Transcript Document

Experience the Eide Bailly Difference
Provider Based and Rural Health Clinic:
Bottom Line Impact
Presented by:
Ralph Llewellyn
Health Care Consulting Partner
[email protected]
www.linkedin.com/in/ralphllewellyn
701.239.8594
Table of Contents
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Rural Health Clinic
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Provider Based Clinics
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Compliance
Cost Report/Billing
Clinic Productivity
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Compliance
Cost Report/Billing
Hours Worked per Direct Care Hour
Six Tips for Improved Physician Productivity
Scheduling
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Block
Precision
No-shows
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Current Challenges
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The costs associated with operating clinics continue to
rise
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Professional services
• Staffing
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At the same time reimbursements are at risk
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Third party
Medicare
Medicaid
Providers must act to protect their reimbursement and
improve their operational performance
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Rural Health Clinics - Compliance
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Revisions and clarifications to RHC Benefit
Policy Manual
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Issued November 22, 2013
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RHC must be in both a rural and underserved
location
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Existing RHCs not required to continue to meet
Contact CMS if relocating or expanding
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Rural Health Clinics - Compliance
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Revisions and clarifications to RHC Benefit
Policy Manual
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Must post hours of operation at or near the
entrance
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Hours
Days
Administrative time separately
Non-physician providers
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Must be employed to be reimbursable
• RHC
• Entity that has 100% ownership of RHC
• W-2
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Rural Health Clinics - Compliance
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Revisions and clarifications to RHC Benefit
Policy Manual
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Commingling of space
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Cannot pick and choose services to be RHC and nonRHC
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Rural Health Clinics – Cost Report
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Productivity Standards
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Confusion and Inconsistency
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4,200 visits per 1.0 FTE Physician
2,100 visits per 1.0 FTE PA or NP
No standards
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Visiting nurse
Clinical psychologist
Clinical social worker
Locum tenens
Frequently overstated
• Higher calculated standard
• Lower reimbursement
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Rural Health Clinics – Cost Report
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Productivity Standards
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What time is not included in FTE calculation
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Hospital patients
Hospital administrative
RHC administrative
Continuing Education
Vacation
Other
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Rural Health Clinics – Cost Report
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RHC versus non-RHC costs
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Costs associated with non-RHC services must be
offset on the cost report.
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Hospital patients
Hospital administrative
Emergency Room Call
• Develop a strategy to capture cost
• Cost may be allowable in the Emergency Room
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Other non-RHC activity
Recommend time records versus per visit
estimates
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Rural Health Clinics – Cost Report
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Emergency Room Call
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Very difficult to identify and address if not specific
in contract
80% reimbursed in RHC * Medicare utilization
101% reimbursed in ER * Medicare utilization
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Availability requirements
Medicaid may also participate in cost
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Rural Health Clinics – Cost Report
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Pharmacy
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Cost of pharmacy is part of cost per visit
Revenue and Cost must be reported in the RHC
cost center
Do not report as non-RHC pharmacy costs
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Rural Health Clinics – Cost Report
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Lab and other ancillaries
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Separately billable
Revenue and expense in corresponding hospital
ancillary department
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Rural Health Clinics – Billing
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Charges are important
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80% cost based reimbursement
20% charge based reimbursement
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Deductibles impact calculation
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Rural Health Clinics – Billing
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Ancillaries are separately billable
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Lab
EKG
Radiology
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Rural Health Clinics – Billing
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Wellness Services
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No coinsurance or deductible applies
Must be separately reported with CPT code
Multiple lines possible
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Wellness
Other
Market these services!
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Provider Based Clinics
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Blended reimbursement methodology
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Professional fee schedule
Technical cost based
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Provider Based Clinics - Compliance
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42 CFR 413.65
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Must meet all requirements
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Most common challenges
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Public awareness
Must bill all Medicare beneficiaries a technical
component
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Provider Based Clinics - Compliance
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Public awareness
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Signage must indicate the location is part of the
main provider
Patient must know they are entering a department
of the hospital
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Provider Based Clinics - Compliance
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Must bill all Medicare beneficiaries a
technical component
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Cannot treat some Medicare patients as provider
based and others as freestanding
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Provider Based Clinics - Compliance
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Visiting specialists
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Cannot treat provider based space as freestanding
Designate separate and distinct space
Contract for services and bill as provider based
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Provider Based Clinics – Cost Report
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Provider costs
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Costs associated with provision of patient care
must be offset on cost report
Other costs may be allowable
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Medical staff
Mid-level supervision
Administrative time
Emergency Room availability
Separately identify costs in contracts when
possible
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Provider Based Clinics – Billing
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Capture charges for all reportable
procedures.
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Injections
Infusions
Etc.
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Clinic Productivity
Assessing clinic productivity used to be simple:
• Total staff hours / clinic visits = staff hours per visit
Hours per visit could then be compared to:
• Budget
• Historical actuals
• Industry averages
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Number of patient visits / Provider FTEs
Derive average number of visits per clinician per 8 hour shift,
expressed as visits per clinician FTE. Then compare (similarly) to
budget, historical actuals, or industry averages
Source: Assessing Clinic Productivity by Paul Fogel
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Clinic Productivity
Measuring clinic productivity is made more complicated with
1. Increased non-visit patient work: emails, telephone
consults, other non-visit type encounters
2. Employed physicians and use of NPs and PAs
Source: Assessing Clinic Productivity by Paul Fogel
Image: reach-montana.org telehealth network
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Clinic Productivity
The nature of clinic work has changed
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Patients are often assessed and given medical advice without having to
visit
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No registration
No discharge
Avoid multiple layers of clinicians
Only visit when needing to be seen in person
Not all clinic visits are the same
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A visit for a vaccination takes considerably less time than a visit for a minor fracture
Both would be counted as visits
 Instead
of using the usual metrics, count the direct labor time
it takes for various types of visits (and non-visits)
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Count the minutes: a five minute flu shot counts as five minutes. A one
hour appointment is counted as one hour, and a 15 minute phone
consult counts as 15 minutes
 Your new metric is Direct Care Hours
Source: Assessing Clinic Productivity by Paul Fogel
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Clinic Productivity
Employed Physicians and Mid-levels
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Physicians, NPs, PAs, allied health professionals, etc. all spend
different amounts of time per patient
 Create
a template to track minutes per encounter
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Various appointment types are tracked with minutes per encounter and then
totaled to direct care hours
 Your new metric is Hours Worked per Direct Care Hour
= Total Hours Worked in the Clinic / Direct Care Hours
 This productivity ratio accounts for both patient volume and patient
mix
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Source: Assessing Clinic Productivity by Paul Fogel
Clinic Productivity
Six Ideas for Increasing Physician Capacity:
1. Support physicians in declining tasks that do not require a
physician, except in emergencies or special situations
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Train staff well and hold accountable to performance
standards
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“My time is limited and I need your help” as opposed to “I am too
important for this menial task”
Make expectations clear: vitals taken and recorded, chief complaint
is noted, patient’s chart is complete
Limit physician interruptions by batching questions and
documents for review/signature
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Other staff also benefit from fewer interruptions
Source: Simple Tips to Improve Physician Productivity by Carol Stryker
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Clinic Productivity
Six Ideas for Increasing Physician Capacity:
4. Minimize variability in the clinic schedule
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Minimize variability in the exam room
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If possible, group appointment types such as annual exams, office
procedures, or rechecks. This minimizes changes in mindset
involved in switching from one appointment type to another
Stay on track by improving your approach to scheduling. Develop
strategies to prevent missed appointments and tardiness
Supplies, their locations, and room layout should be consistent
across all exam rooms
Encourage and support physician work/life balance
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Fatigue and poor health affect efficiency and quality
Fewer work hours may allow for higher quality and more efficient
work hours
Source: Simple Tips to Improve Physician Productivity by Carol Stryker
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Scheduling
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Patient scheduling can make or break critical relationships,
as it’s often the initial point of contact for many patients
To optimize your scheduling
processes, first maximize
appointment accessibility
• But, choosing an
appointment strategy that
strikes the right balance
between optimizing capacity
and providing exceptional
service is a difficult
undertaking
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Scheduling
Block Scheduling:
• Uses a set time block for all visits, regardless of complaint.
• Advantages:
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Ease of scheduling
Minimization of unusable slots
Limited need for clinical expertise among scheduling staff
But, this fails to account for difference in types of visits
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Scheduling
Block Scheduling, continued
• Different types of visits can take more or less time
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New patient
Chronic conditions
Follow up
Annual Wellness Visit
Physicals
DOT
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Scheduling
To account for variations, consider Precision Scheduling
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The idea is to more accurately match appointment times to actual
complaints/complexity
To execute, organizations must first conduct a procedure analysis, which
involves time studies to track the minutes required for each scan
Also, providers must calculate the average duration of each visit and
analyze historical volumes to determine visit mix
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Scheduling
Lowest Common Denominator Scheduling
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The shortest visit becomes the lowest common
denominator with all additional visits scheduled in this
increment (for example, 15 minutes)
• This begins to adjust for variations in visit lengths and
minimizes the risk of unusable time slots
• But, it can reduce scheduling flexibility and may result in
appointment inflation (rounding up)
• For example, a 21 minute visit gets two blocks and takes
a 30 minute slot
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Scheduling
Which model will meet your needs?
• Block scheduling can reduce the number of available
appointments but it offers flexibility which is important for
institutions with high volumes of unscheduled visits
• Lowest common denominator blocking methods are good
for providers with a stable visit mix but having significant
variation in visit lengths
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Scheduling
Accommodating emergencies and unscheduled
outpatients: the principled add-on policy
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Administrators track unscheduled patients and analyze the data by day
of week, time of day, location, and referral source
The output of this analysis is used to reserve appointments when addons are most likely to occur, maximizing the ability to accommodate
unscheduled visits without compromising access for scheduled patients
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Scheduling
What to do with no-shows:
Some patients simply don’t show up
• To minimize the negative impact from no-shows, look at when and why
this is happening
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If there is a specific patient or group of patients that are the
majority of the no-shows, communicate with them, learn why, ask
for help, etc. You may be able to emphasize the importance of
keeping appointments
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Scheduling
What to do with no-shows: Principled Overbooking
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Providers can consider this when there is a highly
predictable no-show pattern and when additional patient
volumes can be more easily absorbed
• No-show patterns and patient satisfaction must be
continually monitored to ensure that customer service isn’t
compromised
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Questions??
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