18
IMPLEMENTING A MEDICAL BILLING MODEL: STUDENT HEALTH CENTER REVENUE POTENTIAL Donna Hash & Merry Lawrence

IMPLEMENTING A MEDICAL BILLING MODEL: STUDENT HEALTH CENTER REVENUE POTENTIAL Donna Hash & Merry Lawrence

Embed Size (px)

Citation preview

Page 1: IMPLEMENTING A MEDICAL BILLING MODEL: STUDENT HEALTH CENTER REVENUE POTENTIAL Donna Hash & Merry Lawrence

IMPLEMENTING A MEDICAL BILLING MODEL:STUDENT HEALTH CENTER REVENUE POTENTIAL

Donna Hash & Merry Lawrence

Page 2: IMPLEMENTING A MEDICAL BILLING MODEL: STUDENT HEALTH CENTER REVENUE POTENTIAL Donna Hash & Merry Lawrence

Presentation Overview• Background

• Getting Started• Terms & Definitions

• Fee Schedule

• Planning Process

• Operational Changes• Key Considerations

• Implementing the Process

• Evaluation• Monitoring & Reporting

• Lessons Learned

• Next Steps

Page 3: IMPLEMENTING A MEDICAL BILLING MODEL: STUDENT HEALTH CENTER REVENUE POTENTIAL Donna Hash & Merry Lawrence

Background: Motivating Factors

• Our Previous Approach

• Financial Considerations• University Administrative Charges

• Student Fees

• Organizational Aims• Improve Services to Students

• Recruit & Retain Quality Clinicians

• Data• In 2008, ~90% of students surveyed were insured*

*Based on spring 2010 NCHA data (1,632 student respondents)

Page 4: IMPLEMENTING A MEDICAL BILLING MODEL: STUDENT HEALTH CENTER REVENUE POTENTIAL Donna Hash & Merry Lawrence

Getting Started: Exploring New Opportunities

• Health Services Fee• Ongoing cost increases and budget/resources decreases

• Medical Billing Model (old vs. new)• Provide cost-effective services & generate revenue

• Consistent with industry billing standards

• Establish a Fee Schedule• What to charge? How much?

• Conversion factor

Page 5: IMPLEMENTING A MEDICAL BILLING MODEL: STUDENT HEALTH CENTER REVENUE POTENTIAL Donna Hash & Merry Lawrence

2007-2008 2008-2009 2009-2010 2010-2011 2011-2012 2012-2013$0

$100,000

$200,000

$300,000

$400,000

$500,000

$600,000

$700,000

$800,000

$900,000

$1,000,000

Gross Revenue

Gross Revenue

Page 6: IMPLEMENTING A MEDICAL BILLING MODEL: STUDENT HEALTH CENTER REVENUE POTENTIAL Donna Hash & Merry Lawrence

Getting Started: Learning the Lingo

Page 7: IMPLEMENTING A MEDICAL BILLING MODEL: STUDENT HEALTH CENTER REVENUE POTENTIAL Donna Hash & Merry Lawrence

• In-house Billing vs. Billing Service• EMR/EHR

• Establishing a Fee Schedule• Conversion factor

• CPT, E&M Codes

• RBRVS

Operational Changes: Preliminary Decisions

Page 8: IMPLEMENTING A MEDICAL BILLING MODEL: STUDENT HEALTH CENTER REVENUE POTENTIAL Donna Hash & Merry Lawrence

Code DescriptionWork Value

Non Fac PE

FAC PE Malpractice

Non Fac Total

Fac Total

Global Gap

15952

Excision, trochanteric pressure ulcer, w/ skin flap closure;

12.31 12.03 12.03 2.63 26.97 26.97 090

15953

with ostectomy 13.57 13.29 13.29 2.67 29.53 29.53 090

15956

Excision, trochanteric pressure ulcer, in preparation for muscle or myocutaneous flap or skin graft closure;

16.79 14.05 14.05 3.42 34.26 34.26 090

15958

with ostectomy 16.75 14.83 14.83 3.39 34.97 34.97 090

16000

Initial treatment, first degree burn, when no more than local treatment is required

.89 1.01 .34 .12 2.02 1.35 000

16020

Dressings and/or debridement of partial-thickness burns, initial or subsequent; small (less than 5% total body surface area)

.71 1.56 .77 0.10 2.37 1.58 000

16025

Medium (eg, whole face or whole extremity or 5% to 10% total body surface area)

1.74 2.27 1.26 0.29 4.30 3.29 000

16030

Large (eg, more than 1 extremity., or greater than 10% total body surface area)

2.08 2.86 1.45 0.37 5.31 3.90 000

16035

Escharotomy; initial incision 3.74 1.53 1.53 0.63 5.90 5.90 000

16036

Each additional incision (list separately in addition to code for primary procedure)

1.50 0.69 0.69 0.27 2.46 2.46 zzz

17000

Destruction (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), premalignant lesions(eg, actinic keratoses), first lesion

0.65 1.65 0.92 0.08 2.38 1.65 010

Page 9: IMPLEMENTING A MEDICAL BILLING MODEL: STUDENT HEALTH CENTER REVENUE POTENTIAL Donna Hash & Merry Lawrence

Code DescriptionWork Value

Non Fac PE

FAC PE Malpractice

Non Fac Total

Fac Total

Global Gap

17110

Deconstruction (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), of benign lesions other thank skin tags or cutaneous vasular proliferative lesions; up to 14 lesions

0.70 2.48 1.27 0.08 3.26 2.05 010

Fee for Service Example:

Non FAC Total (code value) = 3.26

Sample Conversion Factor = $50.00

Code Value x Conversion Factor 3.26 x 50 = $163.00

Page 10: IMPLEMENTING A MEDICAL BILLING MODEL: STUDENT HEALTH CENTER REVENUE POTENTIAL Donna Hash & Merry Lawrence

• Contracting with insurance plans • Top 3

• Clearinghouses• Electronic medical claim submission (ERA)

• Staffing• Billing Manager

• Payment processing• Check ICD/CPT codes

• Create billable claim forms

• Submit claims (electronically)

• Correct/re-bill claims

• Post payments

• Manage accounts receivables

• Patient responsibility charges to patient accounts

Operational Changes: Key Considerations

Page 11: IMPLEMENTING A MEDICAL BILLING MODEL: STUDENT HEALTH CENTER REVENUE POTENTIAL Donna Hash & Merry Lawrence

• Utilize Practice Management Software/EMR• Document patient information (e.g., store ID cards)

• Use reporting tools

• 3 Primary Reports:• Accounts Receivable Aging Report

• Payer Mix Analysis

• Summary of Charges • Analyze by transaction code

Operational Changes: Insurance Aging A/R

Page 12: IMPLEMENTING A MEDICAL BILLING MODEL: STUDENT HEALTH CENTER REVENUE POTENTIAL Donna Hash & Merry Lawrence

A/R Report:

• Patient charges detailed by plan

• Aging “buckets”

• Focus on oldest claims

• Analysis of aging conducted by the Billing Manager

Evaluation: Monitoring & Reporting

Page 13: IMPLEMENTING A MEDICAL BILLING MODEL: STUDENT HEALTH CENTER REVENUE POTENTIAL Donna Hash & Merry Lawrence

Evaluation: Payer Mix Analysis

Page 14: IMPLEMENTING A MEDICAL BILLING MODEL: STUDENT HEALTH CENTER REVENUE POTENTIAL Donna Hash & Merry Lawrence

Evaluation: Summary of Charges

Page 15: IMPLEMENTING A MEDICAL BILLING MODEL: STUDENT HEALTH CENTER REVENUE POTENTIAL Donna Hash & Merry Lawrence

• Provider Cooperation & Coordination• Clinical staff buy-in

• Management support

• Billing Office Staff• Professional development

• Reporting Process • Payment codes, adjustment codes, charting system, missed charges etc.

• Monitor reimbursements for errors

• Annual Technology Upgrades

• Plan for changes & train staff

Lessons Learned

Page 16: IMPLEMENTING A MEDICAL BILLING MODEL: STUDENT HEALTH CENTER REVENUE POTENTIAL Donna Hash & Merry Lawrence

Next Steps• Adapt to ACA• Contract with additional insurers

• Adjust fee schedule

• Consider the value of an in-house patient advocate• Student advisory board

• Financial assistance plan

• Prepare for ICD 10• October 1, 2015 expected implementation

• Continue to support the health & well-being of students

Page 17: IMPLEMENTING A MEDICAL BILLING MODEL: STUDENT HEALTH CENTER REVENUE POTENTIAL Donna Hash & Merry Lawrence

Contacts & Resources

Contacts at WSU:Donna Hash, Administrative ManagerHealth & Wellness [email protected]

Merry Lawrence, Billing Office ManagerHealth & Wellness [email protected]

Online Resources:Resource-Based Relative Value Scalewww.ama-assn.org//ama/pub/physician-resources/solutions-managing-your-practice/coding-billing-insurance/medicare/the-resource-based-relative-value-scale.page

Medical Group Management Association www.mgma.com

American Medical Associationwww.ama-assn.org/ama/pub/physicians/physicians.page

Credentialing & Contracting Articlewww.articlesbase.com/business-articles/improve-your-practice039s-financial-health-focus-on-the-four-ps-in-a-pod-patients-payers-payments-and-productivity-2003088.html

Page 18: IMPLEMENTING A MEDICAL BILLING MODEL: STUDENT HEALTH CENTER REVENUE POTENTIAL Donna Hash & Merry Lawrence