Steer wrestling and data chasing (Yes, there is a point to this.)

I admit it. I am a born city slicker who likes to wear jeans, cowboy-style shirts from CAL Ranch, a cowboy hat (although it’s been a while since I donned one of them), and a good comfortable pair of cowboy boots. I’ve ridden a horse a handful of times, almost got thrown once, and chased more cows on foot than I care to count when I worked on a farm one summer when I was 17. Now if that don’t qualify me as a rootin’, tootin’, shootin’ wrangler, well…it just doesn’t. But I do like a good rodeo once in a while. And the event that gets my attention happens to be steer wrestling. (Probably because it’s

 

the quickest event and I have a short attention span – where was I?) I mean, think about it. The steer and the cowboy are rocketing along side-by-side at about 30 miles per hour. The cowboy then slides off his horse on to a 600 lb. steer, catches it behind the horns, stops its forward momentum, and then has to wrestle it to the ground. The world record currently sits at 2.4 seconds. (It took me longer that 2.4 seconds to write that last sentence.)

So, what in the pea-pickin’ world does data chasin’ have to with steer wrestlin’ or bull doggin’, as it is otherwise called?

Actually a lot. I mean think about it. It’s the end of the week, the month, the quarter, the year, you name it. Whether you’re a corporate or regional VP of Operations, a facility administrator or executive director, or a department head, you have to file reports and be accountable for the stories they tell. I recall years ago, when operating a 120-bed SNF that I had to meet with the RVP each month and, at times, the divisional VP of Operations as well, to review my facility’s performance. I had a rack on wheels on which I kept all the A/R, A/P, payroll, and P&L printouts and my own manually-generated reports.  I would roll that sucker into the facility conference room ready to present and defend my case. In retrospect it is quite comical to think about. The best way to hide a so-so performance was to bury the RVP and AVP in well-organized outdated and irrelevant summaries based on arcane and rearview-focused information. Yee-haw! It weren’t quick, Ma’am, but it sure got the job done. Sadly, it was also meaningless and unnecessarily time consuming.

Succeedin’ in data wrestlin’

What is the secret to successful steer wrestling? Speed, leverage, and strength. In previously posted blogs, we have repeatedly beat the drum of data mining and business intelligence (BI). Succinctly stated, data mining is “technology-driven processes and practices used to convert raw and sometimes disparate data into easy-to-interpret and actionable information.” Business intelligence gives you the speed and leverage to retrieve the data needed to make sound decisions quickly. And like a good “hazer” (the cowboy riding on the right side of the steer to keep it running straight), BI helps decision-makers focus on what really matters without distractions. Here’s how:

• Speed – business intelligence can retrieve data in real time or at least process the data into useful information in real time as soon as the data is available. (Most of our customers want their data retrieved several times a day.) The BI dashboard displays the data in useful graphs, charts, and tables which are readily accessible and easy to interpret and act on.
• Leverage – Such timely and actionable information gives decision-makers the leverage to make the right decisions to seize opportunities and problems and wrestle them to the ground in record time.
• Strength – Because the dashboard is viewable at multiple levels in the organization with roll-up and drill-down capabilities, organizations can concentrate their leaders at multiple levels to make things happen quickly and powerfully.

Providers today have so many issues, challenges, and opportunities before them and so many regulatory, investment, and regional and corporate stakeholders to answer to. It’s insane to try to wrestle that 600 lb. steer of data to retrieve, compile, make sense of, and report without BI. If you have BI, good job. If you don’t or are not fully taking advantage of it, you don’t need a “steer”-ing committee to create one. There are BI tools available right out of the chute, like PCT’s primeVIEW, designed for the LTPAC steer wrestlers, like you, cowboy.

Now, git off’n your high horse and take a gander.

An associate of mine at primeCLAIMS, recently related a turn of phrase that I agree can apply to working with managed care organizations (MCOs), “If you’ve seen one contract, you’ve seen one contract.”  Depending on the number of managed care organizations your company or facility works with, billing the right payer and submitting the correct claim with the correct information can be quite complicated. MCOs have parallel as well as divergent policies for correct claims submission. Knowing what those contractual requirements are and fulfilling those requirements is the key. So, how does a biller keep this as simple as possible?

What’s in each contract – knowing what is covered, not covered

The devil is in the details. And since each MCO contract may be different from the others, billers should understand what’s in each. The contracts may specify:

• Levels of care by RUG scores or service levels, which specific diagnosis codes are allowed, how many days are considered co-pay days, which ancillaries are covered in the base rate and which may be billed separately or not at all, if a pre-authorization[1] and re-authorizations for a stay is needed, and so forth. Most will agree that no two MCOs are alike. Knowing what services and procedures are covered is essential to and getting paid at the proper pay rates without unnecessary delays.

Caution: Billers need to be mindful that facilities may admit a resident/patient who is to be covered by managed care, but with whom the provider does not yet have a contract. In that event, the provider may not receive full pay for services rendered since the MCO in question may consider the claim out-of-network.

What’s in each contract – knowing how to complete the claim form

Billers need to have a working knowledge of what each MCO expects to have included in the claim form as stipulated in each contract. We recommend that billers have access to the contracts and to know what each requires. Our Managed Care Master App can help. 

Keeping it all in one place – a ready reference

We advise all providers to compile all of their managed care contracts into one location, perhaps a tickler file, a file drawer with a folder for each contract, or a binder. In front of each contract, providers should place a completed summary form highlighting what each payer will pay for under what circumstances using which codes, paying how often. Each summary sheet highlights the essentials that must be included in each claim and should serve as a reference tool during the triple-check meeting. Or better, if you don't want to physically maintain contracts, check out our Managed Care MASTER app for housing your contracts online with easy-to-reference contract summaries.

Set up the system correctly the first time

Another best practice to help simplify the process is to set up each contract’s claims requirements within the billing software, such as rates, included and excluded diagnosis codes, etc. Word to the wise - Take the time now to set it up properly or deal with possible problems later[2].

Last Word

The managed care billing process can be easier to manage if providers will:

• Use available technology, like Managed Care MASTER, or set up a reference binder for each contract and its summary. All billers need to become familiar with each contract.
• Correctly set up the contract provisions within the billing software.
• Refer to the contract summary sheets during the triple-check process.

One More Last Word

My primeCLAIMS colleague, Mike Giel, suggested we mention that in the contract negotiation period, providers need to discuss what provider enrollment procedures the MCO requires before claims can be submitted electronically. Think of it this way. The contract is the key to opening the claims flow door. The enrollment form opens the door. Completing, submitting, and receiving approval prior to submitting the first claim will ensure that the door is open and remains open so that claims can go and payments come in unhindered.  

It just makes good cents.

[1] Example: Pre-authorizations are usually required to pre-approve a specific length of stay. Providers may need to get authorization to extend the stays beyond the initial authorized period. If providers don’t secure a reauthorization, they will have to worry about who will pay for the rest of the stay. Knowing that in advance can eliminate frustrations for all involved: the resident, the resident family, and the provider.

[2] Note: Contracts have a life of their own and can change over time. When those changes occur, record them in the contact binder and billing software set up.

 

Introduction

In a blog posted a few years ago, we introduced how providers can discover the hidden treasures of data mining. In it we wrote, “Refined data transformed into information becomes knowledge and knowledge – the power to act. Data mining, therefore, helps executives discover what is happening now, track trends, anticipate with some accuracy what may happen in the future, and explore the strengths of possible actions.” The data treasure trove becomes meaningful when viewed through dashboards.  

This concept has direct application to your QAPI[1] initiatives.

What is a dashboard?

A dashboard helps deliver information which is easy to retrieve, interpret, and act on. It may include tables, charts, and graphs indicating progress toward your QA goals and can deliver alerts to Key Performance Indicators (KPIs)[2] which may be significantly below or above targeted benchmarks. Because a dashboard offers information refreshed throughout the day, clinicians should monitor it routinely. Beyond regular viewing of the dashboard, making it and its displayed results an integral part of everyday conversation among clinicians is extremely important.

How to leverage your dashboard

You have worked hard to create a culture of quality and the dashboard can serve as a tremendous tool for acknowledging and rewarding progress and for working with your team to take opportune corrective action when performance falls short. Because the KPIs are timely and relevant, dashboards invite involvement among all the organization’s key QAPI players.

Through its KPI roll-up and drill-down capabilities, a dashboard enables clinicians at all levels within the organization to view KPIs germane to their responsibilities. A corporate clinical executive can view rolled up KPIs summarizing information at a corporate level. They can also drill down to a region, facility, and department level as desired or direct region and/or facility managers to focus on outliers. Because they do not have to create or wait for reports created and submitted by others, clinical managers can focus on what needs to be done now.

Dashboards can help clinicians to:

• Facilitate communication within a team and among teams across the organization
• Organize and render KPIs accessible at all levels
• Track progress and opportunities for improvement

Some dashboards, like PCT’s primeVIEW, offer a hybrid of clinically-oriented KPI views for clinicians taken directly from the clinical applications each provider uses, such as PointClickCare, and partnered predictive analytics, such as PointRight, and resident and family satisfaction trends from Pinnacle Quality Insight. For example, clinicians can track such KPIs as:A Monthly Clinical Summary

• Year-to-Date Clinical Trending
• Re-hospitalization rates
• 5 Star Rating, including facility ratings, deficiencies and fines, quality measures, comparison to local facilities, staff PPD ratings and trending
• Resident and family satisfaction trends
• Staffing KPIs including actual to census-adjusted labor hour PPDs
• And more.

Dashboards can help clinicians to meaningfully:

• Identity gaps and opportunities
• Take action to redirect and support

Data converted to information delivers the knowledge to take positive steps to achieve an organization’s goals. Business intelligence enables purposeful data mining to extract the relevant data and display it in meaningful ways through dashboards. If you have not already seized the opportunity to harness the power of dashboards, we highly encourage you to do so.

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[1] From the AHCA/NCAL website we read that ”​QAPI is defined by CMS as ‘an initiative that goes beyond the current Quality Assessment and Assurance (QAA) provision, and aims to significantly expand the intensity and scope of current activities in order to not only correct quality deficiencies (quality assurance), but also to put practices in place to monitor all nursing home care and services to continuously improve performance.’

• “Quality Assurance (QA) = the process of meeting quality standards and assuring that care reaches an acceptable level.
• “Performance Improvement (PI) = continuously analyzing your performance and developing systematic efforts to improve it; also known as Quality Improvement.”

[2] KPIs are quantifiable benchmarks used to measure actual performance compared to, in this case, Quality Assurance and Performance Improvement goals.

 

 

Jim Hoey, Prime Care Technologies, Inc.’s President and CEO, once responded to a question about why his company offers what it offers – cloud-based managed hosting services, business intelligence solutions, automated procurement services, talent management automation, and an LTPAC-focused claims clearinghouse. He proffered the following insight, “We listen to our customers’ concerns and needs and respond with user-friendly and cost-effective cloud-based solutions.” Universally, the needs are the same – to save money, increase productivity, improve the bottom line, and ensure compliance. Among the concerns expressed by billing and AR managers is the need to hit collection targets and to save time.

If you and your team are still processing claims manually, just think of the time, money, and resources wasted – not to mention the frustrations felt. Let’s just take a look at the secondary co-insurance claims process for a minute. Let me quote from a recently-posted blog written for CFO’s about Medicare crossover claims.   

“Secondary claims, if not properly handled can slow up cash flow. ‘A claim is a claim, isn’t it?’ Nope. ‘Well, I’ve got the staff and I am certainly paying enough for them to process the claims. They know what they’re doing.’ Yes, but because of the intricacies of submitting the secondary claim after receiving payment from the primary payer, providers can and often do see a delay in payment or no payment at all. ‘But why?’ you may ask.

“Once Medicare pays the claim, the MAC may through a coordination of benefits agreement automatically forward the secondary claim to the secondary payer. But not in all cases. Only if the secondary payer pays a fee for such services….

“In those cases where the secondary payer does not pay the fee for Medicare to automatically forward the secondary claim, the provider’s Central Billing Office or AR staff or Billers will have to identify, process, submit, monitor, and intervene as needed to collect the…payment. They can do this manually or electronically.

“Paper-based secondary claims – This process is as old as dirt. Because there are many nuances to the process and opportunities for omissions, errors, and procrastination, it creates delays. The billing department receives notices of payment from the primary payer. Then billers have to print the UB04, attach the claim level (and) related remittance advice, and mail or fax these papers to the secondary payer. The manual method usually requires a tickler file, likely an accordion file…to place copies of the submitted documents for follow-up. On the follow-up day, the biller places a call to the payer. Unfortunately, it’s not unusual for the payer to not have a record of the submission. So the biller will have to resubmit the claim again and move the claim documentation further back in the accordion file.

“Oh, and here is another possible ‘… grant me the serenity to accept the things I cannot change…’ moment. Some secondary payers require a 15-30-day waiting period before a provider can resubmit the claim…

“Because preparing, filing, and following up on secondary payer claims can engender procrastination, it's easy to lose track of (these) claims. This can result in further payment delays or no payment at all, if the submission takes place outside the allowable filing window (sometimes up to a year).”

Save time and effort, where possible, with claims automation

Where possible, “Automate. Automate. Automate.” Some claims clearinghouses scrub your claims before submission (according to each payer’s requirements), submits the claims, monitors the claims throughout the process, notifies you of each claim’s status in real time, alerts you (when necessary) to the need for additional information, and informs you of the claims outcome (payment or denial). No more tickler files, no more lost documentation or misplaced claims, no more fruitless and frustrating follow-up phone calls, and you get timely feedback.  

Think of the possibilities

The time you and your team would otherwise normally spend processing and following up with secondary co-insurance claims, you can devote to researching and collecting delinquent accounts, preparing for and appealing denied claims, and, if you are like some billers I know who wear multiple hats, you can focus on your other responsibilities. Whether you process claims at the facility or in a central billing office, automating claims processing makes “cents” for you and your company.

 

“I believe people are like boats.” With that I’ve started many a seminar and webcast. After a brief pause, I relieve the tension by saying, “They toot the loudest when they’re in a fog.” Ambiguity, tardy information, and just plain situational ignorance can keep many a decision-maker in a fog. However, because of the critical need to know how much and when cash will be flowing into and out of the bank, CFOs need crystal clear visibility. And business Intelligence dispels the haze and sharpens the perception of what is happening. From cash collections and revenue projections to labor and non-labor spend management, operations and finance executives alike can know almost up to the minute how much cash is flowing in and how much is flowing out.

Business Intelligence makes it happen

As we have discussed in previous blogs, Business Intelligence (BI) has become the go-to tool to help managers keep their fingers on their business’s multiple pulses all in one convenient easy-to-view location. For LTPAC providers, this amounts to such Key Performance Indicators (KPIs) as census, cash, accounts receivable, labor and non-labor spend, clinical, and other information. Roll up. Drill down. It doesn’t matter. CFOs can glimpse a consolidated view of KPIs important to them and then drill down as deep as they need to track, trend, and act. It’s real time and it’s highly effective. How? BI makes information visible at all levels within the organization simultaneously. And visibility drives accountability

But let’s limit this conversation to cash flow

Turning revenue into cash in the bank

Let’s explore a day-in-the-life-of one of a CFO who uses BI to monitor and hold accountable those responsible for keeping the cash flow steady and predictable. It’s mid-month and after logging into the BI tool (in our customers’ case, primeVIEW), the CFO, we’ll call him, “Craig”, reviews the tiles he’s configured for his home page displaying what to him are the critical KPIs. From there he clicks on the Cash/AR tab to view such information as:

• The current month collections-to-goals performance with 12-month trending
• What’s been collected and deposited each day by payer type for the current month, recent quarter, and year-to-date (Remember. He can view a corporate summary or drill down to a region or facility level.)
• How each facility or region ranks compared to their company peers by payer type
• The status of each facilities aging with payer type drilldown capabilities
• The Days Sales Outstanding (DSO) over a specified period of time
• How revenue is trending by payer typ

Craig notices that the South region is falling short of its MTD collections through the 15^th of the month. He calls Melissa, one of his veteran regional managers, and invites her to open up primeVIEW to discuss these outliers and what her staff can do today to right the regional ship and get it back on course by the next collection benchmark which is the 20^th. Melissa reports that she and her staff have been working with Facilities A and D since noticing the slowdown in collections on the 10^th. She assures Craig that her team is confident that these facilities will reach the month-end harbor very close to their goals

Financial performance

After concluding the call, Craig clicks on the financial tab to check on current revenues generated compared to budgeted projections by region as well as by facility by payer type. He further reviews revenue by occupancy by day, by payer, and by service. Convinced that the company is on track to meet goals and, in a couple of facilities, to exceed goals, Craig then turns his attention to the bad debt allowance status by facility as well as month-to-month trending. He makes a note to himself to address this issue in the next meeting with his corporate AR manager

Conclusion – Visibility is more than just clarity of sight

Because of BI, cash flow visibility is current, communication is specific, and required action is timely. Visibility encourages accountability and fosters real results.