Show Me the Numbers! How Strategic Planning Can Pay Off for Your Health Center.

Show Me the Numbers!How Strategic Planning Can Pay Off for Your Health Center

What Are the Numbers?• Key indicators chosen to measure a basic level of success• 14 Sites w/ completed evaluation results assessed by SNS 2006-2008• Where located: Massachusetts, Maine, Connecticut

– 10 FQHCs– 4 Non-FQHC CHCs

• Key indicators measured: – Net revenue– Number of patient visits– Gross charges – Number of unduplicated patients

Gross Charges Net Revenue # of Visits # of Unduplicated Patients

Baseline 12 Months Baseline 12 Months Baseline 12 Months Baseline 12 Months

39,523,721 48,732,525 19,659,879 22,410,721 178,769 206,799 64,871 84,572

Aggregate Data – 14 Health Centers

Average Increase Per Site – 14 Health Centers

Gross Charges Net Revenue # of Visits # of Unduplicated Patients

↑$657,771 ↑ $196,488 ↑ 2,147 ↑ 1,519

How Did They Get There?

Common Strategies Employed• Education of dental and administrative team related to

opportunities to maximize access and productivity• Improved scheduling systems to maximize productivity

and make best use of chairs given current staffing• Created or refined policies designed to reduce or

eliminate chaos (eg, emergencies, no-shows)• Tweaked patient mix to improve access for priority

populations (such as children) which also aided the practice financially

• Developed clinical protocols to standardize services provided to patients at each visit, which fostered the completion of treatment plans, ensured the avoidance of churning and maximized revenue opportunities

Common Strategies Employed (cont.)

• Adjusted fee schedules to be more in line with Usual and Customary Rates

• Revised encounter forms to enhance their functionality• Established access and productivity goals for the

practice, ensuring elimination of disease and creation of financial sustainability

• Met with dental and administrative staff to review current situation and present the action steps recommended for practice enhancement and/or recovery

• Showed the practice how to monitor success or lack thereof in achieving action plan goals

• Promoted the development of a process to reward and celebrate success on a regular basis

Common Strategies Employed (cont.)

• Reviewed monthly progress reports with dental leadership related to progress in accomplishing each action step according to the agreed upon timeline

• Adjusted action steps when needed • Reviewed SNS key data reports with practice at

6,12,18, and 24 months

Case StudySix-Chair Federally Qualified Health Center

Before After

Number of Visits 18,150 21,341

Net Revenue $1,464,116 $2,336,873

Total Expenses $1,723,007 $2,114,528

Profit/(Loss) ($258,891) $222,345

Revenue/Visit $81/visit $110/visit

Cost/Visit $95/visit $99/visit

About This Program

• Six-chair clinic located in Boston suburb (FQHC)• Six FTE dentists, each seeing an average of 13

patients per day• Fee-for-service reimbursement for Medicaid• Practice located in an area of enormous need and

demand for care• Only FQHC in service area• As a result of moving from red to black, this practice

is in the process of expanding from 6 to 12 chairs!

Case Study: How Did They Increase Visits?

Before AfterPractice was achieving a lot of visits, but high level of chaos detracted from productivity

Put systems in place to replace chaos with control

No show policy was not consistently enforced

Tweaked no-show policy and began enforcing it consistently

Scheduling system undermining productivity

Recreated the scheduling system; moved to 30-day schedule and developed new policy

Emergency policy was overly complex; practice overwhelmed by emergencies

Created new emergency policy and method of accommodating emergency patients into the practice without causing disruption to scheduled patient care

Strategies for Increasing Visits

• Managing Emergencies

• Managing No-Shows

• Scheduling

Managing Emergencies• Define what constitutes a true emergency• Create an emergency management system that meets

the level of need, but preserves regularly scheduled appointments

• Develop and implement an emergency policy, and stick to it

• Provide training for registration and reception staff in the triage of emergency walk-ins and calls

Managing No-Shows• Create and distribute no-show policy to patients and staff• Post the no-show policy in several areas• Have patients read, sign and insert signed policy in chart • Enforce the no-show policy consistently across the

practice • Track:

– No-shows– Cancellations– Fill-ins– Scheduled visits vs. actual appointments

Managing No-Shows (cont.)

Provide reminder messages for upcoming appointments

Schedule appointments no further out than 30-45 days

Schedule one follow-up appointment at a time

Improving Scheduling System

Some factors that affect scheduling policies:• Demographics of the patient population• Typical needs of the patient population • How far in advance appointments are scheduled• Appointment lengths• Number of appointments available

Improving Scheduling (cont.)

• Schedule appointments no further out than 30-45 days

• Schedule appointments one at a time Exception: patients undergoing complex procedures that require multiple visits to complete

• Determine basic appointment length by type of service provided: 30-45-60 minutes

Allocate10-15 minute increments for procedures requiring additional time

Case Study: How Did They Increase Net Revenue?

Before After

Inconsistency in services provided to patients from provider to provider, resulting in lost revenue opportunities, as well as delays in completion of treatment plans and discontent

Created clinical protocols to standardize services provided to patients, maximize revenue opportunities and foster the completion of treatment plans

Large amount of money owed to the practice out past 90 days, primarily from Medicaid and other third-party payers

Reviewed entire billing process to identify reasons for denied claims; developed strategies to improve the billing process (with the goal of getting clean claims out the door) (eg, assigned dental staff person to review each day’s encounters before they were submitted to billing)

Practice (providers and support staff) did not know the Medicaid rules and regulations; were providing lots of non-covered services; also were not aware of many new covered services that had recently been added

Created abbreviated guidelines for Medicaid showing covered services and accompanying rules and regulations. Practice began regularly educating and updating providers and staff

Case Study: Increasing Net Revenue

Before After

Fee schedule was low (in some cases, below what Medicaid would pay)

Increased fee schedule to 75th percentile of UCR

Practice did not have a sliding fee scale for self-pay patients

Created a sliding fee scale that balanced affordability for self-pay patients with need to achieve financial sustainability

Strategies That Increase RevenueDocumentation of Eligibility• Flow charting and establishing accountability for every step of

the eligibility process through staff orientation and trainingManagement of Self-Pay Patients• Define the responsibilities of patients and staff• Communicate expectations for payment at the time of the visit• Support front desk staff to perform this crucial task through

training and scripting; use objective performance measures to evaluate staff success

Billing Efficiencies• Flow charting and establishing accountability for each step in

the process from patient registration through reconciliation• Identify barriers to successful billing and develop strategies to

resolve• Staff training to increase probability of success through the

billing process

Strategies That Increase RevenueCross-train staff (receptionists, registration staff, dental

assistants) to fill in as needed, according to priority• The consideration of incentive programs to reward

the dental team (not just providers) • Use of DAs and RDHs for expanded duty to

maximize availability of dentists for treatmentStaff are regularly educated and trained relative to the

rules and regulations of the practice’s primary third-party payers (especially Medicaid)

• Determination of a defined scope of service fostering elimination of disease, yet preserving financial viability

Strategies That Increase RevenueEstablishment of a fee schedule, sliding fee scale and nominal fees that sustain the practice yet do not pose barriers to careNon-emergent procedures requiring prior authorization should not be initiated until PA is received or patient agrees to self-pay statusVerification of patient’s eligibility before and at each visitSkillful utilization of IT systems to maximize clinical effectiveness and enable the practice to obtain the data needed to evaluate program performance

Self-pay patients and those with insurance co-payments need to pay at the time of the visit

Patients should be educated about the true value of the services they are receiving and the discounts they are eligible for

Policies That Increase Revenue

• Slide fees from full charges (set at 75-80th percentile of UCR) based upon household income and Federal Poverty Guidelines

• Slide categories are typically 100% FPL and below; 101-150% FPL, 151-200% FPL, with percentage discounts offered for each category (patients above 200% FPL pay full charges)

• In setting sliding fee scale, need to create a balance between compassion and financial sustainability

• FQHCs – set a nominal fee for patients 100% of FPL and below

– Can be determined by setting a dollar amount (e.g. $30), a percentage of 20% of full fee, or the Medicaid adult fee for same service

– Make every effort to collect, but those 100% of FPL and below who are unable to pay are subsidized by the practice [330 funds?]

Developing a Sliding Fee Scale

Strategies for Creating an Effective Billing System

• Utilization of an up-to-date, practice-friendly encounter form

• A policy that all staff responsible for any part of the billing process be trained and held accountable

• A policy guiding the transfer of information from dental to billing with built-in accountability

• The creation of a flow chart that defines each step in the billing process and assigns accountability for each step

• A policy that guides the reconciliation of remittances and the resubmission of denials with designated accountability

• A prior approval policy and process • A billing manual and orientation/training process for

accountable staff

Creating an Effective Billing System

Sample Billing Flow ChartPatient calls for appointment; registration

documents eligibility and schedules appointment

Patient comes in for appointment; eligibility is checked again; patient is asked to pay any co-pays due at the time of the

visit

Encounter form (or routing slip) is generated; patient sits in chair; provider sees patient and documents services on

encounter form or on routing slip

Patient meets with patient accounts specialist to review follow-up care needed and

estimated costs

For patients covered by Medicaid or other third-party insurers, DA takes encounter

form and puts it in holding cart

Encounter form goes to billing, where it is reviewed

by dental specialist

Patients with co-payments (self-pay or commercial insurance) take encounter form to

registration and check out

If patient agrees to care plan, next appointment is made

Encounter form goes to billing, where it is reviewed and patient invoice is generated for balance due, if any

Patient accounts specialist takes encounter form

Third Party insurance Self-Pay

Patient gets bill and pays or continues to get billed

Written off

Claim is filed

Claim is paid or denied

Paid Denied

Reconciled against patient account

Investigated, corrected and

rebilled

Claim is paid or denied

Reconciled against patient account

Paid

Written off

Hopeless

Submitted for payment again

Still Hope

Sample Billing Flow Chart (cont.)

Encounter form goes to billing, where it is reviewed

by dental specialist

Reconciled against patient

account

Paid Hopeless

Strategic Planning

• After establishing where it is (through practice analysis), the practice needs to decide where it wants to go and how it will get there

– Define the practice’s mission and explore scope of service– Develop an action plan to get the practice to achieve the goals of:

• The dental practice’s mission (access and services) • The overall health center mission• Financial sustainability• Quality dental health indicators• Completion of Phase 1 Treatments

• Develop policies, procedures, and operations that foster the attainment of the dental practice’s goals

• Develop long- and short-term goals and action steps• Regularly review practice data to monitor performance of dental

program

What Data Should We Gather?Gross Charges

Net Revenue

Expenses (Direct and Indirect)

Total Number of Visits

Revenue per visit

Cost per visit

Number of Completed Phase 1 Treatments

Number of New Patients

Number of Unduplicated Patients

Number of Transactions (by ADA Code)

No-Show Rate

Emergency Rate

Number of FTE Dentists

Number of FTE Hygienists

Number of FTE Dental Support Staff

Any Change in Scope of Service?

Any Change in hours of operation?

Partnering to Strengthen and Preserve the Oral Health Safety Net

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