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RCM Challenges in Healthcare Reform. hfma Georgia Chapter November 10, 2011. Presentation Outline. Contracting and Payment Approaches Payment Methodologies Integrating Clinical and Financial Aspects of the ACO New Revenue Cycle Requirements Basic Revenue Cycle Challenges and Solutions

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rcm challenges in healthcare reform

RCM Challenges in Healthcare Reform

hfma Georgia Chapter

November 10, 2011

presentation outline
Presentation Outline
  • Contracting and Payment Approaches
  • Payment Methodologies
  • Integrating Clinical and Financial Aspects of the ACO
  • New Revenue Cycle Requirements
  • Basic Revenue Cycle Challenges and Solutions
  • Advanced Revenue Cycle Challenges and Solutions
  • A Practical Health System Discussion Guide
the three tiers of payment approaches
The Three Tiers of Payment Approaches
  • Tier 1: Fee-For-Service and the World we have lived in for the past 20 years Approach
  • Tier 2: The Near Term changes of Procedure and Episode of Care Bundling, and Combined P4P with Physicians and Hospitals Approach
  • Tier 3: Managing an Accountable Care Organization Approach
tier 1 fee for service
Tier 1: Fee-For-Service
  • Hospitals Separate and Physicians Separate
  • CMS maintains Part A and Part B
    • APCs, DRGs, Fee Schedules, UBs and HCFAs
  • Payers/Providers negotiate the methodologies
    • %Charges, DRG Case Rates, Procedures, Per Diems, Fee Schedules, % Medicare, etc.
  • Administrative and Clinical Utilization Review
    • Denials, Underpays, Disputes, etc.
tier 2 bundling and value based contracting
Tier 2: Bundling and Value-Based Contracting
  • Physicians and Hospitals Combined Services
  • All-Inclusive Procedures and Services
  • Procedure Specific or Episode of Care
    • Single Site (Acute Care) or Multiple Site (IP,OP, Office, Rehab, Home Care)
  • Performance Payments Severity Adjusted
  • EBM Guidelines Across Continuum
  • Contracting and Claims Adjudication
tier 3 health systems as accountable care organizations
Tier 3: Health Systems as Accountable Care Organizations
  • Integrated Physician/Hospital Organization
  • Responsible for Identified Populations
  • Direct Contracting with Buyers
  • Accept Risk for Defined Patient Services
  • Have an Information Platform to Measure Clinical Performance and Perform Financial Transactions
  • Act like a Payer?
a combined solution for all three tiers
A Combined Solution for All Three Tiers
  • A Common Platform for All
  • Manage Scenarios Simultaneously
    • 80% Tier 1, 15% Tier 2, 5% Tier 3
  • Combined Performance Reporting
  • CMS and Payer Tier Profiles
  • MC & PFS Desktop Simplification
  • Physician/Hospital Care Coordination
  • Enrollment and Payment Functionality
new expanded payment models
New & Expanded Payment Models
  • Patient-Centered Medical Home Payment
    • Primary Care Driven Front End of Acute Services
  • Bundled Procedure Payment
    • High Cost Services – CABG, Joints, Backs, etc.
  • Bundled Episodes of Care Payment
    • Tied to Patient Condition and Time Related
  • Performance Based Payment
    • EBM Based, Severity Adjusted, Outcome Based
  • Partial and Total Capitation Payment
    • Population and Condition Driven
aco integration roadmap
ACO Integration Roadmap
  • Clinical Service Line Alignment
  • Clinical Pathway Development
  • Benchmarking Complex Procedures
  • Benchmarking Episodes of Care
  • Modeling Episodes and Procedures
  • Creating Bundled/Performance Contracts
  • Adjudicating Bundled Claims
  • Reporting/Managing Utilization
expanded rcm requirements
Expanded RCM Requirements
  • Utilization Reporting Across Continuum
    • Health System and Payer Driven
    • IP, OP, Physician, Ancillary Providers
  • Data Aggregation in Multiple Delivery Sites
    • Clinical Data from Physicians, Rehab, and Home Care
    • Financial Data Across the Continuum
  • Revenue Cycle Calculations & Transactions
    • Contracting, Claims Management, Adjudication
  • Patient/Payer Membership Management
basic revenue cycle challenges
Basic Revenue Cycle Challenges
  • Create and Model Bundled Contracts
  • Develop and Manage Combined Charge Masters and Fee Schedules
  • Aggregate Bundled Claims and Payments
  • Calculate Performance Payments
  • Provide Timely, Accurate and Transparent Clinical and Financial Reporting
aco like revenue cycle challenges
ACO-Like Revenue Cycle Challenges
  • Patient Enrollment and Eligibility
  • Contract Modeling across Continuum
  • Maintenance of Multiple CDM/Fee Schedules
  • Case Management/Referral Services
  • Claim Re-Pricing/Clearing/Payment
  • Dispute Resolution/Collections
  • Risk Sharing, Gain Sharing, Treasury Services
the basic solution
The Basic Solution
  • Bundled Payment Capabilities
    • Contract Modeling and Management
    • Integration of Fee Schedules and CD
  • Patient Eligibility for Bundled Programs
  • Performance-based Payment Capabilities
    • Clinical/Severity-based Calculations
    • Financial/Spend-based Calculations
  • Integrated Reporting Capabilities
    • Robust Utilization and Financial Reports
the aco like solution
The ACO-Like Solution
  • Claims Management, Clearing, Posting
  • Enrollment and Provider Rostering
  • Case/Referral/Utilization Management
  • Dispute and Collections Management
  • Provider Credentialing
  • ACO Patient Self-Service Portal
  • Treasury Services
  • Multi-Level Reporting – Financial/Clinical
an organizational discussion
An Organizational Discussion
  • Board Of Directors
  • Senior Leadership Team (C-Suite)
  • Clinical and Financial Department Managers
  • The Revenue Cycle Team Leaders
  • All Revenue Cycle Personnel
who is in our integrated aco
Who is in Our Integrated ACO?

RCM Solution

  • Provider Demographics
  • TINS and Sites
  • Facility Identifiers
  • CMS Information
  • RCM IT Information
  • Clearinghouse Info

Answer

  • All of our Facilities
  • All Active Medical Staff
  • Contracted Ancillary
    • Physicians and Extenders
    • Facilities (Rehab, ASC, etc)
    • Home Care, Hospice
which service lines are in the aco
Which Service Lines are in the ACO?

RCM Solution

  • Physician Roster
  • Sites of Service
  • Services Benchmarks
  • Model Claims
  • Contract Terms
  • Fee Schedules, Codes

Answer

  • Cardiovascular
  • Orthopedic/Joints
  • Spine Surgery
  • Stage 2 Cancer
who are the covered enrollees
Who are the Covered Enrollees?

RCM Solution

  • Contract Terms
  • Payment Method
  • Enrollment Database
  • Patient Demographics
  • Patient Benefits

Answer

  • The Hospital Employees
  • Aetna Fully Insured
  • United ASO Employers
  • Tri-Care
what payment models included
What Payment Models Included?

RCM Solution

  • Charge Coding
  • Calculation Engine
  • Contractual Discounts
  • Payment Posting
  • Performance Measures
  • Distributions

Answer

  • PCMH – Primary Care
  • Episode of Care
  • Medicare SS
  • Blue Cross Performance based grouper outcome
what rates will aco charge
What Rates will ACO Charge?

RCM Solution

  • CDM & Fee Schedules
    • By Provider, By Contract
  • Grouper and EBM performance calculator
  • Medicare Values for all ACO Providers

Answer

  • Will vary by Payer
  • Likely % Medicare
  • Performance-based
    • Individual Provider
  • Whatever we can
how will aco monitor performance
How Will ACO Monitor Performance?

RCM Solution

  • Capture Claim Activity
  • Report Care Variance from Benchmarks
  • Facilitate interfaces to Providers in ACO

Answer

  • Across Care Continuum
    • Primary Care
    • Specialty Care/OP
    • Acute Care/IP
    • Sub-Acute
    • Home Care/Follow up
how will the aco handle claims
How Will the ACO Handle Claims?

RCM Solution

  • Bundled Claims Scrubbing
  • Bundled Claims Clearing
  • Calculation Engine
    • Performance-based
    • Payment Posting
    • Variances

Answer

  • Receive Claims from Providers and Facilities
  • Send Claims or Claim Summaries to Payers
  • Receive Payments from Payers
how will the aco prepare reports
How Will The ACO Prepare Reports?

RCM Solution

  • Standard Reports from ACO RCM Database
  • Payer Report Validation
  • External Data Imports
  • Ad Hoc Reporting

Answer

  • From the Claims Data
  • From Payer Data
  • From Clinical Data
who will manage the aco
Who Will Manage the ACO?

RCM Solution

  • Implement a Platform that will manage these transactions

Answer

  • We will for the Transactions side
  • The Medical Staff will run the care delivery management
so then how to start part 1
So Then, How to Start – Part 1
  • Be Sure that the Revenue Cycle Team is an Integral Part of the Health System discussions about Integrated Care
    • In a nice way, remind leadership that this Reform is Revenue Cycle Management reform
  • Take an Inventory of your Hospital Patient Accounting, Contract Management, and RCM reporting capabilities
  • Identify the likely Providers (Physicians and other facilities) that will be a part of your Integrated Network
  • Talk with your big Payers about their Interests
  • Monitor CMS ACO Progress
how to start part 2
How to Start – Part 2
  • Identify missing parts in existing RCM IT infrastructure
    • These will likely be in complex contract management, cost reporting, CDM and Fee Structure Management, etc.
  • Research opportunities with existing RCM IT vendors
    • Do they have platforms to integrate the new RCM functionalities for providers across the care continuum? What are their plans?
  • Explore the Market for New or Added Solutions
    • Look for platforms that accommodate the entire continuum
    • Remember the new requirements – enrollment, bundled modeling, bundled claim adjudication, treasury, etc.
how to start part 3
How to Start – Part 3
  • Present your researched RCM Functionality Plan to the Health System Integrated Care Leadership Group
  • Incorporate the Clinical Benchmarks, EBM Standards, and Services (CMS ACO, Cardiovascular, Ortho, etc.) under consideration by the Clinical Leadership
  • Determine what Services and Payment Models are being considered by your major Payers
  • Using your new processes, Model the potential arrangements that are being discussed by the ICLG
  • Bring the Information back to the Leaders for Discussion
  • Sign a Contract & Manage the Transactions
summary
Summary
  • The Shift from FFS will likely be gradual and incremental
  • There is sufficient time to design your plans
  • But, it will take time culturally and operationally.
  • Clinical Change Management will require consensus building and professional compromise
  • Revenue Cycle Change Management will require operational retooling, distributed accountability, and technical upgrades to maintain a shared RCM Platform
  • The Market Winners will be Ready for the Change
thank you
Thank you !!

Nick Hilger

nhilger@jdaehealth.com

651-324-2943