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Presented byRon Sterling
Sterling Solutions, Ltd.rbsterling@sterling-
solutions.com
Revenue Cycle Management and EHRs
Wednesday, January 21st, 2015
The information provided in AHC Media Webinars does not, and is not intended to constitute medical or legal advice. Opinions, references and links provided by our speakers are provided for your convenience and do not represent our endorsement of such opinions, products or services.
RONALD B. STERLING, CPASterling Solutions, Ltd.
Ron Sterling is a nationally recognized thought leader onelectronic health records and an award winning author. Ronhas advised healthcare organizations across the country. Hehas analyzed software from over 150 vendors. Ron is afrequent speaker on EHR issues and strategies as well asthe author of over 250 articles on health informationtechnology for dozens of publications including the widelyused Marketing Your Clinical Practice.
EMAIL: [email protected]
Office: (301)681-4247
OBJECTIVES
1. Review the effect of technology on events that produce revenue.
2. Identify effects of evolving Revenue Cycle Management issues on EHR use and management.
3. Discuss techniques to maintain appropriate EHR records for the quality and patient service requirements under evolving payer relationships.
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RCM Issues
Revenue Sources Changing• Fee For Service Decreasing• Increasing
Shared Savings Accountable Care Organizations eVisits Patient Portal Services Patient Service
• Performance/Results Oriented Payments
RCM Focus Changes to Support Evolving Payment Models
From• E&M• Charge Capture
To • Maintaining Quality and Performance• Patient Service• Proving Quality• Patient Centered Specialty Practice• Patient Centered Medical Home
New RCM Flows
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Traditional HC InsuranceEmployer Payer
Hospital Clinic
PMPM Fee
FFS – Fee For ServicePMPM – Per Member Per Month
Alternative Payment Model - ACO
PayerACO
Hospital/Clinic/Provider
Global Payment
FFS – Fee For ServicePMPM – Per Member Per Month
Alternative Payment Model - Shared Savings
PMPM Fee
Shared Savings Refund
Employer Payer
Hospital/Provider
Claims Shared Savings Payment
FF
S P
ayment
FFS – Fee For ServicePMPM – Per Member Per Month
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Issues that Influence RCM Strategy
Meaningful Use HIPAA Security Standards
• Accountable for Integrity• Assure Accessibility
RCM Support Is Complicated Preserve Information to Support RCM
• Notes• New Service Documentation Tools
Clinical Messaging Patient Remote Patient Monitoring Systems
• Patient Quality and Service Objectives Coordinate Patient Populations Track Patient Care
• Performance Standards Quality Improvement
RCM Support Is Complicated
Payers/ACOs May Vary Sustain an Audit of Supporting
Documentation• Requests for Documents• Examination of EHR Based Records
Computer Assisted Review Tools Review of Audit Trails Review Context of Care
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Evolving RCM is Complicated
EHR May Not Accommodate• Tracking of Key RCM Measures• Relevant Status Over Activities
May Require Changes to EHR Use• Activities Measures• Documentation to Trigger RCM
Requirements
Evolving RCM is Complicated
May Require Additional Documentation• Meaningful Use Like Attestation• Global Reporting• Performance Tracking
Payment May Not Be Associated with a Patient• Quality Incentive• “SGR Fix” Payments
EHR Challenges Related to RCM
EHR Records are Vulnerable Payer Patient Service Expectations
• First Response• Final Resolution/Recommendation
Due Diligence to Protect Patient Records• Avoid Degradation• Maintain Accuracy and Consistency
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EHR Challenges Related to RCM
ICD10 Starts October 1, 2015• Not Just About Coding
Clinical Decision Support (MU) Health Maintenance Items Classification of Plans, Visits and More
• ICD10 Specificity Site Laterality Visit Type More
Clinical RCM Objectives
Verify Record Standards Maintain Integrity of Patient Records Protect Against
• Unsubstantiated Services• Quality Lapses• Claim Fraud
Support Contractual, Professional and Industry Standards
Agree on Operational Standards
Standards Based on• EHR Features• Product Use• Payer/ACO• Practice• Services• Doctors
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RCM CHECKLIST
RCM Checklist Items Notes Signed Within X Hours/Days
• Regular Office Visits• eVisits• Evolving Activities (Ex. ACO Support)
EHR Interface with PMS/Billing• Accuracy• Timeliness• ICD9/10 Coding• Changes• Substantiation
RCM Checklist Items Reconcile
• Charges• Appointments• Cancellations• No Shows
Supporting Documentation for Clinically Significant Events
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RCM Checklist Items
Patient Portal Traffic• Patient Submission of Information
New Patients Follow Up
• Turnaround Time• Follow Up on Undelivered Messages• Documentation Supports Care
Standards
Patient Request
Response
Information
Messages – Sent to Inbox and Information Entered into EHR.Information Accepted – Information Flagged and Posted to Patient Chart.
Patient Portal
Patient PortalServer
RCM Checklist Items Outgoing and Incoming Electronic
Traffic Check• Rx• Transition of Care• Lab Results• Patient Orders• Other Results
Workflow Management• Patient Appointments Cleared and
Completed• To-dos and Messages Completed
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RCM Checklist Items
Internal Messaging• Part of Patient Service Strategy• Status and Response by Type• Workflow Issues
Incoming Documents/Images• Status of Items to be Indexed• Routing of Indexed Items• Documentation of Decisions• Changes to Care Plan• Document Patient Notification
RCM Checklist Items Quality Assurance
• Documentation Standards• Outlier Detection – Treatment and/or
Management Meaningful Use
RCM Checklist Items
Quality Patient Services• Procedure/Surgery Follow Up• Referral Follow Up• Reminder Transmission• Reminder Follow Up• Health Maintenance Items• Outstanding Orders• Obsolete Orders
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RCM Reporting
Maintain Statistics to Prove Performance• Payer• Patient Population• Provider• Location
Report on Standards • Performance
• Trends
Supporting Claims and Collections
In addition to copy of notes to match E&M code with documentation….• Includes proving care standards• Depends on operational performance• Requires timely and accurate records
Meaningful Use reporting and Clinical Quality Measures are a window into the future of RCM
RCM and EHR Cases
PMS receives charges for office visits from EHR but does not post transactions for eVisits, RPMS monitoring and other activities that are billed under a quality initiative.• What are the RCM issues?• What are the RCM problems in light of
an ACO environment?
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RCM and EHR Cases
Practice receives a quality incentive payment for managing an at risk patient population. The PMS only posts fee for service charges.• How and where should the payment be
posted?• Can the payment be posted directly to
the accounting system and bypass the PMS?
• How will realization reports be affected?
RCM and EHR Cases
EHR Vendor advises practice to not sign patient notes in case the doctor wants to change the document.• What are the fee for service issues?• What are the professional liability
issues?• What are the RCM problems in light of
an ACO environment?
RCM and EHR Cases
EHR Messages are not included as part of the patient record according to the EHR design.• How does this design complicate quality
patient care?• What are the operational
accommodations needed to support quality care based RCM?
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Go Forward Plan
Monitor EHR Vendor tools to support RCM under evolving payment and performance systems• Meaningful Use as a Start
Maintain EHR Documentation and Performance Standards to take advantage of EHR and align your practice with evolving revenue models (ACO, Shared Savings, PCSP, etc.)
This presentation is intended solely to provide general information and does not constitute legal advice. Attendance at the presentation or later review of these printed materials
does not create an attorney-client relationship with the presenter(s). You should not take any action based upon any information in this presentation without first consulting legal
counsel familiar with your particular circumstances.
QUESTIONS AND ANSWERS
