Increased Revenue Opportunities

1. Increased Revenue Opportunities IV Infusion Charge Capture – Austin Smith Radiology Pre-Authorization Project – Vanessa Calderon Process Improvement (Clinical Quality), IH-DM

2. IV Infusion Charge Capture Team: Executive Sponsor: Maureen Adams – Executive Director – Med/Surg Nursing Patty Armstrong – Director of Compliance Susan Barrett – HIM Manager Angie Boord – Pharmacy Manager Crystal Estabrook – Director of Revenue Cycle Lacy Little – Y7 Adaptive Design Corey Martin – Central Supply Manager Roxy Menke – Clinical Informatics Specialist Mary Parks – P5 Nursing Manager Amber Sandquist – Coding Coordinator Austin Smith – Process Improvement Coordinator Jan Stipe – Director of Case Management Chris Wood – N5 Nursing Manager

3. Revenue Cycle Recovery – IV Infusion • I. Business Case IV. Target Condition (Proposal) II. Current Condition III. Problem Statement VI. Metrics/Follow-up Author: Austin Smith Date: 1/10/11

4. Background • Identified by: Revenue Cycle team during audits • Proposed/Selected for Process Improvement Project • Started: 1/3/2011 Business Case 1. $500,000 additional revenue 2. Accurate Medical Records 3. Reduce Denials Associated with Documentation

5. Current Condition IV Push: Reimbursement Requirement: Chart, Document Start Time Current Practice: Consistently charted, start time documented Coding: Charges for all IV Pushes IV Piggyback: Reimbursement Requirement: Chart, Document Start/Stop Time Current Practice: Consistently charted, start time documented, no stop time Coding: No Charges for IV Piggybacks IV Hydration: Reimbursement Requirement: Chart, Document Start/Stop Time of each bag Current Practice: Seldom Charted, no start/stop time Coding: No Charges for IV Hydration

6. Problem Statement • Patients with “Observation” status are not currently billed for IV Piggyback or IV Hydration because stop times are not documented.

7. Target Condition – Short Term • Decided to narrow the focus to only IV Piggybacks • Coding charges IV Push for IV Piggyback without Stop Times • Justification: Push only requires a start time, this would be under charging January 1st – September 6th Charges: $1,379,815 Estimated Collections: $434,642

8. Problem Solving – Target Condition • How do we document all ACTUAL stop times? Options: • Nurses remember start time and know when to go back for stop time • Not accurate, no reminder, hard to ID observation patients • Get the actual stop time from the event log in the IV Pump • No reminder, hard to ID observation patients, time away from patients • IV Pump interface with CareCast or EPIC • No Capability YET • IV Pump Alarm when switching from IV Piggyback to Hydration • No Capability

9. Problem Solving – Target Condition • Only physically possible solution: Nurses manually chart stop times. We Were at a Stand Still… until… • Asked Lacy Little - Younker 7 UBE to help determine feasibility of options and brainstorm additional solutions. • Found “Done Time” in the charting area of CareCast • Investigated to see functionality • Is a calculated time acceptable? • Does this field appear where a coder could see it?

10. Target Condition – Long Term • Use “Done Time” Field in CareCast to automatically calculate the Stop Time of IV Piggybacks based on: • Administered Time – Nurse Entered • Volume – Pharmacy Entered • Rate – Pharmacy Entered Done Time will show up on DMAP for coding July 24th – September 6th Charges: $65,531 Estimated Collections : $19,659

11. Financial Results 2011 Annualized Charges: $2,400,000 Estimated Collections $776,000 Total Increased Revenue (1/1/11 – 3/2/12) Charges: $2,800,000 Estimated Collections: $905,000

12. Questions?Austin J. Smith Employee Safety ManagerIowa Health – Des Moines515-241-6647Smithaj3@ihs.org

13. Radiology Pre-Auth Project Team: Sponsors: Todd Kranpitz – Executive Director – Radiology Services Crystal Estabrook, Director of Revenue Cycle Amber Sandquist, Denials Coordinator Matt Helgeson, Manager Radiology, IH-DM Yvonne Grant – Supervisor Radiology, ILH Curtis Waddingham – Supervisor Radiology, MWH McKenzie Cooper (CT Tech), Lisa Sandin (MRI Tech) Jane Beeman, Manager Pt. Access – Scheduling Glenda Seemiller, Director Pt. Access Amber Aschan, Michelle Engle (Specialized Schedulers, “Audit Team”) Vanessa Calderon, Process Improvement Coordinator

14. Agenda • Project Background – A3 • Building the Team • Creating a Manageable Scope • Process Mapping to Identify Issues • Building Solutions • Sustaining the Gains

15. A3: Radiology – Pre-Certification Project I. Business Case Radiology was selected at IH-DM as an area of focus given the potential for loss. The benefit of this project is to increase revenue through decreasing the number of denials for missed pre-certifications/uncertain medical necessity. The need for this project is driven by revenue improvement initiatives. V. Target Condition Reduce denials dollars by 50% per month by August 2011 focusing on procedures with highest financial impact. This amounts to a maximum denial level of $27000 (Based on 50% of a 6 month average between Oct. 2010 and March 2010) per month for 2 months of review (through September 2011). II. Scope The scope of the project is from the time the procedure is ordered to the time of the first denial for payment. All 3 campuses’ (IMMC, ILH, MWH) radiology departments are within the scope of this project with a focus on CT and MRI procedures. Outpatients, including observation patients, will be addressed by this project. Only denials relating to Missing pre-auths and medical necessity are within scope. III. Current Condition 2010: Losses due to missing Pre-Auth and Medical necessity - $146,573.80 Baseline: Oct. 2010 – March 2011 –$55770.17 By Payor: By Procedure: Top MRI, Top CT Write-Offs IV. Problem Statement 80% of denials are due to missing pre-authorization and medical necessity. “Missing” means altogether not present or incorrect (correct one is missing). $150,000 in write-offs for 2010 were attributed to these causes. VII. Metrics/Follow-up (Current Avg: $14.166.60 for 5 months post-project) or 74.59% reduction Author: Vanessa Calderon (Updated 9/6/11)

16. Project Background • Pre-authorizations often necessary for procedures • If procedure changes, new pre-auth must be obtained • Gathering pre-auths can be time consuming and time by radiology staff should be spent serving patients

17. Step 1: Gather Data • Use Pareto Analysis and Graphs to Narrow Scope

18. Step 1: Gather Data • Determine mix of cases being denied (Two-Factors) *Focus on CT, MRI (upper left purple area) first, then on specific insurance to capture additional denials (lower pink area)

19. Step 2: Develop Team • Explore the Area • Look for key players in the process • In addition to Managers, Find Area Leaders: • Radiology Staff • McKenzie Cooper (CT Tech), Lisa Sandin (MRI Tech) • Scheduling Staff • Amber Aschan, Michelle Engle (Specialized Schedulers, “Audit Team”)

20. Step 3: Define Scope • Basic Scope and Problem Statement Defined • Present Data to Team to Refine Scope • Pinpoint Areas where Low Effort = High Impact • Set Attainable yet Aggressive Goals based on Facts

21. Step 4: Map the Process • Observation and Group-Work to Map Process (Visio)

22. Step 5: Log Issues • Yellow “Kaizen” bursts on map indicate areas where errors can occur that lead to missing authorizations • Top Issues placed in an Issue Log / Action Item List

23. Step 6: Build Countermeasures • Develop Tools to help brainstorm Countermeasures

24. Step 7: Construct/Conduct Trials • Document Steps involved in Trial • Determine timeframe, scope, and players involved • Communicate Trial • Check Intermittently and capture Results • Trial: One CT Tech will review all Abdomen/Pelvis orders 3 days before cases to determine if orders need to be changed. Contact Audit Team who will obtain New/Changed Authorization before scheduled case.

25. Step 8: Expand Trial • Based on Results • From one CT tech at one campus to all CT techs at 3 campuses (IMMC, ILH, MWH) • Expanded further to include • All MRI • All Cases

26. Step 8: Expand Trial • Use of DCR Tracker to Aid in Automation of Process

27. Step 9: Sustain Process • Ongoing: Finance Tracks denials Monthly, and CT and MRI cases are sorted out as a separate metric • Ongoing: Control Chart based on tracked write-offs • 6 Months: Audit Team tracked each case that traveled through new process to determine viability of process • Challenges: • EPIC changes to all processes • Addressing months outside of control limits

29. Final Results

30. Questions?Vanessa L. CalderonProcess Improvement CoordinatorIowa Health – Des Moines515-241-6887caldervl@ihs.org