“Improving Health Center Sustainability” Revenue Cycle and Health Information Management.
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Transcript of “Improving Health Center Sustainability” Revenue Cycle and Health Information Management.
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“Improving Health Center Sustainability”
Revenue Cycle and Health Information Management
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Improving Health Center SustainabilityLearner 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.
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History/Mission
Policy Information Notice
Health Information Technology Strategy
Sustainability4
3
2
1
Key Discussion Points
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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.”
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Mission
• Medically underserved populations.– Uninsured– Underinsured– Chronically unemployed– Newly unemployed
• Migratory and seasonal agricultural workers.
• Homeless populations.• Residents of public housing.
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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.
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Health Centers
MissionSustainability
Margins
Business Operations
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Financial Management
• Financial Culture
• Business Mindset
MedicallyUnderserved
• Healthcare Access
• Preventive Services
Grant Funds• Primary
Health Services
• SpecialtyServices
Financial Infrastructure
• Financial Quality
Improvement • Financial
Goals
MissionSustainabilityMargins
Health Center
Financial Infrastructure
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Revenue Cycle Management
Leadership
Regulatory Compliance
Information Technology
Quality
Mission
SustainabilityHealth
Center
Margins
Financial Transformation
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• 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
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Revenue Cycle
ManagementExecutive
Leadership
Clinical
Operations
Financial
Operations
Operations
Revenue Cycle Management: RCM
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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
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• What current HIT workflows are in place to support business operations?– Leadership operations– Finance operations– Billing operations– Operations– Clinical operations
Current Status of Business Operations and Workflow
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Leadership• Understand
operations• Team
competence• Cultivate
change
Operations
• Scheduling• Front Desk• Back Office
Finance/Billing
• Practice Management
• Billing Policies/Procedure
s• Collections
Clinical
• Credentialing Scheduling
• Documentation
• Coding• Productivity
Mission
SustainabilityHealth Center
Margins
Health Information Technology Optimization
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Health Information Technology
Finance/Billing
Operations
Clinical Operations
Leadership
• Transformation• Financial
Solvency• Restructure
Workflow• Cultivate
Financial Culture
Health Information Technology
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BeginsRCM
• Pt. Access• Appointment
Management• Initial Contact
• Eligibility• Credentialing
Patient InformationInsurance• Eligibility
• Credentialing HIPPA/Complianc
e• Copayment• Outstanding
Balances
ProviderAccountability
• Patient Experience• E&M
• Documentation• Coding• Time
Management
Fees for Service
• Patient Payments
• Charge Retrieval
• Appointment• Scheduling
HIT Process Improvement
SchedulingPatient
Check-Out
Registration Clinical
Encounter
Health Information Technology Workflow
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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.
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Patient Registration Workflow
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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)
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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:– 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.”
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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?
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Patient Financial Policy
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Patient
Scheduling
Front Desk
Healthcare Team
Your Text
Your Text
Your Text
Your Text
Health Information Technology
Provider
Patient
Clinical Workflow
Integrated Care
Workflow
Check-out Workflow
Clinical Operations and Workflow
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C
PatientEncounter
Chief Complaint
ExaminationClinical decision
Making
Evaluation and Management
• CPOE• Documentation
• E&M Coding• Plan of Care
Electronic Medical Record
Provider
Sustainability
Margins
Mission
Compliance
Clinical Workflow and HIT
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Patient Centered Care
• Medical Decision Making
• CPOE• Documentation/Coding
Patient Accountability
• Self-Management• Patient
Responsibility• Ability to Pay
Information
Exchange
Medical
Orders
Medical
Charges
Information
Exchange
Financial
Responsibility
Medical
Billing
Electronic Health
Record
Practice
Management
Clinical Workflow and HIT
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Improved Access
Quality Healthcare Delivery
Integrated Care
Financial Management
Financial Infrastructure
Healthcare Teams
Health Center
Patients
Sustainability
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65 %
10 %
25%
100 % Mission vs
Margins
Health Center
Mission
Sustainability
Margins
Health Information Technology Workflow
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Questions
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DPM Healthcare Consulting
Stephanie J. Wroten BSN, MS, [email protected]
Anna Gard RN, [email protected]
Contact Information
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DPM Healthcare Consulting