Improving Profit Through Operational Process Analysis in the Medical Office Setting

Aaron Ryan, RN, MBA, FACMPE

This paper is being submitted in partial fulfillment of the requirements for election to fellow

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Improving Profit Through Operational Process Analysis in the Medical Office Setting

Introduction

In today’s complicated heath care industry financial performance can be driven by many

factors, but in its simplest form, it comes down to two factors: revenue and costs. At times, the

solution to medical practices’ profit problems will not be found by adding a new service line or

increasing the number of physicians. Running a medical practice with a sound operational

foundation in the front office, back office and patient care activities must be accomplished before

any other measure can be successful. If we do no charge, bill, collect and purchase our supplies

in an optimal manner, adding a new service line or physician will only grow a practice’s

problems, not improve them. Due to the complex nature of the healthcare industry, it is

important for practice executives to examine performance in many different operational areas in

order to develop effective strategies for maximizing profit. Using literature review, internet

solutions and MGMA resources, this paper will examine the actions taken by a medium sized

academic internal medicine practice when analyzing and implementing improvement

opportunities for the front office, back office and patient care activities. At the end, practice

executives will have examples and tools to analyze both their revenue and costs associated with

providing care.

Background

In 2013, this medium sized academic internal medicine practice found itself with a

negative cash trend for the fourth consecutive year. Previously, the practice had felt that the

negative cash flow was due to the growth undergone by the practice. However, after two years

without the addition of any providers, the negative cash trends were not only continuing, but

accelerating. The executive director met with the department chairman to discuss possible

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causes for the continued losses and how to turn them around. Understanding that practice

profitability is a function of front office, back office and patient care performance, the leadership

team began an evaluation of those areas to identify opportunities for improvement. Leadership

was aware that some hard facts were going to be necessary in order to convince the stakeholders

that change was needed (Collins 69)

Potential Causes of cash flow problems

Back office based Causes

The evaluation began with the back office functions of the practice. The current staffing

mix included three non-certified coders, three insurance follow up specialists, one patient

accounts receivables specialist, one payment poster, one employee completing prior

authorizations and referrals, and one billing manager who had been hired in the previous three

months. An examination of back office production revealed a lag time for claim submission of

nearly six weeks. Utilizing the EMR vendor list provided by the state affiliate of MGMA, the

practice reached out to other practices in the state that utilized the same EMR vendor to review

billing workflows to identify inefficiencies that may have been adopted by the staff. Next, the

executive director and billing manager met with the team to discuss existing expectations for

productivity and what was currently the definition of good performance.

The staff indicated to the team that good performance had previously been defined by

minimizing overtime hours. There were no metrics identified for performance that recognized

the back office’s impact on accounts receivables.

Finally, the executive director and the billing manager reviewed write off policy for the

internal medicine practice. The patient account receivable staff indicated that the policies varied

between providers and some providers were more aggressive with following up on balances than

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others. Also, some written policies were modified by the providers without formally changing

the policy.

Front office based Causes

Following the meetings with the back office, the team began meeting with the front office

staff to examine the workflow for potential contributions to the cash flow problems. The team

began by discussing the co-pay collection policy at each clinic. The team found that the co pay

expectations and policy were varied between clinics. As expected, the collection rate varied

greatly between clinics.

The team discussed with the front desk staff the method for collecting outstanding

balances from patients that return for additional appointments. The staff indicated that most

were uncomfortable with discussing patient balances at the front desk. Some concerns expressed

by the staff were the protection of patient privacy and that collecting balances were not part of

the job description for front desk personnel.

Patient care based Causes

Along with evaluating front and back office performance, the leadership team understood

an analysis of the type of care provided to patients would also be needed. The practice did not

have any full pro forma information on the services provided at the clinics. Historically, putting

all of the business cycle components together hadn’t been done. The practice may be aware of

cost and can identify what fees it is charging for the services, but that information was not being

compared to the reimbursement received for the services to verify the service was adding value

to the practice.

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Cost based Causes

The leadership team began collecting information on infusions and injectable medications

administered in the clinic setting. As the clinics did not perform any procedures, these

represented high dollar expenditures to the clinic. The procurement method in place had the

clinic manager for the respective clinic ordering medications from a variety of distributors.

However, a significant amount of medications came from a third party vendor that provided a

variety of patient care items ranging from durable medical equipment to medications. A review

of invoices for the medications indicated that many were being purchased at a price above

reimbursement. The group was also not receiving any kind of group discount for having all of its

clinics order from the same vendor. There was a lack of inventory control present and purchasing

decisions were being made without solid data to reflect previous utilization or worse, being

influenced by the vendors input regarding upcoming price increases for products. The results

were large amounts of medications on hand. Due to the purchasing terms with the vendor, the

medications required a cash outflow from the practice long before they would be needed for

patient care.

The leadership team set out to identify alternative purchasing solutions based on the

needs of the various clinics. Some methods identified included utilizing a 340B program for a

subset of patients, direct purchasing from the manufacturer, and having the patient purchase the

medications and bring them into the clinic instead of the clinic purchasing and billing for the

medications.

Revenue based Causes

Equally important to purchasing products at the correct price, a medical practice needs

charge an adequate amount for the services provided. While conducting the cost analysis of the

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medications, the leadership team also discovered that several of the medications were being

reimbursed at 100% of charges. As the team dug deeper, it became apparent that the fee

schedule for the practice had not been updated in over five years. For some medications, the

practice found itself in a position where the charges for the medications were lower than the cost

to purchase the medication.

There was a thought process in the clinic that such a high collection percentage must

equate to a value added service. Instead of completing a full reimbursement analysis, the

practice had become tied to monitoring for write off percentage. The perception had become that

the lower the write offs, the better off the clinic must be doing. By not putting all the factors

together, the clinics had created a false perception about the profitability of providing injectable

medications and infusions within the clinic. A review of the analysis indicated that 17 out of 23

medications were either being purchased at a price above reimbursement levels, being

reimbursed at 100% of charges or both in some instances.

During the analysis of the medications provided, the team realized that a serious

communication deficit existed between the clinicians and the practice administration. The clinic

was providing flu vaccine in three different presentations. However, the EMR only had the

ability to document one presentation of the flu vaccine. The presentation being documented

represented the cheapest form from a cost standpoint. It also had the lowest rate of

reimbursement.

Proposed Solutions

Following the information gathering period, the leadership team gathered to discuss

possible solutions based on their findings. The team understood that the healthcare revenue

cycle is a complex function with multiple variables. Much like the causes of the revenue

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problems, there would be no one solution to solve the issues. Solutions would need to be

implemented at the front office, back office as well as patient care environment in order to

maximize the impact on the system.

Back office Solutions

The team began by examining areas for improvement within the back office. The team

felt the easiest way to measure performance with this operational area was to define key

performance indicators and establish industry benchmarks to measure themselves against. The

team turned to MGMA articles to help identify key performance indicators (Gans, 2010).

Along with MGMA resources, the team participated in a webinar led by Elizabeth

Woodcock, discussing back office performance metrics. The team felt that the key performance

indicators for back office performance would be: Days in Accounts Receivable, % Accounts

Receivable greater than 120 days, and Adjusted Collection Rate. Days in Accounts Receivable

would measure how long it typically takes for a service to be paid by all financially responsible

parties, % Accounts Receivable greater than 120 days would help identify collection issues and

how fast the company was able to receive payment. Lastly, Adjusted Collection Rate would

measure the company’s ability to collect on patient balances and monitor for adjustments. The

adjusted collection rate measured how effective the company is at collecting the money that was

left after any contractual adjustments. (Woodcock, 2012)

In addition to identifying key benchmarks to measure operational performance, the team

felt it was important to evaluate the staffing mix and ratio to determine if the department was

adequately staffed to meet the needs of the clinic. Utilizing the MGMA standard of .62 staff per

FTE doc, the department was identified as being on the low end of staffing for high performing

practices. Considering the amount of changes that needed to be made, the practice had to

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consider if staffing at a “higher performing” level was adequate. More importantly, how is staff

allocated? Considering the department was supporting 25 FTE physicians, only having one

patient A/R follow up person did not seem appropriate considering recent trends in patient

deductibles and the amount of medical revenue being attributed to patient balances. With

pressures already mounting regarding overhead expenses, the leadership team knew adding staff

would be a hard sell.

Lastly, the leadership team had to wonder about the proper implementation of the

existing EMR. The EMR had been in place for over seven years and the billing department had

seen significant turnover since the original training took place. In addition, the practice did not

have a dedicated EMR team. EMR administration was the responsibility of the billing manager

in addition to the usual expectations of running the department. The team utilized resources

made available by their state affiliate of MGMA to identify other practices in the city and area

that had the same EMR. With this information, the practice reached out to other practices to

discuss specific workflows and best practices within the EMR.

Front Office Solutions

After a review of work processes, the team identified several opportunities for

improvement at the front desk. To begin, the team wanted to take the same metric based

approach when possible that they had applied to the back office performance. The team

identified co-pay collection as an area that had no current metrics. After working with other area

practices, the team decided that a monthly monitoring of co-pay collections would be beneficial.

Secondly, the team had identified that patient balances were not being discussed at the time of

check in. All collection activity was being placed on the billing department using the statement

remittance method.

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Next, the team felt it was important to evaluate the practice’s policies regarding provider

write offs, credit balances, and low balance write offs. During the information gathering stage,

the leadership team had identified provider write off policies that had morphed into something

different from the documented policy through staff turnover and the provider’s own desires. The

leadership team reached out to the providers in question to make sure they understood the

provider’s intent regarding write offs and what communication methods would best keep the

provider in the know about the amount of balances written off at any given time. Considering

the limited resources available to chase outstanding balances and the cost associated with

pursuing them, the team wanted to examine the low balance threshold as well as how to handle

low balances to ensure the financial standing of a department was most accurately represented.

Lastly, the team discussed the current method of balance follow up. In the period

between 2011 and 2014 InstaMed Network reported a 193% increase in number of consumer

payments to providers. In addition, the average bill had increased 11% to $142. Not only are

patients receiving more healthcare bills, but bills with higher balances (InstaMed, 2015).

Practices are no longer able to rely on collecting from a few insurers. In order to be successful,

they will need to collect form their patients. Following MGMA guidance, the team understood

that the best place to collect patient balances were at the front desk as they attempted to check in

for their next visit. The practice attempted to be understanding of the cost of healthcare and had

implemented payment plans with their patients. The team worked with their credit card vendor

to discuss what was being done in the industry in regards to collecting on these outstanding

balances. Research indicates that when given options that simplify the payment process, patients

are willing participants (InstaMed, 2015). The team felt that implementing a payment plan

schedule based off of the amount of money owed would provide relief for patients as well as

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attempt to get the balance paid to the practice in a timely manner. Also, due to the small amount

of resources available to pursue patient balances, the team wanted to maximize that team

member’s effort. Working with the credit card vendor allowed the practice to establish a method

for auto-drafting patient payments at an agreed upon time instead of attempting to contact the

patient on a monthly basis. Utilizing a third party vendor for the storage of bank and credit card

information ensured the practice minimized risk of credit card fraud while freeing up the patient

accounts receivable position to continue pursuing new balances.

Patient care Solutions

In addition to the changes made in the business office, the team realized that there could

be some opportunity for improvement in the patient care setting. Medications and infusions

represented large expenses for the practice. With that in mind, the team began examining current

purchasing processes and other options that may be available.

Medications

The team analyzed the utilization of vaccines at the various clinic sites and identified the

manufacturers for those vaccines. All of the vaccines utilized in the clinic setting had

representatives in the area that were more than willing to meet with leadership in order to discuss

options for providing access to their medications.

In addition to vaccines, the leadership team examined other high priced infusions and

contacted their manufacturers. Many options were available to the clinic. Possible solutions

included purchasing from a different vendor, through local pharmacies, and sometimes utilizing

the patient’s pharmacy benefit instead of having the practice purchase medications and then bill

the insurance company.

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Lastly, one of the clinics is a designated 340B site due to a specific population that is

served there. All of the medication distributors were willing to extend 340B pricing for all

medications purchased for use at that clinic site. For information regarding 340B eligibility,

please visit www.hrsa.gov.

Fee Schedule

The team realized that there was an inherent responsibility in charging market prices for

the professional services provided by the physicians and other providers at the clinic level. Due

to the significant time that had passed between updating the professional charges that the amount

of increase needed would cause an increased burden on the patients. In addition, team had to

identify what were appropriate fees for the current time period? What was an appropriate

schedule for reviewing the fee schedule moving forward? It was anticipated that the amount of

change to the professional fees would probably result in some patient defection to other

providers in the city.

Making the decision to change

The executive director realized that the problems for the organization weren’t limited to

one department or area. An effective solution would require changes in all areas of the practice

and require significant buy in and support from leadership. A team was assembled that included

the executive director, the chairman of the respective department, the billing manager as well as

the medical directors from the clinics involved.

The executive director went over the identified areas of improvement and some proposed

solutions. When considering solutions, the committee was cognizant of several factors. First

and foremost was maintaining the high quality of patient care. Other factors included the needs

of the patients. What was being given and why? What populations were the clinics trying to

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serve and what were appropriate interventions for those clinics? Focusing on the care delivery

mission was more important than trying to be everything to every patient.

For the non-patient care related items, the committee wanted information on industry

benchmarks and then cost vs reimbursement on the proposed solutions. No one was interested in

making changes that would only continue to create financial losses for the organization. What

would be the impact on cash flow of any of the proposed solutions? Financially, the clinics were

running on negative margins monthly and a significant cash flow disruption would require

additional reserves to be spent. Lastly, the committee wanted to make sure that ongoing

monitoring would be possible to prevent a recurrence of some of the issues that had been

identified.

Implementing change

Once the committee had decided on what steps to take next, they began the difficult

challenge of implementing change across the clinics. The EMR team was brought in to facilitate

the changes within the EMR.

Back office Changes

The team began by working with the back office. A department meeting was called and

the billing manager went over the findings regarding the back office performance. Key

performance indicators such as days in accounts receivable, accounts receivable greater than 120

days, and adjusted collection percentage were discussed. The team’s current performance using

the new metrics was shared and expectations for future performance were identified. The

manager and executive director received buy in from the billing team on an expected time frame

to bring performance up to the new standard. Everyone agreed that three months seemed to be a

fair timeframe considering current staffing levels. The billing manager outlined the process for

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future monitoring and a scoreboard was placed in the billing department for everyone to see the

team’s progress on a monthly basis (Appendix A).

Front office changes

The team understood that the easiest time to collect payment from patients was when the

patient arrived at the clinic for their next appointment. The committee decided that at the very

least, the front desk should be expected to collect the copay required by the insurance. The

medical directors agreed that each clinic would have a goal of 90% for their copay collection

rates. The clinic managers and billing manager worked together to create a copay collection

reporting tool that could be used to monitor monthly performance (Appendix B).

In addition to copays, the committee wanted the front desk staff to also begin collecting

outstanding balances at the time of the appointment. First, the staff was trained on how to

appropriately post payments within the practice management system as this was a new procedure

for them. Secondly, the practice worked with its collections company on developing a script on

how to ask for payments. The front desk staffs at the respective clinics worked with the

collection company representative to go through the script and role play various situations to

develop a comfort level with the conversation as well as prepare them for the challenges that

could be seen at the front desk (KaMMCO 2015).

Next, the committee examined the high priced procedures such as colonoscopies that

were being performed and wanted to implement a change that would help collect payments that

were being assigned to the patients insurance. The practice already had a preauthorization

process in place that would verify a patient’s benefits and could provide an estimation of the

patient responsibility. The practice established a merchant account that would allow them to set

up recurring payment plans without needing to contact the patients again. A schedule was

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created that would pay off most balances within six months, but could potentially take a year

based on the size of the balance. The preauthorization staff was trained on the new procedures

and began setting up payment plans with the patients during the phone call to verify coverage for

the procedure.

The committee wanted to look internally at the policies that were in place and whether or

not they were appropriate. The committee specifically examined policies for write offs, credit

balances, and low balance amounts. The committee discovered that while the write off policies

in place were sound, the physicians had stopped tracking the amounts of write offs and had

allowed the amounts to become higher than expected. A monthly reporting of write offs by

location was created and would be monitored. The billing manager provided the committee with

a report outlining the amount of credit balances that existed in the system. The practice was

moving into its third EMR and had been carrying balances for nearly eight years in some

occasion. In order to provide an accurate representation of any clinic’s financial standing, a

policy was created to refund all the credit balances greater than 365 days old. Finally, the

committee interviewed other MGMA affiliated practices in the area and found that $10 was

identified as an appropriate low balance write off point. This would allow the practices to

maximize the limited human resources to pursue balances without costing the practice more

money than the balance itself.

After addressing financial manners, the committee turned their attention to the decisions

that could potentially impact patient care. The executive director worked directly with the

manufacturers of the providers’ preferred medications to establish direct buy contracts. These

contracts provided substantial savings over the existing vendor for medications the clinic desired

to provide. Management developed a monitoring tool that brought together all the components

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needed to determine profitability of a medication (Appendix C). The executive director worked

with the accounting department to maximize the prompt pay discounts as well as monthly review

medication invoices to monitor for profitability. The clinic mangers worked with the EMR team

to understand how to build historical reports on medication usage. Utilizing historical data, the

clinic managers would examine their existing inventory and determine if there was a need to

order medication based on the estimated usage for the next thirty days. As a condition of the

direct buy agreements, the manufacturers were able to deliver medication within 48 hours which

allowed the clinics to be conservative with their monthly ordering as they had the confidence that

medication would arrive quickly if demand was higher than anticipated. These moves helped

eliminate excess inventory and improve cash flow to the clinics.

To address the outdated pricing for services, the practice began by adding a comment

about the price increase to the patient statements that were going out. The same message was

also available when patients utilized the patient portal. The committee hoped this approach

would mitigate any patient loss due to the increase in prices. The practice completed a

comparison of their top five commercial payers and determined that commercial prices averaged

1.5x Medicare allowable rate per CPT code. Using that information, the practice set their fee

schedule at 2x Medicare in order to catch up the fee schedule and capture the higher commercial

rates that were now available. As an academic practice, many decisions and shared liabilities

were set based off of the annual budget. This led the committee to believe than an annual review

of the fee schedule would be sufficient. To do it more often would have significant unintended

consequences across the overall organization.

Lastly, the EMR team was brought in to update the EMR to accurately represent the

presentation of the medications that were being provided. Working with the clinic managers and

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staff, the EMR team provided education at all the locations regarding how correctly document

the administration of medications and which selection represented the appropriate presentation.

The clinic managers were then able to generate reports out of the EMR to identify usage for a

given month. That information was rolled into the ordering process and provided a monthly

check that the staff were correctly documenting the medication they were giving.

Conclusion

By confronting the facts and examining all aspects of the medical practice operation, the

academic practice was able to improve all of the key performance indicators for the back office

billing staff, improve on front desk collections and provide medications in a cost effective

manner. All of those steps helped improve payments for all existing services lines for the

practice from fiscal year 2014 to fiscal year 2015.

The organization learned many lessons about how to optimize their medical revenue.

Optimization and really any improvement call for an examination of all aspects of the medical

practice from the front office, to the patient encounter to the back office. Some takeaways for

the leadership team were:

Payments FY 14 FY 15 Change Comments

Hosp VC 602,835.39$ 666,999.66$ 64,164.27$

Hosp WMC 474,020.93$ 509,848.55$ 35,827.62$

Adult Med 298,840.62$ 275,982.83$ (22,857.79)$

Down one

provider for

9 months

Endo 962,495.42$ 1,272,787.50$ 310,292.08$

Gastro 1,034,295.74$ 1,218,755.74$ 184,460.00$

Sweet 500,168.35$ 564,022.78$ 63,854.43$

N Topeka 701,054.38$ 717,128.07$ 16,073.69$

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You have to measure and monitor what is important and that cost control is an ongoing

process.

Staff is able to perform at a high rate when given defined goals to meet.

It’s important to utilize all of your resources to collect outstanding balances.

Everyone from the front desk, to the practitioners to the back office needs to understand

their role in the revenue cycle and be pulling in the same direction.

Additional training is necessary when asking staff to take on new responsibilities or take

on tasks outside of their comfort zone.

Technology, such as merchant account, can be a great way to maximize the work

capacity of limited human resources.

Over time, policies can become outdated, forgotten or misinterpreted without monitoring

and periodic re-evaluation.

It’s important to monitor cost as well as charges and reimbursements in order to

determine the profitability of providing clinical services.

By utilizing the lessons learned from this practice and the tools developed, medical practice

executives will be able to examine their own practices for areas of improvement.

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Appendix A

Days in A/R Scorecared

A/R >120 days Scorecard

Days in A/R

Best Practice: less than 35 2014Formula: Receivables/(Gross Charges/30 day month)

Month Receivables Mth Gross Charges 30 Days A/R Yr Gross Charges 365 Days A/R Average

January $1,661,392.06 $1,838,598.50 25.30 $15,534,316.62 39.04 32.16

February $1,851,473.85 $1,636,511.98 31.68 $16,070,172.72 42.05 36.86

March $1,933,005.66 $1,623,890.73 36.90 $16,418,785.38 42.97 39.93

April $1,689,736.09 $1,444,997.78 35.08 $16,660,437.24 37.02 36.04

May $1,693,164.55 $1,559,212.47 33.66 $16,865,676.21 36.64 35.15

June $1,601,765.32 $1,372,470.77 35.01 $16,976,254.16 34.44 34.72

July $1,549,671.51 $1,339,903.28 35.85 $17,176,683.58 32.93 34.39

August $1,146,899.67 $1,327,106.28 25.93 $14,761,132.72 28.36 27.14

September $1,127,706.55 $1,058,688.64 33.02 $14,765,116.48 27.88 30.44

October $1,457,055.66 $1,753,689.30 25.76 $15,086,310.65 35.25 30.50

November $1,275,197.27 $1,163,586.72 32.88 $15,136,411.47 30.75 31.81

December $1,017,302.51 $1,057,852.13 29.81 $15,008,067.36 24.74 27.27

Best Practice: less than 12% Best Practice: less than 15%

Formula: 120+AR/Total AR Formula: (collections+120 AR)/Total AR

120+ A/R Total A/R % >120 days Collection balance120+ A/R Total A/R % >120 days

January $1,661,392.06 0.00% January $0.00 #DIV/0!

February $1,851,473.85 0.00% February $0.00 #DIV/0!

March $1,933,005.66 0.00% March $0.00 #DIV/0!

April $152,456.40 $1,689,736.09 9.02% April $101,243.27 $152,456.40 $1,790,979.36 14.16%

May $147,116.68 $1,693,164.55 8.69% May $143,123.51 $147,116.68 $1,836,288.06 13.81%

June $110,838.40 $1,601,765.32 6.92% June $44,966.78 $110,838.40 $1,646,732.10 9.46%

July $136,738.88 $1,549,671.51 8.82% July $60,019.80 $136,738.88 $1,609,691.31 12.22%

August $1,146,899.67 0.00% August $0.00 #DIV/0!

September $1,127,706.55 0.00% September $0.00 #DIV/0!

October $1,457,055.66 0.00% October $0.00 #DIV/0!

November $1,275,197.27 0.00% November $0.00 #DIV/0!

December $1,017,302.51 0.00% December $0.00 #DIV/0!

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Adjusted Collection Rate Scorecard

Adjusted Collection Rate

Best Practice: >99%

Formula: (Payments-Refunds)/(Charges-Adjustments)

Practice Payments Refunds Total Charges Total adjustments Adjusted Collection Rate

1Q 2014 $1,780,093.77 $3,534.24 $5,099,001.21 $2,406,738.53 65.98%

2Q 2014 $1,601,765.32 $3,977.72 $4,376,856.02 $2,510,283.07 85.60%

3Q 2014 #DIV/0!

4Q 2014 #DIV/0!

1Q 2015 #DIV/0!

2Q 2015 #DIV/0!

3Q 2015 #DIV/0!

4Q 2015 #DIV/0!

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Appendix B

Co-pay Monitoring Report

Clinic Month Co-Pay Due Co-Pay

Collected Un -Collected

Copay % Collected

CHC January-14 $10,962.00 $9,544.00 $1,418.00 87.1%

February-14 $12,772.00 $10,491.91 $2,280.09 82.1%

March-14 $13,606.00 $11,724.00 $1,882.00 86.2%

April-14 $13,613.00 $11,618.51 $1,994.49 85.3%

May-14 $14,081.00 $12,791.30 $1,289.70 90.8%

June-14 $13,154.00 $11,515.79 $1,638.21 87.5%

July-14 $11,437.00 $10,680.00 $757.00 93.4%

August-14 $13,293.00 $12,798.47 $494.53 96.3%

September-

14 $10,739.00 $9,535.70 $1,203.30 88.8%

October-14

November-14

December-14

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Appendix C

Medication Analysis

Svc Procedure Code Svc Procedure Desc Cost Revised cost Svc Fees Svc Payments

90714 Td Vaccine No Prsrv >/= 7 Im 24.07 24.79 $63.00 $26.51

90715 Adacel 51.94 29.85 $132.00 $48.82

90715 Boostrix 41.1 33.01 $81.00 $48.82

90716 Chicken Pox Vaccine, Sc 110.17 94.93 $275.00 $124.10

90732 Pneumovax 76.87 68.81 $192.00 $76.29

90734 Menactra 108.25 108.25 $275.00 $135.37

90736 Zoster Vacc, Sc 214.97 184.13 $255.00 $192.63

90744 Hepb Vacc Ped/adol 3 Dose Im $31.00 $28.04

90746 Hep B Vaccine, Adult, Im 67.79 40.4 $179.00 $83.47

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Works Cited

Collins, Jim. Good to Great. New York: HarperCollins, 2001. Print.

Gans, David. “What Matters and What Doesn’t”. MGMA Connexion September 2010. 19-20.

Print

Strategies to Improve Cash Flow and Reduce Patient A/R. Kansas Medical Mutual Insurance

Company. August 2015. Webinar

Trends in Healthcare Payments Fifth Annual Report: 2014. InstaMed May 2015. Print

Woodcock, Elizabeth.”Key Metrics in Revenue Cycle Management”. Navicure. 2013. Webinar