OhioHealth MAP Experience and Denial Management Case Study

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OhioHealth MAP Experienceand Denial Management
Case Study

• NE Ohio HFMA
• March Madness Chapter Education
• March 15, 2012
• Independence, Ohio

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Agenda

• OhioHealth HFMA MAP Award Experience
• OhioHealths Revenue Cycle journey to success
• OhioHealth Denial Management Case Study

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• MAP Award

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MAP Award

• What is the MAP Award?
• The MAP Award, first given in 2009, previously
  was known as HFMAs High Performance in Revenue
  Cycle Award.
• MAP stands for measure performance, apply
  evidence-based strategies for improvement,
  perform to the highest standards in todays
  challenging healthcare environment.

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MAP Award

• How are the winners chosen?
• The award recognizes healthcare organizations
  that are distinctive, innovative, and effective
  in revenue cycle process improvements, as well as
  sustainable financial performance that serves the
  mission of the organization.
• The criteria are based on HFMAs MAP Keysrevenue
  cycle key performance indicators.

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MAP Award

• Who is eligible?
• All acute-care hospitals are eligible.
• The award is hospital specific, so you must apply
  as an individual hospital, rather than as a
  hospital system.
• To be eligible, an executive leader in your
  organization must be a member of HFMA.
• The application process for the 2012 MAP Award
  will end February 29, 2012.

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MAP Award

• OhioHealth Riverside Methodist Hospital MAP Award
  Winner June 2010 (FY10 Ending 12/31/09)
• Highlighted MAP Keys

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• OhioHealth
• Success

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OhioHealths Revenue Cycle Journey to
SuccessFY08 to FY11
Net Days In Accounts Receivable
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OhioHealth Revenue Cycle MetricsFY08 to FY11
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OhioHealth Revenue Cycle MetricsFY08 to FY11
Actual Write-Offs
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How are Revenue Cycle results achieved?

• Leadership Support (Culture)
• Provides foundation for success
• Recognizes importance of revenue cycle
• Invests in necessary resources
• Alignment of 3 critical areas
• People Exceptional leadership and staff
• Processes Passion for continuous process
  improvement
• Technology Optimization of technology

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Who are the People?
Internal Revenue Cycle Team
Revenue Cycle Operations Supports 6 Hospitals
and Multiple Physician Practices
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Who are the People?

• External Revenue Cycle Partners
• Medicaid Eligibility Vendors
• Patient Statement Vendor
• Transcription Vendor
• Denial Appeal Vendor
• Bad Debt Collection/Legal Collections Vendors
• Retro HCAP/Charity Vendor
• ROI Vendor
• EDI Vendor

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What are the processes?
Patient Access Services
Scheduling
Final Claim Resolution
Pre-Registration
Bad Debt and Charity
Insurance Verification
Appeal Process
Denial Management
Notification
Patient Cash Collections
Pre-Certification
Registration
Statement Generation
Payment Posting
POS Collections
Third Party Follow-Up
Financial Counseling
Claim Submission
Health Information Management
Claim Editing
Claim Generation
Charge Description Master Maintenance
Patient Financial Services
Charge Capture
Enterprise Master Patient Index
Clinical Document Management
Coding
Failed Claim Process
Release of Information ROI
Dictation/Transcription
Electronic Medical Record Management
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What are the processes?
Denial Write-Offs FY09 to FY11 18M to 6.5M .44
to .13 of GPR
FY10 AHIQA Installed Over 400 Registration Edits
Patient Access Services
Final Claim Resolution
Scheduling
FY06 to FY11 0M to 13M Point of Service
Collections
FY09 to FY11 Online Bill Pay 0M to 5.4M
Pre-Registration
Bad Debt and Charity
Insurance Verification
Appeal Process
FY11 IVR Credit Card Payments 2M
Denial Management
Notification
Patient Cash Collections
Pre-Certification
Registration
Statement Generation
FY11 Converted 27 (114M) Self Pay to
Medicaid Gross Rev
FY09 to FY11 Automation of Cash Posting 80 to 95
Payment Posting
POS Collections
Third Party Follow-Up
Financial Counseling
Claim Submission
FY07 to FY11 70 to 85 Clean Claim Rate
FY11 Implemented Computer Assisted Coding
Health Information Management
Claim Editing
Claim Generation
Charge Description Master Maintenance
Patient Financial Services
FY11 Outsourced Transcription to Single Vendor
Charge Capture
FY08 Reduced Chart Delinquency from 16 to 3
Average Monthly Discharges
Enterprise Master Patient Index
FY07/08 Improved Chart Availability for Coding-3
days to 24 hrs
Clinical Document Management
Coding
Failed Claim Process
Release of Information ROI
Dictation/Transcription
Electronic Medical Record Management
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What is the technology?

• Over 20 different systems are used to streamline
  effectiveness and efficiency throughout Revenue
  Cycle
• Patient Access
• Scheduling System
• Imaging System
• ABN/Medical Necessity System
• Insurance Verification
• QA System
• Patient Price Estimator Tool
• Electronic Forms Management System
• Core HIS
• Health Information Management
• Coding Edit System
• HIM Imaging System
• EMPI Integrity System
• Encoder
• RAC Software
• Computer Assisted Coding

• Patient Accounting
• Claim Editing/Transmission System
• AR Follow-Up System
• Denial Management System
• Imaging System
• Credit Card/Check System
• On-Line Bill Pay
• Dialer/IVR Phone System
• Banking/Lockbox Technology
• Cash Posting Automation
• Core HIS

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Success Fusion of People, Process and
Technology
Net Days In Accounts Receivable (FY08 to FY11)
FY11
FY09
FY10
FY08
FY07

• AthenaNet Reinstall
• FormFast
• Horizon Business Folder
• Grady Electronic Medical Record Conversion
• OHMSF relocation to Preserve
• Deployed staff accountability scorecards
• Insourced Patient Collections
• Centralized coding staff
• Enterprise Form Committee
• Reengineered Denial Management
• Opening of Dublin Hospital
• Cash posting automation
• OHMSF Credentialing System

• QMS AR Management Tool
• RevRunner Eligibility
• Horizon Patient Folder
• Automated coding workflow
• Patient Compass
• Rev Cycle move to Preserve
• Revenue Cycle newsletter
• Expanded Rev Cycle IT Support
• POS Collections
• Medicaid Batch Identification

• Initiate EMPI system
• Installed Graphic User Interface
• Developed Project Management Team
• Developed Revenue Cycle Financial
  Reporting Team
• Reengineered bad debt collections
• Charge Capture Audit Program
• OHMSF acquisitions
• OHMSF technical billing
• MedQuist renegotiated contract
• Established monthly operational payer meetings
• Expanded charity care guidelines
• Grady Revenue Cycle integration
• Opening of Westerville Med Center

• AHIQA
• ePremis claim system
• Developed RAC Team
• Grady CBO and Scheduling transition to Preserve
• Continued centralization of Patient Access
  Services
• Outsourced denial appeal process
• Redesigned payer scorecards
• On-line patient payment tool
• Reengineered call center dialer campaign
• System-wide denial reduction initiative

• Computer Assisted Coding
• IVR patient payments
• Grady Healthworks
• Relocation of HIM/RAC to Doctors
• OHNC integration
• Reference lab billing integration
• CDM Redesign Initiative
• Hardin MedQuist
• Nelsonville Rev Cycle integration
• Standardization of transcription services

(WhiteTechnology, BlackPeople, GreenProcess)
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Key Revenue Cycle Strategies

• Patient Collections
• Strategy Decrease bad debt, manage charity care
  and increase patient cash collections
• Enhanced Medicaid Eligibility Program (Conversion
  of Self Pay to Medicaid)
• Implemented in-house self pay collections program
• Implemented point of service cash collection
  program
• Enhanced Charity/HCAP Program
• Expanded patient payment tools (call center,
  on-line, and IVR)
• Reengineered bad debt collection process
• Insurance Collections
• Strategy Strengthen payer accountability for
  contractual responsibilities
• Payer scorecards
• Payer monthly and quarterly meetings
• Team effort between Revenue Cycle and Managed
  Care departments
• Contract language supports Revenue Cycle and
  continues to change as needs evolve
• Development of aggressive denial management
  program

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Key Revenue Cycle Strategies

• Technology
• Strategy Optimize the use of technology to
  streamline processes and to manage costs
• Fully dedicated Revenue Cycle Application IT dept
• Implemented new systems and automated hundreds of
  processes
• Standardization of applications across Revenue
  Cycle
• Human Resource Capital
• Strategy Immerse Revenue Cycle with talented
  leadership, staff and vendors
• Deployed staff accountability
• Strengthened vendor partnerships
• Trained and developed a skilled and talented
  workforce (ongoing)
• Established Right Choice Award Program
• Improved Associate Opinion Survey
• Developed Revenue Cycle newsletter

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• Case Study
• How OhioHealth used the MAP Strategy to Reduce
  Denials

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MAP Strategy on Denials

• Defining and identifying payer denials (Measure)
• Reducing payer denials (Apply)
• Achieving results (Perform)

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Defining and Identifying Payer Denials(Measure)
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Definitions

• What is a payer denial or delay?
• Payment was expected by the service provider but
  was not received from the payer. Additional
  action must be taken by the provider in order to
  receive payment from payer. Additional action
  does not always guarantee payment.
• Initial Denial
• Pre-action initial denial
• Final Denial
• Post action final write-off i.e. claim has been
  appealed and denial upheld by payer
• Payer Delay
• Request for information before payment can be
  received from payer

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Denial Examples

• Payer Denials
• No authorization
• No notification
• No pre-cert
• Not medically necessary
• Pre-existing condition
• Experimental
• Non-covered
• General technical billing errors i.e. Incorrect
  subscriber ID, missing info on UB format, etc
• Timely filing
• Benefits exhausted
• Out of network

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Delay Examples

• Payer Delays
• Medical record request
• Itemized statement request
• Coordination of benefits to determine primary
  payer vs secondary payer

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Identify

• Critical step towards resolution
• Quantification of data tells story and changes
  behavior first step is to identify and then
  quantify
• Very complicated but can be achieved
• Manual identification
• Electronic identification

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Manual Identification

• Posting from paper remittance advice/explanation
  of benefits (EOB)
• Identification through follow-up process
• Inefficient and ineffective
• Opportunity for error

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Electronic Identification

• HIPAA
• The Health Insurance Portability and
  Accountability Act (HIPAA) was passed on August
  21, 1996. Among other things, it included rules
  covering administrative simplification, including
  making healthcare delivery more efficient.
  Portability of medical coverage for pre-existing
  conditions was a key provision of the act as was
  defining the underwriting process for group
  medical coverage. It also provided
  standardization of electronic transmittal of
  billing and claims information.
• October 16, 2003 - Implementation of initial
  ANSI standards associated with the HIPAA law
• Note
• Administrative Simplification
• Standardization has taken too long and still has
  a long way to go!

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ANSI 835

• HIPAA proposed, in part, to standardize and
  privatize the electronic exchange of information
  between providers and payers.
• ANSI 835 is the American National Standards
  Institutes (ANSI) Health Care Claims Payment and
  Remittances Advice Format. This format outlines
  the first all electronic standard for health care
  claims. The format handles health care claims in
  a way that follows HIPAA regulations. Prior to
  the creation and implementation of 835, there
  were hundreds of different electronic remittance
  formats in use. HIPAA requires the use of 835 or
  an equivalent.
• ANSI, ANSI, ANSI Linking ANSI Standards to
  Denial management

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ANSI 835 CAS Codes

• Over 200 Claim Adjustment Reason Codes (CARC)
• Ex. 1-Deduct amt 51 Non-covered/pre-existing
• Over 800 Remittance Advice Remark Codes (RARC)
• Ex. N47 Claim conflicts with another inpt
  stay N-50 Claim missing discharge info
• Claim Adjustment Groups (CAG)
• Ex. CO-Contractual obligations PI- Payer
  initiated reductions

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Health Information System CARC/CAG Mapping Table

• Develop team to review and map CARC and Claim
  Adjustment Groups
• Team to include members from payer follow-up,
  remittance posting, and IT
• Update Health Information System mapping table
• Continue to monitor as payers change codes
• Future changes-Stakeholder signoff from both
  payer follow-up and remittance posting leadership
• Some payers use codes differently therefore
  create master table and then subset for unique
  payer usage
• Keep in close communication with payer EDI
  department/contacts for changes or updates to
  codes

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Internal Mapping Table-Example
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Initial Denial Identification

• Categorize initial denials and develop work flow
  for resolution
• Example CO-197 NPRE Lack of Pre-cert/Auth
  route to clinical appeal team for action
• Develop separate Financial Class for pending
  appeals and monitor, i.e. medical necessity and
  pre-cert/auth denials

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Final Denial Identification

• Create specific denial write-off codes
• Write-off gross charges (vs expected
  reimbursement)
• Track everything even if unclear if contractual
  vs denial
• Do not write off to generic administrative
  adjustment code or to general contractual
• Be able to slice by patient type, service
  location, payer, etc...
• Example Specific Denial Write-Off Codes
• Medicare Medical Necessity Radiology, Lab,
  Heart Services, Behavioral Health, Pharmacy,
  Cardiac, Endo, and Other
• No Medicaid Sterilization Form
• Managed Care Medical Necessity
• No Pre-cert/Authorization
• Untimely Retraction by Payer
• Payer Non-covered

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Reducing Payer Denials(Apply)
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Reducing Denials

• Quantify and Communicate
• Leadership and Associate Accountability
• Payer Accountability
• Process Improvement

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Quantify and Communicate

• Data is powerful and can change behavior!!!!!
• Awareness is key critical
• Quantify initial and final denials by denial
  codes and write-off adjustments both accounts
  and total gross charges
• Distribute denial reports weekly/monthly to key
  stakeholders via email to stakeholders and
  include CFOs, Directors of Finance, Controllers,
  Revenue Cycle Leadership, Clinical Dept
  Leadership
• Example Case Management to receive all Inpatient
  No Auth/Medical Necessity Denials, Pre-cert team
  to receive missing Pre-cert Denials, Business
  Office to receive all timely filing denials
• Transparency-Include all stakeholders on same
  email
• Educate/train stakeholders how to use and
  interpret the data
• Develop hospital/health system teams with
  stakeholders from various departments
• Ongoing

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Quantify and Communicate

• Critical to identify and monitor both Initial
  Denials Pended in AR and Final Denial Write-Offs
  (Balance Sheet and P/L)
• Possible issue if write-offs are down but pended
  denials in AR are extremely high (not working
  denials efficiently and effectively?)
• Possible issue if write-offs are up and pended
  denials in AR are extremely low (writing off
  denials too soon before all efforts are
  exhausted?)

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Leadership and Associate Accountability

• Incorporate target reductions into joint senior
  leadership accountabilities example CFO and VP
  Revenue Cycle
• Incorporate target reductions into all levels of
  leadership in Revenue Cycle Management (Patient
  Access, Health Information Management and
  Business Office), applicable clinical areas and
  Case Management
• Incorporate target reductions into associate
  level accountabilities
• Overall target reduction for health system as a
  whole not individual hospitals
• Target to be established by using external
  benchmarks or historical hospital/health system
  data
• Industry standard Denials Write-Offs 2-4 of
  Gross Revenue (Source Unknown)

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Payer Accountability

• Payer Performance Review and Communication
• Comparative data by payer
• Denial rates
• Types of denials
• Overturn rates
• Appeal turn around time
• Average days to pay
• AR Aging
• and Outstanding appeals over X days old
• and Outstanding overturn denials over X days
  old

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Payer Accountability

• Quarterly Meetings Members to include
  stakeholders from Scheduling, Pre-cert,
  Pre-Registration, Business Office, Managed Care,
  Case Management and Payer
• Weekly/Monthly Operational Meetings to escalate
  claims, process issues, etc.
• Clearly understand payer escalation process (get
  it in writing) and do not take no for an answer
• Payer contract language
• Hospital Managed Care Team and Business
  Office-critical relationship/must support each
  other

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Process ImprovementExamples

• Managed Care Inpatient Authorization/Medical
  Necessity
• Managed Care Outpatient Pre-cert/Medical
  Necessity
• Timely Filing Denials
• Medicare Outpatient Medical Necessity Denials

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Process Improvement

• Managed Care Inpatient Authorization/Medical
  Necessity
• Inpatient notification process fax, email,
  website, AUTOMATE (ANSI 278)
• Inpatient case management clinical review
  submitted to payer
• Complete payer/provider authorization process
  prior to discharge
• Include authorization or reference on UB
• Ensure discharge date is communicated to payer if
  required during clinical review process (this
  will delay payment)
• Level of care denials-observation vs inpatient
• Continued stay denials
• Appeal all denials
• Centralized Appeal Team-Internal/External
• Submit clinical documentation support for
  admission
• Peer to Peer Physician review if necessary

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Process Improvement

• Managed Care Outpatient Pre cert/Medical
  Necessity
• Require pre-cert for all elective scheduled
  procedures
• Develop a pre-cert physician liaison team
• Order should support Reason for Test
• Use payers to assist with enforcing policy with
  physician offices provide list of physician
  offices for follow-up
• Educate physician offices on payer required pre
  cert process and how to document reason for
  test
• Provide physician offices with payer training
  tool kit
• Establish process for Radiology dept to notify
  Pre-cert dept if original ordered procedure is
  changed necessary to obtain pre cert for revised
  procedure
• Centralized Appeal Team-Internal/External
• Appeal all denials
• Submit clinical documentation for reason for
  test obtain from ordering physician office

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Process Improvement

• Timely Filing Denials
• Payers have time limits for claim submission
  typically 12 months
• Payers have time limits for appeals
• Develop payer matrix of time limits for staff and
  appeal team
• Critical to obtain correct insurance info the
  first time during registration process
• Implement real time registration QA system
  including scoring and grade assignment by
  registrar incorporate into QA and staff
  evaluation process
• Address delays and denials timely
• Develop internal escalation policy for claim
  follow-up team
• Payer retractions if past timely filing-appeal
• Coordination of benefits-get patient involved

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Process Improvement

• Medicare Outpatient Medical Necessity
• Advanced Beneficiary Notice (ABN) process CMS
  regulation to notify patient prior to service if
  service might be non-covered due to lack of
  medical necessity provider cannot bill patient
  for non-covered service unless ABN signed by
  patient prior to service GA modifier must be
  included on HCPCS code of non-covered procedure
  if ABN obtained
• ABN software system
• ABN screening at time of scheduling, registration
  and backend claim edit system
• Follow-up with physician office for applicable
  diagnosis Reason for Test if data fails
  screening and is non-covered

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Process Improvement

• Medicare Outpatient Medical Necessity
  (Continued)
• Very complicated process however, brings
  discipline to obtain diagnosis to support Reason
  for Test
• Medical Records to code Reason for Test not
  just result of test
• Medical Record second review process
• Emergency Room ABN is typically not allowed due
  to EMTALA however opportunity to review protocol
  and improve documentation
• Focus initial process improvement on high
  write-offs i.e. Radiology
• Remember to track write-offs by specific service
  area (radiology, cardiology, pharmacy, lab, rehab
  and other

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Results (Perform)

• OhioHealth reduced denials from .44 (18M) of
  Gross Revenue FY09 to .13 Gross Revenue FY11
  (6.5M)-Over 11.5M in Reduced Denial Write-Offs
• OhioHealth recognized in Modern Healthcare
  January 31, 2011 No Denying the Problem
• OhioHealth 2010 Prism Award Finalist-Cross
  Functional System Denial Team

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Conclusion

• Use MAP Strategy to Achieve Results
• Measure performance
• Apply evidence-based strategies for improvement
• Perform to the highest standards in todays
  challenging healthcare environment

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Contact Info

• Jane Berkebile, System Vice President, OhioHealth
• Phone [phone]
• Email jberkeb2_at_ohiohealth.com