Physician Revenue Cycle and Compliance – Preparing … Presentations... · Physician Revenue Cycle and Compliance – Preparing for the OIG ... Revenue Cycle 6 ... auditing through

Physician Revenue Cycle and Compliance – Preparing for the OIG

2014 Summer Institute Indiana Chapter, HFMA

Katie Gilfillan

Director HFP, Physician and Clinical Practice

Sandra Wolfskill, FHFMA

Director, HFP, Revenue Cycle MAP

Agenda

• A View of the Physician’s World – 2014

• OIG Reports

• Metrics for the Physician Revenue Cycle

• Q & A

2

Physician World - 2014

• Small groups vs. large groups – challenges:

– Administration and financial

– HIT infrastructure

– Ability to respond to health reform

• Options for the small groups

– Align/join larger groups

– Join a health system/ IDN

– Purchase by a hospital

• COMPLIANCE

3

Group Size - 2013

Group Size Number of Providers

Percent of Total Rank

1 203,970 22.9% 1

2 53,128 6.0% 8

3-4 65,301 7.3% 7

5-9 84,482 9.5% 4

10-24 103,569 11.6% 3

25-49 75,048 8.4% 5

50-99 69,865 7.9% 6

100-999 181,197 20.4% 2

1000+ 52,714 5.9% 9

Total 889,274

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Source: Physician Compare database of providers registered with Medicare; includes physicians and physician extenders Leavitt Partners, LLC, Physician Groups in the United States: A Look Forward, February, 2014

Integrated Delivery Networks

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Large Groups: > 25 physicians Affiliation with Integrated Delivery Network

59%

Small Groups: 25 or < physicians Affiliation with Integrated Delivery Network

23%

Implications for: ACOs

Bundled payments Medical homes

VBP Demonstrations

Conceptual View of the Patient-Centered Revenue Cycle

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Physician or patient identifies need for service; contacts “office” to schedule

Time of service activities- Patient arrival ; $$; Clinical services and documentation; Revenue capture, Coding & Patient discharge

m

Post service – completion of activities required to successfully resolve the financial components for patient and provider

EHR

Visit scheduled and pre-service processing completed

Pre-Service Revenue Cycle

• Need for service identified; patient contacts provider to schedule visit

– Potential compliance issue(s): ____________________________________________________________________________________

• Visit scheduled


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• Identification of current and prior balances


• Discussion and resolution of financial issue(s)


8


• Collection of payment


• Automated reminder call(s)


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Time of Service Revenue Cycle

• Patient arrival, check-in; collection of co-payment or other balance(s)


• Clinical documentation


10


• Coding


• Charging


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• Additional services/testing ordered


• Cash posted and bank deposit sent to bank


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Post Service Revenue Cycle

• Patient balance billed


• Unpaid accounts sent to collection agency for processing


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OIG - (OMG)

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The OIG alleged that SRMC submitted claims containing CPT codes 99204, 99205, 99214, and 99215, that it submitted for services provided by the physician that were upcoded and that the physician engaged in a pattern or practice of coding at a higher level that he knew or should have known would result in a greater payment than the code applicable to the services he was actually providing.

Physician pays $17,087.58 for allegedly violating the Civil Monetary Penalties Law. The OIG alleged improper billing of Medicare for: (1) new patient E&M office visits for pre-existing patients; (2) upcoded E&M office visits; and (3) services provided by nurse practitioners that were billed under physicians provider number when he was not in the office.

CHICAGO—Mobile Doctors…arrested today on federal health care fraud charges…warrants to seize up to $2.568 million in alleged fraud proceeds from various bank accounts. The charges allege a scheme of fraudulent upcoding.

Office of the Inspector General Report

• Review of Medicare Part B claims for E/M services

• Found $6.7 billion on improper payments in 2010

• Represents 21.4 % of all E/M payments

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Previous Report:

• 2006: OIG reports 75% of E/M consultations did not meet Medicare coverage requirements leading to $1.1 B in improper Medicare payments.

17 17

Previous report: OIG reports increased billing of higher level E/M codes

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Previous Reports

• 2012 Survey: 57% of physicians who provide E/M Services used an EHR system

– 75% use EHR system to document E/M services

– 88% of Medicare physicians assign codes manually

– 12% have codes assigned by staff or professional coders

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Current Report: Methodology

• Requested medical records from a sample of physicians from each strata.

• Reviewers determined whether the E/M service documented in the medical record for each sampled claim was correctly coded/sufficiently documented.

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High Coding Physicians

• Top 1 %

• Two highest codes

Other Physicians

• Not high coding

Findings

• 42 % of claims were incorrectly coded

• 19 % of claims lacked documentation

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0 10 20 30 40 50

Upcoded

Downcoded

Other

0 20 40

Insufficient Documenation

Undocumented

High coding physicians more likely to incorrectly code

0

10

20

30

40

50

60

70

-4 -3 -2 -1 1 2 3 4

High Coding Physicians

Other Physicians

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Recommendations from Report and CMS response

• Educate physicians on coding and documentation requirements for E/M services.

• Continue to encourage contractors to review E/M services billed for by high-coding physicians.

• Follow up on claims for E/M services that were paid for in error.

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Other Areas of Focus • Upcoming Report: Documentation

vulnerabilities of E/M services using EHR systems.

• Outpatient E/M services billed at the “new” patient rate

• Place of Service Coding Errors

• Ophthalmologists and Anesthesiologists

• Diagnostic Radiology and Electrodiagnostic Testing

• Schedule II controlled substance prescribing

• Meaningful Use Audits by CMS

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Strategies for Physician Offices

• Develop and Implement a Compliance Program

– Now required under PPACA

– Include 7 Steps recommended by OIG

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1. Conducting internal monitoring and auditing through periodic audits.

2. Implementing compliance and practice standards through the development of written standards and procedures.

3. Designating a Compliance Officer or contact(s)

4. Conducting appropriate training and education on practice standards and procedures.

7 Steps to OIG Compliance Plan

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5. Responding to detected violations through investigations of allegations

6. Developing open lines of communication among staff regarding fraudulent conduct

7. Enforcing disciplinary standards through publicized guidelines

7 Steps to OIG Compliance Plan

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Strategies for Physician Offices

• E/M audits should be part of your overall compliance program

• Consult Evaluation and Management Services Guide

• Consult OIG and CMS Resources for Physicians

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Metrics – Physician Revenue Cycle

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Physician Practice KPIs

• Common metrics that provide strategic-level month over month data

• Ability to select and report on a variety of peer comparisons

• Developed by HFMA and industry experts

• Monitored and updated to meet emerging needs

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Benefits of Benchmarking

• Provides performance context

• Aids discovery of improvement opportunity

• Helps identify the right performance targets

• Supports the identification of practices with proven positive outcomes

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Just How Above “Good” Do You Need to Be?

• To optimize improvement efforts, you need to first understand what a change in performance will mean

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You need targets

that are:

Industry accepted

Measurable and quantifiable;

timely

Defined by true “peer groups”

Example: Days in A/R

• Consider a practice where Days in A/R improved to 38.7, and performance has been sustained most months for the past year:

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IMPROVED & SUSTAINED

Days in

A/R

38.7

JAN

FEB

MAR

APR

MAY

JUN

JUL

AUG

SEPT

OCT

Example: Days in A/R

• Meanwhile, Days in A/R for the organizations peers have dropped even more …

Source: Analysis of HFMA's MAP AppSM ,

DAYS IN A/R AMONG PEER GROUPS OF SIMILAR REVENUE, PAYER MIX

33.0 34.0 35.0 36.0 37.0 38.0 39.0

35.5 Peer 3

38.1 Peer 2

38.7 Case Example Practice

38.0 Peer 1

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State

Two letter abbreviation of state in which practice is located

(MAP App utilizes A/B Mac Jurisdiction to group states)

Number of Sites

Total number of sites/locations physicians are practicing by physical address (#)

Number of Practices Total number of MAP App Practices being reporting

Academic Affiliation Practice’s affiliation with major teaching hospital (yes/no)

Net Patient Revenue

(monthly average) Net Revenue of practice (= annual net patient revenue / 12 months). Use last fiscal.

“Buckets” “Options”

Custom Peer Group Options

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Total Number of

FTE Physicians

* Primary Count: number of FTE physicians that are Family Practice, Internal Medicine

and Pediatrics, OB/GYN, and hospitalists

* Specialty Count: number of FTE physicians that are all other

* Specialty Percent - will be calculated for you

* Physician Extender Count: number of FTE physician extenders; includes CRNA, PA,

NP, and Midwife.

* Physician Extender Percent - will be calculated for you

* Total Physicians - will be calculated for you

Note: FTE is defined as greater than 32 patient care hours

“Buckets” “Options”

Custom Peer Group Options

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• Clearly defined

• Measurable

• Discerning

• Comparable

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HFMA MAP Keys

Sample of an HFMA MAP Key

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See the list at www.hfma.org/map

Indicator

Purpose

Value

Calculation

Net days in A/R

Trending indicator of overall A/R performance

Indicates revenue cycle efficiency

Net A/R

Net patient service revenue

Physician Practice Management Keys

• 14 Individual Keys

• 4 Categories

– Patient Access – 2 keys

– Revenue Integrity – 1 keys

– Claims Adjudication – 2 keys

– Management – 9 keys

• Similar concept to hospital side with other keys unique to physician practice management

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14 Physician Practice Management MAP Keys℠

• 1a. Primary Physician Practice Operating Margin Ratio

• 1b. Specialty Physician Practice Operating Margin Ratio

• 1c.Net Income/Loss per Primary FTE§ Physician

• 1d.Net Income/Loss per Specialty FTE§ Physician

• 2. Practice Net Days in Accounts Receivable (A/R)

• 3. Practice Cash Collection Percentage

• 4a.Total Primary Physician Compensation as a Percentage of Net Revenue

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14 Physician Practice Management MAP Keys℠

• 4b. Total Specialty Physician Compensation as a

Percentage of Net Revenue

• 5. Percent of Patient Schedule Occupied

• 6. Professional Services Denial Percentage

• 7. Point-of Service (POS) Collection Rate

• 8. Total Charge Lag Days

• 9.Aged Accounts Receivable (A/R) by Payer Group as a Percentage of Outstanding Total A/R

• 10.Aged Accounts Receivable (A/R) as a Percentage of Outstanding Accounts Receivable

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% Patient Schedule Occupied

0.78

0.8

0.82

0.84

0.86

0.88

0.9

0.92

0.94

Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 Jul-13

A/B MAC 5 & 6 Median Performance 90th Decile 75th Percentile

Peer Group: Nationwide

Specific Region

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POS Collection Rate

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%




Specific Region

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Charge Lag Days

0

1

2

3

4

5

6

7




Specific Region

44

Practice Cash Collection Percentage


0.0%

20.0%

40.0%

60.0%

80.0%

100.0%

120.0%

140.0%

160.0%


A/B MAC 5 & 6 Median Performance 90th Decile 75th Percentile Specific Region

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Practice Net Days in A/R

0

10

20

30

40

50

60

70




Specific Region

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Aged A/R 90+

0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

12.0%

14.0%

16.0%

18.0%

20.0%




Specific Region

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A/R: Medicare Traditional 90+

0.0%

0.5%

1.0%

1.5%

2.0%

2.5%

3.0%

3.5%

4.0%

4.5%




Specific Region

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Payment Denial Rate

0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

12.0%

14.0%

16.0%




Specific Region

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Key Indicator of a Revenue Cycle in Need of Help!

Welcome to a meeting of the practice managers…

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CFO

CMO

Thank You!

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Contact Information

• Katie Gilfillan

Director, HFP – Physician and Clinical Practice

[email protected]; 800-252-4362

• Sandra J Wolfskill, FHFMA

Director, HFP – Revenue Cycle MAP

[email protected]; 800-252-4362

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mailto:[email protected]

mailto:[email protected]

Documents

Physician Revenue Cycle and Compliance – Preparing … Presentations... · Physician Revenue Cycle and Compliance – Preparing for the OIG ... Revenue Cycle 6 ... auditing through