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A Walkthrough of Healthcare
Revenue Cycle Management
Presented by:
Robert Urquhart –
Senior Vice President
Chief Financial Officer
Basic Revenue Cycle Processacross all service lines
Call Center
Manage inbound and outbound calls for the facility in a timely
manner
Identify patients’ needs, clarify information and direct calls to
other departments as needed
Obtain and enter accurate demographic information into the EMR
i.e. name, address, telephone number, insurance or self pay
status
Assist in creating appointments
Make reminder calls for appointments
Call Center
Registration
Help to check-in, transfer or check-out patients
Verify patients’ demographic information
i.e. name, address, telephone number, insurance or self pay status
Verify primary care provider
Determine the collection of co-pays, deductibles, coverage for services and pre-authorization status if necessary
Registration can also assist in helping patients determine appropriate payment plans
Ensure that the patients properly fill out and sign all relevant insurance and healthcare compliance release forms before services are rendered
Assist in making patients’ referrals to specialists
Registration
Clinical
Responsible for documenting all rendered services thoroughly and accurately
Assigns accurate and appropriate CPT and ICD-10 coding for charge capture
Optimizes CPT and ICD-10 coding knowledge of new and changing services by staying up to date with coding changes from year to year
Signs off and submits claims for processing in a timely manner
NOTE: Best recommendation is to encourage submission of claims no later than 72 hours after the date of service
As needed works with Patient Accounts to correct incomplete notes and denials
Clinical
Coding
Review and analyze claims to determine that the correct CPT and ICD-10
codes have been assigned to the tickets before they are submitted to the
payers
Review and analyze claims to ensure that the most specific and highest level
of risk is reflected in the ICD-10 code selection
Optimize CPT and ICD-10 coding knowledge of new and changing services by
staying up to date with coding changes from year to year
Optimize CPT and ICD-10 coding by monitoring center specific fee schedules
updates
Track and monitor CPT and ICD-10 coding monthly/yearly by site by clinician
to ensure appropriate coding accuracy and education
Coding
Patient Accounts
Review encounters to ensure that they are complete, accurate and signed
appropriately for submission
Process payments and refunds
Work with payers to correct denials
Posts cash receipts and analyzes explanation of benefits (EOB) forms to
ensure the facility is being paid for charges
i.e. expected vs actual payments
Transmit all claims to the payers in a timely manner
Work with patients as needed to develop appropriate payment plans i.e.
sliding fee scale, determine copayments and deductibles based on their
contracts
Assist patients with account issues and collect unpaid debt
Patient Accounts
Finance
Review key indicators such as;
cost per visit
cost per patient
revenue per visit
denial rates
cash collection
collection rate
Verify accuracy of monthly revenue entry
Work with Patient Accounts to address and resolve any identified issues
Ensure that the practice management Aged Trial Balance reconciles to the
General Ledger Balance
Reviews Aged Trial Balance and ensures that the reserve for uncollectable
accounts is appropriate
Finance
Pitfalls
Incorrect submission of CPT and ICD-10 codes
Missed opportunities for optimizing new and changing coding updates
Missing timely filing limits
Starting clinicians before they are fully credentialed with payers
Not signing or submitting claims before payer submission deadlines
Not verifying patients insurance eligibility before a visit
Internal pressure/disagreements on revenue cycle management
Pitfalls
Care Coordination at Community
Health Centers
Presented by:
Robert Urquhart –
Senior Vice President
Chief Financial Officer
Agenda
Topics:• Chronic Care Management (CCM)
• Complex Chronic Care Management
(CoCM)
• Transition of Care (TCM)
• “NEW” 2018 Anticoagulation Codes
Chronic Care Management
Billing Code Clinical Staff Time Care PlanningAssumed "work/time" for
billing practitionerBilling Practitioner Work
99490 -
CCM
20 minutes or
more of clinical
staff time in
qualifying services
a month
Established,
implemented,
revised or
monitored
Assumes 15 minutes of
additional work by billing
practitioner
Ongoing oversight, direction and
management.
99487 -
Complex
Care CCM
60 minutes a
month
Established or
substantially revised
Assumes 26 minutes of
additional work by billing
practitioner
Ongoing oversight, direction and
management. Medical decision
making of moderate to high
complexity.
99489 -
Complex
Care "Add-
On" Code
Each additional 30
minutes of clinical
staff time a month
Established or
substantially revised
Assumes 13 minutes of
additional work by billing
practitioner
Ongoing oversight, direction and
management. Medical decision
making of moderate to high
complexity.
G0506 -
Initiating
Visit "Add
On" Code
N/A Established N/A
Personally performs extensive
assessment and CCM care planning
beyond the usual effort described by
the separately billable CCM initiating
visit.
* G0506 can only be billed once per beneficiary
Chronic Care Management
Medicare “Assumed Work”
CCM confirmed that “assumed work time by
billing practitioner,” should be above and beyond
the designated time for the CCM codes i.e. 99490
– 20 minutes of clinical staff time + additional 15
minutes of assumed work by billing practitioner
= total 35 minutes per month
No documentation is required as this time for the
additional assumed billing practitioner work
Chronic Care Management CPT Code: 99490 – At least 20 minutes of clinical staff time directed by a physician or other
qualified health care professional, per Calendars month, non face-to-face time.
Requirements for Billing:
Multiple (two or more) chronic conditions expected to last at least 12 months, or until
the death of patient
Chronic Conditions place the patient at significant risk of death, acute
exacerbation/decompensation, or function decline
Comprehensive care plan established, implemented, revised, or monitored (see next
slide for more details)
Must be at least 2 or more chronic conditions expected to last at least 12 months or until
the death of the patient
ONLY ONE provider per month may bill for CCM services
CCM confirmed that the billing practitioner is assumed to be reviewing 15 minutes of the
work done by the clinical staff every month
Non-clinical staff’s time cannot be counted towards the reportable time
NOTE: ONLY services related to the beneficiary’s chronic conditions should be included in
the billing for CCM services
CCM Care Plan Doc. Req.Verbal Consent must be documented in patient’s chart
“CCM program was reviewed as well as applicable cost sharing with the patient and written materials were provided. The patient wasinformed verbally that only one practitioner can furnish and be paid for these services during a calendar month; and of their right to stop the CCM services at any time (effective at the end of the calendar month). The patient gives verbal consent to initiate CCM services. ”
Care Plan Documentation Requirements:
Problem List Update
Expected Outcomes and Prognosis
Measurable treatment goals
Symptom management
Planned interventions and identification of the individuals responsible for each intervention
Medication management
Community/social services ordered
A description of how services and agencies and specialists out the practice will be directed/coordinated
Schedule for periodic review when applicable
Care plan should be revised with new changes throughout patients care when applicable
Clinical Staff may assist in creating a continuity of care plan with final approval/direction from the provider
NOTE: Billing Practitioner signature is required on the finalized continuity care plan
CCM Ongoing ManagementContinuity of Care Documentation Requirements:
• Systemic Assessment of the patients medical, function and
psychosocial needs;
System-based approaches to ensure timely receipt of all
recommended preventative care services
Medication reconciliation with review of adherence and potential
interactions
Oversight of patient self management of medications
• Managed care Transitions between and among health care providers
and settings, including referrals to other providers including;
Provider follow up after an emergency department visit
Discharge from hospital, SNF, or other health care facilities
• Coordinate care with home and community based clinical servicing
providers
G0506 Initiating Visit & Add-On
CPT Code G0506 Description: Billing practitioner personally
performs extensive assessment and CCM care planning beyond the
usual effort described by the separately billable CCM initiating visit.
Example: Patient presents today for a sick visit, chief
complaint URI. During the encounter you are made aware
that the patient is CCM eligible. You first bill for the URI i.e.
99213.
Then you separately face to face with the patient begin to
initiate the care plan for ALL OF the chronic conditions that
will be managed through the CCM program i.e. G0506.
Billing Summary : 99213, G0506
Complex CCM99487 – At least 60-89 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendars month, non face-to-face time (i.e. Assumes 26 minutes of billing practitioner oversight per month).
+ 99489 – Add on Code for each additional 30 minutes of clinical staff time (i.e. Assumes 13 minutes of billing practitioner oversight per 30 minute increments)
Requirements for Billing:
Must be at least 2 or more chronic conditions expected to last at least 12 months or until the death of the patient
Chronic conditions place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline
Establishment or substantial revision of a comprehensive care plan
Must show moderate to high complexity medical decision making
Transition of Care (TCM)99495 requires moderately complex medical decision-making and a face-to-
face visit within 14 days.
99496 requires highly complex medical decision-making and a face-to-face
visit within 7 days.
TCM codes should be billed for patients who are transitioning from an
Inpatient hospital setting (including acuity, rehabilitation, or long-term acute
care), partial hospitalization, or observation status in a hospital, skilled
nursing facility, or other nursing facility to the patient's community setting
(home, domiciliary, rest home, or assisted living).
Use the E/M Risk Table for Medical Decision Making to determine whether
to use CPT code 99495 (Moderate) or 99496 (High).
If the patient falls under the minimal or low section of the table of risk
then they will not qualify for either of these codes.
Transition of Care (TCM)Documentation Details/Requirements:
Communication with the patient or caregiver within two (2) business days of discharge
by telephone, direct contact, or electronic means, and that, by the first face-to-face
visit following discharge
Medication reconciliation
Review of the discharge information
Review of any follow-up of pending diagnostic tests and treatments.
Interaction with other qualified health care professionals who will assume or re-assume
care of the patient's condition
Education of patient, family, guardian, and/or caregiver.
Establishment or re-establishment of referrals.
Scheduling of any required follow-up with providers and/or other community services
when applicable
Note: Clinical staff under direction from a physician or other provider can provide non-face-to-
face services as communicating aspects of care, self-management and treatment regimen
compliance with the patient, caregiver, or other decision maker, as well as communicating
with home health agencies or other community services the patient is using.
Anticoagulation Therapy In 2018, CPT deleted codes 99363 and 99364 and replaced them with codes 93792 and 93793.
93792 Patient/caregiver training for initiation of home international normalized ratio (INR) monitoring under the
direction of a physician or other qualified healthcare professional, face-to-face, including use and care of the INR
monitor, obtaining blood sample, instructions for reporting home INR test results, and documentation of patient’s/
caregiver’s ability to perform testing and report results
93792 is the code used for patients who test their INR at home, rather than going to the laboratory. Prior to starting this home
testing, the patient needs to understand how do use the test reliably. This instruction and training is now covered service. Notice
that for patient/caregiver instruction and training. This is work that would typically be done by clinical staff or case managers.
93793 Anticoagulation management for patients taking warfarin, must include review and interpretation of a new
home, office, or lab international normalized ratio (INR)test results, patient instructions, dosage adjustment (as
needed), and scheduling of additional test (s), when performed
93793 Is payment for managing patients taking warfarin. It includes the review and interpretation of a new lab test done in the
home, office or lab. A physician/NP/PA work needs to interpret the lab results, make a dosing adjustment if needed, and schedule
additional tests, again if needed. The dosage does not need to be changed in order to report 93793. It is for a new test result.
QUESTION: Can these be performed on the same day as an E/M service?
ANSWER: CPT says that a separately identifiable E/M service may be reported on the same day as 93792, instructions and training for a
patient who will start home INR monitoring.
Presented by:
Robert Urquhart –
Senior Vice President
Chief Financial Officer
Financial And Operational
Reporting
Comparative Results
53% 58% 60% 59%
32% 25% 20%
30%
15% 17% 20%6%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
FY13 FY14 FY15 NationalMedian 2014
Revenue Mix - GLFHC vs National Median
Other (including Pharmacy)
Grants and Contracts
Net Patient Service Revenue
National data from Capital Link, Inc.
Comparative Results
0.0%
2.0%
4.0%
6.0%
8.0%
10.0%
12.0%
FY13 FY14 FY15
Operating Margin
GLFHC CHC National Median
0
10
20
30
40
50
60
70
80
90
FY13 FY14 FY15
Days Cash on Hand
GLFHC CHC National Median
National data from Capital Link, Inc.
Income Statement
Patient Visits Dec-YTD Actual
Dec-YTD
Budget Variance
Total Visits 126,518 128,731 (2,213)
Total Deliveries 415 411 4
Total Pharmacy RX's 281,795 276,266 5,529
Revenue and ExpensesOPERATING REVENUE
Net Patient Service Revenue $18,313,155 $18,854,932 $(541,777)
Grant and Contract Revenue $5,563,498 $5,403,370 $160,128
Other Revenue $1,745,961 $341,353 $1,404,608
Pharmacy Revenue $6,625,750 $5,699,874 $925,876
Total Operating Revenue $32,248,364 $30,299,529 $1,948,835
Revenue Per Visit $255 $235 $20
GREATER LAWRENCE FAMILY HEALTH CENTER
FY 16 RESULTS - GLFHC Total (YTD)
Operating ExpensesDec-YTD Actual Dec-YTD Budget Variance
Salaries $19,645,007 $19,501,417 $143,590
Fringe Benefits 3,446,914 3,613,991 (167,077)
Supplies 1,242,182 1,324,959 (82,777)
Sub-Contracts - Patient Service 302,761 324,659 (21,898)
Other Purchased Services 976,767 906,710 70,057
Facility Operation and Maintenance 1,773,077 1,718,820 54,257
Insurance 64,468 67,493 (3,025)
Travel and Training 315,296 282,539 32,757
Other 1,787,617 1,832,188 (44,571)
Total Operating Expenses $29,554,089 $29,572,776 $(18,687)
Subtotal Before Allocations $2,694,275 $726,753 $1,967,522
Total Expenses Per Visit $234 $230 $4
Net Surplus/(Deficit) $2,694,275 $726,753 $1,967,522
Net Surplus/(Deficit) Per Visit $21 $6 $16
Revenue AnalysisPayor Net Patient Revenue Net Global Revenue Total Net Pt. Rev.
Medicaid MMC $145,438 $30,742 $176,180
Network Health (6,164) 1,266 (4,898)
Tufts 20,092 - 20,092
Blue Cross/HMO Blue 81,265 8,758 90,023
Workers Comp 6,708 - 6,708
Commercial Revenue 11,517 1,863 13,380
Other State 22,926 - 22,926
NHP 736,396 46,875 783,271
Medicare 326,032 (1,741) 324,291
Uninsured 72,719 - 72,719
BMC 249,995 24,748 274,743
Celticare 37,697 - 37,697
Fallon 14,877 - 14,877
Harvard 28,015 2,200 30,215
United Hlth 92,969 (157) 92,812
Health Safety Net 363,750 - 363,750
MM-PCPR - - -
$2,204,232 $114,554 $2,318,786
Avg Charge per Visit $138 $1,975
Total Visits (less prenatals) 15,950 58 Deliveries
Rebillable DenialsReason YTD
Rebillable Denials Amount
Emergency Services Only 12,137 1,201,817
Billed to Wrong Insurance 2,969 306,235
Deductible not Met 1,002 73,231
Service Not Covered 1,011 32,963
Patient Not Eligible 492 48,500
Unacceptable Procedure 204 36,511
Unacceptable Diagnosis 132 3,467
Billed With Incorrect ID 92 1,819
Needs a Modifier 40 191
Incorrect Patient Name 21 0
Invoice Missing 63 7,513
Totals Rebillable 18,163 1,712,248.11
Non-re-billable Denials
Reason YTD
Non-Rebillable Denials Amount
Billing Deadline Exceeded 1,394 137,316
No Referral 1,132 161,003
Denied Bundled 1,817 121,710
MD Lacks Credentials 847 91,591
No PCC 45 3,890
Not Medically Necessary 36 3,257
Non Reportable Codes 19 1,909
Not Documented as Rendered 7 1,134
Totals Non-Rebillable 5,297 521,811
Cost Per Visit Summary
Per Visit Per Patient
Total Visits / Patients 84,752 68,829
Total Cost - Direct Provider 46 57
Total Cost - Direct Medical Support Staff
Expenses49 60
Total Cost - Direct Enabling Expenses 2 2
Total Cost - Site Overhead Expenses 22 27
Total Cost Non Medical and Administrative 42 52
Total Cost 161 198
All Sites FY16 YTD (Through November)
Cost Per Visit Detail
All Sites
Total Visits 84,752
Direct Provider Costs:
Salary & Fringe Benefits 3,937,818
Total Direct Provider
Costs 3,937,818
Total Direct Provider
CPV 46
Direct Provider Costs
Salary & Fringe Benefits 2,788,331
Direct Expenses 696,653
Call Center Allocation 460,703
Referrals Allocation 191,773
Total Direct Medical Support Staff
Expenses 4,137,460
Total Direct Medical Support Staff
Expenses CPV 49
Direct Medical Support Staff Costs
Cost Per Visit Detail
Salary & Fringe Benefits 127,461
Total Direct Enabling Expenses 127,461
Total Direct Enabling Expenses
CPV1.50
Salary & Fringe Benefits 721,178
Other Direct expenses 1,134,211
Total Site Overhead Expenses 1,855,389
Total Site Overhead Expenses CPV 22
Direct Enabling Costs:Site Overhead Costs:
General Admin Allocations 2,816,080
Billing Allocation 464,052
Medical
Administration308,104
Total Non Medical and
Administrative Expenses3,588,236
Total Non Medical and
Administrative CPV42
Total Provider, Direct Support
Staff, Enabling and Overhead
Expenses
13,646,36
4
Total Cost Per Visit 161
Non-medical and Administrative Costs:
Total Costs:
Support Staff Ratio Pyramid
Statistical Detail
All Sites
Visits by new patients last week: 147
Weekly budget for new patients: 167
Difference from budget for
week: -20
YTD new patients: 5842
YTD budget for new patients: 5448
Difference from budget YTD: 394
Number of Enrolled Patients All Sites
Enrollment YTD (includes
unassigned) 56084
Percent of Goal Achieved YTD 97.1%
Minimum Goal To Achieve by 6-
30-16 57775
Number of Visits All Sites
Patient visits last week: 4337
Weekly budget for patient visits: 3521
Difference from budget for week: 816
YTD patient visits: 151694
YTD budget for patient visits: 146732
Difference from budget YTD: 4962
Prescriptions Filled Total
Prescriptions filled this week: 12403
Weekly budget for prescriptions: 10698
YTD Prescriptions filled: 385909
YTD budget for prescriptions filled: 348787
Patient Satisfaction All Sites
Goal: 4.65
July-September, Q1 4.63
October-December, Q2 4.44
January-March, Q3 4.41
Year-to-date: 4.50
Clinician Summary
Clinicians / NP
PPHTotal Visits
Projected visits
Visit Variance
Total Clinic Hours
AA's +Walk Ins
AA's % WIEP
No-Shows
% No-Shows
New Patients
Cycle Time
July 2.5 12,470 12,580 (110) 4,962 3,192 25.6% 2,868 18.7% 418 61
August 2.5 12,298 11,313 985 4,832 3,303 26.9% 3,035 19.8% 391 65
September 2.4 12,718 12,747 (29) 5,287 3,608 28.4% 3,073 19.5% 410 64
October 2.3 12,790 14,037 (1,247) 5,490 3,543 27.7% 3,223 20.1% 482 65
November 2.3 12,498 11,276 1,222 5,492 3,569 28.6% 3,084 19.8% 483 64
December 2.3 12,373 11,905 468 5,451 3,770 30.5% 3,443 21.8% 513 63
Total 2.4 75,147 73,858 1,289 31,513 20,985 27.9% 18,726 19.9% 2,697 64
NACHC
PAYOR Net Patient revenue Net Global Revenue Total Net Patient Revenue Total Visits
Medicaid $2,839,671 $264,344 $3,104,015 46,256
Network Health $1,863,712 $147,683 $2,011,395 12,563
Tufts $150,052 $0 $150,052 1,171
BCBS $505,968 $33,988 $539,956 4,928
Workers Comp $51,333 $0 $51,333 75
Commercial $80,829 $2,800 $83,629 4,097
Other State $102,567 $0 $102,567 939
NHP $2,761,802 $215,050 $2,976,852 18,425
Medicare $1,879,966 $7,348 $1,887,314 10,806
Uninsured $417,719 $2,817 $420,536 3,368
BMC $1,442,505 $135,628 $1,578,133 9,731
Celticare $148,038 $0 $148,038 1,351
Fallon $141,874 $4,871 $146,745 2,038
Harvard $179,603 $12,131 $191,734 982
United Health $834,314 $8,075 $842,389 6,981
Health Safety net $837,545 $0 $837,545 3,407
MM-PCPR -19,442
$14,237,498 $834,735 $15,072,233 107,676
Avg. Charge per Visit $132 $2,056
Total Visit (less prenatals) 107,676 406
Greater Lawrence
Patient Revenue Reasonableness Analysis December 2014
All SitesHaverhill
Street North West South MethuenLGH
Outpatient
Total Visits 89,543 26,796 24,665 14,574 13,926 5,971 3,611
Direct Provider CPV
$44 $41 $44 $47 $52 $46 $18
Medical Support Staff CPV
$45 $46 $42 $46 $47 $47 $49
Direct Enabling CPV
$2 $2 $2 $3 $2 $3 $0
Site Overhead CPV
$17 $17 $11 $15 $24 $32 $7
Non Medical & Admin CPV $32 $21 $35 $38 $40 $43 $23
Total Cost Per Visit $141 $128 $135 $148 $166 $171 $97
GLFHC Cost Per Patient
FY15 YTD
All SitesHaverhill
Street North West South MethuenLGH
Outpatient
Total Patients 73,519 23,542 19,306 11,144 11,487 5,062 2,978
Direct Provider CPV
$54 $47 $57 $62 $63 $54 $21
Medical Support Staff CPV
$55 $53 $54 $60 $57 $56 $59
Direct Enabling CPV
$3 $2 $3 $3 $3 $4 $0
Site Overhead CPV
$21 $19 $15 $19 $30 $38 $9
Non Medical & Admin CPV $39 $24 $45 $50 $49 $51 $28
Total Cost Per Visit $151 $126 $158 $175 $172 $164 $109
GLFHC Cost Per Patient
FY15 YTD
You Can’t Manage
If You Can’t Measure
____________________________
Not for Profit is a Tax Status
Not a Business Objective
