FINDING NEVERLAND: New Jersey HFMA June 9, 2015

Transcription

1 FINDING NEVERLAND: NAVIGATING CHARGE MASTER STANDARDIZATION New Jersey HFMA June 9, 2015

2 ABOUT THE SPEAKERS Stacey Harper, RHIA, CPC, CPMA Senior Manager WeiserMazars LLP 33 West Monroe Street, Suite 1530 Chicago, IL Stacey Harper is a Senior Manager in the Health Care Advisory Services Practice of WeiserMazars LLP. Stacey s background includes assessment and implementation of process improvement initiatives across the revenue cycle including charge capture, patient financial services, denials, strategic and transparent pricing, and compliance. She is a Registered Health Information Administrator (RHIA), Certified Professional Coder (CPC), and Certified Professional Medical Auditor (CPMA).

3 ABOUT THE SPEAKERS Taylor Pedone, CPC, Senior Consultant WeiserMazars LLP 33 West Monroe Street, Suite 1530 Chicago, IL Taylor Pedone is a Senior Consultant in the Health Care Advisory Services Practice of WeiserMazars LLP. Taylor s background includes assessment and implementation of process improvement initiatives across the revenue cycle including charge capture, patient financial services, denials, strategic and transparent pricing, and compliance. She is a Certified Professional Coder (CPC).

4 LEARNING OBJECTIVES 1. Charge Master Standardization Overview 2. Key Considerations for Charge Standardization 3. Pricing Strategies for Multi-Hospital Systems 4. Implementation Strategy 5. Case Study Six Hospital System 4

5 WHAT IS A CHARGE MASTER STANDARDIZATION? Detailed line by line review of each facility s charge master for accuracy and compliance Revenue Codes, CPT/HCPCS codes, Billing Descriptions, Usage Aligning facility charge masters with best practices to result in one cohesive charge master Aligning departmental and system-wide charge master and charge capture policies and procedures Consistent pricing strategy (not necessarily prices) 5

6 BENEFITS OF CHARGE MASTER STANDARDIZATION Consistent CPT/HCPCS, Revenue Code Assignment and Billing Descriptions Ensure accurate coding and appropriate billing Improved charge capture Clinical manager involvement in standardization process Uniform price and volume analysis Improves revenue comparison and charge capture trending Improved collections and reduced third-party denials Compliant procedural coding, clean claims Reduced risk of payer audits/penalties Compliance, policies & protocols Guidance Provided by protocols Formal protocols, improved consistency Easy updates on a global level Streamlined process, central repository 6

7 STANDARDIZATION PROCESS Develop a chargemaster workgroup & project leader Line by line CDM review with clinical departments Implementation and Maintenance Affected departments: Compliance, Finance, Managed Care Contracting, Billing, Clinical Departments, Care Management, Patient Access, Revenue Integrity, HIM/Coding, IT Initial Standardization & Go- Forward Maintenance Revenue & Usage review Charge capture method/process CPT/HCPCS code and Revenue Code accuracy Billing description accuracy Review for gaps and redundancies Annual review for CPT/HCPCS deletions & additions Policy for new charge generation 7

8 CRUCIAL WORKSTEPS Develop a chargemaster team 2-6 individuals focused on maintaining the chargemaster and protocols, verifying ongoing compliance, and a departmental resource Assign a project leader Representation from each hospital Assign a project champion / sponsor Ensure system-wide support with backing from CEO/CFO Set timelines Ensure project remains on track with realistic goals and timelines Weekly/Bi-Weekly project meetings Develop a process for maintenance Ongoing review of chargemaster accuracy, data review, and usage trending 8

9 KEY CONSIDERATIONS FOR STANDARDIZATION Will the hospitals be standardized on the same billing/clinical system(s)? Both the billing and clinical system affect standardization Affects actual process and capture of the charges as well as how charges are processed Can be accomplished on same or different systems (far more complexity) Is there common leadership over similar departments across hospitals? Requires leadership to work collaboratively for ultimate success Migrate to best practice Avoid converting hospitals to chosen hospital s structure and processes Instead move toward best practice and encourage adoption by all facilities Charge masters can be completely standardized yet still maintain separate pricing by facility or other factors

10 OVERALL IMPLEMENTATION SUGGESTIONS Make critical decisions upfront Pricing, Contracting, Billing/Clinical Systems, Leadership Roles Use pilot departments who are engaged and not adverse to change Identify ways to measure value and outcomes as project progresses Encourage detailed financial analytics Use parking lot mentality to control scope Overcommunicate expectations, timeline and involvement of clinical departments Hold project leaders, sponsors and champions responsible for outcomes 10

11 PRICING CONSTRAINTS Academic, Urban, Rural, Community Hospitals merging into one Health System can be problematic How do you address pricing in a world of transparency & defensibility? How do you address varying cost structures, patient acuity and competition? How do you standardize charge master and charge structure in this environment and ensure net neutrality (or net revenue improvement)? 11

12 STRATEGIES FOR PRICING Requires significant involvement and input from Executive Leadership regarding vision and strategy Where do you want to be in the market place? Are your Hospitals different enough to warrant different pricing? Do you Managed Care Contract restraints? And do they vary by facility? Do you want to be the low cost provider or have specific service lines that warrant being above/below market? Do you have reliable cost data? Do your variances in cost structure by facility make sense? 12

13 STRATEGIES FOR PRICING Consolidated pricing across hospitals versus tiered pricing categories (i.e. rural, urban, academic) Consistent methodologies across Departments with varying mark-ups above cost (most effective in supplies, OR, pharmacy type departments) Consistent pricing methodologies are far easier to implement with consistent charge structure and departmental processes across facilities Consider phased approaches to updating prices (over 1-5 year period, staggering departments, etc.) Set floors and ceilings for changes and perform detailed analytics on net impact at a procedure, service line/department and facility level by each payor to fully grasp impacts 13

14 CASE STUDY SIX HOSPITAL SYSTEM

15 CASE STUDY- SIX HOSPITAL SYSTEM Six hospital system More than 17,500 employees and 4,600 credentialed physicians 1,725 Hospital Beds Annual volumes 200,000 Emergency Room Visits 90,000 Inpatient Discharges 8,000 Newborn Deliveries 25,000 Inpatient Surgeries 57,000 Ambulatory Surgeries 10,700 Cardiac Catheterizations 4,000 Coronary Angioplasties 1,500 Open Heart Surgeries In process of migrating each of its six hospitals to new integrated EMR Wanted to review charge capture processes and structure and standardize across the Health System 15

16 CASE STUDY- SIX HOSPITAL SYSTEM Review identified the following initial variances: Dramatic variances in Emergency Department acuity level assignment Variances within peri-operative services to include Anesthesia, OR, Recovery, Endoscopy Variances in most other clinical departments across the Health System relative to either charge master build and/or process Compounding factors: Hospitals on different clinical systems Varying payor mix, patient acuity and complexity of service offerings by facility Variances in leadership and executive presence 16

17 STANDARDIZING CLINICAL DEPARTMENTS Operating Room/Peri-Op Standardized all facilities to a 5 level OR acuity system Developed criteria and worked with staff to assign levels, assess overall financial impact and reprice OR services by facility Standardized all facilities to same charge structure for anesthesia & recovery/pacu Criteria and policies/protocols developed Labor & Delivery Inpatient Standardized all facilities consistent delivery structure Protocol developed/updated and implementation completed Outpatient Standardized charge capture and acuity level system for outpatients seen in the department Converted hospitals with varying charge capture methodologies to standard process Endoscopy Standardized all facilities to 6 level acuity system for Endoscopy services Updated charge capture methodologies to align with peri-op changes for anesthesia and recovery Accommodated any additional processes required due to varying clinical systems 17

18 STANDARDIZING CLINICAL DEPARTMENTS Emergency Room Standardized all facilities to same acuity system being utilized by HIM Updated all charge master build and methodology of charge capture across facilities Pain Management Standardized varying clinical and charge capture processes across facilities to align Infusion Services Provided standardized charge methodologies and build of charge master One of the most complicated transitions based upon the varying processes across each facility and clinical department 18

19 RESULTS OF STANDARDIZATION Consistent protocol utilization in Peri-Operative services to determine OR level assignment Improved charge capture of anesthesia and recovery services Implemented consistent Labor and Delivery acuity structure for delivery charge assignment Consistent protocol utilization in Endoscopy for procedural level assignment Standardized Emergency Department acuity levels with consistent criteria utilized across all facilities resulting in stable ED bell curve system-wide Improved procedural and supply charge capture in Emergency Department and Outpatient Labor & Delivery Improved supply and pharmaceutical charge capture in Operating Room, Labor & Delivery, Endoscopy, and Pain Management Improved accuracy of Infusion Services charge capture as direct result of improved clinical documentation and education of training 19

20 QUESTIONS

21 CONTACT Stacey Harper Senior Manager (P) (E) Taylor Pedone Senior Consultant (P) (E) Visit us at: Follow us on: