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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??
