At its core, healthcare is a business. As a healthcare organization administrator or practice owner, you’re well aware of this. You need to make smart business decisions to ensure a profitable bottom line; decisions that promote quality services, compliant documentation and coding, competitive prices, and most importantly, productive employees.
But like any other business owner, you’re not just focused on a profitable bottom line – you also need to constantly increase profits. How? Most businesses focus on 3 core strategies: (1) lower prices, (2) lower operating costs, or (3) measure and increase employee productivity.
I’ve found the third strategy to be very useful to healthcare organizations and medical practices, since there’s often room for improvement. So, let’s talk. How can measuring employee productivity boost your profits?
The importance of productivity
Productivity is important in any setting. However, it’s particularly important in healthcare organizations and medical practices, where the volume of work seems to increase daily.
Coders are increasingly overwhelmed with preparing for ICD-10, capturing all relevant conditions, ensuring clinical validation for diagnoses that are coded, and querying physicians when necessary. Clinical documentation improvement specialists are faced with the daunting task of educating physicians about ICD-10 and providing documentation audits to identify gaps. Physicians, nurses, and other providers are inundated with new patients who have entered the healthcare marketplace thanks to the Affordable Care Act. The influx of new patients into the system also places an increased demand on administrative staff who must answer patient inquiries, promote the practice’s patient portal and other new technology, schedule appointments, and more.
If you’re like most healthcare organizations or practices, you probably don’t necessarily have the financial resources to hire additional full-time equivalents (FTEs) to accommodate for unexpected changes in workflow and other demands. This means you’ll need to increase the productivity of current staff members to remain fully operational.
To do this, you’ll need to have a solid process in place to ensure that all employees perform at predicted productivity levels, particularly as new tasks are added. This process is particularly important as new employees are hired. When you’re unable to closely monitor and enhance productivity, you’ll likely start to see a slow decline in profits that can ultimately lead to the need to cut FTEs during a time when those FTEs are needed most.
Finding the right candidates
Productive employees are those who not only work hard but who also believe in the overall mission of the organization. When recruiting employees, you should take the time to sort through candidates who may be looking for a short-term job vs. those who understand the critical nature of the work they perform and how it fits in with your goals.
How do you do this? Spend extra time crafting the job posting and provide information about the workplace and the organization or practice’s goals. Post the application on online job search sites to maximize exposure.
During the interview, itself, consider asking the following questions to get a sense of candidates’ work ethic:
- Why is this job important to you?
- Why do you think this job is important to the organization overall?
- How would you describe your own work style?
- Provide an example of how you’ve handled a time when you needed to multi-task and how you handled that.
- Describe a time when you set a goal at work. Explain how you accomplished that goal.
Performing ongoing productivity analyses
Setting productivity goals and monitoring those goals regularly is an important component of overall success. The specific goals will vary according to function; however, what’s most important is that you take the time to establish these goals and hold all staff accountable for achieving them. This includes tracking employee time management and attendance, both of which are critical to productivity. Revisit these goals throughout each month. When productivity has declined, identify and address the root cause of the problem. When productivity has remained constant or increased, take the time to praise and reward employees for their good work.
Providing training, when necessary
Knowledge is power, and employees remain productive when they have the most updated information they need to perform their jobs. For example, staff performing coding require ongoing ICD-10 training, access to quarterly changes published inCoding Clinic, and more. Patient registration and billing staff members need ongoing training regarding medical necessity and other insurance policy changes. Providers need training regarding the most updated clinical protocols and/or how to use the EMR. Some employees could benefit from refresher training or more specialized education in an area in which they need improvement. Establish a schedule for employee-specific training and then track employee compliance with that schedule.
Measuring employee productivity is an important aspect of running a business that no healthcare organization or medical practice can afford to overlook. Employee productivity is important for everyone, and it is particularly important for those roles that are task- and volume-driven. Take the time to establish role-specific productivity standards, educate employees about these standards, and then hold individuals accountable for meeting—and exceeding—these requirements.
Monitoring employee productivity ensures that employees are performing at full capacity, maximizing their time and getting high-quality results. When all employees give 100% effort to ensure productivity, the business benefits. Dedicated employees who strive to improve performance and increase their knowledge may be one of the most important weapons a healthcare organization or medical practice has against the big changes in healthcare and top threats to revenue this year.
Insurance carriers routinely cite evidence-based clinical guidelines when denying treatment authorization. However, a number of insurance industry resources confirm that insurance medical decision makers must consider the patient’s unique medical condition and should deviate from the clinical guidelines when appropriate.
Requesting deviation from the guidelines will typically require an appeal focusing on the patient’s unique medical needs and why application of the guideline is not appropriate. Some of the specific factors to address in such an appeal include the following:
- Patient’s previous treatments and discussion of failed treatment attempts and unwanted side effects
- Patient’s secondary diagnoses which potentially complicate treatment
- Any anatomical anomalies or age-related factors (pre-natal or geriatric challenges)
- Ongoing diagnostic assessment for unexplained symptoms/atypical disease/disorder presentation
Further, the guideline itself can be called into question if it does not appear to adhere to current industry quality care standards and incorporate the latest treatment options. Some of the specific questions useful for assessing the quality of the guideline include the following:
- How frequently the guideline is updated to incorporate recent medical developments
- Patient demographic used to develop standards, ie, did the guideline development include studies involving a diverse patient population inclusive of prenatal patients, geriatrics and minorities to ensure appropriate application across a diverse population.
A study of medical necessity decisions made by private health plans discusses the widespread adoption of clinical guidelines for use in medical necessity decision making. According to this study entitled “Medical Necessity in Private Health Plans: Implications for Behavioral Health Care“, several insurer medical directors acknowledged that clinical guidelines are simply a decision making tool and should allow for flexible implementation.
“Interviewees stated that guidelines are not mandates or absolute protocols; rather, they are considered ‘guideposts’ to be informed by, and adapted to, individual circumstances and psychosocial needs of patients. Ongoing audits, performance measurement of in-house care managers and contracted providers, and member and provider satisfaction surveys are used to monitor the appropriate use of treatment guidelines in medical necessity decisions and to build in quality improvements at all levels of decision making,” states the study, available online at http://download.ncadi.samhsa.gov/ken/pdf/SMA03-3790/SMA03-3790.PDF.
Estimates show denied claims represent over 13% of gross revenue for providers nationwide. Some studies suggest that over 90% of those denials were preventable and nearly 70% could be overturned. An additional 6% of gross revenue was lost to underpayments. These numbers are staggering when you combine lost revenue as a result with the high cost associated with resolving these denials.
To face this challenge, providers must have an effective strategy in place to identify denials, manage their resolution and analyze root cause to facilitate prevention of future denials. Some keys to an effective denial management strategy include:
1) Capturing all remittance information necessary for denial management
A primary source of denial information is the payer remittance advice (RA). Many providers focus on payment posting from the RA and neglect to capture all of the information critical for effective denial management. For denial follow-up, it is important to capture and categorize all payer reason and remark codes.
2) Paying attention to payers who provide hard copy remittance reports
To maximize collections, providers must manage denials for 100% of their payer mix. Payers who cannot provide electronic remittance advice (ERAs) typically represent around 15% of total revenue, and many providers feel that the cost of capturing denial information from a hard copy remittance report is just too high to chase such a low percentage of revenue. A simple cost/benefit analysis will likely reveal that the cost of capturing denial information from a hard copy remittance report is easily outweighed by the denial recovery opportunity, and the opportunity to identify and prevent future denials.
3) Identifying and managing underpayments
If your denial management process does not identify and manage underpayments, you may be losing up to 6% of your annual gross revenue. Managing underpayments is frequently overlooked as part of a denial management strategy. First, you can qualify partial payment denials from remittances by looking for specific reason codes to identify charge-level denials. Second, it is critical to identify payment variances by comparing remittance paid amount to the expected payment amount. This can be challenging if HIS systems, contract management systems and denial management systems don’t work well together, however, this problem is easily and clearly worth resolving given the amount of revenue at stake.
4) Considering how denied accounts are assigned to follow-up staff
Too often, the focus on resolving EVERY denial results in chasing hundreds of low balance denials while sacrificing valuable resources who could be working on resolving collectible denials. Make sure follow-up assignments are reasonable. If a follow-up work queue has 2,000 denied accounts in it, the likelihood of staff always working on the most important account will be pretty low, and the likelihood of timely follow-up on all 2,000 denied claims is even lower. There are always exceptions that require judgment, however, consider filtering follow-up work queues to include a smaller number of high priority accounts. Also, consider setting a threshold (based on cost to collect or other defined criteria) for automating low-balance write-offs on denials, eliminating those accounts from work queues.
5) Automating or streamlining follow-up activity
Efficiency is the key to maximizing recoveries. Follow-up staff should have tools to save them time, allowing them to work and resolve more accounts. Some examples:
• Payer-specific appeal letter templates that can be auto-filled with account-level information like Patient Name, PCN, MRN, DOS, Denial Reason Codes, etc.
• Write-off authorization tools to streamline the request and approval process
• Canned follow-up actions and notes to prevent staff from wasting valuable time typing the same thing over and over again
• Quick access to view and/or print the EOB and the denied claim
• Automated alerts that notify users when a prior follow-up action has not resolved the denial within the designated period of time.
6) Tracking and analyzing the outcome of denial follow-up
Make sure the outcome of each resolved denial is clearly identified. Analyze outcomes and educate staff to evaluate processes that historically have not been successful overturning denials. If sending the same appeal letter to the same payer for the same denial reason on 100 different claims has not overturned any denials, consider creating a new follow-up plan for that denial reason.
7) Identifying root cause and focusing on prevention
Increasing denial recovery rate is good. Decreasing initial denial rate is better! The key to prevention is in identifying the root cause. When providers understand root cause, they can make business decisions to facilitate prevention. Studies suggest that almost 80% of denials are Patient Access errors, but if the cause is unknown, staff may not be solving the right problem. It is worth the effort to evaluate and assign root cause to denials whichinclude identifying trends and taking steps to prevent future denials.
8) Setting and tracking financial and operational performance goals
Dashboard-style reporting tools are very helpful to communicate performance metrics throughout the organization and to manage performance. Important denial performance metrics includes : initial denial rate, recoveries on denials and underpayments, rate of appeals overturned, monthly denial trends by payer and error type, denial outcomes by payer and error type.
These tips are some of the keys to a comprehensive and effective denials management strategy.
by Todd Thomas, Director of Provider Product Management (Emdeon)
One of the biggest trends we’re seeing in healthcare today is a shift towards high deductible plans. This shift first started as more and more employers stopped offering insurance or cut the type of health insurance they offered. This started the trend towards individuals purchasing high deductible insurance plans.
While the shift to high-deductible insurance plans started well before the Affordable Care Act (ACA), the government mandated health insurance and associated health insurance exchanges (HIX) have thrown gas on the already flaming fire. What most patients didn’t realize when they signed up for insurance on the government’s HIX is that a large majority of the plans were high deductible insurance plans. This has led to a huge influx in high deductible plans entering medical offices.
What does this increase in high deductible plans mean?
This change is one of the most significant changes in healthcare reimbursement we’ve seen.High- deductible plans mean a major shift in who will be paying the bill. Instead of collecting most of your money from insurance companies, your clinic will need to becomeexpert at collecting money from patients as well. Yes, that’s right. You’re still going to have to collect from the insurance companies like before, but you’re going to have to build additional expertise around collecting payments from patients too.
While it’s true that clinics have been collecting payments from patients forever, that doesn’t mean that clinics have been doing a good job of actually collecting the money. In fact, I find practice after practice who hasn’t stayed on top of their patient collections. In the end, they often send their patient collections to a collections agency which frustrates the patients and tarnishes their name or they just write off the patient pay portion completely.
Suggestions to Improve Patient Collections
The first step to improving patient collections is to really understand the details of your patient’s insurance plan. This starts with doing an insurance eligibility check and verifying your patient’s plan details. We wrote about ways to streamline your insurance eligibility checks previously. Doing it right takes time, but with the right workflow automation solutions you can make sure that those working in your practice have the right insurance information. Once they have the right payment information, you’re much more likely to collect the payment from the patient while they’re standing in front of you at the office.
While collecting the patient payment from the patient while their in your office is ideal, there are dozens of reasons why this won’t happen. Some don’t have the money on them. Some walk out before you can collect. How then do you engage the patient in the payment process once they’ve left your office? In the past, the best solution was to send out bill after bill through mail service or possibly call the patient directly. This is an extremely time-consuming and costly process that can take 60 to 90 days to obtain results. Plus, it costs several hours of manpower and postage.
In the electronic world we live in, the first thing you can do to improve your patient collection process is to implement an online patient payment portal. This online payment process increases patient collections dramatically. The next generation patient is so unfamiliar with writing checks and sending snail mail, that those payments often get delayed. However, by offering the online patient payment option, you remove this barrier to payment.
The other way to improve patient collections is to use an automated messaging and collection process. This approach uses a collection of text, secure text, email, secure email and even smart -phone notifications and automated calls in order to ensure the patient knows about their bill and has the opportunity to pay the bill. Plus, these customized decision rules provide a much more seamless and consistent approach to patient collections.
This movement to the empowered patient with a high deductible insurance plan is not likely to go away. Employers are happily getting out of the health insurance business and many want patients to have more responsibility over the healthcare they receive. Being sure that you have a well- thought out-patientcollection workflow is going to be critical to the ongoing success of any medical practice.
In an effort to shift healthcare from a fee-for-service payment model toward a care quality-based model, CMS continues to offer support and incentives to physicians that form or join an accountable care organization. With that in mind, CMS has released a proposed rule that aims to improve care coordination within ACOs as part of the agency’s Shared Savings Program. The industry can submit comments about the proposal through February 6, 2015.More than 330 accountable care organizations (ACOs) are members of the Shared Savings Program, and there are 4.9 million beneficiaries in the participating organizations. Fifty-eight organizations that participated in the first year of the Shared Savings Program reported earning a combined $315 million in shared savings payments.
The 110-page proposed rule aims to clarify the following aspects, among others, of accountable care.
- Requirements for ACO participant agreements, the application and application review process. This provision was added because past Shared Savings applications contained incorrect information which caused them to experience processing delays. CMS recommends ACOs view itsACO Participant Agreement Guidance to confirm their application will be accepted.
- The identification and reporting of ACO participants. This step specifies that an ACO must include a list of all its ACO participants during the application process and submit an updated list annually.
- Eligibility requirements based on the ACO’s number of beneficiaries, structure and governing body. A section of the ACO agreement clarifies participating ACOs must “include primary care ACO professionals that are sufficient for the number of Medicare fee-for-service beneficiaries” and that the amount of beneficiaries must be 5,000 at a minimum.
- The two-sided performance-based risk tracks for ACOs. Track 1 is a shared savings only option, while track 2 applies to ACOs that take on performance-based risk. Upon reviewing these two choices, CMS has proposed the creation of a third track in which providers would accept even more performance-based risk. Track 3 ACOs would have greater incentive to improve their care quality because doing so could maximize their cut of any shared savings.
- ACO public reporting and transparency. This can be accomplished by each ACO maintaining a website that lists the organization’s name, identifies ACO participants and discloses data on their shared savings and losses owed to CMS.
The new proposed ruling is a clear indication of how important health IT is to the success of an ACO. As detailed in the document, the rule would require an ACO to outline in its application what technologies would be used to promote more coordinated care for their beneficiaries. Examples of things that could be listed in an application include the use of EHRs to track patient’s data, telehealth services to remotely monitor patients and the electronic exchange of patients’ health information.
CMS is working to document the success of ACOs and share insights and accomplishments with the healthcare industry to spur the creation of more accountable care groups. The proposed rule offers a template for participating ACOs to make to make certain information — such as the identification of ACO participants, governing body members and the amount of any shared savings or shared losses incurred — available to the public on a website that meets CMS requirements.
The need for an outcome-based payment model and a reduction in healthcare costs are the leading forces behind the creation of ACOs. Some of the first ACOs faced significant challenges during the early adoption stages due to a lack of supporting technologies and health information exchange platforms. Due to the public disclosure of ACO success stories, along with a helpful push from meaningful use criteria, physician-led groups and hospitals have a growing interest in signing up for ACOs.
Article by: Reda Chouffani