SUNY BOARD MEETING AUGUST 3, 2015
CONCERNS/ISSUES TO BE ADDRESSED Provide an explanation of why the Downstate CMI is low compared to Upstate and Stony Brook Clarify, specifically, what has been accomplished (with Pitts guidance and assistance) to correct coding and billing problems and highlight that the problems identified a few years ago are not the same as UHB is faced with today Effort/status to fill key leadership vacancies in the organization Transition plan prior to PMA s departure 1
CASE MIX BACKGROUND Case mix index (CMI) is a relative value assigned to a diagnosis-related group of patients in a medical care environment. The CMI value is used in determining the allocation of hospital resources to care for and/or treat the patients in the group plus to determine relative weights by government payors for payment rates. Patient 1 Patient 2 Patient Diagnosis Heart Failure and Shock Artificial Lung/Trach Code in ICD-9 System 428.33 440.24 Medicare DRG 291 003 Medicare Weight 1.5031 17.6369 Case Mix can be quoted differently for two reasons: First, all payors do not use the same weighting system Second, all patients are not included in some CMI reporting requirements; in particular, case mix is often reported without newborn nursery 2
CORRECTION OF UHB CASE MIX INDEX NUMBER PRESENTED ON JUNE 15, 2015 FY12 Actual FY13 Actual FY14 Actual FY14 Projected FY15 FY15 Budget As Disclosed June 15, 2015 1.4175 1.2435 1.2853 1.2264 1.2300 (Projected) 1.2264 As Corrected And Updated 1.2478 1.2435 1.2853 1.2264 1.2347 (Actual) 1.2264 3 Medicare weights with Nursery
COMPARISON WITH OTHER ACADEMIC MEDICAL CENTERS HOSPITAL CASE MIX INDICES BY PRIMARY PAYOR Overall Hospital Case Mix Index Mean 1.745 Minimum 1.259 25 th 1.602 Median 1.753 75 th 1.907 Maximum 2.430 SUNY Downstate 1.259* SUNY Stony Brook 1.774* SUNY Upstate 1.619* UHB has the lowest CMI among all AMCs Function of patient population and competitors: Stony Brook and Upstate are Level I Trauma Centers and UHB is not UHB has a Level I Trauma Center competitor across the street * Case Mix Index has been calculated using Medicare DRG weights 4 Source: COTH Annual Survey of Operations & Financial Performance Autumn, 2014
WHILE THE CMI HAS REMAINED STABLE, OTHER CHANGES IN UHB S SERVICE MIX OF PATIENTS HAVE HAD A NEGATIVE IMPACT ON CMI The service mix has shifted away from higher-cmi services such as Surgery and Neonatal to lower- CMI services such as Medicine 5
WHILE THE CMI HAS REMAINED STABLE, OTHER CHANGES IN UHB S SERVICE MIX OF PATIENTS HAVE HAD A NEGATIVE IMPACT ON CMI Similarly, the intensity of inpatient surgeries has moved from higher-cmi specialties such as Cardiothoracic to lower- CMI specialties such as Otolaryngology 6
UHB CASE MIX SUMMARY Negative Influencing Factors UHB s Counteracting Initiatives More discharges with lower resource utilization More surgical discharges with lower resource utilization Continuing Medicare weighting reductions Improved clinical documentation by faculty physicians and residents Improved coding quantity and quality Improved billing policies, procedures, monitoring and staff productivity 7
CLINICAL DOCUMENTATION IMPROVEMENTS IN TWO PHASES Phase I The UHB documentation improvement program was completed in February 2013 with a focus on acute Medicare cases only and included physician and CDI staff education. 8
CDI FINANCIAL IMPROVEMENT (12/1/12 TO 11/30/14) (millions) Exceeded plan by over $2M 9
CLINICAL DOCUMENTATION IMPROVEMENTS IN TWO PHASES Phase II Documentation improvement expanded to include not only Medicare cases, but also other acute cases paid on a DRG basis; targeted are about 1/3 of total cases; full implementation is expected in September 2015 6.3% actual improvement 3.1% actual improvement 3.5% targeted 3.5% targeted 10 Excludes psyc, rehab, OB/newborns, one-day stays, Medicaid and Medicaid HMO.
CLINICAL DOCUMENTATION IMPROVEMENTS IN TWO PHASES Phase II Continuing Plan includes improving clinical documentation to increase the CMI by 3.5% Financial impact on RAP2 of CDI on CMI projected to be $1.28 to 1.45M UHB CDI issues to achieve these improvements Number of trained and effective clinical documentation specialists Extending contract with outside CDI vendor for additional interim experienced staff Physician and Resident education and training Additional follow-up training this fall for Physicians and Residents Number of cases reviewed Improving processes for expanded case review 11
IMPROVING CLINICAL DOCUMENTATION IS NOT THE END Coding checking a variety of sources within the patient s medical record to verify the services provided, abstracting the information from the clinical documentation, assigning the appropriate codes, and creating a claim to be paid Billing (and collecting) getting an accurate and timely claim out the door, following up on unpaid claims, resubmitting claims when necessary to ultimately get cash in the door 12
CODING PROBLEMS OF A FEW YEARS AGO Staff - Difficulty in securing services of a sufficient number of coders Training - Lack of initial and ongoing training for coders Inefficiencies within the HIM Department - Tracking and working unbilled accounts were not structured, resulting in unbilled accounts exceeding the allowable billing timeframe Inefficiencies outside the HIM Department - High number of unbilled accounts due to delays, i.e., missing medical records, delayed physician query responses, and decision on patient types from Case Management Lack of accountability within and outside the HIM Department 13
CONTINUING ACTIONS RELATED TO CODING ISSUES Executed two outside vendor contracts to augment coding staff remotely Achieved HealthBridge (EMR) access for remote coders and made access more efficient The current coding turnaround time blended for Inpatient, Ambulatory Surgery, and ED cases is 2.5 days (uncoded total/average daily gross revenue) Average days in DNFB was 12.1 in March 2013; in May 2015, average days in DNFB was 8.7 Established managerial policy to assign daily tasks to each employee A daily tracking tool was established allowing close monitoring of coded account volume by employee as compared to the newly established productivity goals Medical record receipt by the HIM Department is monitored; UHB is experiencing 100% compliance Paper inpatient and ambulatory surgery records are scanned and available for review within 24-48 hours of discharge In-house coders are receiving training via the American Health Information Management Association s on-line training program An in-house quality control program to review denials is on-going resulting in substantial decline in denials Recently engaged an outside vendor to perform a medical record review for coding quality On June 12, the pure uncoded backlog for Inpatient, Ambulatory Surgery and ED was $4.2M, the lowest it has ever been. 14
TODAY S CODING ISSUES Maintaining the number of coding staff necessary to perform timely coding of medical records, while at the same time training the same staff on ICD-10 effective October 1, 2015 Maintaining the extensive process and efficiency improvements Hiring and training permanent coding staff (a new inpatient coder was hired the week of 7/6/15) Assessing the quality of coding being performed and developing plans for improvement 15
BILLING PROBLEMS OF A FEW YEARS AGO Decentralized management structure for Revenue Cycle, in which several components affect billing Minimal information technology to automate processes and monitoring of patient accounts operations; most existing reports were manual Inefficient processes for working patient accounts did not conform to industry standards and was not efficient Minimal attention paid to the maintenance of the Charge Description Master No structured denial management program No standards established for late charges, denials, account follow-up, queries, underpayments, and insurance verification No point of service cash collections 16
CONTINUING ACTIONS RELATED TO BILLING ISSUES Restructured the billing department and cross-trained staff so they can efficiently work both inpatient and outpatient accounts Implemented workflow software to enable the billing department to better organize, prioritize, assign, and monitor charge capture, billing, and collection efforts Contracted with specialized collection agencies to which Downstate can refer accounts to reduce bad debt write-off and improve cash collections In process of establishing a formal denial management program Reduced bill lag days from 7 to 5 as of 7/1/15 Reduced net days in AR from 83.1 to 57.2 Improved edit first pass rate from 84% to 92.7% Implemented RelayAnalytics Acuity to identify and reduce denied claims Implemented RelayClearance to verify insurance eligibility and reduce denied claims; trained billers on using RelayClearance to correct eligibility rejections Implemented electronic payments for 15 payers Currently training Billing Manager to develop analytical skills to identify trends and billing issues and how to escalate for resolution 17
TODAY S BILLING ISSUES Instilling in patient accounts staff buy-in on the use of recently implemented technology versus reverting to past manual practices; holding staff accountable for production standards Re-staffing and providing leadership to the managed care department; making sure that UHB is receiving the correct reimbursement from managed care companies Transitioning to ICD-10 Keeping current on information systems releases given the competition for IT capital 18
STATUS TO FILL KEY UHB LEADERSHIP VACANCIES POSITION Senior Vice President of Hospital Affairs and Managing Director Assistant Vice President of Ambulatory Care Assistant Vice President Hospital Finance/Controller Director UHB Clinical Practice Physician Compensation Data Analyst UHB Clinical Practice Physician Compensation Assistant Vice President Managed Care Teaching Hospital Associate Administrator Perioperative Services STATUS Search underway by KornFerry with recommended candidate to be selected by 8/1/15 Hired and will start in August Hired and will start in August In Process Hired and will start in August Position vacant since February 2015; search underway by Cejka with recommended candidates to be presented in July Position filled July 2015 19
PMA/UHB TRANSITION PLAN Pitts Management s contract with Downstate concludes on 12/2/15; transitioning of two subject matter experts (HIM and Patient Access) has already occurred since the UHB leaders of these areas are in place As additional Downstate leadership positions are filled (Ambulatory Care, Physician Compensation), transitioning of work will begin as soon as practical Each PMA consultant will review work to-date and ongoing with his/her Downstate counterpart Documentation will be given to and discussed with the Downstate counterpart ; a copy of all of documentation will also be delivered to the UHB CEO Bi-weekly progress reporting continues to be transitioned to Downstate staff as staff are identified to assume this responsibility 20