|Volume IV Number 4
|The Newsletter of
DEKAYE Consulting, Inc.
231 Oakview Avenue
Rise and Fall
COLLECTION AT TIME OF SERVICE
(Both Money and Information)
by Allan P. DeKaye, MBA, FHFMA, President & CEO, DEKAYE Consulting, Inc.
While we shouldnt blame the resurgence of interest in "collection at time of service" solely on the growth in managed care, it certainly is a contributing factor. The scene--at doctors offices and at hospital registration points--is becoming more common: staff asking for, and receiving payment from the patient for the more prevalent deductibles and co-payments associated with managed care.
The number one benefit of time of service payments is increasing cash flow and reduced A/R. For years, this approach has been touted, but often left to unimaginative roll-out plans that spent the money before laying the foundation for capturing it. Secondly, the reduction in the number of open accounts that is attainable can be significant. Patients paying their responsible portions at the time of service is in itself a re-affirmation that the insurance is in effect (why else would I make co-payment?). This should lead to more accounts reaching "true zero"; that is--the insurance and patient balances are both at zero. When these accounts drop off the trial balance (or at least are in an inactive status), the amount of workload assigned drops which should allow staff to increase their follow-up tasks on the remaining accounts.
Convincing patients to pay can have a plus on the customer service side, too. By reducing the number of patient pay bills, one of the leading sources for customer inquiries (and complaints) may be eliminated or severely reduced. These results may also translate to better customer service numbers on patient surveys, notably in response to the questions:
Increasing Collections and Percent of Total
A program that emphasizes time of service payment can be measured in terms of total dollars collected. An effective program will show continuing increases in total self-pay remittances. If the systems (or sub-systems) exist, the ability to report true time of service payments can identify contributing areas (e.g., clinic, ER, private ambulatory, etc.).
Even more important are the percent of total measures such as: actual dollars collected/maximum dollars due on a per case basis, and percent of cases where maximum dollars were collected to total cases. These measures identify the degree to which you maximized collections. With maximum dollar collection, you are in a better position to reduce open accounts which will have a significant impact on A/R and follow-up activity.
Finally, the provider community needs to be involved. The Board of Trustees should be involved to endorse the policy, and set about policy directives. The medical and nursing staff need to understand the policy so they can reinforce it with their patients. Patient literature should provide information that helps explain both clinical and financial information.
While there may be incentives for enhanced collections, it is important that as with all follow-up actions, a caring, compassionate attitude needs to be maintained. With improved interview skills and techniques, front-end staff is as likely to not only collect money, but more demographic and financial information. Another benefit will be the surfacing of secondary insurances, and "hidden" insurances that only get unearthed when self-pay bills or collection agency efforts help unveil them. These timely efforts can go a long way to increasing cash flow and improving the bottom line.
Emphasis on Education
GOAL SETTING AND GOAL ACHIEVEMENT
by William G. Bliss, Bliss & Associates Inc.
Much has been written about goal setting. Yet, many people comment that they are not satisfied with their performance in achieving those goals. This article is intended to address not only the effective setting of goals, but also to identify 8 steps to ensure that you achieve the goals you have set.
To begin, lets be sure we have a clear definition of what constitutes a goal. There have been many definitions of a goal; for purposes of this article, I would like to define a goal as follows: "A written statement that clearly describes certain actions or tasks with a measurable end result."
To elaborate on this definition, a goal must be written. If it is not written, it is merely an idea with no power, conviction or motivation behind it. It will lack energy and purpose. A written goal will allow you to remind yourself and others exactly what has to be done. Rereading this written goal on a regular basis will help provide the motivation to achieve the goal.
A goal will clearly describe certain actions or tasks. A goal that is clearly described will eliminate misunderstandings between you, your colleagues, your staff and your boss. Clearly described goals will include action verbs such as create, design, improve, organize, purchase, etc. A test to determine the clarity of your stated goal is to show the statement to 5 people. Ask each of them individually to explain the purpose and objective of the goal. If each one has the same response, your goal is clearly stated. If the responses differ, even in the slightest, it is a signal to make your goal more clear.
Goals must have a measurable result with a time frame for completion. A measurable goal is quantifiable. It is described in such a way that the actual result cannot be disputed. If you cannot measure something, chances are you cannot effectively manage it.
Now that you have a written goal, what steps can you take to ensure you achieve the goal? The following will help you:
What I have outlined is a process for effective goal setting and achievement. A process will work if two components are present - the process itself is sound and the people utilizing the process have the discipline to follow the process through. The process described above is sound and has worked in thousands of situations. The discipline is up to you.
Should you wish to discuss this topic further or need more information, please feel free to contact Bill Bliss at Bliss & Associates Inc. at 914-279-7300 or through E-mail at firstname.lastname@example.org.
Please click here for more
information about the DEKAYE Consulting Inc.
Emphasis on Education Course Curriculum.
Perspectives And Commentary
AVOIDING "UNFORCED ERRORS"
by Allan P. DeKaye, MBA, FHFMA, President & CEO of DEKAYE Consulting, Inc.
In tennis, the server slams the ball into the net. In basketball, the forward misses the slam-dunk! In golf, you slice the ball off the tee shot. These are all examples of "unforced errors," and each is preventable. In the admitting/registration process, we simply just miss some of the data.
Its not deliberate, and its not always sloppy. It just seems to happen. No not with the disruptive patient, although they contribute to some of our problems. It is in the course of the normal everyday activities that "our misses" tend to add up.
Repetitive Tasks Takes Its Toll
A good example is in the classic "I Love Lucy," when Lucy and Ethel are in the candy factory, and need to remove defective candy from the conveyor belt. When the pace is slow and steady--no problem. But as the pace accelerates, Lucy and Ethel have no choice but to try to save time, and salvage the process. They eat a few, discard a few, and some just slip by.
Perhaps that is similar to our ER and Outpatient (including Private Referred testing) registration areas, where increased volumes and typically fewer staff find themselves "cutting registration corners" as the patient conveyor belt of arrivals make for long lines during peak periods of activity.
Good customer service dictates that we speed patients along, but financial pressures and managed care mandates require that we slow the pace sufficiently to verify coverage, obtain referrals or pre-certifications--and even collect deductibles and co-pays at the time of service. In some elective, non-emergent situations, we will even defer or reschedule appointments when the utilization management or payment requirements are not met. So where do we go wrong?
Things We Tend to Miss
With the advent of submitting electronic "clean claims," most billing departments know that a rejection for failing to "dot the"Is" or cross the "Ts" will usually result in a soft denial--one that is re-billable after appropriate research and correction. While costly--still reversible.
It is the hard denial--those causes not easily corrected because time factors and/or failure to act may be at the root cause. These include (but are not necessarily limited to):
These ten (and Im sure some others or variations) may be occurring throughout your facility. There are two steps that can be taken to reduce these "unforced errors": measurement and education.
While some of these errors seem minor, finding the pattern of claim denials, rejections, or pends, in itself can be time consuming--although necessary. Most of these types of errors are measurable. Once quantified, they can be tracked, and a sampling examined more closely to pinpoint operational impediments or staff deficiencies in procedural execution.
While system problems, and extreme events beyond your control may appear from time to time, it is more likely that errors of the type noted above will have a more dispersed pattern affecting perhaps many departments and different staff.
Measurements and reporting is most effective when consistently applied so that the output and analysis will be viewed as valid and reliable. It is also necessary to have representation and participation from the department heads of the affected departments. When senior management is advised of the baseline measures, extent of the deviation from the norm or expected values, and the intended plan of corrective action, then that it is possible to create the "priority" necessary to effect compliance.
One approach to meeting the in-house training needs of staff is to combine a program of both lecture and practical exercise. Since time away from workstations is difficult given the day-to-day pressures and recent downsizing, re-engineering, etc., classroom training needs to combine theory and practice. Group dynamics and role-playing can be useful in helping front-line staff take a fresh look at the tedium, frustration and pressure that accompanies some of the more stressful areas of the patient administrative services continuum.
Finally, an often unsung, and sometimes forgotten player is the supervisor. Through process re-design different levels of "supervisor" have vanished or had their review and quality control function diminished or eliminated. Somewhere the presumption that "zero defect" was already in existence has prevailed. It has not. In order to get to the "perfect registration," we have to collectively demonstrate that we can overcome the patients objections to providing data, as well as our own complacency and ennui, in order to regain the ability to monitor ourselves and take corrective action.
If today, Lucy and Ethel were in the modern candy factory, they might be assisted by computers and sophisticated robotics to perform their quality control effort. Somehow, I can see them still wanting to taste the "forbidden" fruit, and deviate just slightly from the norm. Even as we strive for perfection, there is still room for us to overcome the "unforced errors" that detract from the bottom line. Tennis anyone?
: Ask The Expert
by Allan P. DeKaye, MBA, FHFMA
Q: After reaching our settlement agreement with the OIG, what other follow-up actions should we be taking?
A: Providers are reminded to be certain to implement the various aspects of the details of their settlement agreements. In some instances, it will be ensuring that staff education has been scheduled; in others, it will be to ensure that the pre- or post-bill edit routines to review claims (e.g., for 72 hour rule compliance) has been effected. Now is a good time to review the settlement agreements to check for any open items, and also to ensure continued adherence to items/procedures previously implemented.
In addition to settlement agreements, providers should be reviewing their corrective action plans from any recent or open internal or external audits. Departments need to demonstrate that these open items have been addressed. In many cases, you'll want to show that accounts were targeted, as well as the reviewed and that a remediation process has occurred. The ability to show that a problem has been resolved, and that preventive action has been effectively implemented will prevent the repetition of an unresolved item on a subsequent audit report or interim follow-up.
Q: We have been asked by patients to produce a zero balance bill. We cant seem to be able to produce these without changing the masterfile settings . Is this a good procedure?
A: I would caution not to change masterfile settings to generate zero balanced bills to secondary carriers. It may make sense to first answer these questions:
Q: What would be the best way to calculate days in A/R for benchmarking purposes?
A: I prefer gross days in A/R as a benchmark number. I'd take my gross receivable outstanding and divide it by the average daily gross revenue. For average daily gross revenue, most people will use a rolling three month average to smooth out any seasonal or unusual variations.
But remember, there are a lot of factors that can influence this calculation, so at best it is a broad measure--but one that usually translates to the monthly financial statements.
You might also want to further calculate the gross days in A/R by inpatient or outpatient [if you are in a physician's practice or multi-specialty consider breakdowns by practice (e.g., medicine, pediatrics, etc.)]. In any case, A/R days by financial class is also a good way to spot strengths/problems. I also find that tracking the number of open accounts is a good way to see if progress is being made from a pure production perspective.
Q: We are attempting to reorganize or Business Office. We currently have three different systems but the same software and we want to integrate. What are your suggestions?
A: If by same software, but three different systems, you mean same vendor or platform, but three different versions or releases, your first order of business (or at least high on the priority list) should be the selection of one software and system. Without making this commitment (decision and resources to get there), your ability to reach the economies of scale associated with a Business Office Reorganization will fall far short of your expectation.
However, if you have three very different vendor systems (e.g., SMS, Meditech, HBOC. et. al) with one underlying system/software infrastructure, you will also have to commit to an ultimate conversion.
The degree of difficulty for each type of conversion will vary based on which of the above scenarios best fits your enterprise network, and the extent of your resources.
While you will want to assemble the data on job positions and functions, in a similar client situation, they first concentrated on developing the underlying workflow and policies and procedures to ensure that they were uniform. They then proceeded to manpower assessments, and then training and implementation of the new procedures. They later went through a systems conversion (consolidating from 3 to 1). The preliminary workflow analysis for the preferred methods and procedures not only helped with short term operational and financial benefits, it also helped them with the systems conversion planning and custom programming they required.
You"ll also want to review Chapter 21 ("Improving Operations through Process Re-engineering." by Kempton Smith) and Chapter 22 ("Cost Savings and Efficiencies Attained through Consolidation," by Steven Kurz) in The Patient Accounts Management Handbook (Aspen, 1997). They will offer suggestions on several of the questions you raise, as will information in Part IV of the book (Where Cash is King: The Collection Cycle).
Q: Our business office has been plagued by return mail. How can we address this problem?
A: Return mail represents a problem that should not exist! It is preventable, and while it won't go away totally, it should be minimized by trying to:
Some electronic eligibility verification systems will match on or report on address discrepancies. Other facilities are using commercial credit bureau checks to confirm addresses, etc. But if you do generate edit reports of any type, be certain to work them for corrections, otherwise your edit reports will be as high as your return mail.
Q: We are have difficulties identifying indigent patients in the ER. How can we get better information ?
A: ER registration has traditionally been viewed as an area where demographic and financial data capture has been weak. However, there are a number of technological and training initiatives that can improve the accuracy and completeness of data.
For more information, you can consult "The Patient Accounts Management Handbook," Chapters 5-8 (Bolen, Edens, DeKaye and Roberts), in Part II, Knowing Who the Customer Is: The Registration of the Patient," and Chapters 25 and 28 ("Learning to Cope with Regulations" [Ryan], and "Changing Directions in Uncompensated Care" [Douglas]).
Q: There are so many billing systems and vendors available. How can you decide which is best in functionality and the best fit for us?
A: Whether you're a multi-speciality practice, or billing company/service, there are some limitations you will likely face in analyzing system functionality. Sometimes the best fit isn't a 100% solution (it rarely is).
Keep in mind that as regulations change, and the make-up of organizational entities also are transformed, your system will also have to be modified. If you have a vendor who is willing to contractually commit to meeting all of your specific design features, you will have the best chance at coming close to meeting your goals.
Since it won't make sense in most cases to support more than one system platform, you should heavily weigh the system that gives you the 90+ % solution. Anticipate negotiating for at least another 5% in custom programming (assuming you can afford the cost, and the vendor has the resources and capability to deliver the enhanced product). Remember, it has to be a good business decision for the vendor to add this functionality to their system design. If there is a market for this enhancement, it will receive consideration, and increase the possibility it will occur (hopefully in a reasonable time frame). Anticipate 5-10 % workflow modifications until you can get an automated solution in place. Keep in mind, the cost of the enhancement may outweigh the manual production costs, and the cost should be such that it doesn't outweigh the overall benefit.
Q: We are having a tough time deciding whether we should keep our physician practice coding and billing service done in-house or through a vendor. What criteria should we be using to discover which would be a better ?
A: In deciding whether a physician's office should retain its coding and billing services, it may want to consider answering the following questions:
The answers to these questions may give the practice reason to consider an outside service. However, MSO's (Management Services Organizations) come in a lot of varieties--with not all of them supporting the functions that are needed. Further, there will be performance variations among competing MSO's or billing and coding vendors.
Practices need to be able analyze the level of improvement that is attainable from an outside vendor. You will need to determine if the vendor's track record in similar situations supports their marketing contention that they can do the job, and achieve the incremental performance level that will justify the cost for this service.
I have addressed this subject in several articles: "MSO: Friend or Foe," "Medical Record Coding and Risk,"and "How Managed Care Has Changed Practice Management's Vital Signs." These articles can be found in the On Target newsletter (see the April 1996, January 1997, July 1997, and October 1997 issues, respectively) located at our web site.
The Contributor's Corner
by Andrew Schulman, Carpenter & Onorato Health Care Consulting
Congress developed an interim payment system in an effort to curb the explosion of spending in home health care. In recent months, it has been reported by the National Association for Home Care that over 1,100 home care agencies have closed their doors. It is certainly looking more and more like relief from the IPS will not come from the federal court system since three of six lawsuits, attempting to block the imposed reimbursement systems, have been dismissed by federal judges. All six have argued, along with the majority of industry sources, that IPS is putting reputable home health agencies out of business and leaves some seniors without access to home care. IPS continues to threaten the existence of many smaller-sized certified agencies. While many in the industry today were hoping for a moratorium or a substitution for a co-pay, it appears at the eleventh hour that not much relief is on the way before Congress adjourns in the next week.
Calculating how much an agency can seek in reimbursement for a patient that has been served by multiple agencies is probably one of the hottest topics still to be decided with the IPS methodology. One of the key provisions of the Balanced Budget Act of 1997 was that if services are provided by more than one HHA during a year, the beneficiary limit will be pro-rated. However, HCFA needs to devise a specific formula on exactly how to figure out how "proration" should work. The proration of claims when more than one agency is involved in a Medicare patients care was supposed to begin October 1, 1998.
Another topic to have received much publicity of late is the pending implementation and final rule on HCFAs Outcome and Assessment Information Set (OASIS). Many agencies are preparing for OASIS and have standard patient assessment forms, have taken steps to integrate OASIS into the assessment process and should have computer capabilities compatible with HCFAs minimum requirements for OASIS data transmittal. OASIS has been proposed to be required under the new Medicare Condition of Participation, however, it appears submission of data will be postponed until April 1, 1999 at the earliest. Coincidentally, April 1999 corresponds with the revised proposed implementation of the Prospective Payment System (PPS). Industry sources might perceive this delay as a "mixed blessing." On one hand, certified agencies are presently struggling to survive the IPS, but getting the system in place quickly might help determine reimbursement rates for the Prospective Pay and might be a boost for agencies attempting to figure out monthly/annual budgeting forecasts.
Finally, the Balanced Budget Act of 1997 also requires Medicare certified hospice programs to file a cost report beginning on/after October 1, 1998. The report will be utilized to evaluate rates for hospice payments. In the last few years, the number of Medicare beneficiaries getting hospice care has increased over 40%. However, the average length of stay for Medicare hospice beneficiaries fell by about 10 days during the identical period. That is quite a significant trend downward because Medicare reimburses providers of hospice care for a period of up to six months. During the six month period, hospices would provide counseling and physical and emotional support for patients and their respective families at the end of a patients life. Patients who enter just days before death require more acute care and ultimately might drive up per diem costs which could translate into financial burdens for hospices. Still, the increasing demand for hospice corresponds with dramatic growth as there are about 3,200 existing U.S. hospice organizations today, versus about one half some eight years ago.
Should you wish to discuss this topic further or need more information, please feel free to contact Andy Schulman at Carpenter & Onorato Health Care Consulting at 516-745-0808 or through E-Mail at CandOPC@aol.com.
by Paul Bednar, Principal, Quality and Productivity Resources LLC
As administrators and members of organizations, you make and experience many changes. If there is one certainty to change, it is that some changes stick and some don't, regardless of the idea's merit. We have all seen good ideas fail, bad ones make their way through, and been left wondering why? What happened?
As witness to much organizational change, we identified, regardless of scale, conditions that are necessary to make change materialize and succeed.
While the above are necessary, they do not guarantee a change will be a lasting, accepted, or positive experience.
Conditions that embody successful change
* Address the true problem. Over time, a change may prove ineffective because it addressed some obvious or irritating symptom of a problem rather than a less obvious root cause.
* Understanding. The employees need to understand why the change is occurring. You can't force this, it has to come from within them. All you can do is communicate and facilitate.
* Support. Those impacted require the necessary equipment, training, and management attention.
* Involvement. Involving employees in the change process improves the quality of decisions and facilitates buy-in.
* Complete picture. Consider all parties affected and determine how the change fits into the organization's future. Plan the details to the greatest extent possible, but you don't want to be short-sighted.
* Impact. Understand and address the impact a change has down the line to the front-line workers. Consider the job's logistics and worker's feelings. Most people are personally vested in their work habits, even in jobs they don't like.
* Managing resistance. Every change encounters resistance. Anticipate it, let it happen and manage it. Resistance is not something to be conquered or stifled.
* Performance measures. Use objective measures to evaluate the performance of your change.
History. The organization's past should be a consideration. Has this change or one like it ever occurred? If so, what were the results?
Limited by what is around you. You can develop and educate employees, but you are ultimately limited by what is around you--both above and below. In short, your environment should be a consideration when contemplating organizational change.
Copyright, 1998, by Quality and Productivity Resources L.L.C.
Should you wish further information from the author, Mr. Bednar can be reach at his E-mail: email@example.com or by Phone: 804.985.4603/ Fax: 804.985.9848
For more information about our services, or Strategic Alliance Partners, please write to us at: Adkcmpa@aol.com or DKConsult1@aol.com
Copyright © 2011 DEKAYE Consulting, Inc.. All Rights Reserved.
No part of this web site, or the contents, and images contained herein may be used or reproduced
in any manner whatsoever without the prior written permission of DEKAYE Consulting, Inc.
D E K A Y E
231 Oakview Avenue, Oceanside, NY 11572 Phone: (516) 678-2754 Fax: (516) 825-4458
URL: http://www.dekaye.com E-Mail: Adkcmpa@aol.com or DKConsult1@aol.com