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[Music] hey guys jen vaughn here coming to you from genta with our presentation today what is revenue cycle and why does it matter so we're going to go through 10 essential concepts that you need to know i'm jen vaughn i am the revenue cycle subject matter expert at genton i've been in revenue cycle in some role for the past 18 years so to get started let's all understand what revenue cycle management is it's the step-by-step life cycle from when a patient first books an appointment until the claim is fully reimbursed by the payer now this means as soon as you get that patient's information their demographics their insurance to the encounter to the claim to the submission of the claim and back to the reimbursement revenue cycle management we'll call rcm and billing can be managed in-house or you can outsource this to a billing company there's pros and cons to both and we're going to go over the difference of each so in-house billing you have an entire team demographics insurance verification coders auditors uh billers air follow-up posting patient balances you have to hire all of these roles and you need backups and cross-trainings and things like that to determine that are to make sure all of your roles are going to be covered in the event that you're short staffed someone's out someone leaves and you need to rehire with an outsourced billing company you typically get a bigger team so the way this is set up is you get a contact person so you have a revenue cycle manager in-house or a billing manager a director a billing in-house and that person works directly with a contact person at your billing company there's often shared responsibilities but you often get more experience more people and more technology than what you have in house as an independent physician you know practice owner you are focused on getting the patients in for the appointments getting them the treatment they need and a lot of times an outsourced billing option is a good thing because that is uh one piece of the the process that you don't have to be hyper focused on on a daily basis so let's go over in network versus out of network if you are in network this is a contract between you the physician and the payer this means you know what you should be paid this is your guarantee this is your paycheck this is also going to eliminate burden on patients with balanced billing so the patients know in advance how much they may owe you what their deductible is their co-pay but also you can give an estimate based on your contract with the payer with in-network status as a physician with a payer if a claim underpays or a claim denies you have the ability to fight for reimbursement so that means you can submit an appeal or a reconsideration and have that claim reprocessed with the payer out of network you're really it makes it difficult to forecast income you could also have higher patient balances from patient billing so if you don't have a really good collection process up front you could end up with patient balances on the back end meaning that you're working with collection or you're using a lot of attempts effort resources to collect on those patient balances you're often unable to send an appeal or a reconsideration and that's because you don't have a contract with payer so there's no agreement between you and the payer saying what you should be paid on a specific encounter date of service procedure maybe key performance indicators so there's a lot of kpis that you want to track with your revenue cycle process and we'll go through some of the highlights charge lag how many days does it take you to submit a claim one to five days is really considered the industry standard people that we talk to places i've been one to five days is uh acceptable anything you know six to ten maybe that's the average and over that you're really getting into the risk zone days in ar this is also known in some some specialties as dso so this this is a different metric this is the number of days from the date of service to the payment date so how many days from that encounter are you waiting to get your paycheck 35 days is the goal um you can be really aggressive with anything from 30 to 34. anything 45 or higher that's more of a risk and you need to really dig in and see is it taking you um longer to get your charges out the door back to your charge lag or is a payer just by you know by process taking that long clean claims rate so you want your clean claims to be like a really big metric 95 or above is a is a great goal and the reason why is you want to put your resources on the front end to make sure you you have went through every check and balance that you can to assure a clean claim is going to a payer for reimbursement you don't want to have to work this stuff on the back end you want to put your work in on the front end um ar so let's talk about ar we age it in 30 day buckets right anything over 90 days aged from the date of service you want that to be less than ten percent so ten percent ninety days and over there's some things out there um that take time to work maybe you're waiting on an addendum with medical records but you really wanna keep that ar 90 days and below rejection rate and denial rate those are just two ways a claim could get hung up and start hanging out on your ar for for an extended period of time so you want your rejection rate to be less than ten percent meaning that you've attempted to submit a claim but didn't get it there to the payer and you want your denial rate to really be less than five percent so you want to make sure again you're going back to that clean claims rate and measuring to make sure you have checks and balances on the front end this may be with your technology this may be with scrubbers in your software this may be people looking at the process to make sure you're not missing anything cash collection so 90 plus percent you want to you want to have a net collection rate um of 95 or more now across the industry anything from 85 to 96 are the common numbers we hear 90 plus percent i would have a goal of 95 that to me is aggressive but it assures that you're getting that cash back in the door especially with those in-network payers where you have a contract and you know what you should be paid by debt this can be measured uh a lot of ways so the metric gauges the amount of non-contractual charges things that are right off you really want to limit this uh you don't want to work for free so you want this to be less than five percent if at all possible in the genten platform we can walk through some of these metrics just as as an example to show you how you should see this on the screen i'm sharing here you can see how many payments what's in your account receivable over to the right you can see your charges the allowable and the total reimbursed this is how you calculate your net collection rate so for any time frame you should be able to go in and calculate what you filled what you should have been paid and what you were truly paid this gives you a good sense as to how the process is going overall to know that your net collection rate is high analytics this is very important with revenue cycle knowing you know having the data knowing how to manipulate the data or access the data you know if you're using a great software it may be easily uh seen or reviewed like it is here on this screen if not you may be uh exporting spreadsheets and and doing that yourself but as an example this is a very user friendly um software and it's really easy to see what you're looking at so days to submit that is your charge like in this example you see two days that's a really great number like i said before one to five is is good and it's typically the industry standard median days in ar on this example 35 that number is good anything from 30 to 35 is a great goal uh you may have payers that pay a little sooner so if you have a payer that pays really quick you may get to that 30-day mark if you have a lot of commercial liability third-party payers you may see an extended amount of time you may see a 35-40 day mark of course your denials your rejections and your clean claims rate all again very important very easy to see here in this example so let's go to insurance verification insurance verification is a very very beginning of the process and it can be repetitive you may need great software to do this uh sometimes pair portables will not give you the detail that you need you need to know if this is an office visit a telehealth visit in network out of network the big things here are the patient's deductible what's remaining the copay and the coinsurance those are the three things that you need to know to provide an estimate to a patient again in the software you can see here it gives you that in detail so you can very easily say you know hey to your patient this is your deductible remaining this is the expected reimbursement from the payer your portion will be it's a much better process to collect up front than on the back when you're sending out those text statements email statements paper statements and possibly getting the payment you know in a payment plan maybe getting the payment delayed or even not getting the payment at all which means that you have to consider a collection process cpt coding and the claim scrubbing editing process now hopefully most of us are in a software that has warnings and alerts and edits that we can either build or that just that they exist for us but coding and scrubbing is very very important to submitting a clean claim the most important factors out in my opinion are making sure your coder has uh knowledge within the specialty in the industry that you are in so if you're a cardiologist you know a coder that has the ability to gain that knowledge by working with an internal team or an external team for you or someone that has has been in that industry and has knowledge around that specialty pair guidelines and payer performance each payer commercial or government can have guidelines on what cpt diagnosis and modifiers that you're applying to a claim payer performance that's important this is really very similar to payer guidelines but payer performance means you know anytime you have a certain cpt diagnosis combination you may need a modifier or let's say you know you're a pain doctor and sometimes the rtlt modifier is very important or a surgeon and the rtlt is very important but having that knowledge or that access to knowledge is very important now we've said before the billing platform with the ability to create these rules it's not ideal to manually scrub claims individually by a person so this is where you want to leverage technology if you have it available the billing platform that you're using should have the ability to create those rules and edits and warnings that i mentioned earlier so let's talk about the process front to back this is a chart that shows you everything from benefit eligibility to payment so the patient calls you obtain the demographic information you get the insurance information and step one of securing your revenue cycle process is checking the benefits and eligibility making sure that you have the right payer and making sure that there's not a term date on that plan making sure that it's a covered benefit your network all of those things are helpful once you get the patient's insurance information once that happens and the encounter has happened so the patient and the physician or the clinician have met the coding and charge capture comes into play so you're coding from the documentation that the physician has provided and then you're entering the charges or hopefully the charges are populating for you once you enter those cpt codes and diagnosis codes to create the claim the claim is what goes to the payer so now you want to have your claim scrubber kick into play hopefully again that is an electronic you know magical process that happens where your software gives you a warning or a stop you know if it's something that's a date of birth that's absolutely going to be needed on all claims that should be a hard stop in your software your software should say don't go past this point there's a field missing um there may be some softwares that have a warning though and that may say you know this diagnosis and this cpt code are mismatched and that's a warning to show you may want to go back and look at this one more time with your documentation to make sure there wasn't a typo or maybe in a lot of scenarios there's a drop down where you get an error claim status inquiry you've submitted the claim 30 days let's say has passed and you don't have an era correspondence or a paper this is where you call the payer you go online you utilize your clearing house your billing software to get an enquiry on the claim so what's what's going on is the claim still in process is the claim denied uh maybe the claim was just processed and you're going to get an era soon but you do need to follow up on those claims the recommendation is that a claim not go 30 days without a follow-up remittance advice so a remittance advice is the equivalent to what the patient gets as an eob an explanation of benefits most providers now have eras so you have an electro electronic remittance advice that comes back through your clearinghouse that's definitely a quicker way um and in a more secure way of not losing paper not getting mixed or lost in the mail you want to try to get an era when at all possible he already comes back in you're at the risk of denials and appeals so let's say you have a partial denial a full denial an underpayment this is where either you have a full denial and you need to maybe submit medical records with a payer specific form for reconsideration maybe you can call to submit an appeal maybe you can go on the payer's website or a lot of times again in your tools your software that you're using you can select to submit an appeal electronically to a payer posting any money that's come back in you need to post that you need to make sure it's posted in your software and you need to reconcile your bank to your software to make sure that you're not getting money in the bank with claims not posted or make sure that claims are not posted and the money is is missing from the bank patient statements go out and there's patient follow-up at the end we all hope that just you know one statement goes and payments come in but the reality is mailing paper statements isn't the only approach or method we should have now you should be able to text email and send some paper statements you want to give people the ability to pay on their phone you want to give people the ability to send it in of course they may call in to make that payment but the big thing is hopefully you've collected the majority of the what's going to be due up front and now you're on the back end sending a smaller balance and you have options on how to get that delivered to the patient claim rejections and denials so we went over this a little but there's a lot to know about claim rejections in the niles so appeals reconsiderations corrected claims these are all the path you're taking to get the payer to to re-review the claim whether that be um an automated process with their software or there's a form or an approach or a submission that says please manually review this we understand that this diagnosis and the cpt may appear to be a mismatch but here's the documentation please review it so know your payer specific forms and ways to send the appeal this is super important a lot of commercial payers will let you log into their portal but some payers and i'll say medicare specifically still uses the actual printed paper that you need to send in for an appeal so this is important knowing the delivery method of how to get your appeal or your reconsideration to the payer very important another important fact around sending these appeals to the payer is the timeline filing so just like you have a timely filing limit for the initial claim submission you have a timely filing limit uh in some pay it with some payers for the appeal or the reconsideration so if you get a denial on january 1 you may only have until february 1 to get that reconsideration back out to the payer payer underpayments this is payer performance um a lot of times when we say payer performance the folks that we talk to don't really understand but what this means is how well is your payer performing to your contract so if a claim is underpaid you need to have the ability to identify that you have to have the ability to track and trend and know how often the payer's underpaying or how often the payer hopefully is paying the way it should to your contract so you have to have a tool in a lot of cases or you have to have a lot of excel spreadsheets that you're downloading and manipulating and doing all of your analysis with to identify and resolve the underpayments by paying things to remember most payers process claims in 7 to 14 days that's in the perfect scenario you've submitted a clean claim you have the right payer everything's went through great seven to 14 days medicare on average we have found seven to 14 days as normal commercial payers a little higher 14 to 21 days so those are just some some things to know as you go through your revenue cycle process the payment posting process this is important you need to know that you've been paid you've received the reimbursement or the paycheck as a provider that you expected when you when you had the visit of the patient so the billing or sometimes called the posting team will post the payer's reimbursement to your software this is a snapshot of your financial health this is showing um that the process has been completed right this is kind of the final stage you may get this in an eft you may get a paper check i mentioned this earlier reconciling your bank deposits to your postings is very important this is a a practice function in in most scenarios if you're in-house billing outsource billing you always still need to make sure that your bank account matches what's posted in your software any mismatches um it may mean that you have less or more money than you think you have or more or less ar than you think you have balance billing payments could be sent to patients out of network this is huge with balance billing um and when you're out of network where your payments go so again there's no contract between you and that payer meaning they can send that you can file that claim as a courtesy and they can process that claim and then send the payment to the patient this is another really good reason to make sure you have an upfront collections process patient statements now i talked earlier about some patient statements having the ability to send them by text email paper um a lot of us in in the year of 2022 always have our phones with us so if we get a reminder or a bill and our alert you have an appointment or you have a balance it's easy to pay right there so collecting payments up front is important sending an estimate is really important so you're letting that patient know in advance now i've heard complaints from providers saying i don't want to send an estimate that may um you know that may make the patient think well i'm not going to be able to pay this i'm going to cancel the appointment um that's an opinion and i you know my my opinion is that you should still send the estimate if the patient's not going to pay up front you really need to think about if they're going to pay after the procedure too um but giving that estimate getting that information out as soon as possible having all delivery methods available is really important to the collections process or the patient collection process on balances that will be due or are due expect some patients to call the office so even though the tool that you're using says this is an estimate some patients will call some p some patients will you know really understand their benefits and really want to know how you determine this to be the estimate and some may pay right away some may not pay right away these are all uh you know different things that need to be considered when you're sending out the estimates but again back to knowing your contract knowing what the allowed amount should be so you can be educated as well as the patient so many patients are unable or unwilling to pay the balance and you know that that's just a risk right you can offer payment plans you can work with a soft collections uh process company again you can do this in-house or you can outsource this a lot of things that i've read a lot of studies a lot of surveys it's a misunderstanding so the patients are not aware of their benefits they're not aware of what the denied claims are they're not aware of you know just the high cost of the service in general so that comes back to the estimates on whether you know you have the ability to send out a good faith estimate that is a good representation of what the patient may owe it does become the responsibility of you the health care provider to contact the patient and attempt collection on these outstanding balances so as you're going through this patient billing and patient collection process you know it it is definitely important to know what your office approach is or how aggressive you're going to be so all of that being said i hope you guys found some of this helpful if you are a current client of gentem you can reach out to your revenue cycle manager with any questions around this webinar so stop wasting time on clunky and outdated processes uh jensen likes to deliver these educations and webinars and you know just little snippets of information to you to show you that we are keeping up with the trends in the industry showing you that we have a platform that's built to help you run a smooth revenue cycle process thank you guys [Music]