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
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)
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
Gross Revenue
$1,000,000
$900,000
$800,000
$700,000
$600,000
$500,000
Gross Revenue
$400,000
$300,000
$200,000
$100,000
$0
2007-2008
2008-2009
2009-2010
2010-2011
2011-2012
2012-2013
Getting Started: Learning the Lingo
Operational Changes:
Preliminary Decisions
• In-house Billing vs. Billing Service
• EMR/EHR
• Establishing a Fee Schedule
• Conversion factor
• CPT, E&M Codes
• RBRVS
Malpractice
Non Fac
Total
15952
Excision, trochanteric pressure ulcer, w/ skin
flap closure;
12.31
12.03
12.03
2.63
26.97
26.97
090
15953
15956
with ostectomy
Excision, trochanteric pressure ulcer, in
preparation for muscle or myocutaneous flap
or skin graft closure;
13.57
16.79
13.29
14.05
13.29
14.05
2.67
3.42
29.53
34.26
29.53
34.26
090
090
15958
16000
with ostectomy
Initial treatment, first degree burn, when no
more than local treatment is required
16.75
.89
14.83
1.01
14.83
.34
3.39
.12
34.97
2.02
34.97
1.35
090
000
16020
Dressings and/or debridement of partialthickness 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
16036
Escharotomy; initial incision
Each additional incision (list separately in
addition to code for primary procedure)
3.74
1.50
1.53
0.69
1.53
0.69
0.63
0.27
5.90
2.46
5.90
2.46
000
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
Code
Description
Work
Value
Non Fac
PE
FAC
PE
Fac
Total
Global
Gap
Fee for Service Example:
Code
17110
Description
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
Work
Value
Non
Fac PE
FAC
PE
Malpractice
Non Fac
Total
Fac
Total
Global
Gap
0.70
2.48
1.27
0.08
3.26
2.05
010
Non FAC Total (code value) = 3.26
Sample Conversion Factor = $50.00
Code Value x Conversion Factor
3.26 x 50 = $163.00
Operational Changes:
Key Considerations
• 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:
Insurance Aging A/R
• 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
Evaluation: Monitoring & Reporting
A/R Report:
• Patient charges detailed by plan
• Aging “buckets”
• Focus on oldest claims
• Analysis of aging conducted by the Billing
Manager
Evaluation: Payer Mix Analysis
Evaluation: Summary of Charges
Lessons Learned
• 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
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
Contacts & Resources
Contacts at WSU:
Online Resources:
Donna Hash, Administrative Manager
Health & Wellness Services
509.335.6759
donna.hash@wsu.edu
Resource-Based Relative Value Scale
www.ama-assn.org//ama/pub/physician-resources/solutionsmanaging-your-practice/coding-billing-insurance/medicare/theresource-based-relative-value-scale.page
Medical Group Management Association
Merry Lawrence, Billing Office Manager
Health & Wellness Services
509.335.5293
mklawrence@wsu.edu
www.mgma.com
American Medical Association
www.ama-assn.org/ama/pub/physicians/physicians.page
Credentialing & Contracting Article
www.articlesbase.com/business-articles/improve-yourpractice039s-financial-health-focus-on-the-four-ps-in-a-podpatients-payers-payments-and-productivity-2003088.html