Analytics & Automation to Improve Revenue Integrity PROPRIETARY - - PowerPoint PPT Presentation

PROPRIETARY & CONFIDENTIAL

Best Practices for Leveraging Analytics & Automation to Improve Revenue Integrity

04.22.16

PROPRIETARY & CONFIDENTIAL CHANGE HEALTHCARE PROPRIETARY & CONFIDENTIAL

Change Healthcare

Intelligent Healthcare Network

Patient Access Advisor Coding Advocate Claims and Denials Advisor Receivables Advisor Remittance Advisor Revenue Discovery Advocate Coverage Discovery Advocate Consulting

Driving Revenue Performance across the entire provider journey

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PROPRIETARY & CONFIDENTIAL CHANGE HEALTHCARE PROPRIETARY & CONFIDENTIAL 3

David Figueredo Business Development and Product Management Revenue Discovery Advocate Change Healthcare www.changehealthcare.com

Introduction

PROPRIETARY & CONFIDENTIAL CHANGE HEALTHCARE PROPRIETARY & CONFIDENTIAL 4

Which of these financial challenges are having the greatest impact on your

• rganization?
• Medicaid\Medicare reimbursement rates
• Bad debt and self-pay volumes
• Managed care and commercial insurance payments
• Deductible and co-insurance escalation

Poll

PROPRIETARY & CONFIDENTIAL CHANGE HEALTHCARE PROPRIETARY & CONFIDENTIAL

How Do Patient Types Compare?

Problem View: Self-pay & Bad Debt

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Today, significant effort is applied to resolve inpatient and emergency AR, often minimizing potentially larger issues with outpatient AR.

• 1. Inpatient Accounts: 2.5%
• 2. ED Accounts: 20.4%
• 3. Outpatient Accounts: 52.5%
• 4. Other Accounts: 24.6%

*Graph based on actual provider performance and is presented to demonstrate potential issue scope

2000 4000 6000 8000 10000 12000 14000 16000 18000 Apr 15 May 15 Jun 15 Jul 15 Aug 15 Sep 15 Oct 15 Nov 15 Dec 15 Jan 16 Feb 16 Mar 16 EMERGENCY HOSPICE INPATIENT OUTPATIENT OTHER

PROPRIETARY & CONFIDENTIAL CHANGE HEALTHCARE PROPRIETARY & CONFIDENTIAL

How Do Patient Types Compare?

Problem Perspective: Money Drives Behavior

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• These recovery efforts are largely manual and drive by perceptions of greatest value.
• When viewing the value and potential of all AR, subacute and outpatient recoveries can

proved significant value to providers. 1. Inpatient Accounts: 22.4% 2. ED Accounts: 17.2% 3. Outpatient Accounts: 53.2% 4. Other Accounts: 7.1%

*Graph based on actual provider performance and is presented to demonstrate potential issue scope

$0.0K $500.0K $1,000.0K $1,500.0K $2,000.0K $2,500.0K $3,000.0K $3,500.0K $4,000.0K Apr 15 May 15 Jun 15 Jul 15 Aug 15 Sep 15 Oct 15 Nov 15 Dec 15 Jan 16 Feb 16 EMERGENCY HOSPICE INPATIENT OUTPATIENT OTHER

PROPRIETARY & CONFIDENTIAL CHANGE HEALTHCARE PROPRIETARY & CONFIDENTIAL

How to Drive Results: Data, Analytics & Automation

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Results Work Productivity =

PROPRIETARY & CONFIDENTIAL CHANGE HEALTHCARE PROPRIETARY & CONFIDENTIAL

How to Drive Results: Data, Analytics & Automation

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Results Work Productivity =

How can you impact your results?

PROPRIETARY & CONFIDENTIAL CHANGE HEALTHCARE PROPRIETARY & CONFIDENTIAL

How to Drive Results: Data, Analytics & Automation

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Results Work Productivity =

What impacts your effort?

PROPRIETARY & CONFIDENTIAL CHANGE HEALTHCARE PROPRIETARY & CONFIDENTIAL 10

How Can Technology Be Part of the Solution

Be aware of and execute on all coverage sources Evaluate patient financial need and enroll in Medicaid\Financial Assistance programs Interview and verify all patient demographic and coverage info at point of entry Identify payment risk and differentiate collections

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Analyze claim pre-submission for under\over coding risks and payments for contractual variances

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PROPRIETARY & CONFIDENTIAL CHANGE HEALTHCARE PROPRIETARY & CONFIDENTIAL

Identify and Execute on All Funding Sources

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Potential Impact of Analytics:

• Up to 40% of self-pay accounts have existing medical coverage at time of service
• Solutions must leverage more than often limited hospital data
• Response times must be rapid (under 24 hours)
• Solutions must be accurate and capable of removing the noise
• Approximately 40% of coverages are limited and do not apply to all episodes of care

HIS Data Feed Enhance Analyze and Target Verify Coverage Identity Management Suppress Non- billable Return Results

Potential impact based on the experience of Change Healthcare

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Over a five month period :

• ~300k self-pay accounts were screened
• ~93k accounts were found to have billable insurance in less than 24 hours

Identify and Execute on All Funding Sources

Graph based on actual lab performances over a five month period

Up to 33% of the total self-pay problem could be solved through a well integrated analytics based insurance identification solution.

PROPRIETARY & CONFIDENTIAL CHANGE HEALTHCARE PROPRIETARY & CONFIDENTIAL

Patient Financial Modeling Leads to Insights

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Recognizing patient financial need allows labs to:

• Direct low income patients to hospital enrollment and FAP processes
• Secure long-term funding sources for reoccurring patients
• Identify financial need before you invest in FTE and other resources
• Become an advocate for patients and improve overall hospital processes

Group Description Charity Code Accounts Balance # % of # $ % of $ 451+ FPL H 1,849 8.67% $3,235,380 9.62% 401-450% FPL L7 645 3.03% $1,012,934 3.01% 351-400% FPL L6 822 3.86% $1,414,813 4.21% 301-350% FPL L5 1,094 5.13% $2,007,766 5.97% 251-300% FPL L4 1,252 5.87% $1,822,538 5.42% 201-250% FPL L3 1,938 9.09% $3,335,780 9.92% 101-200% FPL L2 4,371 20.50% $6,713,507 19.96% 0-100% FPL L1 6,604 30.98% $9,900,098 29.43% Unscorable U 2,743 12.87% $4,194,368 12.47% Total 21,318 100% $33,637,184 100%

Table is an example from a Change Healthcare client

PROPRIETARY & CONFIDENTIAL CHANGE HEALTHCARE PROPRIETARY & CONFIDENTIAL

Identify Risk To Differentiate Collections

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Patient Volume Charges Payment Score # % $ % 10 41,775 16.27% $3,844,943 11.18% 9 36,293 14.13% $3,713,966 10.80% 8 31,922 12.43% $3,536,961 10.29% 7 25,220 9.82% $3,128,353 9.10% 6 23,613 9.20% $3,268,278 9.51% 5 25,010 9.74% $3,718,057 10.82% 4 19,845 7.73% $3,209,435 9.34% 3 19,675 7.66% $3,394,931 9.88% 2 17,676 6.88% $3,321,639 9.66% 1 15,751 6.13% $3,240,947 9.43% Total 256,780 100.00% $34,377,509 100.00% Patient Volume Charges Risk Model # % $ % Low Risk 109,990 43% 11,095,870 32% Moderate Risk 93,688 36% 13,324,123 39% High Risk 53,102 21% 9,957,517 29% Total 256,780 100% 34,377,509 100%

Table is an example from a Change Healthcare client

PROPRIETARY & CONFIDENTIAL CHANGE HEALTHCARE PROPRIETARY & CONFIDENTIAL

Uniform Scoring Can Allow Targeted Processes

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Chart is an example from a Change Healthcare client

PROPRIETARY & CONFIDENTIAL CHANGE HEALTHCARE PROPRIETARY & CONFIDENTIAL

Optimized Revenue Cycle Workflow

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PROPRIETARY & CONFIDENTIAL CHANGE HEALTHCARE PROPRIETARY & CONFIDENTIAL

Defining Patient and Visit Neighbors using Machine Learning: Intuitive visualization enabling the efficient identification and correction of:

• Ranking of likely

missing charges

• Auditor performance

tracking

• Opportunities for

improvement

• Feedback into

models

• Potential root cause

insights

• Similar patients
• Similar visits
• Global similar

patients/visits

• Expected charge

correlations Ensemble model merges scores. Built-in business rules for net cash impact

Daily Internal feeds:

Application Algorithms Billing Data

Analyze Claim Pre-submission for Under\Over Coding & Payment Risks

Diagnoses Attributes Procedure Attributes Charge Code attributes Hospital (Local) History System (Global) History Billing Code Attributes

Scoring and rank-

• rdering of billing

anomalies:

• Account
• Missing charge
• Prioritized by

probability and net cash impact

• Daily Feedback Model
• Rules/Protocols changes
• Half yearly model refresh
• Charge master Updates
• Application Enhancements

Continuous Learning

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PROPRIETARY & CONFIDENTIAL CHANGE HEALTHCARE PROPRIETARY & CONFIDENTIAL

2 4 6 8 10 12 14 16

§Toxoid Products missing Administration charges and toxoids Administration missing Toxoid Product charges §Complex Drugs missing Complex Drug Infusion charges §Angioplasty and

• ther

cardiovascular procedures missing C-codes/Implants to be billed separately §Anesthesia, Surgery and Recovery hours missing for day surgery accounts §Radiology studies with Contrast missing Contrast material charges §ER patients with Chest pain diagnosis missing EKG Charges §96360-96549 - IV Push, Infusions missing including initial infusion missing for accounts with additional pushes §Observation patients missing

• bservation hours

and ER Patients missing ER level charges §Many other areas like Lab charges, Radiology, Drugs etc.

Many other areas like Lab charges, Radiology, Drugs etc.

Technology Can Identify Larger Trends to Empower Auditors and Increase Revenue

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~15% ~9% ~3% ~2% ~3.5% ~3% ~1% ~0.3% Toxoid Products missing Administration charges and toxoids Administration missing Toxoid Product charges Complex Drugs missing Complex Drug Infusion charges Angioplasty and other cardio- vascular procedures missing C-codes / Implants to be billed separately Anesthesia, Surgery and Recovery hours missing for day surgery accounts Radiology studies with Contrast missing Contrast material charges ER patients with Chest pain diagnosis missing EKG Charges 96360-96549 IV Push, Infusions missing including initial infusion missing for accounts with additional pushes Observation patients missing

• bservation

hours and ER Patients missing ER level charges *Graph based on global claims analysis of Change Healthcare platform users

PROPRIETARY & CONFIDENTIAL CHANGE HEALTHCARE PROPRIETARY & CONFIDENTIAL 19

Things to Remember & Questions

• 1. Technology exists today to drive uniform patient

screening for insurance, financial need and propensity to pay.

• 2. Most HIS, PMS and IT systems provide an integration

infrastructure.

• 3. Businesses must be willing to leverage analytics and

automation to optimize labor and outcomes.

• 4. When applied, technology affords the ability to act as

systematic challenger and safety net to existing processes.

• 5. Operational cost reductions and revenue increases far
• ut way the cost and effort to deploy.

PROPRIETARY & CONFIDENTIAL

THANK YOU

David Figueredo Business Development Change Healthcare 615-417-3563 dfigueredo@changehealthcare.com