staff Development

A well trained knowledgeable staff reduces Accounts Receivable Aging and Increases Reimbursement.• Initial Staff Training – New Hire• Continuous Training – at least Annually

• Successful Revenue Management Programs have continuous staff training

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Revenue Cycle Recap

• Scheduling/ Productivity• Registration/Eligibility• Provision of Care/ Documentation• Coding and Billing - Accuracy• Accounts Receivable Management

• Continuous Report Monitoring• Team Work across all departments• Staff Development – Training• Communication

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Development of Revenue Cycle Annual Action Plan

• Annual Action Plan• Annual Setting of Metrics

• Annual Review and Revision P&P’s• Identification of new Medicare and Medicaid

Programs

• Monitoring all Components of Revenue Cycle

Sliding Fee Discount Policies

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Sliding Fee Discount Policies330 Grantee Requirement:

• Health Center has a system in place to determine eligibility for patient discounts adjusted on the basis of the patient ability to pay.

• This system must provide a full discount to individuals and families with annual incomes at or below 100% of the poverty guidelines (only nominal fees may be charged) and for those with incomes between 100% and 200% of poverty, fees must be charged in accordance with a sliding discount policy based on family size and income.*

• No discounts may be provided to patients with incomes over 200% of the Federal poverty level.*

(Section 330(k)(3)(G) of the PHS Act and 42 CFR Part 51c.303(f))

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Program Policy Requirements

• Clear guidelines for qualifying for discounted fee

• Clear guidelines how discounts are determined

• Clear guidelines outlining required documentation

• Available application form with guidelines

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Program Policy Requirements

• Procedure for verifying income and family size

• Clear recertification process• Sliding Fee Scales updated on annual

basis• Required Signage• Staff Training- annually

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Best Practices

• Separate Sliding Fee Application• Separate Financial Class For Sliding Fee

Scale Participants - Monitoring• Signage posted throughout Facility• Patient Financial Agreement• Reminders to patients regarding co-pay

responsibilities – Appointments/Recall

Health Center Fee Schedule Development

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Fee Schedule Development

• Methodology of Development• Resource-based Relative Value Scale-

RBRVS• True Center Costs

• Medical, Behavioral Health and Dental • Updated Annually• Policy describing method and timelines

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Fee Schedule Development

• Current Medicare and Medicaid Prospective Payment System (PPS) Rates

• Managed Care Wrap Rates • Medicare and Medicaid

• Medicare Cost Report• Cost per medical encounter

• UDS Report • Cost per medical encounter excluding lab, x-ray

and nursing visits

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Fee Schedule Development

• Utilization Review• CPT utilization by facility/ by clinician

• Auditing accuracy of services billed• Captured Revenues

Questions??

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Contact Information

Julie Vlasis

Consultant

559-907-4760

559-454-8942

jvlasis@pacbell.net