HTH934: Revenue Cycle Enhancement

1
HTH934 Revenue Cycle Enhancement
Catherine Schulten and Bruce Hendersoncschulten_at_s
ybase.com / bahenderson_at_bearingpoint.net August
5, 2003
2
Our Understanding of the Market
(Call Center, Internet, On-site)
Customer Service
Information Systems
(Core Billing, Bolt-on, Decision Support, AD-HOC)
Acct.
Verification
Charge
Billing/
Collections
Processing
Scheduling
Registration
Coding
Pre-
Cert
.
Entry
E-Billing
Follow-up
(Pmt Posting,
Denial Mgmt)
Monitoring and Measurements
(Industry, System, Functional, Individual)
Pre-Service
Service
Post-Service
Todays revenue cycle relies upon the following
imperatives

• Patient Friendliness Emphasis on patient
  satisfaction in all process improvements
• Cost to Collect Pursuit of lowest net cost in
  this cost/quality indicator
• Consistency and Integration End to end process
  view with integration of supporting systems

• Cash Focus Relentless delivery of realized cost
  savings and improved cash flow in all projects
• Quality of Process Consideration of the true
  cost of errors in pursuit of cost reduction

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Opportunity Indicators

• Financial
• Accounts Receivable Buildup of receivables
  portfolio resulting in reduced cash flow. If
  receivables over 90 days exceed 15 of the total
  portfolio dollar value, we may have an
  opportunity. Gross days revenue in receivables gt
  60 and net days revenue in receivables gt 50 are
  also indicators of potential opportunities.
• Bad Debt High levels of uncollectible accounts
  due to poor denial management, poor gathering of
  demographic and insurance information
• Timely Filing Write-offs Significant amounts
  lost due to expiration of timely filing limits

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Opportunity Indicators

• Financial
• Charge Capture Lost revenue because of unbilled
  charges or inaccurate coding.
• Reimbursement Lack of contract compliance with
  government and other third party payors
• Cost to Collect Duplicate effort and other
  inefficiencies resulting in high cost to collect.
• Patient Service
• Patient Access Inefficient scheduling and
  registration processes resulting in patient
  dissatisfaction
• Insurance and Demographic Data Front-end
  gathering of patient data is ill-defined and
  inaccurate resulting in claim denials

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Opportunity Indicators

• Infrastructure
• Patient Management Systems Lack of enterprise
  wide integrated systems designed for efficient
  processing of claims.
• Technology Absence of claims editing or
  contract management software
• Organization Lack of management accountability
  and business based measurement system
• Reimbursement Complex reimbursement processes
  because of federal and stage regulations and
  non-standard payor payment methodology

6
Provider Challenges

• Reduce Accounts Receivables (AR)
• Decrease Days Outstanding in AR
• Reduce Claims Denied
• Reduce Claims Reviewed and Resubmitted
• Reduce/Realign FTEs Focused on fixing claims
• Direct Submit EDI Transactions, Decreasing
  ClearingHouse Costs

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Solution Objectives

• Generate clean transactions first time/every
  time, avoiding costly delays in reworking
  rejected claims
• Reduce intermediate processing to reduce costs
  and cycle time
• Increase auto claims generation and adjudication
• Study reimbursement trends to avoid pitfalls in
  the future

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Streamlining the Process

• Immediacy and Accuracy of Charge Capture
• Eligibility Checking prior to procedure
• Point of service charge capture
• Revenue Cycle Time Reduction
• Clean Claims (scrubbing, apply business rules,
  HIPAA validation)
• Transaction Exception Handling and Resubmission
• Automatic Claim Status Checking for claims
  outstanding gt x days

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Information Liquidity

• Analytics
• Identify trends in claim rejections
• Identify reasons for low/no payment
• Spot trends in delayed payment of claims
• By Procedure
• By Payer
• By Diagnosis

10
Sybase Solution Architecture
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Business Process Integration

• BPI Suite for Healthcare
• Enterprise Application Integration
• Process Management
• Trading Partner Management
• HIPAA Transaction Translation
• HIPAA Compliance Management
• Business Activity Monitoring
• Claims Conflict Management
• Business Intelligence and Analytics

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Proactive Revenue Cycle Enhancement

• Real Time Eligibility Checking
• Use BPI for Healthcare to format X12 270
  transaction, direct submit to payer, receive 271
  response
• Automated Claim Status Checking
• Use Process Management and Business Activity
  Monitoring to keep track of all claims (837s)
  submitted and establish and monitor a set length
  of time before an automated Claim Status (276) is
  generated to appropriate payer.

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Integrating the Process
.

• Charge and Remit Capture
• Use Application Integration to locate and pull
  down charges from various systems throughout the
  hospital (Lab, Radiology, Pharmacy, Admissions,
  etc). Combine these various charges into a
  single claim (837).
• Use Application Integration to facilitate
  Remittance Advice Posting (835), making sure all
  line items are received and posted to appropriate
  system(s).

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HIPAA Enablers

• Direct Connectivity
• Establish direct connects to payers via Trading
  Partner Management
• HIPAA Transaction Validation
• Validate all inbound and outbound transactions
  for compliance to the HIPAA IGs, catch
  non-compliant transactions before they go out the
  door or before they are sent to backend systems

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Managing the Revenue Cycle

• Claims Conflict Management
• Generate report of non-compliant transactions
• Workflow management
• Collaborative process driver
• Automatic escalation
• Claims editing and resubmission

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Turning Data into Economic Value

• Business Intelligence and Analytics
• Use HIPAA Repository and Industry Warehouse
  Studio to quickly store the data content found in
  the various Provider inbound HIPAA transactions
  (835, 271, 277) and provide a solution for
  ongoing, long term analytics
• A key ROI of HIPAA can be found in the wealth of
  data content returned in the various response
  transactions coming back from the plans