Survival in 2012 and BeyondLynne P. Byrd Lynne P. Byrd

V.P. of Revenue Cycle, Archbold Medical Center

• ● IdentifyIdentify practical operation • strategies for survival.

• ● RecognizeRecognize pilots and specific • programs that have yielded• positive operation results.

• ● CompareCompare operation perspectives • from 4 hospital systems.

LEARNING OUTCOMES OF PRESENTATION

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Value Based Purchasing Performance = Reimbursement

Key Areas of Focus for Revenue Cycle

5010 and ICD-10 Conversion Do you have a plan?

Clinical Documentation Improvement Physician Education & Computer-Assisted coding

Career Ladders - Education is Key!! Staff development is essential to survival

Denials Management Establish an effective process now

Managed Care Contract Compliance Validate your reimbursement

• ●Eligibility – 270/271• Improved transactions• Improved COB

• ●Electronic Claims - 837• ●Claims Status – 276/277• ●Authorizations - 278• ●Remittance Posting - 835• ●Know what your key payers are doing

Key Transactions to validate and test by payer

5010 Conversion

• HIM Preparation• - Coder Education

plan early and provide LOTS!

• - Staffing and Productivity

• *Recruit now• *Augment with

Computer-assisted coding tools

• Clinical Documentation Improvement

• - Concurrent coding @ bedside

• - Improve physician documentation

• - Dedicated staff

• Cash Flow Protection

• - Reduce DNFC• - Reduce DNFB• - Reduce AR

days• - Clean up

denials• NOW• To make room for

the back log!

ICD-10 ConsiderationsWhat you need to be doing now……..

• ●Concurrent coding of the patient record at the bedside

• ●Clinical Documentation Specialist (CDS) RNs will work with physicians to complete the documentation needed in the patient’s record for final coding during the stay

• ●Medical Records staff will perform final coding• ●Overall goal is ACCURACY of clinical record; and Improved QUALITY reporting → SOI and ROM index

• ●Documentation translates into proper reimbursement for care delivered

Essential program for ICD-10 success

Clinical Documentation Improvement

• CMS will withhold a percentage of reimbursement (excluding critical access hospitals) beginning with 1% in fiscal year 2013 and ramping up to 2% by 2017.

• They will then redistribute those dollars as incentive payments based on performance.

• 1st Baseline Period complete: July 1, 2009 – March 31, 2010

• 1st Performance Period: July 1, 2011 – March 31, 2012

• 2 Domains for now : • Clinical Process (70% weight) & Patient

Experience (30%)

• 3 on the way: Mortality, Hospital-acquired Conditions, Patient Safety

Reimbursement Impacted by PerformanceValue-Based Purchasing

Value-Based Purchasing

PATIENT ACCESS

• Driven by training and certifications

• 5 levels:• Level 1 – HTH Pt Access

Cert• Level 2 – HTH Pt Access

Spec• Level 3 – HFMA CFC• Level 4 – HFMA CPAR• Level 5 – HFMA ACPAR

• Driven by experience, training, and certifications

• 5 levels: (under development)

• Level 1 – HTH Business office

• Level 2 – HFMA CPAR• Level 3 and 4 -

• HFMA CFC/ACPAR depending on job code

•

PATIENT FINANCIAL SERVICES

Career LaddersStaff development is a primary key to success

• ICD-10: estimates of • 10-25% increase in government initial denials

• Imperative to have effective process in place now as pace will be accelerating

• Technical Denials are increasing from all payers

Denials ManagementThis is not new, but more important than ever……

Validate your reimbursement

Check for “silent PPO” activity

Check for unauthorized discounts taken by contracted payers

Watch for 3rd party “Re-pricers” being employed by self-insured companies

Validate Managed Care paymentsAre your claims being re-priced by a non-

contracted 3rd party?

• ● IdentifyIdentify practical operation • strategies for survival.

• ● RecognizeRecognize pilots and specific • programs that have yielded• positive operation results.

• ● CompareCompare operation perspectives • from 4 hospital systems.

LEARNING OUTCOMES OF PRESENTATION

.

QUESTIONS?Lynne ByrdVP, Revenue ManagementArchbold Medical Center

lpbyrd@archbold.orglpbyrd@archbold.org