HELP WHERE HOSPITALS NEED IT ®
HELP WHERE HOSPITALS NEED IT ®
Community Hospital Blog
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.
by Alice Fleetwood, CHC VP Revenue Cycle
Many rural hospitals find it a struggle to achieve positive cash flow and maintain enough days cash on hand to meet their capital and operational needs. This intensifies the importance of ensuring that patient accounting processes, especially billing and collection, are performing at optimal levels.
One option many turn to for managing this process is to outsource billing and collections functions. This effort may be seen as a way to improve accurate and timely billing of patient accounts, lower costs, and improve collections. The CHC Consulting Revenue Cycle team is often called upon to evaluate the pros and cons of outsourcing compared to maintaining a hospital-based employed business office.
CHC’s experienced staff has assisted hospitals in improving the entire Revenue Cycle process by helping to determine the best solution, avoid common pitfalls, and achieve a hospital’s cash goals. Here are some insights and best practice tips for evaluating whether outsourcing is right for your facility.
Define the Need.
Based on your business needs and in-house capabilities, determine what can be improved and maintained internally and what would benefit from outsourcing. For instance, evaluate each of the following functions:
Assess Departmental Billing Skills.
A keen understanding of Medicare and Medicaid billing requirements is essential, supported by regular claims management system edits. Having an experienced and strong Medicare biller is essential.
Review your organization’s billing and collections functions – determine which tasks could benefit from outsourcing.
Managing your vendor extends beyond relationship management. Measure the results. Is your outsourcing partner collecting the needed cash? They should be accountable for all accounts you’ve agreed on — not just the “easy” ones. — Follow up through tracking metrics, audits and surprise on-site visits.
Consider the Cost.
For hospitals with strong internal resources, it’s key to weigh potential staff reduction savings against the loss of revenue the hospital will experience with outsourced collections. Compensation arrangements vary and may include:
Choosing the “right” outsourcing partner is rooted in trust. Select a team who understands your needs – ; an organization committed to a shared relationship. Discuss the scope of the outsourcing and define specific Revenue Cycle metrics with your contractor. They must be able to meet or exceed the stated goals, including cash targets and A/R aging metrics.
Learn more about CHC Financial Improvement Services including assistance with outsourcing.
by Lisette Hudson, CHC VP of Planning
The Patient Protection and Affordable Care Act requires not-for-profit hospitals to conduct a Community Health Needs Assessment (CHNA) once every three years – and develop an implementation plan to meet community health needs. Finalized in 2014, the requirements surrounding a CHNA are very specific.
Whether or not your hospital has 501(c)(3) status – which triggers the need to complete a CHNA – conducting an assessment of the existing health needs within your community is a best practice both for your hospital and for the patient population you serve. The following recommendations are designed to help you get organized, go through the development process, and produce an implementation plan.
The CHNA Development Process
Define and map your service area. To start, identify the geographic area you serve. Review patient origin data. Are there other available data sources that could help you more clearly define your area? At this stage, it’s important to identify the area based on where your patients currently reside.
Collect and analyze data. Assess your study area, including demographics and health status. What is the age and ethnic make-up of your service area? What about population growth? Are more families moving into your area, or is the population declining? Investigate mortality data, chronic disease categories and health behaviors. Identify minority populations and evaluate access to healthcare services.
Reach out to gather community input. You may be surprised about what your community really needs. Seek feedback from leaders and groups who represent broad community interests. Consider state and local governmental public health departments, members of medically underserved populations and minority populations, or even written comments received on your hospital’s most recently completed CHNA. Beyond these groups, input from other individuals and groups — including community leaders, local school districts and universities, health care consumer advocates, health insurance and managed care experts, or local Federally Qualified Health Centers (FQHCs) or Rural Health Clinics (RHCs) — could also be relevant.
Document and communicate results. Now it’s time to pull together and organize all the data you’ve collected for the CHNA, documenting:
Be Prepared for an Audit
Lastly – and important to keep in mind – some hospitals that are required to conduct a CHNA are now being audited. This applies to small or rural hospitals as well as larger systems. Here are a few things to keep in mind that regulators are looking for:
Need More Information?
You can learn more about CHC’s Community Health Needs Assessment and Implementation Strategy services – even download our CHNA process document -- or reach out to us. We have completed CHNAs and Implementation Plans for more than 70 hospitals across many states – from community health centers and critical access hospitals to specialty hospitals and large multi‐hospital systems. We are here to help.
by Jim Coleman, CHC SVP of Southeast Hospital Operations
Rural and community hospital leaders – at the forefront in meeting community healthcare needs – frequently encounter challenges that may significantly impact operations and an organization’s long-term financial viability. From variations in patient mix to marketplace mergers and legislative reform, the environment continues to change.
To better position your facility for success, here are some best practice tips to strengthen access to care and delivery of services. Market customization, operational performance, and collaboration opportunities should be at the top of the list.
Customize your hospital’s action plan to your market
Use market demographics and payer mix data to think “outside the box” – every community is different. What works for one hospital may not be right for another. Adopt a strategic approach to evaluating new services and programs. Here are a few specific ideas that have worked for several CHC Consulting clients:
Plan for the future
Annual strategic planning is vital to long-term success. The process should include an environmental assessment reviewing marketplace health needs along with medical staff planning. Proactive retention, succession planning and recruitment efforts are especially important in smaller markets where it can take longer to fill vacant positions.
Improve operational performance
Labor is the largest portion of a hospital’s budget. This means it’s critical to closely monitor and manage labor. Analyze staffing and match your workforce to the services needed; research scheduling options and cross-training opportunities to capitalize on efficiency. Could nurse practitioners, physician extenders or others benefit the hospital or community? In addition to labor, supply costs are one of the fastest-growing hospital cost centers. Carefully review your facility’s potential for savings on supplies and pharmaceuticals through a group purchasing organization (GPO) that specializes in community hospitals. Also, look closely at your revenue cycle for opportunities to improve revenue capture and collections.
Team up with area providers and agencies to meet community needs
Collaborative efforts including clinical affiliations with other hospitals or systems can improve population health management and care delivery. For instance, an affiliation agreement could bring a needed physician specialist to your community, a reasonable alternative to recruiting and supporting a medical practitioner on a full-time basis.
Government support can also improve access to community-based health care to broaden the services you provide. State and federal grant dollars support clinical and preventive services such as mammograms; funding is available for telemedicine services and health information technology as well.
By Mike Williams, President and CEO, CHC
As we usher in 2017 with our country’s new administration, it’s not surprising that hospitals, healthcare providers, insurers, and consumers alike are asking “what’s next?” related to healthcare. There’s no question that some changes will occur, although they won’t happen overnight. Many details are forthcoming in the weeks and months ahead.
Regardless of the road in front of us, we must continue to position community and rural hospitals in optimal fashion. CHC will be looking at innovative ways to help community hospitals during these times of change, by lending our expertise, and upholding our mission to guide, support and enhance the mission of community hospitals and healthcare providers.
Strong community hospitals are critical to the vitality of entire populations, especially in rural environments, because they support both the health and economy of the communities they serve. Here are some top-line recommendations to stay the course for continued success, even with impending healthcare reform changes on the horizon:
Even with health care changes ahead, I’m confident community hospitals can persevere by focusing on and optimizing their strength and position as we welcome the New Year.
Learn more about strategies for success moving ahead in 2017.
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