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today's learning objectives we're going to examine key performance indicators or KPIs we're going to list and identify varying financial reports that you can use for monitoring these KPIs in your facility we're going to discuss common billing pixels things that can negatively affect your revenue in the billing department and we're going to describe the steps in billing financial reconciliation processes recrudescence verb bell curve monitoring so key performance indicators KPIs healthcare kpi's they're valuable tool in monitoring the operations and the overall effectiveness of your organization so what okay what is the KPI it's measurable and it's a value that demonstrates how effectively or efficiently your business is running there are lots of different KPIs in healthcare and depending upon the size and an amount of staff members that you have in your facility well that will depend on which KPIs you select to track you know determining the gold and the mission statement of your facility is important because then you can associate certain KPIs with that mission statement and goals and once you select those KPIs it's a good idea to keep a spreadsheet and perhaps generate a schedule for when these KPIs will be tracked during the year and we'll get to how to schedule and which KPIs would fit a particular organization so as I said there's different types of KPIs in healthcare the first ones I'd like to speak about our operational KPIs oh these KPIs do measure patient experience because you know when the paid the first step is when the patient steps into your office so you want to ensure that from the first time the patient comes to your office until they leave that you are assessing their their visit and their experience so let's talk about patient wait time which would be the average amount of time the patient waits between the check-in and seeing the provider not check-in and going to the to the room or the exam room but between the amount of time the patient is in the waiting room until they're actually seen by the provider a lot of times patients are very savvy and a lot of times the patients understand that yes you're taking them back to the exam room but what is the exact time between the time they walked in until the actual time the provider is seeing that another thing is the average number of patient rooms in use at one time in the facility you want to demonstrate how well the facility space is used perhaps you have five rooms you're only allowed to operate to for certain reasons for maybe for staff staff concerns but it's very important to understand your patient satisfaction in relation to the good use of your facility space another thing to measure which is a hard measure is the staff to the patient ratio and this indicates the use in the capacity of your resources and of course if it's not if it's not efficient not going to be effective and the quality of your patient care being delivered could be diminished and also of course the patient satisfaction to be diminished financial KPIs so these financial kpr is very important and actually these kpi's I would suggest that they be monitored monthly you know familiarize yourself with some RV use which is the relative value units that's now use for position productivity so you know it's very important now that financial KP use are looked at monthly because they really do demonstrate your volumes and your effective use of your resources of your providers so efficiency and utilization yes you want to make sure that your provider time is being efficiently used in other words we talked about space in the previous slide is your provider waiting around because there's no room available you know is there enough staff to assist this provider physician productivity as I said RV use a lot of physicians are now compensated based upon these RV use or relative value units revenue cycle optimization so you always want to keep track of your monthly financial reports which demonstrates your net charges kiss collections total collections missing charges claims and I erase all this should be monitored monthly you do get a lot of billing reports and there's an abundance of reports that can be generated from your billing system but it's very important to look at these main topics that are underneath the bullet revenue cycle optimization communication KPIs communication is important not only among staff members but with your patients and that's also very much connected to patient satisfaction everybody is giving out surveys nowadays so the overall patient satisfaction is very important how is the hell is this calculated well you want to calculate your satisfaction levels by combining a lot of things accessibility to your practice the appearance of the practice telephone etiquette a lot of times the first the first appearance of your patient to the office yes that that's great but that's not the first time they had communication with your office it's usually over the phone if they're a new patient you want to make sure your telephone is also working properly if you do have a telephone tree your staff evaluation as I said you want to make sure your staff to staff and your staff to patient communication is optimal quality of care you want to ensure that your patients are taken care of and they're not they don't feel rushed and they feel like they're getting everything that they wanted to present for that day for that service fees and payment procedures you want to make sure that the fees are communicated to the patient if they have a co-payment their deductible and you want to make sure that all of your financial papers are very clearly written out so the patient understands exactly what the monetary responsibility for their visit will be internal KPIs so internally you're also going to monitor KPIs within your organization and your staff and it's basically how your staff works so departmental trainings very important we've spoken about different types of trainings in previous modules such as HIPAA OSHA so it's very important that these trainings be tracked and that the staff members do either sign a paper or sign something that says that they attend this training number of mistake events measure this will measure the number of mistakes made and it could be a small mistake it could be a large mistake but it's very important that mistake events or issues or patient complaints be documented and then can be used then for learning experience perhaps at a departmental meeting monthly meetings patient confidentiality very important so this measures a number of times patients pH I or pickup protected health information has been exposed or anything on their medical record has been seen by somebody who shouldn't have seen it we did talk about HIPAA and these disturbances in the confidentiality would be something that needs to be tracked and monitored Public Health KPIs so Public Health KPIs are very important to programs that are very much into public health KPIs is Macra and PCMH so the Macra is the MIPS that's the reporting for the value-based incentives and PCMH which is the patient-centered medical home program they very much are based upon quality of care and public health so immunization reporting so you want to demonstrate the number of patients who have received immunizations and this reflects the contribution to the overall community health by the public health department's understanding who's received immunizations and what immunizations have been received education programs time and effort that you provide education to your patients at your facility do you per you know perhaps have brochures in your waiting room do do you have a particular health care population that you want to refer to outside community education programs so public health KPIs is a great contribution to quality of care for the patient clinical KPIs now we spoke about eras well clinical specifically we'll deal with medication errors so that is you want to measure the number of times in era perhaps in prescribing prescribing medication occurs you know perhaps a patient follow-up are your patients coming in every three months or every six months to ensure that they have a visit before their prescribed or Reaper scribed their their medication do your patients receive follow-up calls if a patient you know was in for for a visit and they need to follow a poll is your staff providing that follow-up call perhaps patients are no shows are those patients receiving a call to to follow up on why they have not come to their visit and are they rescheduling it so along with key performance indicators or KPIs are quality assurance lockers so we want to make sure that any kind of marker that we want to target provides you know optimal patient health we want our practice or clinic to grow and these KPIs if they're targeted if they're looked at and if the the outcome of the KPI monitoring is is not forgotten about and we looked at every three months basically the goals can be met goals can grow and new goals can be discovered you want to increase your outside referrals you know patient satisfaction word-of-mouth is that KPI you know patients are very happy and score high on their patient satisfaction surveys your increase in outside referrals increase in follow-up appointments if you keep reminding your patients yes you know you need to come back or you call your yearly yo-yo really visits to then they need to make an appointment that increases satisfaction the patient is aware that the practice of the facility is very interested in their health and that helps their quality of health and you our facility grow so where do we start if we want to start a KPI monitoring and we haven't done it at all well a good place to start is at the front desk we can start with things such as cash receipts money collected and deposited so are you monitoring your charge receipts in other words are you comparing what was put into your billing system to what you have in either your envelopes or your safe drawer your charges are you looking at your charges weekly daily monthly what is the fluctuation in your charges this should be monitored if there's a reason your charges have gone down one week or one month that's fine but what is the fluctuation caused by could it be a provider was on vacation but it's very important to understand fluctuations in charges patient appointments you want to track the number of points that you have that should be done I could be done monthly also is there a trend is it going up and down again no show and patient cancellation rates very important all your no-shows receiving a phone call that day are they you know answering and are they rescheduling their appointment so it's very important like I said not only for the quality of care but for your facility to track and find out why your patients have been cancelled or have a no-show so action steps so decide what markers you want to be measured for your clinic your KPIs that you'd like to focus on choose how this marker will be measured for example new patient numbers your average visit reimbursement how many patients have canceled you know is is somebody at the front desk doing your reconciliation of charges and then you want to track this data month to month select another quality assurance marker if that data has improved and you always want to take corrective action implement any changes that need to be done to keep the data level or keep improving and you don't want to forget about it you want to check it again in a few months you want to ensure that it's a constant quality assurance marker so financial measures for new medical billing as I say financial KPI is very important so what can you measure what would be a hard number well data service and date bill what is that gap is it two days is it three days what is the gap between the data service and the state does data the data service is built the percentage of claims denied due to front-end edits versus coding errors what do we mean by that well front-end edits is your front desk taking correct demographic information are they putting in the information manually into the system correctly sometimes it could be just a number that is input incorrectly and that would be versing coding errors in other words your CPT charges and your icd-10 coding is that the problem so it's very important that you compare your your denials you look at them to see what exactly they're being denied for and it should be fixed training and then monitored again what is the percentage of the claim denied due to authorization referral as I said this will if this is a task of the front desk it could need training collection KPIs so what is your days and account receivable sometimes it's looked at monthly and you want to make sure that your days and it can't receivable most of your money is not at over that 120 bucket your percentage of claims denied overall so not only breaking down the denials to see what particular denials are there you want to see well how am i doing percentage of claims denied percentage of no response claims so if you perhaps you know do that electronic billing are you sending out claims and getting a no response are they being scrubbed correctly average life of denials no response incidents and of course again with denials by category very important to look at so here is an ample KPI report there's a lot of different things going down the side a lot of different brackets but it's just an example so you can break it down by month depending upon how you depend on that who's going to monitor it and how they plan on monitoring it but for example you can just be looking at a provider and indicating you know their visits their number of patient visits from January through December you could be monitoring the number of new patients that your practice has you could be monitoring your no-show rate your days an AR you know your self pay how many patients are self-pay so there's a lot of different KPIs but as I said it depends on the goals of your institution where you want to grow and the size of your so let's talk about the financial report which is very important and these as I said should be reviewed reviewed minimum ly monthly but there are some small reports that should be looked at daily or even weekly so what do you want to look at daily if you're a front-end manager perhaps you want to look at your daily activity and your net production your charges your payments adjusters and refunds for in the billing department you know if your ability if you have a billing department and your billing manager you want to look at your billing backlog what's happening how what is the timeframe that your your claims are going out and coming back in your balance of over the counter collections you know your cash checks and remittance it's very important to balance out your balance sheet every day from the front desk even if you don't deposit every day you should always be balancing out your activity at the front desk to ensure that your collection is what you physically have between your cash your credit cards your cheques is what is indicated in your software program weekly so you want to quantify your payment posting backlog you want to see how far back you are in posting of what you have received if it's not automatically posted you know because it does depend upon you or your facility and how much electronic you you use so you want to quantify your collection backlog and you want to quantify under payments of course you want to make sure that what you're receiving from your carrier is what you should be getting if nobody is watching watching your EOB is your explanation of benefits um the patient payments could be under being underpaid and you don't know it so your monthly so you want to review your outstanding a are very important your accounts receivable you want to review your monthly production by provider why is there as I said you know mentioned earlier why is near Al and why is there a shortage in production by a particular provider look for the reason is it is it that you know they're not being reimbursed correctly vacation time off what's the issue look at your denial activities as I said very important to track your denial trends and you want to review your reverse aging of payments so every month someone in the practice should be looking at the financial reports even if it is at a high level and these reports even if you outsource your billing those monthly reports should come in a package to whoever is responsible for the financial needs of the practice so common billing pitbull's so let's talk a little bit about what happens in billing that affects the efficiency so up-to-date information at the time of appointment scheduling and patient registration we've talked about this many times and throughout the modules but this does affect it couldn't even slow down your billing process you know if you don't obtain the right information if you don't take the correct insurance card if you don't have the correct number you know the claims goes out and then it comes back you know you want clean claims you want the claim to go out and be paid and sometimes if we don't collect the right information it's hard to get in touch with patients you know if they don't have an up-to-date phone number if they don't give you know updated demographic information you know even when the patient presents and you ask them Oh has anything changed you know sometimes they forget it has changed but you know they forget so again I would like to stress to actually look at that insurance card at every visit even if it's not scanned just take a look at the card look up at your information if it's good handed back health insurance status and coverage verify every patient encounter is very important patients are you know changing their health insurance very frequently so if you don't verify the coverage you know you can you can be stuck without a payment financial responsibility as we had said in regard to patient satisfaction it's very important that you implement clear financial policies the patient should always know what they're responsible for and that you know is also part of verification you can ask you know about deductibles you know how much their deductible is so there's a lot of things that you learn when you verify an insurance you want to make sure even if the patient is a self-pay or you're at a network you want to estimate the course of their services and you want to inform them about what their responsibility is and you want to make sure that they sign a paper understanding what their financial responsibility is and you want to make every attempt to collect monies as the patients visit you know collecting co-payments when the patient leaves really isn't such a good idea it's better to collect them upfront you know some patients you know sometimes just slip out afterwards but collecting the co-payment upfront is definitely a better workflow process so claims management very important is your practice automated do you use your electronic programs to the best that they can be utilized you know utilizing you know the software and anything electronic will streamline your denials your denials management procedures it will automate medical billing of the claims you know automation it reduces an accuracy you know putting in manually we talked about the software the electronic remittance and claim scrubbing when your claims are scrubbed electronically it is much better because you know that each claim that goes that system is being touched and scruff coating so there's a lot of issues with medical coney coating you know and of course it can it leads to increase in denial but also you know how does your facility handle coating are you with specialty do you have certified coders on staff or your doctors you know booted coating you know are they trained and educated in what needs to be coded or is perhaps your coding dependent upon your billing department do you add so is coloring there's a lot of different ways that a facility can handle coding but you want to make sure that when your denials are being managed if you're coding denials are high it's you know it's time for either education encoding or perhaps for for an audit of your coding so you want to see icd-10 diagnosis codes are you assigning them to the highest level of specificity incomplete or missing read medical record documentation you want to make sure that your what your coding is all in the medical record you want this could be a fail you to assign updated code sets every November new CPT codes come out are you updating your charge tickets over coding and decoding especially in the evaluation in management services or your E&M services you know unbundling the national correct coding initiative the NCCI edits are you the services that you filling you know if you have two codes are you allowed to build them together so there's a lot of important coding rules that your facility should be following and that absolutely goes along with looking at your claim denials to see where these areas might be it also could be a denial such as the the improper use of a modifier so it's important to look at those claim denials and provide education and training for the people or the staff members that are doing the coding so the billing financial reconciliation process is very important to the health of your financial welfare so what do we do in the day of a facility and we want to make sure that our financial health stays healthy so we want to do the daily cross-reference the end day totals in a billing department or you know the financial person that's responsible for the financial you want to make sure that your cash and your AR balances your daily patient totals generally that you know those sheets are generated from your software you want to generate the report summarizing the total billing for each patient for the day so that this total should match the itemized patient encounter report that is in your practice management system and again in red on this slide reports are only as accurate as all uses data entry so as I said even with the demographic information you want to make sure that your staff takes the time to put in the information correctly and is taught from the beginning on how to use your software system so step to your billing components total so your billing components include your cash some your checks and credit card receipts that are collected you know for your cold payments and your deductibles and then your daily claim total so this daily claim total okay is what is submitted to the carriers or your Clearing House if you're billing by clearinghouse so that's the total amount of claims submitted for the day all of your daily components for billing equal the daily transaction total the daily patient total okay and then of course you're going to account for your rejected claim so anything that was rejected of course you're going to take away from that daily total step 3 we're going to track our reimbursement components so you want to post payments upon receipt some payments from carriers and depending upon your system are posted electronically some aren't so you want to make sure that your payments are posted you know upon receipt there shouldn't be much of a lag you know one thing about this is that if your payments are posted timely you know you can have patient complaints you know if you send out if you're savvy and you send out your patients statements you know your patient can receive a statement that's you know erroneously sent because the payments were posted correctly there's a lot of things you know that that that go wrong if you don't post your payment's timely you know and you want to post each patient transaction code by line item so line items that means by CPT code so you want to post each payment by what you received for that code okay and as it says here you want to pay careful attention attention to the variations in determine co-pays and deductibles and what the carrier is saying you want to make sure that the allowed amount okay that's what the carrier is paying is correct and it's not diminished because that's a problem if you know you think you're not looking at your contracts for your carriers and you will getting perhaps lower than what you're allowed amount should be so that's very important credentialing so if credentialing is not done properly or monitored that can be a big problem a big pitfall for your billing department because if your providers are not credentialed or recrudescence they you know shouldn't be seeing patients and that definitely puts a kink in your cash flow so when your recrudescence go over very important parts of that wreak Redentor lling process because if it's not done as I said it really affects your cash flow see when she want to ensure that you have that workflow going for your recrudescence and that you maintain that up-to-date documentation and then somebody is monitoring at least it monthly so you can catch those expiry bills monthly you know your licenses your DEA your state license and of course your payer contracts when they expire if someone is monitoring that monthly you should be able to catch it on time work if you're a small facility you know I'm sure that you know Human Resources they keep their provider files make sure you know either the credentialing person and the human resource person of both tracking those files to make sure that they're up to date you know the recrudescence I said review your denials if you're being denied and it's saying pay or not and plan or something could be due to a reek redemption it expired and nobody was monitoring monitoring the date you know and of course you want to accurately record the reason for those deny claims okay and the number of accounts that were written off of that you want to make sure that your recrudescence in you Aslam on etre and built you know for someone to be able to pick up where somebody else leaves off if necessary so bill courage monitoring so bill curb monitoring is very important you know the enm services their ongoing focus of the federal payers so what why and what do those federal payers look at well the federal payers are of course looking for lack of medical necessity if you cannot show medical necessity your claim will be denied over coding and under coding very important incorrect EMM code category consult some consult requirements aren't Metro consult with particular area preventive services should it has been billed or should it not have been billed there's certain criteria for preventive services chief complaint missing not clearly stated assessment and plan same not clearly documented time there are services that depend upon the amount of time that you spend with the patient if you're billing a code based upon time and you're not documenting it clearly it should not be paid documentation not authenticated all records must be signed it's very important on electronic medical records you know sometimes providers forget to sign is someone in the office looking at the unclosed charts that's very important test ordered and build but not documented this happens often with blood work sometimes you know the provider will say what is what work won't specifically say what the test is ordered and it will be billed so it's very important to put that test you know specifically on the documentation of the medical record so this is what we call bell curve data so Medicare provides this annual bell curve data for all recognized specialties you know we have right up here one for internal medicine and new patient office visits but this bell curve data is utilized by the carriers to determine if your providers are billing outside of the national trend for their specialty and this is how what it's begin so let's just look at this this one has 99204 as almost a 50% mark so it's saying that most visits the National is nine ninety two or four so if you're billing a nine ninety two or five and most of your business and 99205 are you going to be audited there's a good chance the same as if your billing and nine ninety two oh three just because your billing or undercoating does not mean that you're going to not going to get audited so it's very important you know even as part as your of your facilities compliance plan to audit your provided shots for accuracy here we have internal medicine for established patient losses visits here you'll see it goes between nine ninety two and three and that excuse me nine ninety two one four as the the criteria or the national for these these services so the same would be here if you're billing in nine nine two one five or nine nine two one two chances are that you will be complicated so let's talk about how you can monitor your providers with the enn bilker so generate the enm bell curve data for each provider that you have which it can be done and compared to the the current national um data perform coding QA as i said it's a great practice in education to perform coding quality assurance on your services for you provided you know especially it on your hai services you 99214 and you nine nine two one five that I would do prior to claim submission just to take a look and see what you're submitting you know because sometimes there are or it's called prepayment audits and if you are on prepayment audit the carrier wants to see all of your documentation before they will even let you submit that bill so it's always good to take a look at your services and make sure that they're compliant to perform your animal annual provider education and training the more you educate your providers the more aware and more efficient they can become in there imitation as I said things change CPT codes change procedure codes change if the facility and its providers aren't aware that's when inefficiency occurs you want to monitor your payer guidelines changes and updates carriers follow different rules a lot of them are starting to follow CMS rules but ensure that you understand in your payer contract if you have one what you're being reimbursed for and what services you are being reimbursed for let's take a look at a case study okay this case study is regarding evaluation and management services or EMM services so the scenario patient underwent a left inguinal hernia or an lih repair on a Tuesday morning the physician writes an order to place the patient in observation following surgery for post-op pain control the nurse documents the patient arrived in recovery at 11:00 a.m. there were no complications no services rendered outside of the routine post-operative services and the physician discharges the patient at 11:00 p.m. so the patient is there from 11:00 a.m. to 11:00 p.m. can the facility bill for observational services so what's the observational conclusion even though the patient was being observed for 12 hours the facility cannot bill for the observation services the observation was part of the regular post-operative treatment and should be billed as recovery room treatment or services if the physician documented a post-operative complication then it would be available but since the patient is placed in observation because of the complication facility can bill for observation as long as the physician writes the order so in this case there was no complication the patient was just not under observation for 12 hours and that is part of the post-operative care so let's go over some of the session highlights so we spoke about kpi's or Kay performance indicators as measurement tools to monitor the various aspects of your healthcare facility we talked about all different types and which ones you could possibly start using to either increase your workflow efficiency or perhaps look at your financial KPIs maybe financial KPIs you haven't been focusing on so that would be something also to start critical KPIs to focus on to ensure the practice clinic is working at an optimal level as I have said and we spoke about front desk and financial KPIs the use of financial reporting to assist in monitoring these KPIs of and for the medical billing office very important financial reconciliation processes allow for better controls and monitoring of course if you're looking at these reports monthly you'll be able to spot a change either an up or down or trend the importance of maintaining and up-to-date credentialing process for efficient workflow of cash also cash balancing cash trending so you want to make sure your recrudescence buttoned up and somebody is monitoring it and we want to we did understand the importance of the bell curve data and E&M related risks so it's very important that you know you look at what codes you provide or billing and the trend with compared to the bell curve data that's provided nationally so here's something that you can look at for your practice just things to think about KPI selection for your practice or clinic perhaps you know take one or two of the simple KPIs that we discussed and put them in practice reconciliation process if you do not have a reconciliation process at all there are some suggestions that we spoke about you begin with your software daily reconciliation something that you can implement right away enm we talked about a.m. bell curve data under coding and over coding of are there any related concerns that you have for your practice or clinic perhaps maybe you want to schedule an audit prior to claim submission as we spoke about and then it's great idea to put everything together from sessions one two three and four all the sessions are interrelated and it would be great to look at the prior sessions and the series conclusion questions and thoughts and how they relate to your practice well I hope you enjoyed phase one modules one through four we have come to the end of the step by step initiating and or enhancing billable services online learning module series so thank you for trusting your training and technical assistance needs with the sustainable strategies for Ryan White hiv/aids program community organizations program for questions regarding today's module please contact us at HRSA at P CDC org for more information about a program products and services please visit our page on the target HIV website thank you and have a great day