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
Aggregate Data – 14 Health Centers
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
22,410,721
206,799
84,572
19,659,879
178,769
64,871
Average Increase Per Site – 14
Health Centers
Gross Charges
Net Revenue
↑$657,771 ↑ $196,488
# of Visits
# of Unduplicated
Patients
↑ 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 Study
Six-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
After
Practice 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, Increased fee schedule to 75th
below what Medicaid would pay)
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 Revenue
Documentation of Eligibility
• Flow charting and establishing accountability for every step of
the eligibility process through staff orientation and training
Management 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 Revenue
Cross-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 treatment
Staff are regularly educated and trained relative to the
rules and regulations of the practice’s primary thirdparty payers (especially Medicaid)
• Determination of a defined scope of service fostering
elimination of disease, yet preserving financial
viability
Strategies That Increase Revenue
Establishment of a fee schedule, sliding fee scale
and nominal fees that sustain the practice yet do not
pose barriers to care
Non-emergent procedures requiring prior
authorization should not be initiated until PA is
received or patient agrees to self-pay status
Verification of patient’s eligibility before and at each
visit
Skillful utilization of IT systems to maximize clinical
effectiveness and enable the practice to obtain the
data needed to evaluate program performance
Policies That Increase Revenue
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
Developing a Sliding Fee Scale
• 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; 101150% 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?]
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
Creating an Effective Billing System
• 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
Sample Billing Flow Chart
Patient 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
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
Patient meets with patient
accounts specialist to review
follow-up care needed and
estimated costs
Third Party
insurance
Sample Billing Flow Chart
(cont.)
Self-Pay
If patient agrees to care plan,
next appointment is made
Encounter form goes to
billing, where it is reviewed
by dental specialist
Patient accounts specialist
takes encounter form
Claim is filed
Encounter form goes to billing, where it
is reviewed and patient invoice is
generated for balance due, if any
Claim is paid or denied
Paid
Patient gets bill and pays
or continues to get billed
Denied
Reconciled against
patient account
Investigated,
corrected and
rebilled
Paid
Reconciled
against patient
account
Claim is paid or
denied
Paid
Reconciled against
patient account
Hopeless
Written off
Still Hope
Submitted for
payment again
Hopeless
Written off
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
A PROGRAM OF THE
2400 Computer Drive, Westborough, MA 01581 Tel: 508-329-2280 Fax: 508-329-2285 www.dentaquestinstitute.org