What makes billers effective? Habitual attention to specific details and consistent execution of routine, yet critical tasks. I’d like to share with you what our team considers to be nine habits of highly effective long term care billers. Caution the resultant success can be addictive. That's a good thing. 

1. Make sure your census is correct. We can’t stress this enough. Work closely with the Director of Nursing to make sure the night shift nurses are indeed taking a midnight census. Here is an example of what could happen if they don’t. Let’s say Mrs. Brown is discharged to the hospital, but the discharge is not correctly noted. Because she is still considered in the census, you may bill for the entire month incorrectly. Daily stand-up meetings are great opportunities to confirm the census count and to review the previous 24 hours’ admissions, discharges, and bed holds. Whatever procedures are in place to track the census, relentlessly encourage accuracy and timeliness.
2. Check eligibility regularly. Do this at least monthly. For example, residents can change from the traditional Medicare model to a Medicare HMO plan at any time. It’s impossible to bill for Part A days when the resident has already exhausted the days available in the Benefit Period.
3. Triple check during the month-end close. We’ve mentioned month-end triple checks before. If your facility or facilities a significant volume of Part A and Part B claims each month, you may be willing to check a random sampling of bills during this meeting. But what should you cover during the triple check?

• Consistency of nursing and therapy documentation – Make sure that the nursing documentation supports the therapy documentation and vise-versa. If the resident needs therapy to learn to ambulate, nursing and therapy documentation needs to support that.
• Verify that the medical record supports the intervention performed – This is, of course, dependent upon the supervising clinician’s judgment. Make sure the team addresses this issue.
• Verify therapy minutes – Confirm that the minutes to be billed are consistent with the RUG level’s requirements.
• Charting – Especially for skilled Part A services, clinicians need to chart as required. Make sure clinical documentation has progress notes, noting that the resident needs skilled intervention.
• Benefit days availability - Communicate available Part A days.
• MDS assessment reference dates - Verify the MDS-assessment reference dates are accurate for the 5 day, 14 day, 30 day, etc.
• Physician orders - Make sure that physician orders have been received and have been implemented.
• Physician certification/re-certification – Make sure the attending physician has certified or recertified the need for skilled services and that the record includes reliable documentation.

4. Know your payer contracts – As we discussed in the last blog, review your payer contracts regularly.
5. Make sure the business office staff is continually learning – Dr. Covey referred to it as sharpening the saw. If you are an AR manager, this is important. The world of claims processing and billing requirements change constantly. Challenge yourself and your staff to learn something new every day. Also, acknowledge that turnover among billing staff exists which means in some cases, you must start over again. Take advantage of the webinars provided by the MACs when available.  They’re free!
6. Get organized and know where to find and plan what needs to be done by when. Remember today’s technology can be your best friend with digital calendaring, automatic reminders and alerts, software-based task lists, and more.
7. Don't be an island to yourself - Be transparent in your billing practices and routines. Just as back-up and failover procedures are critical to IT, so is “cloning” yourself extremely important. Billing must be on time. Train others to pick up where you may have to leave off, just in case.
8. Foster positive working relationships among staff members – An atmosphere of open dialogue and trust contributes to a smooth-running operation. Have a go-to person in each department. Those “insiders” can give you the information you need quickly and accurately.
9. Be the go-to person yourself – Let trust and dependability begin with you.

Okay, I am sure you can add to the list, but we suggest you keep it short and do what matters most in your role as a biller. It just makes good cents.

“If you build it, they will come.” For those of you who are Field of Dream fans, like me, yes, I admit this is a misquote. (It should read, “If you build it, he will come.”) But for the purposes of this blog, we can take some liberties and Hollywood should forgive us.  Let’s assume you and other members of the management team are persuaded that business intelligence (BI) is THE way to go to improve performance through data mining and KPI reporting automation. You’ve determined that outsourcing BI makes the most sense and you’ve purchased and are ready to implement the best, most cost-effective, and easy to implement solution available. You’re ready to go, but what about those further down the decision chain? Just because you’ve made the decision, doesn’t mean they will follow. Are they ready? Will they use it? How can you be sure?

Not surprisingly, we have noticed that unless leaders take certain steps, they will be frustrated by implementation’s fitful nature. They spend more time trying to get manager buy-off than solving the problems and seizing the opportunities BI reveals. So what’s required? Leadership. Leadership of change. (I give credit to my mentor, Dr. D. Tyler Nelson, PhD, who over twelve years ago introduced this to me and I now share its highlights with you.)

Change is only the beginning

First of all, change is only the start; it’s a beginning. It’s situational. Over your career how many times have you seen new initiatives introduced with a big announcement, training programs, perhaps a new policy and procedure manual, only to see them at best take longer to be implemented than desired or at worst die of inertia? Why? Lack of effective transition management. A successful transition is essential if the change is to work as planned. In this case, helping people transition from the old reporting habits to enthusiastically embracing BI.

“Faced with the choice between changing one’s mind and proving that there is no need to do so, almost everybody gets busy on the proof.” - John Kenneth Galbraith

Transition starts with and ending and ends with a beginning

To be brief, while change is simply situational, transition, on the other hand, is psychological.  It’s guiding people through the process of:

• Realizing an ending to the old ways,
• Acknowledging and dealing with the sense of loss associated with the ending,
• Letting go of the old ways,
• Seeing the vision of the new when the new isn’t fully operational, and
• Embracing and making a new beginning.

Change management is to understand the desired outcome and how to get there; transition management is to convince people to leave “home”.

As the BI champion, you’ll succeed when you acknowledge that transition starts with an ending (of the old) and finishes with a beginning (of the new).  It starts with the ending your BI users will have to make to leave behind the old ways of reporting.  Within the bullet points above are the keys to what you must do to help your users move through transition to:

• Significantly reduce the negative effects change can have on productivity
• Shorten the length of time from the inception of BI implementation to the achievement of the final desired performance targets. i.e. the use of BI to achieve your organization’s goals
• Minimize the decline in productivity that naturally follows before full implementation is realized

How’s it done?

In short, our successful clients have made BI part of their management culture. It starts at the top; all decisions are referenced and based on the KPIs viewable in the BI dashboard and reports. One COO refers to the primeVIEW dashboard, PCT’s BI product, during the monthly facility financial review. His regional staff and facility leaders must be just as conversant with the KPIs displayed as he is. Not only do they look at the prior month’s financials, but also at the present situation revealed in primeVIEW. It’s the expectation he has established that. “I am using it; so should you.”

In another company, management accepts only reports viewable and generated by primeVIEW. No other reports are accepted.

At the beginning of its primeVIEW implementation, another customer clearly stated to its management team what is going away, that primeVIEW is replacing it, and clearly described how it will make their lives easier. Because managers no longer have to manually prepare reports, they can more productively spend their time making decisions.

Conclusion

One last point, not everyone transitions at the same pace. Each person is different and that’s where leadership comes in to play. As the BI champion you have to acknowledge where your team members are in the transition process and help them to:

• Leave the past behind,
• Get through the wilderness of reporting uncertainty, profiting from it, and
• Embrace new attitudes, behaviors, and identity (as decision makers, not data gatherers)

While BI tools, like primeVIEW, can be easy to learn and use, each organization’s leaders must ensure that transition is skillfully managed and sound leadership principles applied. It’s putting people and processes together to achieve a certain end – full BI implementation.

Change + Human Beings = Transition

In the spirit of to our January 7, 2016 blog, we want to continue with the New Years’ resolution theme by concentrating on other important tasks every Post-acute Long Term Care AR manager should address. The following checklist can be helpful in steering your accounts receivables in a cash-positive direction for 2016:

• Contract Management – Perhaps this is a good time to blow the dust off those payer contract file folders. Get to know the details and the impact they will have on cash flow for the next year. Do they include changes for 2016, such as reimbursement rates and contractual write-offs? Being familiar with and responding to such details can help AR managers more reliably predict payment requirements, amounts, and timing.
• Co-insurance and deductibles – The ruleof thumb is if insurance is going to change, it will be at the beginning of the year. Specifically, check each payer’s copayments and deductibles. They typically seem to parallel Medicare guidelines which went into effect January 1^st. The following table highlights some of these changes:

• Patient liability – Not many states have fiscal years beginning on January 1, but in the event the states your facilities operate in do, then knowing what the patient liability rates will be and communicating them to Medicaid residents’ responsible parties will be helpful to collections. Even if the Medicaid fiscal year end is later, now may be a good time to review anticipated changes.
• Contract folder and tickler file - If you haven’t already, we highly recommend that you set up a tickler file to effectively manage and track your payer contracts. Whether the tickler file is a traditional binder with physical folders or an electronic version, this is a good time to bring them up to date and to calendar critical changes and negotiation/renewal dates.

This list is small, but important. It will help you address not only these important revenue cycle management tasks, but also other tasks tied to your 2016 billing and collection goals.

You’re driving down the freeway, heading home from a busy day at work. Remembering the many conversations you had today, you are somewhat preoccupied. You appear to be going with the flow of traffic, but you fail to notice that traffic’s pace is considerably above the posted speed limit. However, your attention is instantly snapped to the here-and-now when you see flashing lights immediately in the rearview mirror. With a statement of frustration (censored, of course), you realize you’ve just been tagged as the bad-boy poster child of speeders and are about to have a one-on-one interview with law enforcement. Now, yes, you have a speedometer. But when was the last time you looked at it?

Having a working speedometer in your car doesn’t prevent you from getting a traffic ticket. It’s only useful if you use it. Likewise, Business Intelligence (BI) is only as good as it is intelligently used. For today’s blog, let me summarize how some of your peers are intelligently using BI.

A vital routine – it’s a matter of culture

We have discovered among our primeVIEW[1] customers that the common thread of success is that BI is an integral part of their corporate culture. Let me quote from a recently-published case study about Health Services Management and how it uses BI, “Today with primeVIEW conspicuously displayed on a large monitor in his office for group discussion, Ray Tyler, HSM’s Chief Operating Officer, and team can observe and examine such Key Performance Indicators (KPIs) as census, labor, RUG levels, and accounts receivables throughout the day.”

In another case study, Greg Seeger, Health Care Management’s Chief Operating Officer, reports, “Since the system is so intuitive, the learning curve was short and our staff could just run with it….We train our team to use primeVIEW as their go-to KPI information source to track census, labor, 5-star, length of stay, clinical quality, receivables, cash flow, and more. It’s a tremendous resource.”

We have also learned from another COO of a large multi-facility, multi-state operation[2] that from the time a new decision maker is hired, the use of Business Intelligence is ingrained into her or his daily routine and reinforced regularly.

Daily - facilitating meaningful conversation and accountability

It’s one thing to have the information; it’s entirely another to know what to do with it. Data mining and business intelligence foster communication and meaningful conversation. From the corporate to the division to the region and facility levels, BI is the reference point for clinical, cash flow, labor, and compliance-related conversations. Because the information is timely, decision influencers and decision makers are able to address issues before they reach critical mass.

Further, HSM’s Tyler reports that “primeVIEW’s flexible reporting features related to date ranges and formats are also very valuable to us, because primeVIEW enables us to quickly prepare and submit reports to key stakeholders, such as REITs. We can view and report on actual-to-budget reports, wage rates, OT, etc.’”

Some providers have found that BI-generated information is useful in fostering positive working relationships with referral sources by demonstrating on a regular basis admissions, discharges, and rehospitalization rates along with quantifiable clinical data.

Weekly - staff meetings

In this case study, Dean Kiklis, Frontline Management’s Chief Financial Officer observes that “during its Monday morning staff meetings, …primeVIEW plays a large role. ‘We can readily view what is or is not on target. It’s helpful to be able to keep the team focused on what’s important for the coming week with relevant and up-to-date data….It allows us to surgically address challenges as they arise. It’s up to date so we don’t have to wait for someone to create reports for us.’”

Monthly - financial reviews

Tyler’s use of primeVIEW goes beyond daily operations; “he also refers to it during his monthly financial reviews with facility administrators who simultaneously view performance in specific areas of focus. ‘By the time our P&Ls are ready, they are a month or more in arrears,’ commented Tyler. ‘But with primeVIEW, we can discuss what happened last month and examine current KPIs which directly impact financial performance and help us predict month-end outcomes.’”

Conclusion

By making BI a part of the corporate culture, it facilitates timely and meaningful conversation, adds relevancy to weekly planning and goal-evaluation sessions, and breaths relevancy into monthly financial reviews. Now that is a sound way to help executives and their teams achieve their goals on time and on target. Now, that’s the ticket…to success.

[1] PCT’s Business Intelligence tool

[2] It’s case study will be published in the near future.

Ah, yes, it’s that time of year – time to make those New Year’s resolutions. Exercise, diet, vacations, revisit the old “bucket list”, maybe even finances. Finances? Now a financially-focused resolution or two should resonate with any AR Manager. Maybe we can help you kick off 2016 right with some helpful resolution hints. They may not be earth-shaking taken independently, but together, they can certainly have a positive impact for you and your team.

Resolution #1 - Make sure that pre-admissions screening covers all the financial bases before the admission. This may sound overly simplified, but it is so essential with numerous moving parts. It is a time not only to be informed, but to inform not just once, but regularly after the admission.

• To be informed – All members of the admissions team must know who the payer is and the proper billing procedure - how much, how long, and for what services. Not only immediately after admission, but should the length of stay outlast such coverage as Medicare or private insurance, the team, the family, and resident must know who will pay. You might say that you want to make sure all your “bucks” are in a row.
• To inform – This is something that some providers forget to proactively pay attention to and communicate. Communicate to whom? The rest of the team, the party (private or third party) who will be paying the bill, and the family. Providers need to keep in mind that placing a loved one in a facility is traumatic and unavoidably new. Prior to and on admission, family members/responsible parties encounter so much information. Your team needs to compassionately and frequently remind them of expectations and their loved one’s status. Changing from one payer to another should never be a surprise. Fostering a positive relationship with responsible parties throughout each resident’s stay will pay big dividends in the long run.

Resolution #2 - Make sure the census is correct, up to date, and entered correctly in the billing software. Whether your facility or facilities are still laboring under a manual census tracking and recording process or you are enjoying the benefits of electronic charting, knowing who is in what bed each midnight is critical. Even electronic charting still requires the personal touch, that is, someone has to make the rounds to confirm the beds are occupied, on hold, or vacant.  

Resolution #3 - Make sure to conduct a triple check before submitting any bills or claims. We are not going to elaborate on the triple check process at this time, but stay tuned for helpful tips in future blogs.

Resolution #4 – Stay informed by attending seminars and webinars. Medicare, Medicaid, Bundled Payments, ACOs, VA, etc. are changing and unless you and your team are informed about what has changed or is about to change, you may be a day late and a dollar short. State and Federal agencies, your state and national trade associations, industry media publishers, and others conduct education sessions throughout the year to help you effectively manage the revenue cycle. Plan on attending as many of these as possible.

Resolution #5 - ICD10 training and updates. Although you and your team are usually not the initial coders, you still have to be ICD10 savvy. The key here is specificity – the highest level of specificity. You have our permission to review those codes and if you are uncertain about the codes specificity, push back on admission and during the triple check. At primeCLAIMS, we have seen many claims rejections since the ICD10 implementation due to a lack of specificity.

Resolution #6 – Stay on top of your Days Sales Outstanding (DSO). Discuss DSO with your team and set goals to reduce it to an acceptable level – ideally around 30 days. However, realistically identify what is in your control. For example, Medicaid in some states pay much later than others. Consider that carefully, set goals thoughtfully, and collect aggressively.

Making and successfully achieving resolutions specific to your department’s and business’s needs can make 2016 truly a Happy New Year at least financially.

It just make cents.