Get the E-newsletter
Participation in accountable care has significant implications not only for care delivery systems but for the revenue cycle. Both providers and health plans can take steps to ensure that the transition to population health management is financially tenable for hospitals and health systems.
Efficient and accurate revenue cycle processes are even more important under accountable care, says Blake Allison (pictured at right), COO of the Baylor Scott & White Quality Alliance, the accountable care organization (ACO) for Dallas-based Baylor Scott
& White Health.
The Baylor Scott & White Quality Alliance (BSWQA) serves 450,000 lives, mainly in commercial contracts. The ACO is comprised of more than 5,700 primary care and specialist physicians and 49 hospitals, and more than 95 post-acute care facilities and other healthcare stakeholders throughout
north and central Texas.
BSWQA operates mainly under shared savings contracts; if the ACO achieves certain performance and outcomes targets, it shares in the resulting cost savings.
Given all the aspects of care that reflect performance, which affects revenue under shared savings, tracking services provided using claims data is critical. Claims therefore must reflect all services performed, Allison says.
“What we’re finding now is—because so much of our data is claims-based, and so many of our metrics are based on claims—the accuracy and completeness of the claim that we send to the payer is even more critical in our new environment of accountable care,” says Allison, who presented on the
topic of accountable care at HFMA’s 2017 Revenue Cycle Conference in October.
“If we don’t appropriately account for a test that we did, and send the claim off, it can have ramifications for our performance.”
For example, targets in some of BSWQA’s contracts require more than 80 percent of diabetes patients to have completed an A1C test. At one point, the ACO discovered that several large physician groups were not documenting the test on claims sent to payers. Consequently, BSWQA was at risk of losing
more than $1 million in shared savings revenue if the target was inadvertently missed because the performance did not reflect the required testing.
The example demonstrates the need for providers to build effective communication channels with revenue cycle partners, including physician offices that send claims to payers. BSWQA has teams composed of analytics and network experts, along with practicing physicians and other clinical
leaders, who work with revenue cycle staff at physician groups to identify issues that may result in inaccurate claims and to then develop solutions.
Solving the A1C test issue involved educating physicians on the importance of documenting all services performed on the patient and then ensuring that the claim reflects those same services. In this way, key performance elements are accurately captured, Allison says.
Another consequential impact of accountable care is the restructuring of the traditional health plan-provider relationship into more of a partnership.
To help smooth the transition to accountable care, plans and providers should develop a set of guiding principles that include aligned objectives, says Brigitte Nettesheim (pictured
at right), vice president of joint venture markets in the Clinical Services & Joint Venture Markets division for Aetna. For example, Nettesheim says the sides should agree to focus on how to improve the health of the community first, before deciding on the terms of the contract. “What’s right for the
consumer? And then we figure out the financial model after that,” she says.
Aetna has value-based contracts with more than 500 ACO arrangements across its commercial and Medicare lines of business, including with large health systems such as Mt. Sinai Health System in New York City, Memorial Hermann Health System in Texas, Centura
Health in Colorado, Vanderbilt Health Network in Tennessee, and Wakemed Health & Hospitals in North Carolina.
Because ACOs represent a newer approach, there will be natural business conflicts between provider and health plan. Having a documented set of guidelines will help to navigate disagreements, Nettesheim says. “It’s important to be able to refer back to those guiding principles and
make decisions based on those,” she says.
Allison says the key to forming a strong business relationship is transparency, especially in the context of how to meet the goals that are stipulated in the contract. For example, health plans and providers have to agree on which financial and quality metrics to use for the ACO.
“Payers want to measure everything that’s important to a payer, and understandably so,” Allison says.
However, because physician performance drives the performance of the ACO, metrics should reflect what physicians can actually deliver based on their capabilities and workflow, for example. “We spend a lot of time working on aligning the metrics all the way through from the contracts to the doctors,”
Allison says. Utilization metrics such as emergency department visits per 1,000 lives as well as key clinical outcome metrics (e.g., blood pressure in control, breast cancer screening, etc.) that may require clinical reporting from the ACO, need to be integrated into the
overall performance discussions that take place between the health plan and the ACO.
Providers also need claims data to determine patient utilization outside of the ACO network. It is important, for example, to evaluate high costs of care that are associated with patients who are high users of care and often find themselves making an unnecessary trip to the emergency room. However,
payers are often reluctant to provide this type of data.
For BSWQA, that expectation is non-negotiable. “That’s an easy conversation for us,” Allison says. “There’s not going to be a relationship with the Quality Alliance if you do not give us every ounce of claims data that ever happened on one of our patients.”
Any expectations regarding data must be explicit from the beginning of the relationship, Allison says.
Nettesheim says Aetna views part of its role as helping providers establish the infrastructure that is necessary to participate in population health management. That effort includes helping the provider obtain the data access and robust reporting capabilities that are required to track and
monitor performance and communicate that information to the payer, whether a commercial insurer or employer.
“Our goal is to help with that transition,” Nettesheim says.
Because providers are at different stages in their abilities to manage populations and accept financial risk, Nettesheim says health plans should be willing to implement contracts based on the provider’s readiness for value-based models. For example, Nettesheim says an initial contract may
involve gainsharing only; that may transition into a contract with some financial risk, which gradually increases as the provider gains expertise in managing populations.
This approach allows time for providers to make the necessary investments in the leadership and other infrastructure that is necessary for population health management. It also gives the provider and health plan time to learn how to work together, she says.
“This is a staged approach so that everyone is in lockstep and the providers will be successful, both financially and from an outcomes perspective,” Nettesheim says.
A fundamental part of a successful transition to population health management is planning. Allison says a good time frame is 18 months. “If you think you’re going to do value-based care in 2019, then in my view you’re already behind if you’re not in active dialogue with your payers,” he says. “You’ve
got to commit to a time frame that is reasonable.”
Karen Wagner is a freelance healthcare writer based in Forest Lake, Ill.
Interviewed for this article:
Blake Allison, COO, Baylor Scott & White Quality Alliance, Dallas;
Brigitte Nettesheim, president, joint venture market operations, Clinical Services & Joint Venture Markets, Aetna, Hartford, Conn.
This article is based in part on a presentation at
HFMA’s 2017 Revenue Cycle Conference.
HealthTrust: Solving Workforce Management Challenges
Two of HealthTrust’s senior leaders talk about strategies for optimizing the hospital workforce to improve productivity and reduce waste.
Grant Thornton: Optimizing the Ambulatory Workforce
One of Grant Thornton’s senior healthcare consultants addresses the topic of workforce management and the importance of a data-driven approach.
Cedar: Reimagining the Patient Financial Experience
Cedar’s CEO and co-founder tackles the topic of patient payment and the importance of having an innovative patient financial management system.
TRIMEDX: Moving Healthcare Providers Toward Mature Clinical Asset Management
This article includes a discussion by TRIMEDX leaders about the best ways to mature a clinical asset management program.
6 Patient Revenue Cycle Metrics You Should Be Tracking (and How to Improve Your Results)
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.
10 Ways to Reduce Patient Statement Volume (and Reduce Costs)
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.
Reduce Patient Balances Sent to Collection Agencies: Approaching New Problems with New Approaches
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.
The Future of Online Patient Billing Portals
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.
Payment Portals Can Improve Self-Pay Collections and Support Meaningful Use
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.
Large Health System Drives 10% UP (Patient Payments) and 10% DOWN (Billing-related Costs)
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.
ICD-10: Managing Performance
With the ICD10 deadline quickly approaching and daily responsibilities not slowing down, final preparations for October 1 require strategic prioritization and laser focus.
Clarity Drives Collections
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.
Orlando Health Gains Insight into Denials, Reduces A/R Days with RelayAnalytics Acuity
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.
Revenue Cycle Payment Clarity
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.
Streamlining the Patient Billing Process
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.
Wallace Thomson Hospital Automates to Maximize Limited Resources
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.
7 Steps for Building and Funding Sustainability Projects
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.
Key Capital Considerations for Mergers and Acquisitions
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.
Key Capital Considerations for Mergers and Acquisitions
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.
Trend Watch: Providers adapt as value-based care moves from hype to reality
Announcements from several commercial payers and the Centers for Medicare and Medicaid Services (CMS) early in 2015 around increased efforts to form value-based contracts with providers seemed to point to an impending rise in risk-based contracting. Rather than wait for disruption from the outside in, health care providers are now making inroads on collaborating with payers on various risk-based contracting models to increase the value of health care from within.
Yuma Regional Medical Center case study
Yuma Regional Medical Center (YRMC) is a not-for-profit hospital serving a population of roughly 200,000 in Yuma and the surrounding communities.
Before becoming a ZirMed client, Yuma was attempting to manually monitor hundreds of thousands of charges which led to significant charge capture leakage. Learn how Yuma & ZirMed worked together to address underlying collections issues at the front end, thus increasing Yuma’s overall bottom line.
Reforming with a New 50-Bed Acute Care Facility
Kindred Hospital Rehabilitation Services works with partners to audit the market and the facility’s role in that market to identify opportunities for improvement. This approach leads to successes; Kindred’s clinical rehab and management expertise complements our partners’ strengths. Every facility and challenge is unique, and requires a full objective analysis.
5-Minute Briefing on Revenue Integrity Through HIM WhitePaper Hospitals FS
As the critical link between patient care and reimbursement, health information enables more complete and accurate revenue capture. This 5-Minute White Paper Briefing shares how to achieve cost-effective revenue integrity by your optimizing HIM systems.
5-Minute Briefing on Accelerating Cash Flow Through HIM WhitePaper Hospitals FS
Speedier cash flow starts with better CDI and coding. This 5-Minute White Paper Briefing explains how providers can improve vital measures of technical and business performance to accelerate cash flow.
5-Minute Briefing on Reducing the Cost of RCM WhitePaper Hospitals FS
Qualified coders are getting harder to come by, and even the most seasoned professional can struggle with the complexity of ICD-10. This 5-Minute White Paper Briefing explains how partnerships can help improve coding and other key RCM operations potentially at a cost savings.
Providers Focus Too Much On Revenue Cycle Management
The point of managing your revenue cycle isn’t just to improve revenue and cash flow. It’s to do those things effectively by consistently following best practices— while spending as little time, money, and energy on them as possible.
Lucille Packard Children’s Hospital Stanford Case Study
How Lucile Packard Children’s Hospital Stanford increased payments received within 45 days by 20% and reduced paper submission claims by 70% by using ZirMed solutions.
Using Predictive Modeling To Detect Meaningful Correlations Across Claims Denials Data
The reasons claims are denied are so varied that managing denials can feel like chasing a thousand different tails. This situation is not surprising given that a hypothetical denial rate of just 5 percent translates to tens of thousands of denied claims per year for large hospitals—where real‐world denial rates often range from 12 to 22 percent. Read about how predictive modeling can detect meaningful correlations across claims denials data.
ZOLL and Emergency Mobile Health Care Case Study
Emergency Mobile Health Care (EMHC) was founded to be and remains an exclusively locally owned and operated emergency medical service organization; today EMHC serves a population of more than a million people in and around Memphis, answering 75,000 calls each year.
Maximizing Medicare Reimbursements White Paper
Since the Physician Quality Reporting Initiative (PQRI) introduction, CMS has paid more than $100 million in bonus payments to participants. However, these bonuses ended in 2015; providers who successfully meet the reporting requirements in 2016 will avoid the 2% negative payment adjustment in 2018, so now is the time to act! Included in this whitepaper are implications of increasing patient responsibility, collections best practices, and collections and internal control solutions.
Denials Deconstructed: Getting Your Claims Paid
Getting paid what your physician deserves—that’s the goal of every biller. Yet even for the best billers, achieving that success can be elusive when denials stand in the way of success, presenting challenges at every turn. Denials aren’t going away, but you can learn techniques to manage and even prevent them.Join practice management expert Elizabeth W. Woodcock, MBA, FACMPE, CPC, to: Discover methods to translate denial data into business intelligence to improve your bottom line, determine staff productivity benchmarks for billers, and recognize common mistakes in denial management.
Automation and Operational Improvement Drive Sustainable Results
Physician practices must improve organizational efficiency to compete in this era of reduced reimbursement and escalating administrative costs.
Revenue Cycle Management Resolves Migration Implementation Issues
Many healthcare organizations are pursuing next-generation health information systems solutions. Learn more about Navigant's work with University of Michigan Health System.
Partnering For Success – Provider Achieves Strength in Stability
The proper implementation of healthcare information technology systems is crucial to an organization’s financial health.
Building a Clinically-Integrated Network
As value-based payment models evolve, providers are challenged to maintain superior clinical outcomes while controlling costs.
Winning in the Post-Acute Marketplace
Read more about factors contributing to the changes in the post-acute marketplace and what it means for manufacturers, physicians, clinicians, patients, and post-acute facilities as they anticipate the transition to the second curve.
Building A Common Vision with Employed Physicians
HSG helped the physicians and executives of St. Claire Regional in Morehead, Kentucky, define their shared vision for how the group would evolve over the next decade. As well as, develop the strategic and operational priorities which refocused and accelerated the group’s evolution.
Practice Performance Improvement
The client was a nine-hospital health system with 14 clinics serving communities in a multi-state market with very limited access to care, poor economic conditions, high unemployment, and a heavy Medicare/Medicaid/uninsured payer mix. In most of these communities, the system was the sole source of care.
Though the clinics were of substantial size (they employed 98 physicians) and comprised of multiple specialists, the physicians functioned as individuals and the practices lacked any real group culture.
Clinical Integration Without Spending a Fortune
Clinical integration can be expensive, but it doesn’t have to be, as this four-step road map for developing a CIN proves. Does it have to cost millions to initiate a clinical integration strategy?
Contrary to popular belief, we have clients who have generated substantial shared savings and a significant ROI over time, without massive investments. Yes, some financial capital is required for resources the CIN providers can’t bring to the table themselves. But the size of that investment can be miniscule relative to the value it produces: improved outcomes and documentation for payers.
Adding Value to Physician Compensation
Today’s concerns about physician compensation are the result of the changing healthcare environment. The transition to value is slow, but finally becoming a reality. Proactive hospitals want to ensure that provider incentives are properly aligned with ever-increasing value-based demands.
This report focuses on the three big questions HSG receives about adding value to physician compensation; Why are organizations redesigning their provider compensation plans? What elements and parameters must be part of successful compensation plans? How are organizations implementing compensation changes?
Effective Revenue Cycle Management in Your Network
Revenue Cycle Management has become an even more complex issue with declining reimbursements, implementation of Electronic Health Records, evolving local carrier determinations (LCD), and payer credentialing [The emphasis on healthcare fraud, abuse and compliance has increased the importance of accuracy of data reporting and claims filing).
The efficiency of a medical practice’s billing operations has critical impact on the financial performance. In many cases, patient billings are the primary revenue source that pays staff salaries, provider compensation and overhead operating cost. Inefficiencies or inaccurate billing will contribute to operating losses.
Succeeding in Value-Based Care
This publication identifies and outlines the necessary characteristics of a fully-functioning clinically integrated network (CIN). What it doesn’t do is detail how hospitals and providers can participate in the value-based care environment during the development process.
One common misconception is that the CIN can’t do anything significant until it has obtained the FTC’s “clinically integrated” stamp of approval. While the network must satisfy the FTC’s definition of clinical integration before single signature contracting for FFS rates and contracts can legally start, hospitals and providers can enjoy three key benefits during the development process.
Therapy: Benefits at All Levels of Care
Nearly half of all Medicare beneficiaries treated in the hospital will need post-acute care services after discharge. For these patients, a stay in an inpatient rehabilitation facility, skilled nursing facility or other post-acute care setting comes between hospital and home.
Does Your Budgeting Process Lack Accountability?
With the proper process, tools, and feedback mechanisms in place, budgeting can be a valuable exercise for organizations while helping hold organizational leaders accountable. Having a proper monthly variance review process is one of the most critical factors in creating a more efficient and accurate budget. Monthly variance reporting puts parameters around what is to be expected during the upcoming budget entry process.
Cost Accounting: the Key to Cost Management and Profitability
Managing the cost of patient care is the top strategic priority of most hospital CFOs today. As healthcare shifts to more data-driven decision making, having clear visibility into key volume, cost and profitability measures across clinical service lines is becoming increasingly important for both long-range and tactical planning activities. In turn, the cost accounting function in healthcare provider organizations is becoming an increasingly important and strategic function. This whitepaper includes five strategies for efficient and accurate cost accounting and service line analytics and keys to overcoming the associated challenges.