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Are You Ready For Revenue Cycle 2.0?
Presentation Summary & Tools
Presented by:Daniel J. Marino
The Healthcare Reality of Today
• Healthcare costs continue to rise placing pressures on patients, employers and healthcare providers
• Movement from volume-based reimbursement to value-based contacts
– Fee-for-services plus shared savings
– Shared savings with PMPM care management fee
– Risk-based contracts• The importance of data continues to rise– Process-driven outcomes– Performance and care results
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Shift in Revenue Cycle Activities
Based on fee-for-service encountersEncounter-based contract management Based on fee schedule Accounts receivable indicators
Based on clinical performancePerformance-based contract management Bundled payments“New” business metricsConsumer driven healthcare
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Present Future
New Generation of KPIs
• New Generation of financial metrics include:- Tracking “Cost of Care”- Clinical performance- Patient satisfaction/engagement- Beneficiary/program management- Bundled payment indicators
• PM systems tracking by value –based contract- Bundled service- Shared savings- Partial or full risk
• A/R management reflecting performance incentive opportunity
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Physician Key Performance Indicators
Key Performance
Indicators
Revenue Cycle
Payment Analysis
Cost / Profitability
ProductionCare and Outcomes
Patient Access
Patient Satisfaction
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Focused Analytics Help Identify Where to Begin
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Build the total cost of care model on per member, per month bases
Indicators should include: • Allowed versus paid amount• Employee, spouse, child• With and without high cost
claims
Stratify Data based PMPM, Cohorts
Top 10 Diagnoses by Total Cost
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* Diagnoses appeared in the primary, secondary or tertiary codes
Diagnosis Code Description
Allowed Amount
Paid Amount Patients Encounters
Paid per Encounter
Paid per Patient
401.9 Unspecified essential hypertension $1,537,106 $1,434,185 911 5,286 $271 $1,574
585.6End stage renal disease $1,126,685
$1,089,893 9 1,496 $729 $121,099V58.11 Encounter for antineoplastic $746,231 $716,961 28 1,552 $462 $25,606174.9 Malignant neoplasm of breast $758,427 $715,286 72 1,667 $429 $9,935
205.02 Acute myeloid leukemia, in relapse $682,459 $674,449 2 30 $22,482 $337,224
V42.7Liver replaced by transplant $651,863
$634,463 8 309 $2,053 $79,308
V58.0Encounter for radiotherapy $593,219
$593,219 18 766 $774 $32,957280.9 Iron deficiency anemia, unspecified $590,289 $565,894 75 1,198 $472 $7,545
824.8Unspecified fracture of ankle, closed $576,856
$562,333 20 94 $5,982 $28,117
823.82Closed fracture of unspecified part of fibula with tibia
$571,902$560,723 3 58 $9,668 $186,908
Evaluating the High Cost Services Support Bundled Service Tracking
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*Disease categories based off of grouped diagnoses corresponding to condition.
• On a per encounter basis, colorectal cancer is the most expensive cancer type assessed, whereas breast cancer had the highest encounter rate
Cancer TypeAllowed Amount Paid Amount Encounters
Lung $193,509 $179,059 512Colorectal $377,167 $333,967 850Breast $844,232 $797,865 1946
*Figures provided are in Paid Amounts.
Collected vs. Collectable
• Similar to net collection rate, but allows for more accurate review
— Collected: Payment received and line item posted (includes co-pay and
deductible)— Collectable:
The allowable amount as negotiated in contract (includes co-pay and deductible)
• Great metric to evaluate overall revenue cycle performance• Forces you to ask specific questions and drill down to find
answers• Dependent on knowing contract fee schedule• Allows for better contract negotiations
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Collected vs. Collectable
90 Day CvC: Goal 92-94% Payments received in the next 3 months
Allowable posted 4 months ago
180 Day CvC: Goal 95-97% Payments received in the next 6 months
Allowable posted 7 months ago
Annual CvC: Goal 97-99% Payments received in the next 12 months
Allowable posted 13 months ago
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Sample 90 Day CvC Report
JANUARY, 2014INSURANCE PLAN CHARGES ALLOWABLE COLLECTED
(Coll./Allow.) % COLLECTED
AETNA $1,639,044 $1,062,610 $1,043,451 98.20%
AMERIHEALTH $185,361 $145,090 $140,925 97.13%
USHC $1,986,460 $1,267,667 $1,210,398 95.48%
UNITED HEALTH $1,653,396 $1,283,729 $1,219,456 94.99%
MEDICARE $4,532,591 $1,799,580 $1,679,789 93.34%
CIGNA $1,146,525 $911,439 $847,316 92.96%
OXFORD $1,318,334 $1,053,521 $960,497 91.17%
HEALTHNET $579,508 $477,573 $418,675 87.67%
HORIZON $258,003 $258,003 $195,264 75.68%
SELF $272,173 $272,173 $188,777 69.36%
TOTAL $13,571,395 $8,531,385 $7,904,548 92.65%
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End Uses of Clinical Information to Support Revenue Cycle Performance
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• Chronic disease registries• Care gap management• Patient satisfaction
• Quality scorecards• Patient chart view through
continuum of care• Use of referrals and
ancillaries
• Total cost of care reports• Payer analytics• Areas of improvement• Domestic Utilization Mgmt
Program Management
Physician Performance
Financial Effectiveness
Health Directions, LLCTwo Mid America Plaza, Suite 1050Oakbrook Terrace, IL 60181Phone: [email protected]
Daniel J. MarinoPresident/[email protected]
@HDirections
Contact
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