HELP WHERE HOSPITALS NEED IT ®
HELP WHERE HOSPITALS NEED IT ®
Community Hospital Blog
By Cindy Matthews, CHC Executive Vice President
Vital to an organization’s future, a business plan is a framework outlining the steps for financial and operational success. For many hospitals, this process has occurred at five-year intervals tied to strategic planning efforts. However, in today’s healthcare environment marked by ongoing industry, reimbursement, and market shifts, development of an annual business plan offers leaders a greater measure of security and flexibility to manage change.
Best practices for your hospital’s business planning include:
Align business planning efforts with strategic initiatives
Getting started, associate business planning efforts with strategic goals and objectives. Some hospitals benefit by having a board-level strategic planning committee to identify overarching strategic initiatives. The business-unit focused plans you develop for service line growth, physician alignment, operational efficiency, clinical quality and patient engagement/satisfaction must be consistent with the organization’s strategic objectives. Leaders should work with hospital managers to ensure department and service line business plans and budgets align with hospital strategic initiatives.
Conduct a market assessment prior to starting the business plan
A snapshot of your environment—such as demographics, patient origin and market share—will serve as the foundation of your business plan. For example, evaluate volumes coming into the hospital broken down by zip code and/or service line. Who are your competitors in the marketplace? What opportunities are available to stem outmigration?
Draft your business plan concentrating on measurable results; develop an action plan
Incorporate these areas of focus:
Each stated strategy should have a measurable metric. What does the term “enhance” mean, for example? Be specific. Do you anticipate an increase in the number of orthopedic surgical procedures? How would you get there and what are the associated revenue goals?
An integral component is a detailed action plan with tactics to achieve the desired results. Identify who is responsible for achieving a stated goal, and the timeline (a date or quarter) for completion.
Involve Stakeholders in plan development
Although the hospital CEO is ultimately responsible for the business plan, hospital Board members and medical staff members should be included in the planning process, in addition to other C-suite leaders including a marketing representative if available.
Input from Board members can be advantageous particularly at the beginning of the planning process; some hospitals engage Board representatives as part of a pre-planning process, and others have a strategic committee to assist with business plan development.
Stakeholders including physicians are also essential planning process team members. The hospital’s medical staff plan should drive physician recruitment efforts; regular physician-CEO communication integrates valuable physician input into the plan.
A process timeline
Although planning is often viewed as a task or event, something with a timetable marked with a beginning and an end, it’s an ongoing process. “Always be planning and implementing” should be the mindset.
The timeline you develop for the business planning process should
integrate with the hospital’s fiscal plan and associated deadlines. For hospitals with a fiscal plan year running from July 1 to June 30, completing a market assessment in the fall provides much-needed data for business plan development due in January. Next, plans can be presented to respective hospital Boards for approval in February or March —a precursor to development of the annual budget with accompanying action plans. Be certain to allocate additional time if needed depending on the level of Board involvement.
A well-crafted business plan identifies the steps for financial and operational success. Also, the plan places your organization in a position of strength to grow regionally or get ready for a partnership, if desired.
For more information on business planning, see CHC Consulting Annual Business Planning and Budgeting.
Guest blog by Chuck Green, Principal, Healthcare Reimbursement Partners
Ever-expanding in complexity, cost reports influence current and future reimbursement levels for your hospital. Think of a cost report as an annual report with numbers instead of words. Far-reaching in scope, mistakes can result in lost revenue that may profoundly affect your hospital’s sustainability and ability to effectively serve patients.
The Center for Medicare and Medicaid Services (CMS) requires Medicare certified hospitals and other Medicare reimbursable provider facilities to file cost reports annually that identify the costs and charges related to facility Medicare reimbursable activities. Acting as annual reconciliations, these financial reports disclose whether a facility has been underpaid or overpaid for reimbursable services.
Cost reports are filed with one of 12 third-party CMS-approved claims processors known as Medicare Administrative Contractors or MACS. It must be submitted 150 days after the hospital’s Medicare year concludes. Late and/or inaccurate filings can result in penalties.
Service Line Considerations
A cost report almost microscopically examines a facility’s service line and cost center charges throughout the care continuum. When compared with Medicare reimbursement, the hospital can determine a service line’s financial impact versus its community need and/or desirability.
From a business planning perspective, the cost report helps determine the financial consequence of offering a new service, continuing or expanding an existing one, or discontinuing one that is underused and/or unprofitable. Meanwhile, assigning a less profitable service to another hospital area allowing greater reimbursement may be a profitable option, whereas instituting an uncommonly large service increase could trigger a payment penalty.
Preparing an Accurate Report
The comprehensive patient treatment and financial data contained in the annual cost report, collected from multiple hospital-specific financial and operational reporting systems, must accurately mirror the hospital’s current performance. Cost reports are only as accurate as the information provided by each hospital’s system.
Who Should Prepare your Cost Report?
You may need expertise beyond your in-house financial team or CPA. Experienced consultants monitor ongoing changes in government reimbursement, keep your hospital on a timeline, assist with appeals and help ensure your hospital receives the most advantageous allowable Medicare reimbursement.
Example: In one instance, a cost report consultant enabled a hospital to recoup a $2 million MAC underpayment because he spotted a .02 percent rather than a .2 percent reimbursement calculation in the MAC’s compensation system.
Successful Steps to Gainful Cost Reporting
These pro-active, best-practices could help ensure a hassle-free and profitable process and gainful Medicare reimbursement.
by Wilson Weber, CHC Executive VP and COO
Hospital leaders may recognize the need for improvement but may not know where to turn. Even before a hospital shows signs of financial distress, the responsible action is to take a close look at areas of operations. Since operations span the entire hospital, a head-to-toe operational assessment may be warranted to fully address financial and performance issues.
Taking a thorough look at operations may seem daunting. Consider starting with an evaluation of outsourced contracts; some may have been in place for years and can be renegotiated or even eliminated. Below are high-level best practice tips that serve as cost-reduction and revenue enhancement strategies, and can help redirect an ailing situation toward a partial or full turnaround.
Evaluate labor and its costs.
Labor costs typically account for 50 to 60 percent of a hospital’s operating revenue, so a thorough review of productivity is critical. While a productivity tool can help to set productivity targets, it also integrates a level of accountability toward helping to control labor expenses. Productivity evaluation can also indicate the right level of staffing by shift and day. Productivity standards, manager involvement, and executive oversight will move you toward your goals of greater efficiency while reducing labor costs.
Analyze supply costs.
Second only to labor costs, supply spend represents significant expense for hospitals. Often, small hospitals don’t have the negotiating power, so look to the expertise of a group purchasing organization (GPO), or evaluate whether you have the right GPO with your interests in mind. From our experience, the right GPO relationship can mean supply savings from 10 to 14 percent.
One key area to look at is your supply inventory. Have quantities been adjusted based on volumes, or types of procedures such as those performed in orthopedics or the cath lab? It may be possible to work with vendors to be charged for supplies when they’re needed (just-in-time delivery) versus overstocking for procedures that may be scheduled; this practice helps to free up dollars for other purposes. Also examine inventory “turns,” the number of times per year that supplies are being replaced. Based on our experience, a reasonable level of inventory turn is 9 to 12 times per year. This examination could indicate unnecessary items in your inventory.
Examine revenue cycle management.
Because the revenue cycle is a complex function, points in the process may be overlooked or broken. Your hospital may also face common challenges such as keeping your chargemaster current and competitively priced, and keeping up with each payer’s unique rates and payment methodology.
Additional areas to evaluate and address:
Move ahead with greater confidence.
Your overall action plans should identify who is responsible and accountable for each area of evaluation and opportunity. The discipline of frequent review helps to ensure that you are not drifting off the plan and that progress is occurring across all areas. A new level of accountability across team members is one indication that you have arrived. Be mindful that it does take time and diligence to impact turnaround efforts.
By Doug Kent, CHC VP Internal Audit/Compliance Officer
As healthcare becomes more complex, there is also more emphasis being placed on financial considerations, and on preventing and detecting violations of state and federal healthcare laws. What can your hospital do? Start by creating a compliance program to self-police your hospital and staff activities.
Since its inception in 1976, the Office of Inspector General (OIG) of the U.S. Department of Health and Human Services (HHS) has led the charge to fight waste, fraud, and abuse in Medicare, Medicaid, and more than 100 other HHS programs. In 2010, as part of the Affordable Care Act, OIG mandated that all healthcare providers have a Corporate Compliance Program in place as a condition of enrollment for Medicare, Medicaid, and Children’s Health Insurance reimbursement.
Along with assuring that needed dollars go to patient care, compliance programs serve to engage and inform employees and community members that your hospital is committed to “doing the right thing.” It’s also key to have compliance policies in place should you ever face regulatory review or inquiry.
Here are some best practice recommendations to develop or enhance your hospital compliance program.
1. Assemble a compliance committee representing a cross-section of employees. Compliance “belongs” to everyone. It’s a team effort and extends beyond the role of the designated compliance manager or leader. C-suite members, case management, revenue cycle, IT/security, and other employee representatives should serve on your compliance committee. Establish a group charter, meet at least quarterly, and ensure confidentiality of information shared with this group.
2. Develop a robust education and training program. Provide compliance education/information as part of new employee orientation. Offer online education courses to meet yearly training requirements on topics including billing and collections, Medicare rules, HIPAA, compliance issues, EMTALA, and conflicts of interest.
3. Establish a compliance hotline. Make sure employees know the hotline is an anonymous reporting system assuring the confidentiality and protection of individuals who may come forward; communicate the purpose of this hotline (it’s not an employee “complaint” line).
4. Include sanction screenings in your compliance plan. The hospital is required to check state and federal exclusion lists monthly to identify if employees, contractors or third-party vendors have had adverse actions taken against them by federally funded programs. Screenings demonstrate you have a routine process in place to monitor potential compliance issues.
5. Define and document conflicts of interest. To protect patients’ well-being and ensure public trust, board and management team members should sign a conflict of interest statement as part of the compliance plan. Keep these documents on file.
6. Manage compliance risk issues through ongoing monitoring and auditing. Make sure your compliance work plan includes a continuous control process to keep current on changes in rules, regulations and laws. Your work plan should outline internal controls to comply with these guidelines. For auditing, the approach is more proactive. Steps could incorporate chart review to examine how codes are being used and applied, or charge tracking for certain procedures or supplies.
7. Measuring compliance programs. It’s important to measure the effectiveness of your existing hospital compliance program. Authorities recommend that you conduct an internal evaluation yearly to assess your program’s effectiveness, and an external audit every other year with a report back to you that outlines program improvements.
For additional compliance education materials see the OIG Compliance 101 resources.
by Dave Koford, CHC VP Health Plan Contracting
For hospitals, “care” typically refers to providing patient care. Yet a hospital’s financial health requires care and attention, too.
A sound financial strategy supports the provision of patient care and services communities need, and a significant component of healthcare organizations’ revenue frequently comes from health plan contracts.
So what do your health plan contracts look like? Have you reviewed them recently? Are there opportunities to modify those arrangements to maximize your reimbursement?
Here are some best practice tips for health plan contracting.
Review your health plan contracts regularly – at least every year. Place this task at the top of your to-do list to help prevent future revenue loss.
Request full access to Policy and Procedure Manuals for each of your contracted health plans – before you “sign off” on those contracts. Your signature reflects your agreement with the current policy and procedure manual, but plans can (and do) change their policies. You’ll want to stay abreast of changes to make contract adjustments when necessary.
Know the health plan options offered by the largest employers in your community. In addition to the hospital, sizeable employers in a service area often include the school district and the city. Have these employers changed their health plans recently? For instance, has the local school district switched from a lower-paying plan option available to employees to one offering more favorable compensation or the reverse? Monitor these activities and changes. Keep information up to date.
Analyze reimbursement rates by payer. Are you receiving the appropriate compensation for the care you provide? Here are some factors to consider.
How does reimbursement for your commercial health plans compare to Medicare rates? Comparing one health plan’s reimbursement to another’s makes good sense. However, all health plan rates should be measured against Medicare. Plans with rates below Medicare could compromise the hospital’s financial health.
Unearth internal claims data. Review claims history before negotiating with an existing payer. Study how much revenue the payer brings to your hospital by service line. This reimbursement data could significantly influence the negotiation process since patient care and service lines are always changing.
Evaluate fixed rates and patient deductibles in rate negotiation to maximize revenue reimbursement. Hospital compensation under many health plan contracts features a fixed rate. Although this provides a level of predictability for the payer, fixed rates aren’t always the hospital’s best reimbursement option (and at a minimum, fixed rates should be adjusted up each year due to inflation, supply costs, etc.).
Also, for high-deductible health plans (HDHP), consider how easy will it be for a hospital to collect patient charges before a patient’s deductible has been met? HDHPs benefit the employer and the health plan, not necessarily the hospital.
Assess your payer-provider relationships. Look beyond the rates.
Establish or nurture long-term payer-provider partnerships, particularly when health plan payers represent a significant portion of your revenue. Are there new product offerings or risk-sharing models? Enhance positive working relationships to facilitate communication and negotiation.
What’s the revenue cycle telling you? Evaluate the processes associated with claims processing, payment and revenue generation. Are there opportunities for improvement to more effectively support the billing and collection efforts? (See a related CHC blog post for more on this topic.)
Keep up with health insurance changes for consumers covered through the Affordable Care Act (ACA). Many health plans have left the ACA marketplace and others are raising premiums and narrowing provider networks. What percent of patients do you see through the ACA? What impact do their high deductibles have on your collections? Under the new U.S. Administration, it is unclear how changes to the ACA or proposed health reform would impact care delivery – so staying abreast of what’s known will help your hospital going forward.
Learn more about the CHC Health plan evaluation process to review health plan relationships resulting in improved contract terms and reimbursements.
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