Revenue Cycle and Health
Information Management
“Improving Health Center
Sustainability”
Improving Health Center Sustainability
Learner Objectives
• The learner will gain insight into how to
utilize Health Information Technology (HIT)
to improve financial performance.
• The learner will learn how to execute health
team workflow processes to improve RCM.
• The learner will understand the correlation
between employing sound HIT processes,
clinical outcomes and RCM.
• The learner will develop strategies to
improve margins while expanding mission.
Key Discussion Points
1
History/Mission
2
Policy Information Notice
Health Information Technology Strategy
3
4
Sustainability
History
• In 2015 Health Centers will celebrate 50 years of
expanding healthcare access and delivering quality
primary to medically underserved and uninsured
populations.
• The health center model targeted the roots of poverty
by combining the resources of local communities with
federal funds to establish neighborhood clinics.
• Health centers primarily provide health care to
patients who are uninsured or covered by Medicaid.
• Community health centers rely on a combination of
Medicaid payments, grant revenues, and other private
and public funding sources to fund their operations.
• Health centers have established themselves as
mission based healthcare providers that provide care
to patients regardless of “ability to pay.”
Mission
• Medically underserved populations.
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–
–
–
Uninsured
Underinsured
Chronically unemployed
Newly unemployed
• Migratory and seasonal agricultural
workers.
• Homeless populations.
• Residents of public housing.
Policy Information Notice
• Health centers must assure that any fees or payments
required for services will be reduced or waived to
enable the center to fulfill the assurance.
• The Health Center Program statute also requires “a
schedule of fees or payments for services consistent
with locally prevailing rates or charges.
• The PIN requires health centers to design a fee
schedule to cover its reasonable costs of operation.
• And “to make every reasonable effort to secure from
patients payment for services in accordance with such
schedules.
• And to collect reimbursement for health services to
persons covered by public or private insurance.
Business Operations
Health
Centers
Sustainability
Mission
Margins
Financial Infrastructure
Health Center
Grant Funds
•Primary
Health
Services
•Specialty
Services
Mission
Margins
Sustainability
Medically
Underserved
Financial
Management
Financial
Infrastructure
•Healthcare
Access
•Preventive
Services
•Financial
Culture
•Business
Mindset
•Financial
Quality
Improvement
•Financial Goals
Financial Transformation
Health
Center
Mission
Sustainability
Revenue Cycle
Management
Leadership
Regulatory Compliance
Information Technology
Quality
Margins
Revenue Cycle Management
•
•
•
•
•
•
•
•
•
•
Appointment Scheduling
Registration/Certification
Patient Reception
Clinical Visit/Service Delivery
Documentation and Coding of Visit
Charge Processing/Check Out
Patient Statement & Claim Production
Claims & Patient Payments Processing
Denied Claims Management
Accounts Receivable Oversight & Collections
Revenue Cycle Management: RCM
Operations
Financial
Operations
Executive
Leadership
Clinical
Operations
Revenue Cycle
Management
Current Status of Business Operations and Workflow
• What are the health center’s financial policies and
procedures?
• What is your current understanding of FQHC billing and
reimbursement systems?
• Who currently manages the complexities of these billing and
reimbursement systems?
• Who stands as your internal or external finance, billing,
coding, and HIT content expert.
• How often does leadership assess financial workflow and
operations?
• All Inclusive Rate
• Medicare
• Medicaid versus
• Managed
• Sliding Fee
• Self-pay
• Wraparound billing
Current Status of Business Operations and Workflow
• What current HIT workflows are in
place to support business operations?
– Leadership operations
– Finance operations
– Billing operations
– Operations
– Clinical operations
Health Information Technology Optimization
Leadership
•Understand
operations
•Team
competence
•Cultivate
change
Finance/
Billing
Mission
Margins
Policies/Procedures
•Collections
Operations
•Scheduling
•Front Desk
•Back Office
•Practice
Management
•Billing
Clinical
Health Center
Sustainability
•Credentialing
Scheduling
•Documentation
•Coding
•Productivity
Health Information Technology
Health Information
Technology
Finance/Billing
Operations
Clinical Operations
Leadership
•Transformation
•Financial Solvency
•Restructure
Workflow
•Cultivate Financial
Culture
Health Information Technology Workflow
HIT Process
Improvement
Scheduling
Begins
RCM
•Pt. Access
•Appointment
Management
•Initial Contact
•Eligibility
•Credentialing
Registration
Patient
Information
Insurance
•Eligibility
•Credentialing
HIPPA/Compliance
•Copayment
•Outstanding
Balances
Clinical
Encounter
Provider
Accountability
•Patient
Experience
•E&M
•Documentation
•Coding
•Time
Management
Patient
Check-Out
Fees for
Service
•Patient
Payments
•Charge
Retrieval
•Appointment
•Scheduling
Patient Scheduling Workflow
• The revenue cycle starts with scheduling the patient.
• Health center staff should use a check sheet or script
guide to be sure all pertinent information is collected
at the time of scheduling.
• Collecting insurance information will help the
scheduler know what information to ask from the
patient.
• Additional items to discuss with the patient include
explaining what information the patient should bring to
the appointment.
• The expectation of payment of co-pays at the time of
the visit, and the arrival time of the patient if certain
paperwork and registration work needs to be
completed.
Patient Registration Workflow
HIT and Practice Management System
• Practice Management System – key
driver of the RCM process.
• Establish mandatory registration data
entry points.
• Verify patient information at every visit
(phone numbers, UDS data points).
• Front desk must check insurance
eligibility and check patient’s
insurance card at every visit.
• Collect copayments at the point of
registration. (Financial Policy)
Case Study
A new uninsured patient walks into the health center and
requests a same day visit for a physical examination.
Develop a patient centered access friendly workflow for
this scenario. What are the major factors to consider?
• The patient reports the following:
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No current health insurance.
No current primary care provider.
No current history of present illness.
Working part-time at a local farmer’s
market.
– Patient reports occasional headaches
possibly due to stress. “I would like to
take better care of myself.”
Workflow Development Considerations
• Identify internal and external processes influences
that prevent your health center from successful
revenue cycle management.
• Does your health center currently have a financial
policy that serves as the back bone of your RCM
processes?
• How does your health center utilize your practice
management system and electronic health record to
optimize operations and workflow processes?
• What is your health center’s “WOW” factor? How do
you make a memorable first impression? How best
can you utilize HIT to develop sound walk-in
registration/uninsured patient workflow processes?
• What HIT techniques are used to decrease incidences
of registration backlog due to processing delays,
patient literacy support, and triage needs?
Patient Financial Policy
Clinical Operations and Workflow
Health
Information
Technology
Your Text
Patient
Patient
Scheduling
Provider
Front Desk
Healthcare Team
Your Text
Clinical
Workflow
Integrated
Your TextCare
Workflow
Check-out
Workflow
Your Text
Clinical Workflow and HIT
Electronic
Medical Record
Patient
Encounter
Mission
Chief Complaint
Examination
Clinical decision
Making
Provider
Margins
Sustainability
Evaluation and
Management
C
•CPOE
•Documentation
•E&M Coding
•Plan of Care
Compliance
Clinical Workflow and HIT
Electronic Health
Record
Practice
Management
Patient Centered
Care
Information
Exchange
Information
Exchange
•Medical Decision Making
•CPOE
•Documentation/Coding
Medical
Orders
Medical
Charges
Financial
Responsibility
Medical
Billing
Patient
Accountability
•Self-Management
•Patient
Responsibility
•Ability to Pay
Sustainability
Improved Access
Patients
Health
Center
Healthcare
Teams
Financial
Infrastructure
Quality Healthcare
Delivery
Integrated Care
Financial
Management
Health Information Technology Workflow
100 %
Mission vs Margins
65 %
10 %
Margins
Sustainability
Mission
Health
Center
25%
Questions
Contact Information
DPM Healthcare Consulting
Stephanie J. Wroten BSN, MS, LNC
stephaniewrotenlnc@gmail.com
Anna Gard RN, FNP-BC
gardanna@gmail.com
DPM Healthcare Consulting