NEBRASKA
RURAL HEALTH
ASSOCIATION
SEPTEMBER 16TH, 2015
KEY FINANCIAL IMPACT ESSENTIALS FOR FOR
RURAL HEALTH CLINICS
TARA WISDOM
HEALTHCARE CONSULTING
402.827.2076
TWISDOM@LUTZ.US
PAUL BAUMERT
HEALTHCARE CONSULTING
402.827.2315
PBAUMERT@LUTZ.US
AGENDA
•
•
•
CMS REGULATIONS
–
Compliance Issues
–
Cost Report
RHC PRODUCTIVITY STANDARDS
–
Hours Worked per Direct Care Hours
–
Tips for Improved Physician Effectiveness
CHARGE CAPTURE AND PRICING
–
•
Impact on Reimbursement
PROVIDER PRODUCTIVITY MEASUREMENT
–
Physician involvement, compensation, metrics, referrals
•
SCHEDULING MODELS & SUGGESTIONS
•
CONCLUSION
3
RHC CHALLENGES
• Many RHCs are struggling with increased overhead
– Professional services
– Staffing
• Reimbursements are in jeopardy
– Third Party
– Medicare and Medicare Advantage
• Independence RHCs – $80.44 (2015), $79.80 (2014), $79.17 (2013), $78.54 (2012)
• Medicare Economic Index increase 0.8 percent from 2013 to 2015, 0.6 in 2012
• Bad Debts
– Medicaid (RHC base rate plus MEI annually)
• 1999 and 2000 Medicare cost reports or initial cost report
– Billing issues
• Strive to improve operational performance and safeguard
reimbursement
4
RHC - COMPLIANCE
• Clarifications and Revisions to RHC Policy Manual
– Issued November 2013
– RHC must be in a rural and underserved location
• If existing RHC grandfathered in applies only to new RHC’s
• If considering moving or expanding your RHC - contact CMS to
make sure you still qualify
5
RHC - COMPLIANCE
6
RHC - COMPLIANCE
7
RHC - COMPLIANCE
• Must post hours of operations at or near the entrance
– Hours
– Days
• Non-physicians providers
• Must have one employed on staff at each location
• W- 2
• May contract with non-physician providers
• Commingling of Space (Provider Based)
– Non-RHC and RHC services can not share same space during same time
• Public Awareness (Provider Based)
• Signage
• Does the patient know they are entering a department of the Hospital
8
RHC - COMPLIANCE
• RHC Conditions of Participation (CoP); 42 CFR §491.8
– Staffing
• Employ a PA or NP; May also contract with a mid-level practitioner
• NP, PA or CNM must be present at least 50% of the time the clinic is open
• A physician, NP, PA, CNM, or CP must be available to furnish patient care
services at all times the clinic or center is open
– Physician Responsibilities
• Provide medical direction for the clinic’s health care activities and staff
• Participate in the development and implementation of policies
• Periodically review the patient records and provide medical orders
– PA and NP Responsibilities
• Participate in the development and implementation of policies
• Participate in a review of patient records
9
RHC – COST REPORT
• RHC Services
– Visit/Encounter
• A medically necessary face-to-face visit between a Medicare
approved RHC provider (i.e. physician, PA, NP, CNM, psychologist,
or social worker) and a Medicare beneficiary. Please note that the
encounter must be both medically necessary AND face-to-face.
– Incident To
• Services that are provided incident-to a professional service of an
approved Medicare provider. These might include dressings,
supplies and support staff assisting with the provision of a
professional service.
10
RHC – COST REPORT
• RHC Visits
– Where can they be done?
•
•
•
•
•
•
The RHC
Patient’s residence
An assisted-living facility
Nursing Home
A Medicare-covered Part A SNF
Swing-Bed
11
RHC – COST REPORT
• Productivity Standards
– Inconsistency and Misunderstood
• 4,200 visits per 1.0 FTE Physician
– Approximately 2 visits per hour worked (productive)
• 2,100 visits per 1.0 FTE PA or NP
– Approximately 1 visits per hour worked (productive)
– No standards
•
•
•
•
•
Visiting Nurse
Clinical Social Worker
Clinical Psychologist
Locum Tenens
Contracted physicians (exception)
12
RHC – COST REPORT
• Productivity Standards (cont’d)
• Contracted physicians – more
– Benefit Policy Manual - Chapter 13, Section §70.4
– Physician services that are provided on a short term or irregular basis
under agreements are not subject to the productivity standards.
Instead of the productivity limitation, purchased physician services
are subject to a limitation on what Medicare would otherwise pay for
the services (under the Physician Fee Schedule), in accordance with
42 CFR 405.2468(d)(2)(v). Practitioners working in a RHC or FQHC on
a regular, ongoing basis are subject to the productivity standards,
regardless of whether they are paid as an employee or independent
contractor.
13
RHC – COST REPORT
• Productivity Standards
– Commonly overstated on Cost Report
• Higher calculated productive hours
• May result in lower reimbursement
– What time should not be included in FTE calculations
•
•
•
•
•
Vacation/PTO/Sick
Hospital administrative
Hospital patients
RHC administrative
Continuing Education
14
RHC – TIME STUDY
• Example
July
August September
Dr. Smith
RHC Hours
RHC/Hospital Administrative
PTO
Education
Hospital Rounds
ER during RHC hours
Total
15
RHC – COST REPORT
16
RHC – COST REPORT
• PRODUCTIVITY STANDARD EXAMPLES
FTEs
Actual
Visits
Prod Std.
Visits
Total Costs
Actual
CPV
Settled
CPV
$152.67
$152.67
Example #1
MD
PA
1.00
4,300
4,200
1.00
2,250
2,100
2.00
6,550
6,300
$1,000,000
Both the MD and ML meet the PS - no CPV reduction
Example #2
MD
PA
1.00
3,800
4,200
1.00
1,850
2,100
2.00
5,650
6,300
$1,000,000 $176.99 $158.73
Neither the MD nor the ML meet the PS - CPV reduction is over $18/visit
Example #3
MD
PA
1.00
3,850
4,200
1.00
2,500
2,100
2.00
6,350
6,300
$1,000,000 $157.48 $157.48
ML meeting the PS compensated for the MD missing it - no CPV reduction
Example #4
MD
PA
0.85
3,800
3,570
0.90
1,850
1,890
1.75
5,650
5,460
$1,000,000 $176.99 $176.99
Despite not meeting the PS, neither the MD nor the ML worked a full FTEs in the
RHC - no CPV reduction as they met the PS for the hours worked in the RHC
17
RHC – COST REPORT
• Non-RHC costs
– Non-RHC service cost must be offset on the cost report
• Hospital Administrative duties
• Hospital Patients
– Skilled/SWB patients are allowable
• Emergency Room Call
– Develop plan to capture cost
– Cost for Call allowable in the Emergency Room
• Other non-RHC activity
• Use of time records versus per visit estimates highly
recommend
18
RHC – COST REPORT
• Emergency Room Call Pay
– Address in providers contract otherwise very difficult to
Identify
– Importance of Identifying
• 80% reimbursement in RHC times Medicare utilization
• 101% reimbursement in ER times Medicare utilization
• Pharmacy
– Cost of Pharmacy is part of cost per visit
– Revenue and Cost must be reported in RHC cost center
– Should not be reported as non-RHC pharmacy cost
19
RHC – COST REPORT
• Labs, EKG, Radiology
– Separately billable (Provider Based RHC)
– Revenue and Expenses are reported in hospital ancillary
departments
– Tracking
– Charge variances as compared to the Hospital?
20
RHC – CHARGE CAPTURE
• BILL FOR SERVICES PROVIDED
• JUST BECAUSE SOMETHING IS INCLUDED WITH THE
ENCOUNTER, DOES NOT MEAN WE DO NOT BILL FOR IT.
– In order to accurately capture the true charges of the cost of seeing
the patient, all services need to be included on the router sheet.
• EXAMPLE OF MULTIPLE ITEMS ON AN ENCOUNTER
– Patient was seen in the office (office visit 99212), charge $80.00
– Patient received a rocephin injection, charge $110.00
– On the claim form there would just be one line item:
• Revenue code 521 for $190.00
Patient co-insurance is 20%, $38.00
21
RHC – CHARGE CAPTURE
• EXAMPLES
Example #1 Example #2
CPT 99212
$80.00
$80.00
Rocephin Injection
$110.00
Total
$190.00
$80.00
Coinsurance
$38.00
$16.00
Subtotal
$152.00
$64.00
CPV
20% of CPV
$150.00
$30.00
$150.00
$30.00
Reimbursement
Medicare
Beneficiary
Total
$112.00
$38.00
$150.00
$120.00
$16.00
$136.00
22
RHC – PRICING
• PRICING UPDATES
–
–
–
–
Are your charges market?
Have you compared to an outside third party?
When was the last time prices were updated?
Are certain services more price sensitive? Do you know which
ones?
• Lab?
– Do you know the financial impact of pricing services below
market/below cost per visit?
• Coinsurance penalty
23
IMPROVING PROVIDER CAPACITY
• KEEPING PHYSICIANS INVOLVED IN
PRACTICE MANAGEMENT
• USING PERFORMANCE DRIVEN
COMPENSATION METHODOLOGY
• TRACKING PHYSICIANS AGAINST
PERFORMANCE METRICS
• PRACTICE DEDICATED RESOURCES
• NOT ANTICIPATING PHYSICIANS AS
REFERRAL FEEDERS
• SCHEDULING
24
KEEPING PHYSICIANS INVOLVED IN
PRACTICE MANAGEMENT
• FINANCIAL MANAGEMENT
– Establishing and maintaining a budget and
revenue cycle; monitoring and analyzing medical
billing success and financial performance;
negotiating contracts with payers
25
KEEPING PHYSICIANS INVOLVED IN
PRACTICE MANAGEMENT
• BUSINESS OPERATIONS
– Developing a business and marketing plan;
identifying required outside resources; managing
the practice’s physical space; purchasing
26
KEEPING PHYSICIANS INVOLVED IN
PRACTICE MANAGEMENT
• HUMAN RESOURCES MANAGEMENT
– Recruiting, hiring, training, and retaining providers
and staff
27
KEEPING PHYSICIANS INVOLVED IN
PRACTICE MANAGEMENT
• INFORMATION MANAGEMENT
– Acquiring and upgrading telephone and computer
systems including software/services for clinical,
billing, electronic health records and financial
management; securing patient data; reporting on
practice compliance
28
KEEPING PHYSICIANS INVOLVED IN
PRACTICE MANAGEMENT
• PATIENT CARE SYSTEMS
– Maximizing provider efficiency through effective
workflow; establishing systems to keep patients
informed, engaged and satisfied; establishing
practice performance standards
29
KEEPING PHYSICIANS INVOLVED IN
PRACTICE MANAGEMENT
• QUALITY MANAGEMENT
– Establishing and maintaining quality standards;
monitoring clinical quality oversight; setting up
processes and systems to enable participation in
Pay-for-Performance (P4P) programs; ensuring
that all licensing is current
30
KEEPING PHYSICIANS INVOLVED IN
PRACTICE MANAGEMENT
• RISK MANAGEMENT
– Establishing procedures to ensure patient safety
and to address emergencies, disasters and legal
challenges; ensuring governmental compliance
31
USING RVUS TO MEASURE PHYSICIAN
PERFORMANCE
• TWO-THIRDS OF PHYSICIANS ARE FINDING
THEIR COMPENSATION TIED TO
PRODUCTIVITY
• THE USE OF WORK RELATIVE VALUE UNITS
(RVUS) IS DOMINATING THE
METHODOLOGY
32
USING RVUS TO MEASURE PHYSICIAN
PERFORMANCE
• KEEP IT SIMPLE
• ENSURE ADMINISTRATORS AND PHYSICIANS
HAVE A CLEAR UNDERSTANDING
• STAY INFORMED OF DEVELOPMENTS WITH
THE RVUS METHOD
• INCLUDE QUALITY INCENTIVE
• BE AWARE OF POLITICAL RISK
33
TRACKING PHYSICIANS AGAINST
PERFORMANCE METRICS
THE DOS AND DON’TS
• DO ORGANIZE METRICS
– After you complete the process of narrowing down your performance metrics,
use the dashboard as an opportunity to educate your physicians on the most
important performance elements.
• DON’T JUST LIST OUTCOMES
– Show your physicians how their outcomes compare to medical groups goals or
to their own past performance.
• DO DRAW ATTENTION TO LOW (OR HIGH) PERFORMANCE
– Capture your physicians’ attention by highlighting areas that need
improvement, and/or acknowledge metrics where your physicians are
meeting or beating expectations.
• DON’T GO GRAPHIC-CRAZY
– Only include critical charts and graphs that highlight hot-button issues, since
they can be confusing and take up significant scorecard real estate.
34
CHARGES, PAYMENT & ADJ BY PAYOR
BENCHMARKING PATTERNS
BENCHMARKING PATTERNS
SCORECARD EXAMPLE
38
PRACTICE DEDICATED RESOURCES
• PRACTICE DEDICATED MANAGERS
– Experience
– Different management techniques
• BILLING
– Practice dedicated staff
• Not just added to hospital billers
39
REFERRAL FEEDERS
• LEGAL RISKS
• INTEGRATED DELIVERY SYSTEM
40
EFFECTIVE APPOINTMENT SCHEDULING
• STRUCTURED APPOINTMENT SCHEDULING
– Metric
– New Patients
– Consistency between doctors
– Supervisor perspective
– Vacation Scheduling
– Reducing inbound calls
41
EFFECTIVE APPOINTMENT SCHEDULING
• METRIC
– Aligning technology and staff
– # of Days wait to be seen
– Doctors agreeing on how many hours works
• Sticking to the hours
• Avoid rescheduling
42
EFFECTIVE APPOINTMENT SCHEDULING
• NO DOUBLE BOOKING FOR PATIENTS
– New Patients
– Difficult Patients
– Complicated problems
• DO NOT BOOK THESE AT BEGINNING OF HOUR
– Intersperse with others that are likely to take less time
43
EFFECTIVE APPOINTMENT SCHEDULING
• TYPES OF PATIENTS
– Each patient visit has different levels of complexity.
• Assign weight to the different visits and list them for reference by
your schedulers.
– Manage uncomplicated issues outside the office visit by phone, email,
and group visits.
• While this may not be directly reimbursed, it can provide indirect
financial rewards by increasing the complexity of office visits.
• The average reimbursement per visit should go up, offsetting the
loss of simple visits.
44
EFFECTIVE APPOINTMENT SCHEDULING
• SUPERVISOR OVERVIEW
– High level
– Keep patient scheduling on the agenda for
monthly office meetings
– A highly effective technique is when the provider
arrives and is ready to see patients, have a
standup, one-minute huddle with the provider,
the scheduler, and the medical assistant to look at
the upcoming block of patients for a discussion
about how to manage it.
45
EFFECTIVE APPOINTMENT SCHEDULING
• VACATION SCHEDULING
– Change schedule 2 weeks before and after vacation
– Reduce number of follow-up appointments before and after a
vacation
46
EFFECTIVE APPOINTMENT SCHEDULING
• REDUCE UNNECESSARY INBOUND CALLS
– Schedule follow up visits at time of visit
– Have a 3 month schedule template, even with open
access as people plan vacations, days off,
transportation
– Ask physicians to stick to schedule to avoid
rescheduling
– Automate appointment reminders
– Let schedulers schedule without interrupting
physician
– Online Scheduling
47
QUESTIONS?
48