Are You Ready For
Revenue Cycle 2.0?
Presentation Summary & Tools
Presented by:
Daniel J. Marino
The Healthcare Reality of Today
• Healthcare costs continue to rise placing pressures on
patients, employers and healthcare providers
• Movement from volume-based reimbursement to valuebased contacts
– Fee-for-services plus shared savings
– Shared savings with PMPM care management fee
– Risk-based contracts
• The importance of data continues to rise
– Process-driven outcomes
– Performance and care results
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Shift in Revenue Cycle Activities
Present
Future
Based on fee-forservice encounters
Based on clinical
performance
Encounter-based
contract
management
Performance-based
contract
management
Based on fee
schedule
Bundled payments
Accounts receivable
indicators
“New” business
metrics
Consumer driven
healthcare
3
New Generation of KPIs
• New Generation of financial metrics include:
-
Tracking “Cost of Care”
Clinical performance
Patient satisfaction/engagement
Beneficiary/program management
Bundled payment indicators
• PM systems tracking by value –based contract
-
Bundled service
Shared savings
Partial or full risk
• A/R management reflecting performance incentive
opportunity
4
Physician Key Performance Indicators
Revenue
Cycle
Payment
Analysis
Patient
Satisfaction
Patient
Access
Key
Performance
Indicators
Care and
Outcomes
Cost /
Profitability
Production
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Focused Analytics Help Identify Where to Begin
Stratify Data based PMPM, Cohorts
Build the total cost of care
model on per member, per
month bases
Indicators should include:
• Allowed versus paid amount
• Employee, spouse, child
• With and without high cost
claims
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Top 10 Diagnoses by Total Cost
Diagnosis
Code
401.9
585.6
V58.11
174.9
205.02
V42.7
V58.0
280.9
824.8
823.82
Allowed
Amount
Paid
Amount
Patients
Unspecified essential hypertension
$1,537,106
$1,434,185
End stage renal disease
$1,126,685
Description
Encounter for antineoplastic
Malignant neoplasm of breast
Acute myeloid leukemia, in relapse
$746,231
$758,427
$682,459
Liver replaced by transplant
$651,863
Encounter for radiotherapy
$593,219
Iron deficiency anemia, unspecified
$590,289
Unspecified fracture of ankle, closed
$576,856
Closed fracture of unspecified part of
fibula with tibia
$571,902
Encounters
Paid per
Encounter
Paid per
Patient
911
5,286
$271
$1,574
$1,089,893
$716,961
$715,286
$674,449
9
28
72
2
1,496
1,552
1,667
30
$729
$462
$429
$22,482
$121,099
$25,606
$9,935
$337,224
$634,463
8
309
$2,053
$79,308
$593,219
$565,894
18
75
766
1,198
$774
$472
$32,957
$7,545
$562,333
20
94
$5,982
$28,117
$560,723
3
58
$9,668
$186,908
* Diagnoses appeared in the primary, secondary or tertiary codes
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Evaluating the High Cost Services Support
Bundled Service Tracking
Cancer Type
Lung
Colorectal
Breast
Allowed
Amount
$193,509
$377,167
$844,232
Paid Amount
$179,059
$333,967
$797,865
Encounters
512
850
1946
• On a per encounter basis,
colorectal cancer is the
most expensive cancer
type assessed, whereas
breast cancer had the
highest encounter rate
*Figures provided are in Paid Amounts.
*Disease categories based off of grouped diagnoses corresponding to condition.
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Collected vs. Collectable
• Similar to net collection rate, but allows for more accurate review
— Collected:
 Payment received and line item posted (includes co-pay and deductible)
— Collectable:
 The allowable amount as negotiated in contract (includes co-pay and
deductible)
• Great metric to evaluate overall revenue cycle performance
• Forces you to ask specific questions and drill down to find answers
• Dependent on knowing contract fee schedule
• Allows for better contract negotiations
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Collected vs. Collectable
90 Day CvC: Goal 92-94%
Payments received in the next 3 months
Allowable posted 4 months ago
180 Day CvC: Goal 95-97%
Payments received in the next 6 months
Allowable posted 7 months ago
Annual CvC: Goal 97-99%
Payments received in the next 12 months
Allowable posted 13 months ago
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Sample 90 Day CvC Report
JANUARY, 2014
INSURANCE PLAN
CHARGES
ALLOWABLE
COLLECTED
(Coll./Allow.)
% COLLECTED
$1,639,044
$1,062,610
$1,043,451
98.20%
$185,361
$145,090
$140,925
97.13%
USHC
$1,986,460
$1,267,667
$1,210,398
95.48%
UNITED HEALTH
$1,653,396
$1,283,729
$1,219,456
94.99%
MEDICARE
$4,532,591
$1,799,580
$1,679,789
93.34%
CIGNA
$1,146,525
$911,439
$847,316
92.96%
OXFORD
$1,318,334
$1,053,521
$960,497
91.17%
HEALTHNET
$579,508
$477,573
$418,675
87.67%
HORIZON
$258,003
$258,003
$195,264
75.68%
SELF
$272,173
$272,173
$188,777
69.36%
$13,571,395
$8,531,385
$7,904,548
92.65%
AETNA
AMERIHEALTH
TOTAL
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End Uses of Clinical Information to Support
Revenue Cycle Performance
Program Management
• Quality scorecards
• Patient chart view through
continuum of care
• Use of referrals and
ancillaries
Physician Performance
•
•
•
Chronic disease registries
Care gap management
Patient satisfaction
Financial Effectiveness
•
•
•
•
Total cost of care reports
Payer analytics
Areas of improvement
Domestic Utilization Mgmt
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Contact
Daniel J. Marino
President/CEO
dmarino@healthdirections.com
Health Directions, LLC
Two Mid America Plaza, Suite 1050
Oakbrook Terrace, IL 60181
Phone: 312-396-5400
dmarino@healthdirections.com
www.healthdirections.com
@HDirections
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