Beyond the Basics: Strategies for Enhancing Dental …...Beyond the Basics: Strategies for Enhancing Dental Program Success, Part 3 Dori Bingham, Director Dr. Mark J. Doherty, Executive

Beyond the Basics: Strategies for Enhancing Dental Program Success, Part 3

Dori Bingham, DirectorDr. Mark J. Doherty, Executive DirectorD4 Practice Solutions

Learning Objectives for Today

• Understand the factors that

impact dental program revenue

• Learn strategies for maximizing

program revenue

• Learn how to trouble-shoot

billing and collections

• Learn how to set appropriate

fees and discounts

Major Sources of Program Revenue1. Services we provide to patients:

➢ PPS, FFS or sliding scale

➢ Bill third-party and/or collect from patients

2. Grants/other income

➢ 330 Grant award

➢ Other grants (state, local, private)

➢ Fundraising (events, appeals)

➢ Interest from investments

If You’re in Charge of Dental

• Control

• Predictability

• Self-Reliance

Major Impacts on Dental Revenue

• Payer mix—HUGE impact

• Provider productivity (encounters and services)

• Fees/discounts

• Collections (third-party and patient payments)

Impact of Payer Mix on Sustainability

8,000 visits

35% Medicaid =2,800 visits x $125 = $350,000

55% Self-Pay/SFS =4,400 visits x $30 = $132,000

10% Commercial =800 visits x $125 = $100,000

Total revenue = $582,000

Total expenses = $600,000

Operating loss = ($18,000)

8,000 visits

40% Medicaid =3,200 visits x $125 = $400,000

50% Self-Pay/SFS =4,000 visits x $30 = $120,000

10% Commercial=800 visits x $125 = $100,000

Total revenue = $620,000

Total expenses = $600,000

Operating surplus = $20,000

Impact of Productivity on Sustainability6,000 visits

40% Medicaid =2,400 visits x $125 = $300,000

50% Self-Pay/SFS =3,000 visits x $30 = $90,000

10% Commercial =600 visits x $125 = $75,000

Total revenue = $465,000

Total expenses = $600,000

Operating loss = ($135,000)

8,000 visits

40% Medicaid =3,200 visits x $125 = $400,000

50% Self-Pay/SFS =4,000 visits x $30 = $120,000

10% Commercial=800 visits x $125 = $100,000

Total revenue = $620,000

Total expenses = $600,000

Operating surplus = $20,000

Impact of Fees and Discounts• Potential missed

opportunities with FFS reimbursement

• Need to make sure charges aren’t less than third-party payers would pay

• Full fees should be set at “prevailing rates”

• Discounts make dental as affordable as possible

Impact of Collections

• Can be HUGE!

• Demoralizing for dental staff

• Frustrating for all

Are We Collecting What We’re Owed?• Net patient revenue as

percentage of gross charges

• Accounts receivable

➢ Past 90 days

➢ % of total A/R

• Claims management issues (esp. denials)

• Collections at time of service

Billing and CollectionsWhy we leave money on the table:• Non-covered services• Non-covered patients• Failure to submit clean

claims• Flaws in billing process• Don’t collect from patients

The Revenue Cycle

Patient Makes

Appointment

Patient Visit Takes Place

Claim is Submitted

Payment is Posted

Claims are Managed (paid or

written off)

Why Billing Goes Wrong

Steep learning curve with dental billing

How many steps are there and how many people does it take to get from start to finish?

Each step comes with a potential point of failure

Every patient represent a new cycle, so these steps or combinations of steps could possibly occur hundreds of times each week

Common Pitfalls• Overwhelmed or poorly trained/supported front desk staff

• Not having a dedicated dental biller or sufficient staff to keep up with volume of claims

• Not having an interface between the EDR and EHR to send charges over

• Manual charge entry significantly increases likelihood of human error resulting in lost revenue

• Not having fee schedules set up in the EDR/EHR (for 3rd party payers but also for each sliding fee scale discount category)

• Should we bill out of EDR or EHR?

• Coding issues

Common Coding/Documentation Issues• Using obsolete codes

• Using the wrong code

• Codes charged out but procedures not referenced in clinical notes

• Procedure referenced in clinical notes but not charged out

• Referencing one procedure in the clinical notes but charging out a different code

• Not coding for unreimbursed services

Coding Matters

• Get paid for care provided

• Avoid coding errors (and potential fines/takebacks)

• Fully document services provided

• Provider owns responsibility for coding

• BUT don’t assume providers know the right codes to use

• Entire practice must stay abreast of code changes

• Reviewing encounters to ensure complete and accurate coding is wise

Great Resource for Dental and Billing Departments!

Key Elements Supporting Billing/Collections

• Management of self-pay patients

• Eligibility processes

• Documentation of the patient visit

• Patient registration and check-out

• Prior authorization process

• Revenue cycle processes

• Scripting

• Fees/SFDS

• Ongoing evaluation of performance

Billing/Collections Best Practices

Closely monitor A/R past 90 days

Implement scripting for front desk staff

Formulate and sequence treatment plans

Maintain insurance tables in EDR

Faithfully document eligibility

Billing/Collections Best Practices

Communicate clearly and accurately with patients

Schedule appointments WHEN prior auths have been approved

Stay abreast of dental codes

Know each insurer’s rules/regulations/covered services

Review daily encounters for accuracy/completeness

Performance Measures for the Revenue Cycle• Amount of A/R past 90

days (by payer type)

• % of A/R past 90 days as % of total A/R

• Amount of money written off due to denied claims (by payer source) and bad debt (self-pay patients or patient co-pays)

• Number of denied claims as % of all submitted claims

For Example

• Total Accounts Receivable $318,482• Total A/R >90 Days $131,107

• Commercial $71,985• Medicaid $14,384• Self-Pay/SFS $44,738

• Percentage of A/R >90 days = 41% (goal is 15-20%)

What Could be Happening?

• Not always easy to collect from commercial insurers

• Takes time and persistence to follow up on denials

• Insufficient billing staff = denials pile up and time out

• Communication gaps (patients, dental staff and billers)

• Front desk staff not comfortable asking patients for money at the time of the visit

• Lack of accountability (staff and patients)

Trouble-Shooting Billing and Collections• Gather baseline performance data

• Create a Revenue Cycle Management team with representatives from dental (front desk, dental leadership), billing, finance and others who play a role in the revenue cycle process

• Create a flow chart defining each step in the revenue cycle

• Identify the staff person or position responsible for each step

• Using the flow chart as a guide, identify ways to streamline or improve processes

Trouble-Shooting the Billing Process• Determine the root causes for flaws and develop strategies

to correct them

• Work collaboratively to identify and test improvements—no finger pointing!!!!

• Track performance data to determine whether strategies are working

• Revenue Cycle Management team to review and discuss data monthly

Set Goals for Billing and Collections• Decrease the amount of money in

A/R past 90 days

• Decrease the number of denied claims

• Decrease bad debt (increase collections from patients at the time of the visit)

• Increase net patient revenue

Fees/Sliding Fees

General Requirements

• Fees consistent with locally prevailing rates or charges and designed to cover reasonable costs of operation

• No patient shall be denied service due to inability to pay

• The sliding fee discount program incorporates the most recent Federal Poverty Guidelines (FPG)

General Requirements• Eligibility for SFDS based

only on family size and income

• SFDS categories based on the patient’s ability to pay

• Health center must establish systems (ie, policies) for determining patient eligibility for SFDS

General Requirements

• For patients at/below 100% FPG: no fee OR a nominal fee (flat, not percentage)

• Partial discounts for those with incomes between 101% and 200% of FPG

• No discounts for patients with incomes over 200% of FPG

• At least three discount categories between 101% and 200% of FPG

Fee Schedule

• Based on prevailing rates (identify source(s) of data)

• Can choose your own source(s) of data

• The health center’s fee schedule must address all in-scope services

Sliding Fee Discount Schedule Structure

Dental nominal fee can (and probably should) be different than the medical nominal fee

Health centers can set their own discount schedule, percentage of discounts, nominal fees they charge

All in-scope services provided via formal written contracts/agreements must follow HRSA SFDS guidelines

Must ensure fees for services provided via contractual agreements are compliant

Establishing and Collecting Nominal Charges• Nominal charge must not be a barrier to care

• A nominal charge must be a fixed fee that does not reflect the true value of the service(s) provided and is considered nominal from the perspective of the patient

• The nominal charge must be less than the fee paid by a patient in the first “sliding fee discount pay class” beginning above 100% of the FPG (eg, Slide A is nominal fee, Slide B is patients 101-125% of FPG)

Insured Patients Who Are Also Eligible for SFDS• Income and family size make many insured individuals

eligible for sliding fee discounts too

• Generally, if allowed, the insurance is billed at their normal rate and the patient’s co-pay portion is discounted based on their sliding fee schedule percentage

• Some insurance plans do not allow this, so be sure to check!

Multiple Sliding Fee Discount Schedules• Health centers can have different sliding fee schedules for

different service categories

• The SFDS must comply with HRSA guidelines as to nominal fee and percentage discounts between 100% and 200% federal poverty levels

• Only one nominal fee within a single SFDS

• The board must determine the nominal fee and assure it does not create a barrier to care for the lowest income populations

Lab Fees• Can require self-pay

patients to pay lab charges out-of-pocket (must inform patients of these charges prior to the time of service)

• Health center has latitude in what/how to charge patients for these lab fees (eg, at cost, discounted)

Lab Fees

Sample Fee Schedule with Labs

Code Description Full Fee Lab

Slide A--

Patients

at/belo

w 100%

FPG--

Patient

pays $35

per visit

Slide B--

101-

125%,

Patient

pays

30% of

fee

Slide C--

126-

150%,

Patient

pays

40% of

fee

Slide D--

151-

175%,

Patient

pays

50% of

fee

Slide E--

176-

200%,

Patient

pays

60% of

fee

D1110 Prophylaxis, Adult 130.00$ $0 $ 35.00 $ 39.00 $ 52.00 $ 65.00 $ 78.00

D2391 One surface posterior composite filling 220.00$ $0 $ 35.00 $ 66.00 $ 88.00 $110.00 $132.00

D2751

crown - porcelain fused to

predominantly base metal $1,263.00 $75.00 $35.00 $378.90 $505.20 $631.50 $757.80

D2752 crown - porcelain fused to noble metal $1,294.00 $90.00 $35.00 $388.20 $517.60 $647.00 $776.40

D2790 crown - full cast high noble metal $1,402.00 $99.00 $35.00 $420.60 $560.80 $701.00 $841.20

What About Specialty Services?• If not you, who?

• Could be recruitment/retention issue

• Can use designated access scheduling to control number

• If you do this, create objective criteria to determine who gets these appointments (can’t be only given to insured patients!!!!)

• Can also consider taking specialty services out of scope (requires formal approval from HRSA and the creation of a “firewall” between in-scope and out-of-scope services)

Questions/Discussion

D4 Practice Solutions• Individualized Assessments of Oral

Health Programs

• Expert Guidance and Planning for New Dental Programs

• Practical and Achievable Strategies for Success

• National Experts on Oral Health Program Access, Outcomes, Quality and Financial Viability

www.d4practicesolutions.com

Dr. Mark J. DohertyDori BinghamD4 Practice Solutionsc. (508) 776-1826 (Dori)c. (508) 958-0959 (Mark)[email protected]@d4dimension.com