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In this Business Profile, 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.

Roger L. Shaul PMMCTell me a little bit about your organization.

PMMC is a revenue cycle management firm that is all about improving its client's financial performance.

Our services range from strategic pricing to patient estimates to contract management. As the industry has embraced pricing transparency and value-based reimbursement continues to move to the forefront, these three service areas are emerging as an integrated expectation of our clients.

I am very proud of our team's ability responding to these new challenges and leveraging our reimbursement calculation engine in these critical revenue cycle areas. As an example during Q1 and Q2 of 2014, we saved our clients between $8 and $22 for every dollar they spent on our services. Two of our products-Contract PRO for contract management and Estimator PRO for patient estimates-have been HFMA peer- reviewed, and more than 90 percent of our customers rate us 4.5 or higher out of 5 in total satisfaction. Modern Healthcare magazine recently ranked us No. 7 nationally among revenue cycle firms by total number of contracts, which we believe is an indication our clients not only see the value in our service and products but directly leads to our consistent growth.

What are some of the biggest challenges you see affecting healthcare organizations?

While there are many, two of the biggest are accountable care and population health management. Both are driving a new wave of reimbursement methodologies.

With the U.S. Department of Health and Human Services starting to tie Medicare payments more directly to outcomes next year-via bundled payment arrangements-it is no longer an option to stick with fee-for- service. With CMS indicating a goal of moving 50% of their reimbursement to some type of risk associated model by 2018, institutions are going to have to change.

Additionally, there is a shift toward consumerism. Electronic medical records, solutions that provide patient cost estimates, and mobile technology are becoming extraordinarily valuable tools for improving the patient experience. Although they're extremely disruptive in terms of changing the system, they're all very positive for the long term. In fact, people will soon be able to check into the doctor's office much like they schedule a flight and check in with an airline.

Underneath all this change, many hospitals still have a great deal of trouble reconciling what they're supposed to be paid versus what they receive from the payer or the patient. Managed care and growing patient responsibility have made reimbursement quite complicated and, in many cases, hospitals haven't invested in systems and personnel to address denials and collections.

The challenges and pressure will only continue to grow as value-based purchasing takes hold.

How do your product and service offerings respond to these needs?

PMMC is focusing on assisting hospitals in better managing the transition to value-based reimbursement.

First, we help organizations track billings and payments associated with all reimbursement scenarios, including the most complicated bundle type: transplants. This module is being leveraged to assist hospitals not only audit for reimbursement accuracy, but also model or simulate various reimbursement scenarios to understand the financial implication upfront. Having mastered transplant bundle calculations, we anticipate minor incremental adjustments to our calculation engine to address the bundling requirements prescribed by the Centers for Medicare & Medicaid Services.

Reconciling reimbursement is a foundational revenue cycle principle. To ensure all contractual reimbursement is collected, PMMC provides an underpayment recovery program to recoup what may have been left on the table after the provider reconciles receivables and zero balances accounts. This ensures our clients optimize their revenue cycle either through the use of our applications or our recovery service.

Second, we provide analytics for bundling and population health management. Benchmark data is critical. To be successful with the new reimbursement direction, organizations need to understand the changes that will have to occur. For example, an organization can use our technology to benchmark a care episode by bundle, episode length, or patient claims in a given disease category. Each bundle can be analyzed by Metropolitan Statistical Area (MSA) or by state for baseline comparisons. We also provide benchmark analysis using the Medicare Spending Per Beneficiary (MSPB) file data associated with a particular hospital or system's admissions to enable them to identify necessary changes and provide direction on non-system providers they should collaborate with. In terms of population health, organizations can analyze data by age, sex, and disease category so they understand common claims for particular population groups.

Third, we provide consulting and software to assist organizations in balancing net revenue and pricing (charge) adjustments. This is quite useful, especially during the industry's transition to more price transparency.

Fourth, we provide the next generation of patient estimates. Most hospitals have implemented upfront cost estimation and point-of-service collection programs, which have been very successful in laying a foundation for educating patients and collecting the co-payment. Our patient estimation software (Estimator PRO) takes this process to the next level by using statistical models, the actual contractual reimbursement information, and payer eligibility data to generate a more accurate patient financial obligation that includes the co-insurance and deductible. Upfront accuracy is an activity that is becoming essential as patients assume more financial responsibility for their care. Leveraging the actual contract data to produce the patient estimate is the best way to make the estimate as precise as possible.

Finally, PMMC is developing services for procedure scheduling and check-in, so the experience is more convenient for the patient, similar to scheduling a flight online and mobile check-in.

What are some key considerations for healthcare leaders when choosing this type of product or service?

Look at the reputation and specialty of the organization that is providing the service and its collective experience with entities that are similar to you. If you manage an integrated delivery network, the prospective vendor should be able to produce references from other integrated delivery networks. The same would apply for an individual hospital.

As healthcare organizations implement use of your product or service into their day-to-day operations, what advice would you give so they can best set themselves up for success?

How a project is managed during the implementation is critical. It sets the pace and tone for long-term use. On the client side, it's important to appoint an internal project manager who will interact with the supplier's team. Typically, installation involves several different departments with busy people who already have a lot of other priorities. Having an internal project manager is at least as important as the vendor supplying a project manager from their side. These resources make sure projects come in on time, on schedule, and on budget.

Also, I would suggest seeking a partnership with a healthcare focused revenue cycle management supplier instead of merely a vendor relationship. Taking a more collaborative approach ensures you get the most out of the partnership.

Are there any educational materials you would like to share to help healthcare providers in these efforts?

PMMC has a blog with best practices and insights on a range of revenue cycle topics and case studies on our website. I also recommend healthcare providers to contact us to better understand and interpret financial data associated with reimbursement, bundling and population health to help develop strategies to operate successfully in this new era. Regardless of whether an organization chooses to do business with us, we can provide significant insight with how this new direction will financially impact their organization. As a starting point, we can preview reimbursement data for 47 different bundle scenarios by any healthcare provider's specific region. Please visit us online or call 704-944-3081 to request this free assessment.

*HFMA staff and volunteers determined PMMC Estimator PRO and PMMC Contract PRO have met specific criteria developed under the HFMA Peer Review Process. HFMA does not endorse or guarantee the use of these products.


HFMA is the nation’s leading membership organization for more than 40,000 healthcare financial management professionals. Business Profiles are funded through advertising with leading solution providers. Learn more.

PMMC LogoContent for this Business Profile is supplied by PMMC. This published piece is provided for advertisement purposes. HFMA does not endorse the published material or warrant or guarantee its accuracy. The statements and opinions of those profiled are those of the individual and not those of HFMA. References to commercial manufacturers, vendors, products, or services that appear do not constitute endorsement by HFMA.

Publication Date: Thursday, October 01, 2015