Transcript CUMC PPT Tutorial File - Columbia University Medical Center

Session 5:
Academic Medical Center
Revenue Cycles
Session 5:
Academic Medical Center
Revenue Cycles
Part 1: Sponsored Research Revenue Cycle
Part 2: Patient Care Revenue Cycle
Part 3: Tuition Revenue Cycle
Session 4 - Financial Reporting
AGENDA
Introduction
15 Mins
Part 1: Sponsored Research Revenue Cycle
60 Mins
Break
15 Mins
Part 2: Patient Care Revenue Cycle Processes & Controls: A
Closer Look
45 Mins
Break
15 Mins
Part 2: Patient Revenue Cycle at CU & Case Studies
60 Mins
Part 3: Tuition Revenue Cycle
30 Mins
TOTAL
240 Mins
November 2004
Page 3
GOALS AND OBJECTIVES
– Revenue Cycles
• Understand the key processes that make up these revenue cycles
• Understand the controls that can be instituted and monitored within the revenue
cycle process
• Understand potential pitfalls associated with various key processes
November 2004
Page 4
CUMC: 2003-2004 Source of Operating Funds
Total = $1.2 Billion
Tuition
5%
ICR
9%
Sponsored
Awards
33%
Other
9%
Affiliations
12%
Clinical Practice
32%
Note : Other includes gifts, endowment, patent and miscellaneous revenues
November 2004
Page 5
Part 1
SPONSORED RESEARCH
REVENUE CYCLE
The sponsored research funding cycle begins with a program announcement
by a granting agency and ends with the final progress report and financial
close-out. Investigators prepare applications which are approved by their
institution and the granting agency performs peer review and scoring. A
notice of grant award is issued and the principal investigator begins
conducting research. Post-award activities include financial monitoring to
ensure funds are spent in accordance with program goals and objectives.
November 2004
Page 6
CUMC: SPONSORED RESEARCH FUNDING
Millions
400
300
200
100
0
'95
'96
'97
'98
Government
'99
'00
'01
'02
'03
'04
Non-Government
November 2004
Page 7
SPONSORED RESEARCH
REVENUE CYCLE
Program announcement
Final Reports & Closeout
Application preparation
Progress Reports
Institution Request
Reimbursement
Award Adjustment
Institutional review
Post Award
Pre Award
Application submission
Functions
Functions
Peer review and scoring
PI expends funds;
Institution Monitors
Notification of
pending award
Cost center created
Award negotiation
Award issued
November 2004
Page 8
SPONSORED RESEARCH
REVENUE CYCLE
November 2004
Page 9
SPONSORED RESEARCH
REVENUE CYCLE
Pre Award Process
Finding the Money
– Senior Investigators
•
Know about announcements
•
Should need minimal support
– Junior Investigators
•
Access to announcement databases (e.g. Community of Science)
•
Need support
November 2004
Page 10
SPONSORED RESEARCH
REVENUE CYCLE
Pre Award Process
Application Preparation
– Generally prepared by the PI
– Guidance from research administration office on:
•
Sponsor format and forms
•
Necessary regulatory approvals
•
Sponsor due dates
– Scientific content may be reviewed by senior investigator
November 2004
Page 11
SPONSORED RESEARCH
REVENUE CYCLE
Pre Award Process
Application Preparation
– Some institutions provide grant writing support and “mock” peer review
•
Effectiveness needs to be assessed
– Grant applications generally are reviewed differently than contract
applications
•
“Best Effort” vs. Procurement
November 2004
Page 12
SPONSORED RESEARCH
REVENUE CYCLE
Budgeting Considerations
– Institutional policies
– Program announcements
•
PI effort
– NIH Grants Policy Statement
•
Modular Grants policies
– Federal cost principles
•
OMB Circular A-21
– Cost accounting standards
– Departmental budget
November 2004
Page 13
SPONSORED RESEARCH
REVENUE CYCLE
Award Budget
Award Budget = Direct Costs + F&A Costs
November 2004
Page 14
SPONSORED RESEARCH
REVENUE CYCLE
Criteria for Budgeting and Charging a Direct Cost
– Some simple maxims
•
The budget should represent the best intentions of the investigator
•
Direct costs charged should represent those costs necessary to meet the
project’s scientific and technical requirements
•
The relationship between the charge and the science should
– Be “clear and close”
– Costs should support the project’s purpose and activity
– To be charged to an award, a direct cost should be included in the awarded
budget, or the cost must be permitted within rebudgeting authority granted
by the sponsor
– The cost must not be restricted by the sponsor
November 2004
Page 15
SPONSORED RESEARCH
REVENUE CYCLE
Pre Award Process
Institutional Reviews
– To ensure compliance requirements are met for
•
Human / animal subject use
•
Research safety and hazardous materials management
•
Facilities
– That the budget is appropriate for research proposed
– That budgets costs are consistent with institutional practices
– To identify agency restrictions and cost share
– That the application is complete
– Provides assurance to the institutional official signing the application that
the scientific and administrative requirements have been met
November 2004
Page 16
SPONSORED RESEARCH
REVENUE CYCLE
Pre Award Process
Submission of the Application
– Submission can be
•
Electronic
•
Manual
– Institutional systems may have
•
Common database
•
Shared with
– Central Office of Research Administration
– Finance
November 2004
Page 17
SPONSORED RESEARCH
REVENUE CYCLE
Pre Award Process
Sponsor Peer Review and Scoring
– Applications are reviewed for scientific merit and the research goals of the
agency
– Priority scores are often used, e.g., NIH, based on:
•
Significance
•
Approach
•
Innovation
•
Investigator track record
•
Environment and facilities
•
Representation of population to be studied
•
Reasonableness of the proposed budget
•
Adequacy of proposed protection for humans, animals, and the environment
November 2004
Page 18
SPONSORED RESEARCH
REVENUE CYCLE
Pre Award Process
Award Negotiation
– Limited negotiation effort with federal sponsors
•
Generally a unilateral cut: Feds argue grants are “assistance”
•
Contracts require extensive cost justification
– Greater negotiation effort with non-government sponsors
•
Indirect costs
•
Cost reimbursement
•
Intangible costs
– Technology transfers, e.g., patent ownership, licensing
– Coordinate with Central Office of Research Administration
November 2004
Page 19
SPONSORED RESEARCH
REVENUE CYCLE
Post Award Process
Award Issued
– About 20%-25% of applications are awarded
•
Renewals generally higher
– Award is made to the institution, shared responsibility between Institution
and PI for proper project administration
– Terms and conditions are specified on the notice of grant award
November 2004
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SPONSORED RESEARCH
REVENUE CYCLE
Post Award Process
Federal Awarding Mechanisms
– Research and Training Grant
•
Federal assistance providing money, property, or both to an eligible entity to
carry out an approved project or activity
– Cooperative Agreement
•
Substantial federal programmatic involvement with the grantee, e.g., clinical
trials or multiple site projects
– Contract
•
Mutually binding legal relationship between the contractor and the government
for procurement of goods and services
– Most restrictive of all award mechanisms
– Most often used by Department of Defense and NASA
November 2004
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SPONSORED RESEARCH
REVENUE CYCLE
Post Award Process
FAS Account Created
– Budgeted in accordance to expenditures of approved project
– Direct expenditures
•
Salaries and wages of personnel
•
Lab supplies and materials
•
Equipment
– F&A (Indirect) expenditures
•
Assigned to the project through the government negotiated overhead rate
– Facilities and operations
– Other administrative support
November 2004
Page 22
SPONSORED RESEARCH
REVENUE CYCLE
Post-Award Process
Reimbursement Methods
– Letter of credit
•
Used for federal agencies awarding grants and cooperative agreements
– Vouchers
•
Used for federal agencies awarding contracts
– Billing
•
Used with non-federal sponsors
•
May be cost reimbursement or payment for completed clinical trial study
participant
– Whatever mechanism is used, consideration has to be given to cash flow
and monitoring receivable amounts
November 2004
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http://www.cumc.columbia.edu/research/
CUMC Faculty and Research Information
Research Administration, Electronic Res Admin (RASCAL), Office of Grants and Contracts,
University & Campus Profiles, Faculty Profiles, Shared Equipment/Core Facilities, Campus
Research Activities, Research Courses and Seminars, Publications, Policies and Procedures
Research Funding
Funding Databases, Funding Information by e-mail, Award Programs, Grant-Related
Publications, Sources of Funding Information
National and International Research Resources
Links to Funding Agencies: NIH, Private Agencies, and others Grant Writing Tips, Electronic
Forms, Grants Management, Bio & Medical Research Ethics, Clinical Trials, Intellectual
Property/Tech Transfer, Commercial Institutions, Professional Societies
November 2004
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http://www.cumc.columbia.edu/research/faculty.htm
| Office of Research Administration/Office of Grants and Contracts |
| CU's Electronic Research Administration System (RASCAL) |
| Columbia University & Health Sciences Campus Profile |
| Faculty Profiles | Shared Equipment & Core Facilities Directory |
| Research Activity and Sponsored Projects |
| Courses and Seminars | Publications |
| University Research Policies and Procedures |
Office of Research Administration/Office of Grants & Contracts
Manual of Policies and Procedures
Research Administration Forms
Office of Grants & Contracts, IRB, IACUC, Environmental Health and Safety, Radiation Safety, Columbia Innovation
Enterprise, Office of the Treasurer & Controller, Purchasing Office
Research and Grants Journal
Monthly listing of funding opportunities in the biomedical and behavioral sciences; including those from federal agencies, state
and local governments, voluntary health organizations, and foundations. Available in web-based and hard-copy formats.
November 2004
Page 25
Manual of
Policies and Procedures
http://www.cumc.columbia.edu/research/manual/ogcm2598.htm
Columbia University
Health Sciences Division
Office of Grants and Contracts
Manual of
Policies and Procedures
TABLE OF CONTENTS
| 1. Introduction | 2. General Information | 3. Preparing the Application |
| 4. Application Submission Procedures | 5. Post-Award Administration | 6. Close-Out |
1. Introduction
2. General Information
– 2.1 Types of Sponsored Projects
•
•
•
•
•
2.1.1 Grants
2.1.2 Contracts
2.1.3 Research Subcontracts or Consortium Agreements
2.1.4 Fee for Service Contracts
2.1.5 Cooperative Agreements
– 2.2 How is a Sponsored Project different From a Gift?
3. Preparing the Application
November 2004
Page 26
Research Funding
http://www.cumc.columbia.edu/research/funding.htm
Research Funding
•Research and Grants Journal
•Research Funding Databases
•Research Funding Information by e-mail
•Award Programs with a Limited No. of Allowed Applications
•Award Programs Reviewed and Funded Internally
•Award Programs Specifically for Equipment
•Honorific Awards
•Grant-Related Publications and Other Sources of Funding Information
•Links to Funding Agencies
•Writing a Grant Proposal
Research and Grants Journal
Monthly listing of funding opportunities for research, training, and service activities in the biomedical and behavioral sciences; including
those from federal agencies, state and local governments, voluntary health organizations, and foundations. Funding opportunities are listed
chronologically by deadline, then alphabetically by funding agency.
Word and PDF (Adobe) Versions
These Word (PC) and PDF (Adobe) Versions of the Research and Grants Journal contain active e-mail and web links.
January 2004 Deadlines: Word (PC); PDF; Listing of Funding Agencies
February 2004 Deadlines: Word (PC); PDF; Listing of Funding Agencies
March 2004 Deadlines: Word (PC); PDF; Listing of Funding Agencies
April 2004 Deadlines: Word (PC); PDF; Listing of Funding Agencies
May 2004 Deadlines: Word (PC); PDF; Listing of Funding Agencies
June 2004 Deadlines: Word (PC); PDF; Listing of Funding Agencies
July 2004 Deadlines: Word (PC); PDF; Listing of Funding Agencies
August 2004 Deadlines: Word (PC); PDF; Listing of Funding Agencies
September 2004 Deadlines: Word (PC); PDF; Listing of Funding Agencies
October 2004 Deadlines: Word (PC); PDF; Listing of Funding Agencies
November 2004 Deadlines: Word (PC); PDF; Listing of Funding Agencies
December 2004 Deadlines: Word (PC); PDF; Listing of Funding Agencies
Web Version
To access: Login to Rascal, Columbia University's web-based research administration system, with your University network ID (UNI) and
Password. Select “Finding Funding”, then “View Research and Grants Journals”.
November 2004
Page 27
Faculty & Research:
Grants Management
http://www.cumc.columbia.edu/research/grants.htm
Faculty & Research:
Grants Management
Columbia University
•Columbia University Medical Center's Manual of Policies and Procedures
•Research Administration Forms
Office of Grants & Contracts, IACUC, Environmental Health and Safety, Radiation Safety, Columbia Innovation Enterprise, Office of the
Treasurer & Controller, Purshasing Office
•Administrative Information for Grants & Contracts Applications
•Information on NIH's Modular Grant Program
•Information on NIH's Non-Competing (Type 5) Grant Progress Reports
•Support of Graduate Research Assistants on research grants
•Subcontracts
Slide presentation on Subcontracts and Subawards
•Training Grants
Slide presentation on Pre-award and Post-Award Management of Training Grants
•Support of Graduate Research Assistants (GRAs) on Research Grants
•
•
Slide Presentation
PDF version of slides
•University Research Policies and Procedures
•Comprehensive Research Funding Information
Federal Policies and Regulations
•Code of Federal Regulations
•Travel
November 2004
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BREAK
November 2004
Page 29
Part 2A
COLUMBIA UNIVERSITY PATIENT CARE
REVENUE CYCLE
The patient care revenue cycle involves preparing for a
patient encounter, interacting with patients during a patient
encounter, capturing and recording services rendered and
processing claims and managing a patient’s financial account
to zero balance resolution.
November 2004
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COLUMBIA UNIVERSITY
PATIENT CARE REVENUE CYCLE
FINANCIAL
COUNSELING
ENCOUNTER
CHARGE
CAPTURE/
CODING
COMPLIANCE
BILLING/CODING
REVIEW
CLAIM
DEVELOPMENT
&
SUBMISSION
PAYMENT
POSTING
CHECK IN /
REGISTRATION
SCHEDULING/
REFERRAL
MANAGEMENT
FOLLOWUP
CONTRACT
MANAGEMENT/
PROVIDER
CREDENTIALING
PATIENT ACCESS
CYCLE BEGINS
REJECTION
& DENIAL
PROCESSING
November 2004
Page 31
PATIENT CARE REVENUE:
INTERSECTION OF PATIENT CARE AND
TEACHING
Medicare Program:
– Began in 1967
– Two trust funds:
• Part A for hospital and other facility
services (eg, nursing home)
• Part B for provider and other outpatient
services
– Intermediary Letter (I.L.) 372 : Federal
guidance for teaching providers
establishing conditions under which
providers can teach residents
(reimbursed under Part A) and provide
patient care (reimbursed under Part B)
at the same time.
November 2004
Page 32
WHO BILLS FOR WHAT?
HOSPITAL vs. PROVIDER SERVICES
Hospital Services
(billed by NYPH)
• Inpatient hospitalizations
• Ambulatory surgeries
• Outpatient diagnostic testing (facility,
supplies, equipment and support staff costs)
• Outpatient physical, occupational and
speech therapy
• Outpatient clinics (facility, supplies,
equipment and support staff costs)
• Emergency room services (facility
• Skilled nursing and home health services
Hospital
Claim
Provider Services
(billed by CUMC)
• Daily provider visits and consults to hospitalized
patients
• Surgeries and administration of anesthesia
• Office visits and office consults
• Office-based diagnostic testing (eg, EKGs)
• Provider interpretation of diagnostic tests
performed in a hospital
• Provider diagnostic and treatment services for
patients seen in the hospital outpatient clinic,
emergency room or skilled nursing facility
Provider
Claim
November 2004
Page 33
CONTRACT MANAGEMENT
– Objectives
•
Provider establishes contracts with their significant payers to determine claims
processing, payment and rejection terms and conditions
– This often requires the establishment of rates for particular services
– Providers must regularly evaluate the reimbursement rates to ensure that they are
being reimbursed appropriately
November 2004
Page 34
PROVIDER CREDENTIALING AND
RECREDENTIALING
– Objectives
•
Evaluate credentials of potential or existing providers to ensure that appropriate
licenses and certifications are accurate and up to date
– Valid state license to practice and prior sanctions against licensure
– Education and Training Board Certification
– Drug Enforcement Agency (DEA) Certification
– Verification of clinical privileges
– Malpractice coverage and malpractice history
– National Practitioner Database Query
– Medicare/Medicaid Sanctions
– Application processing for Medicare, Medicaid, Blue Cross/Blue Shield, and other
insurance companies
•
Re-credentialing typically occurs ever 2 years at CU
November 2004
Page 35
SCHEDULING/REFERRAL MANAGEMENT
– Objectives of Scheduling/Referral Management
– Appropriately identifying the service to be rendered
– Determining a provider who can provide the service (based on that
person’s treatment schedule, insurance enrollment status, and
qualifications)
– Initiating a pre-registration process by obtaining a minimum data set of
patient demographic information
– Communication with patient’s regarding payment expectations and
referral requirements
– Columbia Best Practice:
– Use IDXtend (institutional billing system) for scheduling of appointments
– Collect minimum data set of demographic and insurance information for previsit insurance verification
November 2004
Page 36
INSURANCE VERIFICATION…
A CRITICAL PRACTICE
– Objectives
– Obtaining and verifying coverage prior to rendering services
– Minimizing bad debt by contacting the patient prior to service to address
any problems or limitations with coverage
– Improving patient satisfaction by
– Minimizing the amount of time spent registering patients “on the spot”,
therefore reducing patient wait times and increasing patient satisfaction
– Managing patient expectations regarding their out-of-pocket obligations
November 2004
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INSURANCE VERIFICATION
– Verification of coverage
– Effective date of coverage
– Types of benefits available
– Coverage Limits – Yearly/lifetime
– Authorization requirements
– Provider participation status
– Billing address
– Patient responsibility (deductible and/or co-payments)
– Types of verification procedures
– Phone call
– Internet
– Electronic system eligibility check (Medicaid)
– Columbia Best Practice: Centralized Insurance Verification Unit
November 2004
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CHECK IN
– Objectives:
• Beginning or completing registering of a patient
• Identifying missing information
• Obtaining provider referrals from patient
• Collecting co-payments and deductibles
• Administering Advance Beneficiary Notices (ABNs)
• Administering assignment of benefits
• Provide patient privacy notice
November 2004
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FINANCIAL COUNSELING
– Objectives:
• Discussing, in advance, how patients will pay for their out-of-pocket
responsibilities.
– Payment plans
– Discounts based on financial need
• Helping patients work through some eligibility/coverage issues in order
to ensure that the services to be provided are covered
– Pre-existing conditions issues
– COBRA
– Lack of authorization
– Out of network services
November 2004
Page 40
ENCOUNTER CHARGE CAPTURE/CODING
– Objectives:
– Provider must complete charge capture forms for each service rendered
which includes the patient’s name, medical record number, billing
account number, identification of procedure codes that should describe
services rendered and diagnosis information that should describe the
patient’s diagnosis
– Staff enters charges accurately, timely and to the correct account so
that services are billed and reimbursed appropriately
– Columbia University Best Practice:
– 24-48 hours within date of service
November 2004
Page 41
COMPLIANCE BILLING/CODING REVIEW
– Objectives:
– Control mechanism to ensure that billing information is supported by
documentation in the medical record
– Comparing clinician documentation in the medical record to the procedure
and diagnosis codes assigned by the clinicians/coders
– Performed prospectively and retrospectively
– Random selection of certain areas, 100% review in other areas
November 2004
Page 42
CLAIM DEVELOPMENT & SUBMISSION
– Objectives
– Scanning data through a series of pre-defined edits to identify coding
and billing discrepancies or missing information that would prevent a
claim from passing claim edits
– Reviewing and resolving edit reports of claims that contain errors.
– Review the lists and resolving any errors.
– Submitting “clean claims” to third party payers for processing
– Reviewing and reconciling clearinghouse reports which then forwards
electronic claims to appropriate third party payers
– Reviewing electronic acknowledgements that claims were received
– Columbia Best Practice: Department responsibility for the weekly
evaluation of claim edit reports and “working” claims to get them to pass
claim edits.
November 2004
Page 43
PAYMENT POSTING
– Objectives
– Posting of payments to patient accounts after payment has been made
is vital to ensuring an accurate accounts receivable
– Payment is posted timely, accurately, to the correct account to reduce A/R
follow up
– Payments may include zero payments and the posting of a rejection/denial
code
– Payments may include self-pay as well as insurance payments
– Electronic as well as manual payment posting processes
– Posting contractual allowances in concert with payments
– Ensure that allowance codes are utilized appropriately
– Columbia University Best Practice
– 1-2 days of receipt of payment
November 2004
Page 44
FOLLOW UP
– Objectives
– In person, phone, and written communication with patient, the
“responsible party", or insurance companies regarding unpaid patient
account balances
– Determination that claim was sent to correct insurance company and
that it is being processed
– Each claim may have multiple payors - primary and secondary
insurance companies, patient
– If internal collection efforts fail, the account may be outsourced to a
collection agency
– Credit balances are resolved by issuing refunds to patients and
insurance companies
November 2004
Page 45
REJECTION & DENIAL PROCESSING
– Objectives
– Evaluating claims that have been rejected or denied.
– Discussions with the clinician that rendered the service
– Reviewing billing system claim information to determine whether incorrect information
was entered (either demographic, insurance, procedure code or diagnosis information)
– Determining whether appropriate pre-authorization was obtained prior to the service
being rendered. If the service was authorized, was the authorization number submitted
with the claim
– Rebilling the claim with corrected information or contacting the
insurance company to resolve or appeal the claim.
– Evaluating accounts for potential administrative write-offs (e.g. late
filing, unauthorized service)
November 2004
Page 46
QUANTIFYING THE OPPORTUNITY:
EXAMPLE OF DENIAL DISTRIBUTION BY
REASON
Total
Denials
$1.6M
4%
20%
13%
5%
2%
By Volume
11%
9%
36%
Registration
Data Collection
Benefit Verification
Related/Included
Coding Related
Provider Enrollment
Claim Issue
Other
* Hypothetical example
November 2004
Page 47
BREAK
November 2004
Page 48
Part 2B
COLUMBIA UNIVERSITY PATIENT
CARE REVENUE CYCLE
November 2004
Page 49
HISTORICAL INFORMATION ABOUT COLUMBIA
FACULTY PRACTICE REVENUE CYCLE
• 575,000 Annual Faculty Practice Outpatient Visits; 55,000 Inpatient Admissions
• 30 years ago, most CUMC physicians managed patient revenue independently and “owned” the
economics
• Over time CU departments developed faculty practice plans with their own full-time faculty:
 Practice plans promoted program collaboration across departments;
 Clinical revenue generated supports academic mission & research initiatives
• Up until 1993 departments billed and collected on a multitude of billing systems
• In 1993, IDX was installed as the enterprise-wide billing system that became a common platform for
faculty across CU clinical departments
• Common billing system more efficiently manages revenue cycle in ways such as:
 Interfacing with other CUMC information technology systems;
 Providing shared information for better monitoring of managed care contract compliance
 Scrubbing and submitting cleaner claims for faster payment turnaround and lower percentage of claim denials
• Future IDX enhancements also being developed, such as:
 Electronic patient eligibility
 Payor contract module
 Web based software version
November 2004
Page 50
COLUMBIA UNIVERSITY
PATIENT CARE REVENUE CYCLE
Training Internal Control Priorities
–Cash Management
–Credit Balances
–Write -offs
–Charge Capture
November 2004
Page 51
COLUMBIA UNIVERSITY
PATIENT CARE REVENUE CYCLE
Cash Management
–Use of Lockbox and Electronic Funds Transfer
–Secure Time of Service Cash Receipts
–Timely Deposits and Payment Posting
–Cash Reconciliation Procedures
November 2004
Page 52
COLUMBIA UNIVERSITY
PATIENT CARE REVENUE CYCLE
Credit Balances
–Work all credit balances within 60 days of identification
– (30 Days Best Practice)
–PREVENTION!
– Identify and correct root causes of credit balances
November 2004
Page 53
COLUMBIA UNIVERSITY
PATIENT CARE REVENUE CYCLE
Write-off Policies
–Use standard set of transaction codes for administrative, bad debt, small balance
write-offs
–Ensure that appropriate approval mechanisms are in place for management review
of account write offs
November 2004
Page 54
COLUMBIA UNIVERSITY
PATIENT CARE REVENUE CYCLE
Charge Capture/Charge Entry
–Ensure timely capture of charges into billing system.
–Ensure accurate recording of charges into billing system
November 2004
Page 55
COLUMBIA UNIVERSITY
PATIENT CARE REVENUE CYCLE
Faculty Practice Revenue Management
–Faculty Practice Revenue Management Policies & Procedures issued Fall 2004:
– Website:
http://www.cumc.columbia.edu/facultypractice/policies/
November 2004
Page 56
COLUMBIA UNIVERSITY
PATIENT CARE REVENUE CYCLE
Charge & Payment Payor Mix of Columbia Faculty Practice Groups on IDX
IDX Payor Mix Analysis Charges July 2003 - June 2004
IDX Payor Mix Analysis by Payments July 2003 - June 2004
Other
2%
Self-Pay
5%
Medicaid
Managed Care
8%
Medicaid
11%
Self-Pay
14%
Managed Care
In-Network
36%
Medicaid
Managed Care
3%
Managed Care
In-Network
39%
Medicaid
3%
Commercial
5%
Other
4%
Commercial
9%
Medicare
24%
Managed Care
Out-of-Network
9%
Medicare
16%
Managed Care
Out-of-Network
12%
November 2004
Page 57
COLUMBIA UNIVERSITY
PATIENT CARE REVENUE CYCLE
Clinical Revenue Improvement Project
Introduction and Background
– Timeline
– Participants
– Stockamp Consultants
November 2004
Page 58
COLUMBIA UNIVERSITY
PATIENT CARE REVENUE CYCLE
Clinical Revenue Improvement Project
Goals
– Create “Hub & Spoke” Responsibility/ Accountability Model (Culture
Change)
– Establish Faculty Oversight & Leadership
– Implement a Consistent Set of Efficient Business Practices Across All Units
– Maximize Revenue
– Improve Internal Controls
– Improve Employee Satisfaction
– Improve Patient Satisfaction.
– Improve Provider Satisfaction
– Data Driven Management: Weekly & Monthly
November 2004
Page 59
COLUMBIA UNIVERSITY
PATIENT CARE REVENUE CYCLE
Clinical Revenue Improvement Project
Clinical Revenue Office
•
Accounts receivable follow-up: New approach , New Tools & Training
•
Coordination with CPPN
•
Insurance Verification
•
Patient Call Center
•
Coordination with Departments
November 2004
Page 60
COLUMBIA UNIVERSITY
PATIENT CARE REVENUE CYCLE
Clinical Revenue Improvement Project
Department Practice Access Sites: “Front-End” Re-Engineering
•
Process Redesign
•
New Approach & New Tools & Training
•
Securing Patient Visits Before they occur
November 2004
Page 61
PATIENT REVENUE CYCLE PROCESSES
FRONT END:
Revenue Cycle Process
1
Appointment Scheduling
/Registration
2
Insurance Verification
3
Authorization/PreCertification/ Referral
4
At Risk Decision
5
Point of Service Checkin
Process
Owner
Department
Work Driver /
Process Control
Patient / Physician
Phone Call
Job Aids
Management Reporting
Minimum Data Set Criteria;
FSC Selection Reference
Sheet
ONTRAC Exception Report; Staff
Performance Reviews
CRO
ONTRAC Worklist
Situation Response
Guidelines; FSC Selection
Reference Sheet; Passport
ONTRAC Securing Sponsorship
Summary; IV Ineligible Report; Staff
Performance Reviews; IV Productivity
Report
Department
ONTRAC Worklist
Situation Response
Guidelines; FSC Selection
Reference Sheet; Passport
ONTRAC Securing Sponsorship
Summary; Auth Productivity Report;
Staff Performance Reviews
Department
ONTRAC Worklist
Situation Response
Guidelines
ONTRAC At Risk Decision Report
Department
ONTRAC Worklist
Situation Response
Guidelines; FSC Selection
Reference Sheet; Passport
ONTRAC Securing Sponsorship
Summary; Rejection Report; Staff
Performance Reviews
November 2004
Page 62
PATIENT REVENUE CYCLE PROCESSES
BACK END:
Revenue Cycle Process
6
7
8
9
1
0
Coding and Charge
Capture
Billing
Denial Processing
A/R Follow-up
Cash Posting
Process
Owner
Department
Work Driver /
Process Control
Job Aids
Management Reporting
Charge Lag Reports; Staff Performance
Reviews
Charge Tickets;
Encounter Forms
Department
Charge Tickets; IDX
Edit List; QUIC List
TRAC Summary; TRAC Billing WIP
Report
Department
and CRO
QUIC List, TRAC
Worklist,
Correspondence
Situation Response
Guidelines, WebCis,
Passport, NeuroNet
TRAC Summary; TRAC Follow-up WIP
Reports; Staff Performance Reviews
CRO
TRAC Worklist
Situation Response
Guidelines, WebCis,
Passport, NeuroNet
TRAC Summary; TRAC Follow-up WIP
Reports; Staff Performance Reviews
Department
Remittance Advice
Cash Report; TRAC Summary; Staff
Performance Reviews
November 2004
Page 63
COLUMBIA UNIVERSITY
PATIENT CARE REVENUE CYCLE
Clinical Revenue Improvement Project
Data Driven Management
•
Weekly management meetings
•
Faculty Oversight Committee
•
Performance standards, metrics and benchmarks
November 2004
Page 64
Columbia University Revenue Cycle
Key Performance Indicator Dashboard
Dec 2004 – Feb 2005
CRO (6 Departments)
Baseline
December
January
February
February Goal
Goal
Variance
$10,846,767
$12,637,130
$12,975,524
$11,976,046
$11,936,309
$39,737
A/R Days
112.9
85.4
85.0
85.1
70.0
-15.1
A/R > 365 Days
31.4%
15.1%
13.8%
14.0%
15.0%
1.0%
$13,340,683
$7,202,456
$7,300,560
$6,623,850
$5,878,854
$744,996
18
18
22
20
5
-15
Pre-registration (Min
Data Set)
N/A
74%
80%
80%
90%
-10%
Pre-service Secured
N/A
78%
89%
86%
92%
-6%
Indicator
Cash Receipts
Billing WIP
Charge Lag Days
November 2004
Page 65
COLUMBIA UNIVERSITY
ORTHOPAEDIC SURGERY – Case Study
BEFORE July 2000
 12 independent physicians, average staff of 3 per office, 5 major locations
 Each maintained their own charts, appointment protocols, billing fees and
office policies
SINCE July 2000
 Major initiative to centralize all work flow processes
November 2004
Page 66
COLUMBIA UNIVERSITY
ORTHOPAEDIC SURGERY – Case Study
Created teams:
Medical records
Appointment scheduling
Surgical scheduling
Secretaries
Billing and collections
Front desk reception
November 2004
Page 67
COLUMBIA UNIVERSITY
ORTHOPAEDIC SURGERY – Case Study
•Physicians were polled as to their preferences and templates were created as to the needs of each
physician - how long should a new patient be scheduled for, are x-rays needed first, what types of
patients will they see, what insurance plans do they participate in, what equipment is needed in the OR
for a surgery.
•All charts were centralized and a standard chart format established (what is included and where in the
chart). There is one chart per patient seen by the group.
•Secretaries are shared one for each 2 physicians.
•There is one appointment scheduling phone number created for all physicians.
•Front Desk Teams (including a front desk biller) are set up at the 5 major locations, where they are
trained to collect demographic info, referral forms, HIPPA forms, research questionnaires
•Billers, upon check-out, collect copays and past due balances and post charges and payments at time
of service.
November 2004
Page 68
COLUMBIA UNIVERSITY
ORTHOPAEDIC SURGERY – Case Study
Today:
– 17 physicians with a centralized staff of 67.
– Higher expenses but revenues increasing even faster
– Reduced charge delays and billing rejections because of attention to front
desk
– Ability to add physicians without adding staff
– Better referrals, no missed phone calls, filing up to date
– Maximized use of the operating room
November 2004
Page 69
COLUMBIA UNIVERSITY
ORTHOPAEDIC SURGERY – Case Study
TODAY:
– A/R is 67 days (vs. CU goal of 70 and actual of 88 days in September 2004)
– 3 day charge lag (vs. CU goal of 5 days and actual of 17 days in September
2004)
– 90% of patients have secured billing information before they arrive (vs. CU
goal of 92% and actual of 73% in September 2004)
November 2004
Page 70
Part 3
COLUMBIA UNIVERSITY
TUITION REVENUE CYCLE
The tuition revenue cycle involves a continuum of activity from
student recruitment to matriculation, including billing and
collection. This includes the student application, interview and
screening process. Tuition rate setting and financial aid
considerations are also key components.
November 2004
Page 71
COLUMBIA UNIVERSITY
TUITION REVENUE CYCLE
Cash
FAS
Recruitment
Inquiry
Application
Collection
Cash
Financial Aid
Interview
Applications
Acceptances
Yield
Registration /
Billing
Acceptance
Financial Aid
November 2004
Page 72
CUMC ADMISSIONS
5,000
3,000
40%
2,000
20%
1,200
1,000
Acceptance Rate
60%
1,400
100%
4,000
Number of Applications
80%
800
60%
600
40%
400
1,000
20%
0%
0
'94
'95
'96
'97
'98
'99
'00
'01
'02
0%
'03
School of Dental & Oral Surgery
100%
200
0
'94
2,500
'95
'96
'97
'98
'99
'00
'01
'02
'03
School of Nursing
120%
700
600
100%
2,000
1,500
40%
1,000
20%
500
Acceptance Rate
60%
Number of Applications
Acceptance Rate
80%
80%
400
60%
300
40%
200
Number of Applications
Acceptance Rate
80%
Mailman School of Public Health
120%
Number of Applications
College of Physicians & Surgeons
100%
500
20%
0%
0
'94
'95
'96
'97
'98
'99
'00
'01
LEGEND:
'02
'03
100
0%
0
'94
Admit Rate
Applications
(left axis)
(right axis)
'95
'96
'97
'98
'99
'00
'01
'02
November 2004
'03
Page 73
COLUMBIA UNIVERSITY
TUITION REVENUE CYCLE
Tuition Setting Metrics
– Demand / yield
– Student retention
– Economic trends
– Socioeconomic mix of applicant pool
– Availability of financial aid
– Affordability of competition
– Public opinion of quality of education
– Track record of graduates
November 2004
Page 74
COLUMBIA UNIVERSITY
TUITION REVENUE CYCLE
Net Tuition Revenue Example
Gross Tuition
$10,000,000
Less: Institutionally Funded Financial Aid
$ 3,000,000
Net Tuition Revenue
$ 7,000,000
Tuition Discount
30%
November 2004
Page 75
COLUMBIA UNIVERSITY
TUITION REVENUE CYCLE
Financial Aid Considerations
– Tuition / Aid
•
Low / Low
•
High / High
– Need based
– Merit based
– Family / student contribution
– Employer reimbursed tuition
– Competition
– Loan availability
– Net Tuition Revenue
November 2004
Page 76
COLUMBIA UNIVERSITY
TUITION REVENUE CYCLE
CUMC Sources of Student Support
Total Cost (Tuition, Living, Fees)
100%
90%
80%
70%
Other Grants
Dean
Loans
Family / Student
60%
50%
40%
30%
20%
10%
0%
MD
Bio Sci
PhD
Nurse
ETP
SPH F/T
November 2004
Page 77
Appendix
GLOSSARY
November 2004
Page 78
GLOSSARY
• Bad debts Bad debts are amounts considered to be uncollectible from accounts
and notes receivable which were created or acquired in providing services.
"Accounts receivable" and "notes receivable" are designations for claims arising
from the rendering of services, and are collectible in money in the relatively near
future.
• Charity allowances Charity allowances are reductions in charges made by the
provider of services because of the indigence or medical indigence of the patient.
Cost of free care (uncompensated services) furnished under a Hill-Burton obligation
are considered as charity allowances.
• Coinsurance The amount a patient is required to pay for medical care in a fee-forservice plan after the patient has met the deductible. The coinsurance rate is usually
expressed as a percentage. For example, if the insurance company pays 80 percent
of the claim, the patient pays 20 percent.
November 2004
Page 79
GLOSSARY
• Co-payments are payment sharing amounts that the patient is responsible for as a
result of the coverage the patient has with the insurance company. Patient copayment amount usually are applied to each visit and range from $5-20 per visit.
Patients may also have co-payment amounts may also represent a percentage of
allowed charges
• Courtesy allowances Courtesy allowances indicate a reduction in charges in the
form of an allowance to providers, clergy, members of religious orders, and other as
approved by the governing body of the provider, for services received from the
provider. Employee fringe benefits, such as hospitalization and personnel health
programs, are not considered to be courtesy allowances.
• Covered Expenses Most insurance plans, whether they are fee-for-service, HMOs,
or PPOs, do not pay for all services. Some may not pay for prescription drugs.
Others may not pay for mental health care. Covered services are those medical
procedures the insurer agrees to pay for. They are listed in the policy.
November 2004
Page 80
GLOSSARY
• Deductibles are payment sharing amounts that the patient is responsible for. A
deductible is usually the first $X dollars per a specified period (usually per year)
which the patient is responsible for.
• Normal accounting treatment: reduction in revenue Bad debts, charity, and
courtesy allowances represent reductions in revenue. The failure to collect charges
for services rendered does not add to the cost of providing the services. Such costs
have already been incurred in the production of the services.
• Preexisting Condition: A health problem that existed before the date your
insurance became effective.
• Reasonable and Customary Charges Most insurance plans will pay only what
they call a reasonable and customary fee for a particular service. If your doctor
charges $1,000 for a hernia repair while most doctors in your area charge only
$600, you will be billed for the $400 difference. This is in addition to the deductible
and coinsurance you would be expected to pay.
November 2004
Page 81
GLOSSARY
– Types of Insurance Coverage
• Indemnity Fee-for Service - This is the traditional kind of health care policy.
Insurance companies pay fees for the services provided to the insured people
covered by the policy. This type of health insurance offers the most choices of
doctors and hospitals. You can choose any doctor you wish and change doctors any
time. You can go to any hospital in any part of the country.
• HMO (Health Maintenance Organization): Prepaid health plans. You pay a
monthly premium and the HMO covers your doctors' visits, hospital stays,
emergency care, surgery, checkups, lab tests, x-rays, and therapy. You must use
the doctors and hospitals designated by the HMO.
• PPO (Preferred Provider Organization): A combination of traditional fee-forservice and an HMO. When you use the doctors and hospitals that are part of the
PPO, you can have a larger part of your medical bills covered. You can use other
doctors, but at a higher cost.
November 2004
Page 82
GLOSSARY
– Medicare
• Medicare is the Federal health insurance program for Americans age 65 and older
and for certain disabled Americans. If you are eligible for Social Security or Railroad
Retirement benefits and are age 65, you and your spouse automatically qualify for
Medicare.
• Medicare has two parts: hospital insurance, known as Part A, and supplementary
medical insurance, known as Part B, which provides payments for doctors and
related services and supplies ordered by the doctor. If you are eligible for Medicare,
Part A is free, but you must pay a premium for Part B.
– Medicaid
• Medicaid provides health care coverage for some low-income people who cannot
afford it. This includes people who are eligible because they are aged, blind, or
disabled or certain people in families with dependent children. Medicaid is a Federal
program that is operated by the States, and each State decides who is eligible and
the scope of health services offered
November 2004
Page 83
QUESTIONS?
Session 5 – Revenue Cycle
COURSE
EVALUATION
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Session 5
Session 5 – Revenue Cycle