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One often overlooked but potentially critical step in the preparation for the October 2014 transition from ICD-9 to ICD-10 is updating agreements between providers and payers. Although the change is ultimately expected to be valuable due to the increased specificity and granularity of diagnosis coding, the potential for unintended financial consequences should not be understated. Most providers are well under way with their operational transition plans, but many have not considered amending their payer agreements to mitigate the potential impact of problems that arise.
Specific risks to address include:
To mitigate these risks, we suggest that providers consider the following points when negotiating amendments to their payer agreements.
Revenue neutrality. How will providers confirm revenue neutrality? We suggest an approach that consists of both prospective and retroactive validation, comparing representative claim samples using both ICD-9 and ICD-10 diagnosis coding. If a sample indicates a financial variance, the applicable inpatient and outpatient prospective payment base rates, per diems, and other diagnosis-dependent payment methodologies should be adjusted before the ICD-10 transition occurs.
A retrospective review should be conducted to confirm that revenue neutrality occurred. If revenue changed due to coding methodologies alone, a methodology will be needed to make each party whole.
Testing. What is the schedule for testing? Which criteria will be used to determine its success? Although testing should already be in progress, we suggest that providers determine the key milestones and factors that will be used to indicate that they are ready to “go live” or that the contingency plan will need to be initiated.
Operations. What type of protection is needed against problems with claim submission? How will the payer compensate the providers for delays in claim payments? Will the payer assist the provider with improving coding? One consideration for protection against claim submission is the allowance for an extension of timely filing deadlines during the transition period. If the payer is unable to adjudicate claims timely, there should be provisions for interim payments and subsequent reconciliation.
Rather than automatically denying claims that are coded incorrectly, providers should require a transitional period during which they can work with insurers to improve coding skills and capabilities. This period should include a long-term process for monitoring performance and improving the quality of coding.
Contingency planning. How should providers and payers plan for the possibility that claim payment operations could fail due to the change in coding? Coding issues, like other transition considerations, should be addressed in advance rather than waiting for a potential crisis. Providers should consider requiring interim payments subject to retroactive reconciliation if operations appear to be affected or revenue neutrality is in jeopardy.
Because provider reimbursement methodologies are highly dependent upon proper diagnosis coding, there is a very real possibility that the change from ICD-9 to ICD-10 could adversely affect revenue cycles. Certainly, providers hope to avoid this negative prospect through careful advance transition planning, including efforts to ensure that potential impacts can be mitigated. With only 10 months to go before the ICD-10 implementation date, it is critical that providers review their payer contracts and address possible transition-related issues with the payers.
Charles Brown is a senior manager, ECG Management Consultants, Inc., Arlington, Va., and a member of HFMA’s Colorado Chapter.
Publication Date: Thursday, January 09, 2014
TriMedx helps health systems control costs and uncover savings opportunities by optimizing the clinical engineering function.
Patient financial engagement is more challenging than ever – and more critical. With patient responsibility as a percentage of revenue on the rise, providers have seen their billing-related costs and accounts receivable levels increase. If increasing collection yield and reducing costs are a priority for your organization, the metrics outlined in this presentation will provide the framework you need to understand what’s working and what’s not, in order to guide your overall patient financial engagement initiatives and optimize results.
A leader from McKesson discusses how healthcare reform is forcing hospitals and health systems to take a different approach to capacity management and patient flow.
No two patients are the same. Each has a very personal healthcare experience, and each has distinct financial needs and preferences that have an impact on how, when and if they chose to pay their healthcare bill. It’s no longer effective to apply static billing techniques to solve the complex challenge of collecting balances from patients. The need to tailor financial conversations and payment options to individual needs and preferences is critical. This presentation provides 10 recommendations that will not only help you improve payment performance through a more tailored approach, but take control of rising collection costs.
Emad Rizk, MD, president and CEO of Accretive Health, discusses the uncertainty facing hospitals and the transitions affecting revenue cycle management.
This white paper, written by Apex Vice President of Solutions and Services, Carrie Romandine, discusses the importance of patient segmentation and messaging specifically related to the patient revenue cycle. Applying strategic messaging that is tailored to each patient type will not only better educate consumers on payment options specific to their billing needs, but it will maximize the amount collected before sending to collections. Further, targeted messaging should be applied across all points of patient interaction (i.e. point of service, customer service, patient statements) and analyzed regularly for maximized results.
Jim Bohnsack, vice president, solution & corporate development for Conifer Health Solutions, explains how the company helps healthcare providers leverage data to deliver better outcomes while optimizing reimbursement for all payment arrangements.
This white paper, written by Apex President Patrick Maurer, discusses methods to increase patient adoption of online payments. Providers are now seeking ways to incrementally collect more payments due from patients as well as speeding up the rate of collections. This white paper shows why patient-centric approaches to online payment portals are important complements to traditional provider-centric approaches.
Steve Scibetta, senior director of channel sales for Ontario Systems' healthcare product line, shares insights into effectively managing receivables.
Increased electronic engagement between healthcare providers and patients provides significant opportunities for improving revenue cycle metrics and encouraging patients to access EHRs. This article, written by Apex Founder and CEO Brian Kueppers, explores a number of strategies to create synergy between patient billing, online payment portals and electronic health record (EHR) software to realize a high ROI in speed to payment, patient satisfaction and portal adoption for meaningful use.
Elena White, vice president of risk, quality, and network solutions for Optum, discusses how healthcare providers can leverage data and technology as they enable risk in their organization.
Faced with a rising tide of bad debt, a large Southeastern healthcare system was seeing a sharp decline in net patient revenues. The need to improve collections was dire. By integrating critical tools and processes, the health system was able to increase online payments and improve its financial position. Taking a holistic approach increased overall collection yield by 10% while costs came down because the number of statements sent to patients fell by 10%, which equated to a $1.3M annualized improvement in patient cash over a six-month period. This case study explains how.
Somnia President and CEO Marc Koch, MD, MBA, explains how hospitals can drive transformative change in the perioperative experience for outstanding clinical and financial outcomes.
With the ICD10 deadline quickly approaching and daily responsibilities not slowing down, final preparations for October 1 require strategic prioritization and laser focus.
PMMC President Roger L. Shaul discusses the effects of healthcare reform on revenue cycle management and how PMMC's products help clients adapt to a changing financial environment.
Read how Gwinnett Medical Center provides clear connections to financial information, offers multiple payment options for patients, and gives onsite staff the ability to collect payments at multiple points throughout the care process.
Greg Burgess, Founder and Chief Product Officer at Burgess Group shares insights and opportunities for payment integrity in the rapidly changing healthcare IT landscape.
Read how Orlando Health was able to perform deeper dives into claims data to help the health system see claim rejections more quickly–even on the front end–and reduce A/R days.
To maintain fiscal fitness and boost patient satisfaction and loyalty, healthcare providers need visibility into when and how much they will be paid–by whom–and the ability to better navigate obstacles to payment. They need payment clarity. This whitepaper illuminates this concept that is winning fans at forward-thinking hospitals.
Financial services staff are always looking for ways to improve the verification, billing and collections processes, and Munson Healthcare is no different. Read about how they streamlined the billing process to produce cleaner bills on the front end and helped financial services staff collect more than $1 million in additional upfront annual revenue in one year.
Effective revenue cycle management can be a challenge for any hospital, but for smaller providers it is even tougher. Read how Wallace Thomson identified unreimbursed procedures, streamlined claims management, and improved its ability to determine charity eligibility.
Before launching an energy-efficiency initiative, it’s important to build a solid business case and understand the funding options and potential incentives that are available. Healthcare leaders should consider taking the steps outlined in the whitepaper to ease the process of gaining approval, piloting, implementing, and supporting sustainability projects. You will find that investing in sustainability and energy efficiency helps hospitals add cash to their bottom line. Discover how hospitals and health systems have various options for funding energy-efficient and renewable-energy initiatives, depending on their current financial structure and strategy.
Health care is a dynamic mergers and acquisitions market with numerous hospitals and health systems contemplating or pursuing formal arrangements with other entities. These relationships often pose a strategic benefit, such as enhancing competencies across the continuum, facilitating economies of scale, or giving the participants a competitive advantage in a crowded market. Underpinning any profitable acquisition is a robust capital planning strategy that ensures an organization reserves sufficient funds and efficiently onboards partners that advance the enterprise mission and values.
The success of healthcare mergers, acquisitions, and other affiliations is predicated in part on available capital, and the need for and sources of funding are considerations present throughout the partnering process, from choosing a partner to evaluating an arrangement’s capital needs to selecting an integration model to finding the right money source to finance the deal. This whitepaper offers several strategies that health system leaders have used to assess and manage capital needs for their growing networks.
Copyright 2016, Healthcare Financial Management Association.
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