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Fee recovery from denied claims is a critical strategy healthcare practices must have to safeguard profitability; however, executing a denial recovery plan is far more complicated than merely setting a billing staff goal. Teams need to track denial patterns, understand transactional activity AFTER the denial, and formulate an appeals process that includes measurable results. An effective analytics platform, along with highly targeted and organized visualizations, will support a practice’s revenue integrity efforts.
We discuss key strategies to maximize the denials recovery process, track successes and weak areas, and ensure your practice is in the optimal position for financial strength.
Webcast topics include:
- Essential categorization of denials into meaningful groups
- Analysis of recovery successes and failures from different angles
- Departmental causes and corrections with focused dashboards
- Implications of recovery efforts on cashflow
- Financial benefits of incorporating prevention efforts
Originally recorded on February 24, 2021.
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The lessons of 2020 still linger. The pandemic and variable patient volumes have led to financial uncertainty in many practices. As healthcare organizations move into 2021, providers now must navigate the new RVU valuations and reimbursement decreases from CMS as part of their 2021 Physician Fee Schedule. Ensuring the utmost revenue integrity is critical at this time.
This webinar will explore revenue integrity strategies around the new E/M Coding rules, A/R Management, and Denials Prevention and Recovery to maximize a practice's bottom-line cash-flow.
Webinar topics covered include:
- Understanding the CMS 2021 Physician Fee Schedule Final Rule impacts
- Analysis of what this could mean for practices
- Understanding Key Levers driving Revenue Integrity
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On December 2, 2020, CMS released the final rule for the 2021 Physician Fee Schedule (PFS). It was revised on January 7th as part of the COVID Recovery Act. Every year, practices can expect to see small changes to the RBRVS scale and the expected budgetary modifications to the RVU Conversion Factor, but the 2021 changes to the PFS are significant.
RVU values for some of the highest volume codes were increased substantially. However, to maintain budget neutrality, the RVU conversion factor utilized to determine the approved payments to providers for services rendered was decreased at a proportional level. These changes could have significant impacts not only on practices with high Medicare and Medicaid patient panels, but also practices that rely heavily on the CMS RVU calculations for anything ranging from provider productivity reporting and benchmarking, to utilizing RVUs to determine physician compensation. The modifications are significant enough that practices should start modeling these changes immediately to be able to plan for the impact they will have on their bottom line.
On the positive side for physician practices, there was a revaluation of the RVU values for common Evaluation and Management (E/M) procedures – particularly the New and Established Patient Office Visit codes. In most practices, these are the most commonly billed codes by a fairly significant margin. The highest-level New Patient E/M Codes (99203-99205) increased by an average of approximately 10%. The Established Patient Outpatient E/M Codes increased by an average of 30% to 35%. Because these codes are so commonly billed in most practices and RVU values are universal across all patients, many providers will see significant RVU increases in their productivity reports. Additionally, most CPT codes will see a small increase in Practice Expense components of the Total RVU which is utilized to calculate Medicare reimbursement.
These RVU increases are offset from a budgetary standpoint by CMS originally proposing to drop the RVU conversion factor for all codes from the 2020 value of $36.08 to $32.41 in 2021. This equates to approximately a 10.5% decrease. The COVID stimulus act appropriated some additional funds for the physician fee schedule so that the decrease would only be around 4% to approximately $34.89.
To understand what this means, we will use an example of billing code 99213 - Established Patient Office Visit:
- In 2020, the Work RVU value for this code was .97 and the NF Total RVU was 2.11.
- When the 2.11 is multiplied by the 2020 $36.08 Conversion Factor, it led to an approved payment of $76.13.
- In 2021, the Work RVU component for the same code increases to 1.3, and, with the practice expense increase the NF Total RVU increases to 2.68.
- When multiplied by the 2021 RVU Conversion factor of $34.89, the approved payment amount is $93.51 – an increase of $17.38 or nearly a 23% increase.
Most codes, however, do not see similar increases.
For example, a New Patient Office Visit Level 5 – CPT Code 99205 – which does have an increase in the Work RVU component, does not see as significant an increase. This particular code projects a 2% increase from the 2020 approved reimbursement of $211.07 to $215.62 Other codes including surgery, radiology, etc., do not see an RVU increase at all, so the reimbursement could decrease by up to 4%.
Modeling the Medicare Reimbursement impact can help practices better understand how this rule affects their bottom line. By taking the utilization of the seven impacted E/M codes, modifying the RVU, and then repricing their Medicare Total RVU values – including the E/M increases – at the 2021 RVU Conversion Factor, a practice can predict the change in Medicare reimbursement that will be realized. This should be done at a division, specialty, or and provider level depending upon the organization and the level of Medicare in the organization’s payer mix.
Keep in mind, however, that the Reimbursement changes are not the only impact. The RVU changes are universal, regardless of payer. This will have an impact on Provider Productivity reporting and benchmarking. Depending upon the benchmarking service a practice uses, new benchmarks incorporating the E/M changes may not be available for 6-months to a year. As such, the provider’s RVU productivity compared to the benchmark may be artificially inflated by the E/M RVU modifications for all payers. Practices may want to adjust the benchmarks or productivity reports to take these changes into account.
RVU based physician compensation is also a key area to monitor with regards to the RVU changes. Organizations will see RVU increases across the board for most physicians, even when reimbursement remains flat or decreasing. This may have a significant financial impact on many organizations. Often, there is not a lot that the organization can do about the compensation plan; however, modeling the expected compensation increase based upon each provider’s E/M utilization can be a huge benefit to finance and payroll departments as they plan for the impending financial impact and adjust the budgets and projections accordingly.
The 2021 proposed rule for the Physician Fee Schedule is the most significant change in Medicare reimbursement in a single year that I have seen in my 20+ years in Healthcare. Organizations should model the changes and plan now, to fully understand the impact on their organization.
Written by Scott Everitt, VP of Healthcare Solutions at Practical Data Solutions
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Reporting in the healthcare industry relies heavily on Excel; however, automating report production can be difficult and time-consuming. Without Excel automation, managers and analysts may be spending more time creating and populating reports than using them to improve financial or operational performance in hospitals and practices.
In this webinar, learn about the common challenges with Excel and how to use the automation and dashboard design features in PDS DASH to maximize Excel's visualization and customization features. Understand how this powerful tool can reduce user errors, improve overall accuracy, and increase staff productivity by 20-60%.
Discover how to leverage your current Excel skills using PDS DASH to blend data on the fly, update designs and produce timely dashboards that handle today’s unique reporting requests. See proven template designs that can be automated and implemented rapidly to identify performance improvement opportunities.
Highlights:
- Understanding the advantages and challenges of using Excel for dashboards
- Demonstration of Excel’s powerful visualization capabilities
- How PDS DASH can blend data from disparate sources to leverage Excel capabilities
- Utilizing PDS DASH to automate the creation of visualizations at multiple levels of an organization
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Anyone who manages Revenue Cycle, Reimbursement, Physician Compensation or Productivity will find the content of this webinar extremely beneficial.
On August 3, 2020, CMS released its annual proposed rule changes to the Physician Fee Schedule for 2021. The changes include an increase in RVU valuation and payments for common E&M Codes, and an expanded list of approved telehealth services. However, due to budget neutrality requirements, the proposed RVU conversion factor decreases. Medical groups and practices need to understand – now – the potential impact these changes will have on their financial health and viability.
Learn how data analytics can predictively model the proposed changes and assist practices in forecasting and planning for 2021 and beyond.
Topics include:
- Understanding the practice’s Medicare population by volume and service mix
- Illustrating the impact of the changes in E/M Services vs. other procedures
- Modeling the revised Physician Fee Schedule against historic utilization by Specialty
- Predicting how the revised CMS fee schedule could modify rates from commercial contracts
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On August 3, 2020, CMS released the proposed rule for the 2021 Physician Fee Schedule (PFS) for the Public Comment Period. Every year, practices can expect to see small changes to the RBRVS scale and the expected budgetary modifications to the RVU Conversion Factor, but the 2021 proposed changes to the PFS are significant.
RVU values for some of the highest volume codes were increased substantially. However, to maintain budget neutrality, the RVU conversion factor utilized to determine the approved payments to providers for services rendered was decreased at a proportional level. These changes could have significant impacts not only on practices with high Medicare and Medicaid patient panels, but also practices that rely heavily on the CMS RVU calculations for anything ranging from provider productivity reporting and benchmarking, to utilizing RVUs to determine physician compensation. The proposed changes are significant enough that practices should start modeling these changes immediately to be able to plan for the impact they will have on their bottom line.
On the positive side for physician practices, there was a revaluation of the RVU values for common Evaluation and Management (E/M) procedures – particularly the New and Established Patient Office Visit codes. In most practices, these are the most commonly billed codes by a fairly significant margin. The highest-level New Patient E/M Codes (99203-99205) increased by an average of approximately 10%. The Established Patient Outpatient E/M Codes increased by an average of 30% to 35%. Because these codes are so commonly billed in most practices and RVU values are universal across all patients, many providers will see significant RVU increases in their productivity reports.
These RVU increases are offset from a budgetary standpoint by CMS proposing to drop the RVU conversion factor for all codes from the 2020 value of $36.08 to $32.26 in 2021. This equates to approximately a 10.5% decrease.
To understand what this means, we will use an example of billing code 99213 - Established Patient Office Visit:
- In 2020, the Work RVU value for this code was .97 and the Total RVU was 2.11.
- When the 2.11 is multiplied by the 2020 $36.08 Conversion Factor, it led to an approved payment of $76.13.
- In 2021, the Work RVU component for the same code increases to 1.3, and the Total RVU increases to 2.44.
- When multiplied by the 2021 RVU Conversion factor of $32.26, the approved payment amount is $78.71 – an increase of $2.58.
Most codes, however, will not see similar increases.
For example, a New Patient Office Visit Level 5 – CPT Code 99205 – which does have an increase in the Work RVU component, will not see an increase. This particular code projects a decrease from the 2020 approved reimbursement of $211.07 to $199.37; the RVU increase is not enough to compensate for the decrease in the conversion factor. Of course, other codes, surgery, radiology, etc., will not see an RVU increase at all, so the reimbursement will decrease.
Modeling the Medicare Reimbursement impact can help practices better understand how this rule will affect their bottom line. By taking the utilization of the seven impacted E/M codes, modifying the RVU, and then repricing their Medicare Total RVU values – including the E/M increases – at the Proposed 2021 RVU Conversion Factor, a practice can predict the change in Medicare reimbursement that will be realized by the proposed changes. This may need to be done at a division, specialty, or even provider level depending upon the organization and the level of Medicare in the organization’s payer mix.
But the Reimbursement changes are not the only impact. The RVU changes are universal, regardless of payer. This will have an impact on Provider Productivity reporting and benchmarking. Depending upon the benchmarking service a practice uses, new benchmarks incorporating the E/M changes will not be available for 6-months to a year. As such, the provider’s RVU productivity compared to the benchmark may be artificially inflated by the E/M RVU modifications for all payers. Practices may want to adjust the benchmarks or productivity reports to take these changes into account.
RVU based physician compensation is also a key area to monitor when these RVU changes go into effect. Organizations will see RVU increases across the board for most physicians, even when reimbursement remains flat or decreasing. This can be a significant financial hit for many organizations. Often, there is not a lot that the organization can do about the compensation plan; however, modeling the expected compensation increase based upon each provider’s E/M utilization can be a huge benefit to finance and payroll departments looking to plan for the impending financial impact and adjust the budgets and projections accordingly.
The 2021 proposed rule for the Physician Fee Schedule is the most significant change in Medicare reimbursement in a single year that I have seen in my 20+ years in Healthcare. Organizations should take heed and look into the impact, model the expected changes, and plan now in case all of these changes are adopted so that they will not be caught off-guard.
Written by: Scott Everitt, MBA, VP of Healthcare Solutions at Practical Data Solutions
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How can providers ensure that patient populations have their chronic conditions promptly checked and treated now that practices are reopening for routine and non-critical care?
Learn how to use visit data, structured with Hierarchical Condition Coding (HCCs), to focus efforts, organize care teams, and close the gaps created by the pandemic. We will discuss how the strategic use of data analytics can assist in identifying chronic condition patients in need of visits. We will also show how analytics can manage provider availability, and identify potential efficiency improvements utilizing in-office, phone, and telehealth for improved access and minimized exposure for patients. Through a better understanding of patient populations - and a planned, proactive outreach - practices can more effectively provide quality care, treat at-risk patients, and ensure appropriate reimbursement.
Originally presented on July 29, 2020, by Practical Data Solutions’ Russell J. Hendrickson, President & CEO and Kelly Constantinetis, Senior Business Intelligence Analyst.
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Learn how to design impactful, user-friendly Excel visual dashboards in hours.
Healthcare organizations need the power of data analytics, adaptable reporting, and visualizations now more than ever. PDS will show proven approaches that leverage your current Excel skills and pave the way to providing timely, dynamic visualizations to meet the current – and rapidly evolving – needs of today’s challenging healthcare environment. When needs are critical, and resources are constrained, see how Excel’s flexibility can be enhanced using simple design techniques to produce new cost-effective, insightful reporting. This Webcast will showcase proven Excel dashboard designs that can be implemented today to identify financial and performance improvement opportunities in hospitals and practices.
Originally presented on June 17, 2020, by Practical Data Solutions’ Scott Everitt, MBA, Vice President of Analytic Solutions and Michele Perry, Vice President of Service Delivery & Web Analytics.
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Managing your revenue cycle is critical to the financial health of your organization. The goal is simple—ensure that all entitled revenue has been accurately captured, billed and collected. The revenue cycle creates massive amounts of data transactions which require appropriate staging and modeling to uncover lost revenues, understand denials and identify performance improvement opportunities. Learn how visual analytics can help identify performance gaps and focus leadership to drive and improve your organization’s financial performance.
Topics Include:
- Understanding measurable revenue drivers
- Concisely communicating the cost of poor performance
- Visualizing opportunities and successes
- Techniques to visualize data quickly
- Best practices that drive actionable results
Originally presented on March 18, 2020.
About the Speakers:
Scott Everitt, MBA, has spent over 19 years in the healthcare industry, holding key leadership positions in finance, clinical operations, revenue cycle management, patient access and physician practice management. Scott has achieved significant success in his role as Vice President of Healthcare Solutions by helping clients improve operational and financial efficiency.
Kelly Constantinetis started in August of 2014 as a Senior Business Intelligence Analyst with PDS. Starting her career in hospital finance over 18 years ago, Constantinetis has since served in a variety of roles within the healthcare industry including physician practice finance, operations, application support and analytics. Constantinetis has a bachelor’s degree in Finance from Castleton University.
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Managing medical practices is challenging even in the best of times. But what happens when situations outside of our control force temporary but significant changes upon us? Health systems, hospitals, and clinics need to be among the most stable of businesses no matter what the circumstances in order to best serve patients and the community’s urgent needs. The recent events of COVID-19 have illustrated the need to be adaptable in times of crisis. External changes may force us to modify how we do business for several days, in the case of extreme weather or natural disasters, to several months, in the case of the current pandemic. As leaders in these organizations – and indeed, in our communities – how can we best position ourselves to navigate through these turbulent times?
The Financial Conference is always a great opportunity to connect with healthcare professionals to share the latest in analytics and the challenges organizations are facing today. This conference always sparks great discussions on strategies to run a more profitable and efficient organization. During these great discussions, PDS was able to share how our solutions can help with financial management, payer contracting analysis, business intelligence and revenue cycle management best practices.