Project Statement – Accounts Receivable

Project Statement – Amplify V4 08.16.23
PROJECT STATEMENT [V4 08.18.2023]
Project Name: AMPLIFY
Project One-Liner:
•
Project Amplify is focused on improving our revenue cycle processes to create incremental cash inflow,
enabling further investment in program services and expansion.
•
Provide a roadmap that identifies revenue cycle amplifications that will enable the constellation to
achieve desired incremental cash flow improvements as well as drive enduring change that ensures
future sustained success.
•
To methodically target affiliates with certain revenue and accounts receivable volume as our focus for the initial
90-day project timeline. Through utilization of team members’ expertise, we will analyze the revenue cycle
process to implement short term solutions and recommend long-term investments to improve the constellation’s
conversion of accounts receivable into available cash flow.
Target Stakeholders:
The primary stakeholders for the revenue cycle improvement project include the consumers and payers who we serve
and fund those services, the employees who perform the related procedures, and the leaders who govern and guide the
enterprise.
Employees in the Revenue Cycle
The project intends to address our revenue cycle staff’s needs from the front end at Affiliates through to the local
and centralized service departments so that we can accelerate the ‘treatment to cash’ cycle. These are the
business process owners and subject matter experts who complete the steps that enable our timely cash inflow.
•
AR Managers
o Timely and accurate billing
o Careful integration with claims filings in EHR systems
o Reduced exception handling for customer complaints and inquiries (an accurate, timely invoice as part of our
service reputation)
•
AR Specialists
o Accurate claims and billings; manual and electronic
o Accurate transaction processing
o Timely, accurate payment posting
o Reconciliation of overpayments, recoupments, short pays
•
Collection Specialists
o Proactive action on invoices to address issues which might have delayed payment
o Follow up on past due invoices
o Initiate actions for corrective adjustments
•
Affiliate Program staff (e.g., intake/front desk)
o Insurance verification
o Treatment of Consumers
o Clinician’s recording of treatments
o Data entries into EHR
Leadership
The project will respect the needs of the line managers, the affiliate leaders, and the enterprise’s officers so that
the procedures, systems, and behaviors remain aligned with the core mission of their respective business
charters.
Project Statement – Amplify V4 08.16.23
•
This includes Inperium and Apis leaders, Affiliate CEOs, Directors, Managers and Controllers.
o Aligning management goals with project metrics (e.g., conversion of accounts receivable to incremental cash
flow)
o Providing tools that support the Employees spoken of above so that they have proper tools for their work
o Assuring that the revenue cycle is supporting the enterprise’s plan to reach a scale that better enables
success for the Affiliates, i.e., the leverage from centralized services and more standardized processes.
External Customers (e.g., Counties, States, Managed Care Organizations)
o
o
Accurate and timely delivery of communications and reports for services and financial transactions
Timely and accurate claims and invoices
Stakeholder Measures of Success:
Management comprising the Affiliate CEOs, Directors, Managers, and Controllers
Statement: Ability to manage Abraxas, Conexio and Coras revenue cycles and their impact on the constellation’s
available cash flow.
Measurable Criteria:
o Ability to measure revenue cycle performance through metrics.
o Ability to achieve positive trending of revenue cycle metrics.
o Ability to drive timely billing and payment collection.
AR Managers and Specialists
Statement: Ability to facilitate effective billing and collections processes at Abraxas, Conexio and Coras that ensure
timely and accurate invoicing, collection, payment posting, and reconciliation.
Measurable Criteria:
o Ability to determine benchmarks and KPIs for revenue cycle performance.
o Ability to generate KPI reporting and compare to established benchmarks.
o Ability to achieve established benchmarks.
o Ability to provide effective training and cross training for staff.
o Ability to provide constructive performance feedback to staff.
o Ability to resolve internal and external customer complaints.
o Ability to achieve work/life balance for Apis and affiliate staff.
o Ability to encourage Apis and affiliate staff through incentives.
o Ability to remediate EHR system flow issues and bottlenecks.
Customers/Payors (States, Counties, Insurance companies/MCOs)
Statement: Ability to receive timely and accurate billing from Abraxas, Conexio and Coras.
o
o
Measurable Criteria: Ability to make payment on invoices submitted the first time.
Ability to build working relationships between payors and Apis/affiliate staff.
Affiliate Staff
Statement: Ability to easily access comprehensive training, well-defined process and procedures documentation and
clear performance expectations for Abraxas, Conexio and Coras.
Measurable Criteria:
o Ability to access role specific, comprehensive training and reference materials.
o Ability to access clear process and procedure documentation.
o Ability to problem solve within the scope of their role.
o Ability to appreciate how their role contributes to the organization’s success.
Project Statement – Amplify V4 08.16.23
o
o
Ability to receive clear, constructive performance feedback.
Ability to identify appropriate resources and when to ask for help.
Business Measures of Success:
From an internal perspective, successful delivery of the revenue cycle project will be reflected in the following key financial
objectives:
•
Increase in Free Cash Flow of $20M by 06/30/24:
Create incremental cash inflow above the baseline of $3M by end of 2023, and $XM through June 2024 (to be
determined from the 2023 success and further investment in those opportunities for revenue system improvement
that were identified during the 2023 project).
•
Reduction of Days Sales Outstanding (DSO):
Reduce DSO against the baseline by at least 3 days in 2023, with more targeted in 2024 from system
investments identified in the 2023 project.
•
Reduction of Abraxas, Conexio and Coras Bad Debt Write Offs of 50% by 06/30/24:
Reduction of uncollectible accounts receivable and bad debt write-offs by 50% for each affiliate.
Components:
Structures (allocate capital [physical resources, human resources, money]):
Standardized Affiliate Reporting Statements: Monthly delivery of standardized affiliate reporting statements containing
key metrics for DSO, rejection/denial rates, receivable balances, and other relevant data.
Real-time Reporting Tools: Implementation of real-time reporting tools providing up-to-date insights into rejection/denial
rates, receivable balances, and daily cash application. Automation of payment application and notification process for
discrepancies.
Handbook/Standardized Process Notes: Creation of a formalized handbook with standardized process notes to serve
as a training resource for new and existing employees.
Practices (systematic, maintenance and communication of documents):
Clear Direction and Communication: Clear communication from upper management outlining KPIs, incentives,
performance reviews, and rewards for exceptional performance, emphasizing the importance of improved cash flow and
its impact on company growth.
Training and Onboarding: Utilization of standardized process notes and formalized training practices to onboard and
train employees effectively, ensuring consistent understanding and adherence to established procedures.
Metrics (measurable, impacts culture, identifies what is important):
Key Metrics for DSO: Regular monitoring and reporting of Days Sales Outstanding (DSO) on standard affiliate reporting
statements.
Rejection/Denial Rates: Real-time tracking and reporting of rejection/denial rates to identify areas for improvement.
Receivable Balances: Ongoing assessment of receivable balances to manage cash flow effectively and reduce
outstanding payments.
Language (drive value through communication):
Project Statement – Amplify V4 08.16.23
Clear Expectations: Clear communication of expectations, metrics, and management goals to all stakeholders involved
in the revenue cycle.
Rationale Behind the Project: Providing insight into the reasons for focusing on the project, highlighting the significance
of improved cash flow, and explaining how individual involvement contributes to achieving the project’s goals.
Performance Impact: Demonstrating how an individual’s efforts directly impact the organization’s success.
1
Coras problem issues and monitoring plans Revised 7/24/23
The below items are the urgent problem areas. The below initial plan will address temporary or permanent solutions,
how we know it is working and accountability leads to monitor. Resolved items are listed at the end. There are 3 main
buckets to tackle: eligibility /coverage; residential discharges and auths; and other primary issues. At each level there is a
gatekeeper function, and all items will be reported to Senior management for trends ongoing until resolved. There is a
final section on staff documentation and smaller issues that do not involve a lot of claim activity, these issues will
continue as there is no easy solution but will be managed by Stacey and Vanessa.
Reporting to Senior Management starting July 12th, every Wednesday during standard AR meeting:
• Eligibility and coverage
• Residentials
• Primary Issues
Eligibility and Coverage
Eligibility/Coverage – Stacy / Kim leads
o Missing ID numbers, ID numbers missing prefixes
o Client has different insurance than what was entered in system
o Payor information listed for a client actually belongs to a different client
o No payor selected
The eligibility work team met 6/13/23, 6/19/23 and identified the need to have a general training for all roles involved in
eligibility and coverage (commercials). The group is reviewing an older general PPT and updating. Mini trainings will be
developed to cover the different payer buckets: Medicaid/MCO; Commercial; Medicare/Medicare Advantage; Private
pay – these will include how to recognize the insurance cards, which insurance must be billed first and how to enter
these into the systems. Intake process and procedures will need to be revised and/or developed. Working on a plan for
ongoing review at all levels and include performance reviews and staff re-training as necessary. The goal is that all
clients will have insurance verified as active by July 1st and ongoing.
•
•
For all new clinic clients (MAT, Counseling and MH) we will verify insurance as active and review coverage before
being seen. Ongoing we will verify as active for every counseling visit and at least twice a month for MAT on the
1st and 15th of the month.
Residential client’s eligibility and coverage will be verified at intake, and then once a week (Wednesday). Every
residential client will be checked for active insurance on the 1st of the month. Eligibility for residential clients at
New Hope and MRP will be checked by Kelly; WRP Yolanda.
If someone has a change of insurance or lose insurance they become an “initial” client again which means verifying
coverage and eligibility. If someone loses coverage (unwinding Medicaid), as long as a client has an MCI number DSAMH
currently will be the new payer, if the client doesn’t have an MCI, Kim/Stacey will apply for one within 24 hours.
There are 4 levels of staff that touch eligibility – HUB, front desk, clinic MOAs and then Kim/Stacey. Each level will have a
gatekeeping model and Stacy will report to Senior Management on Wednesdays.
•
•
Roles and responsibilities for all levels – HUB/Front desk/MOAs/audit group – June 26th
Develop revised script for the HUB and front desk – it needs to include prompts to get all insurance information
for those with supplements or other payers and remind clients to bring ID and all insurance cards to their first
visit and ongoing. This script will also include detailed specific instructions for entering initial information.
Written and rolled out July 5th.
2
•
•
•
•
Audit checks at all 4 levels in development, including working with clients to always have their insurance cards
and ID on them – Stacey/Kim are developing a plan to roll out with staff along with their trainings
Initial General Training (anyone who touches eligibility/coverage), PPT in development, tentative training – no
later than July 12th
Payer trainings – 4 proposed, need to develop training. Will need specific ones for each level (i.e., script for HUB,
font desk how to ask about insurance and scan cards, etc.).
o Medicaid/MCO
o Medicare/Medicare Advantage
o Commercial
o Private pay/self-pay
Compassionate care self-pay proposal – Stacy to develop (this can include single case agreements for payers we
are not in network i.e., Humana) July 7th.
How do we know this is working? Within Carelogic there is an active utilization management report that will have all
active clients and their insurance information. Consistent checks is the only way to ensure clean claims. Payers can
change and we won’t know this until a claim denies. Every Monday Vanessa runs the kept report then breaks it down by
clinic and gives it to her 3 eligibility points and then they go through and identify what needs to be corrected. On Fridays
the analysis is given to Stacey and Kim for them to work with the MOAs to resolve.
Residentials – Authorization/Continued Stays and Discharge
•
Authorizations – Ron/Neya/Stacey daily review, weekly review with Lynn on Tuesdays at 9:30. Reports at
Wednesday AR meeting.
o
o
Not obtained for residential services
Authorizations obtained but authorization extensions (continued stays) not requested.
There are two types of required authorizations for residential programs – initial authorization due within 48 hours and
after 14 days a continued stay authorization (due either the last covered day or day before). Reasons stays are not
approved are often clinical proof for meeting ASAM levels or other documentation missing, not approved or not
submitted timely. When stays are denied we have to discharge clients.
•
•
•
•
ASAM level clinical needs training with HO 5/3/23; refresher training to be done by 7/12/23; which should
include 3.5 ASAM expectations.
Residential authorization tracker has been developed and will be updated on a daily basis. Another monitoring
tool that will be used is the Authorizations about to Expire report in Carelogic. The Authorization tracker will be
used to cross-reference the failed claims and authorizations about to expire report to make sure that new or
upcoming CSRs are not missed. This document has been shared with Neya, Yolanda, Kelly and Heather. This
tracker includes all of the active clients, payer information, auth numbers with start and end dates to help keep
everyone on track with due dates. The intake coordinators will use this tracker to send emails to the clinical staff
on a weekly basis so they know what is upcoming and can have the documents completed 48 hours prior to the
date due for submission. The intake coordinators will provide Ron with daily updates of what is submitted and
upload proof in the document library.
Neya and Yolanda are working together to complete initial and CSRs for WRP. Neya will monitor the auth
process for WRP and provide Ron with daily updates. Kelly E will continue to complete all initial and CSRs for
New Hope/MRP and provide daily updates to Ron. Ron will update tracker daily and report to senior
management weekly.
Procedures for prior authorization and continued stays by payer have been reworked and simplified. We will be
requiring them to be done the day of admission versus 48 hours and staff will be required to use online portals
versus faxes when available. Training for all staff on revised procedures by 7/12
3
•
Any write offs need to be reviewed/approved by Lynn, write off requests have to include when prior auths were
approved, when CSRs were submitted and details about the denials. We will use this to work with payers and
advocate with DSAMH to reduce any non-covered stays.
How will we know it is working? Failed claims report will show decreased missing authorizations, no one should have a
missing one for more than 3 days (reflects approval timeframes for payers). The residential authorization tracker will be
updated daily. The tracker will be used to cross reference the failed claims report as well as the Authorizations about to
expire report in Carelogic. The Authorizations about to expire report does show the start date and last covered days and
can be run on a daily basis for each program. If a client is denied, we are using the peer-to-peer appeal process and if
needed requesting an expedited appeal process.
•
Residential Program history not being updated in a timely fashion.
o
o
•
•
•
•
•
•
•
•
Resulting in services being generated in CareLogic that the client did not receive.
Example: Client not discharged from New Hope before being admitted to MRP – claims created for both
programs for same dates of service
Discharge plan developed including time frames to discharge clients if their stays are not approved. If a client is
denied, then staff will have 1-3 days max to find suitable recovery/housing and schedule aftercare appointment
within 7 days. After that time, they will need to be sent to a shelter. We need to keep track of each scenario
when this happens and share with DSAMH.
The Intake/discharge log was created to keep all staff aware of all new admissions and upcoming discharges for
each program. Staff should monitor and update this log on a daily basis.
On the day of discharge, the clinicians must complete the client’s discharge summary and discharge CRF. Once
completed this is submitted to the clinical supervisor/director for review. This will trigger the director/clinical
supervisor to go in and discharge the client from Carelogic.
The intake coordinator has 24 hours to submit the completed discharge form and attach the completed
discharge summary to the insurance company.
The director should verify that all discharge documents have been completed and that the client has been
discharged from the program in Carelogic.
As a final check, Ron will update the Residential authorization tracker and move all discharged clients from the
active authorizations to the old authorizations. Ron will also go into Carelogic and verify that the client has been
discharged from the program.
Bed board training on June 28th unfortunately this will not fix the issue it was more about adding clients to a bed
and helping keep track of census. The only useful piece is it allows us to put a bed on hold for clients who are
hospitalized so that we do not bill those days that the client was not present. It doesn’t help solve the discharge
problem because we still have to discharge clients the same way. We cannot discharge them using the bed
board. We can run a report to see who is active in the beds and use that to help cross reference and recent
discharges from the program.
The authorization tracker will be updated to include discharge date.
Primary Issues
•
Turnaround time related to resolving issues: Missing documentation, documentation not signed, missing
diagnosis codes, employees that have left not completing items such as pending notes, etc.
Staff have 24 hours from time of service to complete their documentation. Carelogic advised that employees already get
alerts about this to their profile for every client they serve. Failed activities and failed claims will alert management to
issues. Directors received training 7/3 on how to respond to failed claims, activities and no status reports. Ron meets
with Clinical Directors on Mondays and Wednesdays to go over errors. Mike Haldeman will send a report on Fridays that
4
shows total failed claims, no status and failed activities along with those over 30 days. The expectation is that all 3
categories will go down weekly.
Clinic Counts YELLOW highlight means it went up over the previous 7 days.
6/14/23
Total Count
Over 30 Days
Failed Activities
536
167
No Status
116
5
Failed Claims
206
110
Total Count
Over 30 Days
Failed Activities
416
82
No Status
200
19
Failed Claims
479
276
Total Count
Over 30 Days
Failed Activities
498
83
No Status
212
7
Failed Claims
93
16
Total Count
Over 30 Days
Failed Activities
543
140
No Status
179
21
Failed Claims
61
14
Total Count
Over 30 Days
Failed Activities
425
85
No Status
194
27
Failed Claims
27
3
Total Count
Over 30 Days
Failed Activities
513
101
No Status
117
7
Failed Claims
Combined Supervisor
Report (errors)
42
7
206
58
Total Count
Over 30 Days
6/23/23
6/30/23
14-Jul-23
21-Jul-23
28-Jul-23
4-Aug-23
5
Failed Activities
No Status
554
106
103
6
Failed Claims
Combined Supervisor
Report (errors)
39
5
177
54
When staff resign or leave, notifications need to be made to Vanessa, Neya and others to ensure transition pieces and
removing their access from payer networks. Audrey / Stacey must ensure all notes are signed and work transferred over.
Neya / Vanessa will ensure staff are removed from payers within 30 days after working with Vanessa to ensure there are
no claims with the staff listed after the end date. PERMS will be notified for outsourced credentialing, Neya in-house
Coras credentialing and Vanessa Carelogic and all other portals.
•
No supervising physician specified for client
Some services require sign offs that need to be in Carelogic, or the claim will not pay. For supervising physician codes
staff are not selecting a code. If the HUB is the initial contact, they are completing a Point of Entry in Carelogic and
selecting the Supervising Physician. If the client is already established but has returned to treatment, the Program
Directors are responsible for selecting the Supervising Physician when they are assigning the client to a counselor.
Carelogic was updated to have the correct doctors at each clinic. Currently, Dover, Smyrna, and Claymont will reflect Dr.
Fenice; Newark Dr. Houser; Millsboro, Seaford. Harrington and Achievement Center Dr. Obua. The HUB had been
updated on this information for moving forward as well as the Site Directors. If staff are not selecting the supervisor it
shows on the daily failed activities report, Site Directors and the Clinical Supervisor are required to correct it that day.
The errors end up on Failed Claims as ” No Supervising Physician specified for Client”. Program needs to clear all errors
weekly.
Client Staff
Reslationships 4-26-23.docx
Staff mistakes/documentation issues that will be ongoing but not a lot of claims activity
•
Diagnosis Codes – temporary work around, not a permanent solution and will continue to be an issue
o
o
o
Diagnosis codes not associated with service provided
Non-covered diagnosis codes
Entering same diagnosis code twice
This is one that comes up on audits or medical records. Findings for audits on diagnosis include Diagnosis added/removed
without discussion of why, Conflicting Diagnoses, Incorrect Diagnoses
ICD-10 updated last October, codes we used prior are no longer allowed or not tied to the new correct code. Carelogic
has old codes that have not been removed from their system. In Carelogic, there is an issue of “copy forward” where the
previous diagnosis is carried forward but might not be active with ICD-10. The “copy forward” function is simpler for
staff; the only other option is to add a new Dx code each time which then loses history or a combination of codes which
payers are looking for. Carelogic is using a 3rd party vender and does not appear to have a fix. Because codes change
every year this will continue to be an issue.
6
There is no solution to this issue. A ticket has been created with Carelogic requesting an error message whenever a
provider/clinician tries to copy over a diagnosis that no longer exists. Carelogic has told us that if this does get created, it
could take 6+ months before it will go live. Providers have been notified that there are several diagnoses that are no
longer active. When they diagnose a client, they are to review those diagnoses and remove any that are no longer
active. This could take a long time for them to get through all clients as some clients may only be seen annually. When
Vanessa catches a wrong diagnosis in the failed claims, she will email Stacey to go in and correct it in Carelogic. Stacey
and Vanessa will update the “naughty” code list and share with providers monthly. This is not a workable long-term
solution while some diagnoses have easy replacements, there are some where Stacey may not be comfortable
changing them as she is not the treating/diagnosing provider.
Naughty codes
• The F43.8 is no longer valid. F43.81 or F43.89 should be used instead.
• F32.8 became an invalid code in 2016. An additional digit is required. F32.81 or F32.89 should be used.
New 2023 ICD-10 codes
•
•
•
•
•
•
•
•
•
•
•
•
F10.90 Alcohol use, unspecified, uncomplicated
F10.91 Alcohol use, unspecified, in remission
F11.91 Opioid use, unspecified, in remission
F12.91 Cannabis use, unspecified, in remission
F13.91 Sedative, hypnotic or anxiolytic use, unspecified, in remission
F14.91 Cocaine use, unspecified, in remission
F15.91 Other stimulant use, unspecified, in remission
F16.91 Hallucinogen use, unspecified, in remission
F18.91 Inhalant use, unspecified, in remission
F19.91 Other psychoactive substance use, unspecified, in remission
F43.81 Prolonged grief disorder
F43.89 Other reactions to severe stress
•
Timing issues – time based services – Stacey/Vanessa
o
Example: Client was seen 7am to 7:30am, however time selected was 7am to 7:30pm
▪ Causes claim to be created with an invalid high quantity count which results in a high dollar
value on the claim.
This is an error done by a clinician. This error should be caught when a supervisor signs off. This shows up on failed
claims reports that are to be sent out and reviewed daily by the Program Director and Clinical Supervisor, managed by
Stacey.
• 1st check should be done by Clinical Director to make sure that times match the sign in sheets.
• 2nd check should be the person that is the second signature should be checking the time
• 3rd check would be by the Carelogic claim engine
Time issues
Put the start or end time in Carelogic correctly, some staff have picked the wrong start or end time (normally it is the
radio button being checked incorrectly like the one below)
7
•
No statuses – service has not been updated from “Checked In” to “Kept”. Once a claim is updated to
“Kept”, the claim creation process can start. If left in a “Checked In” status – no claim can be created because
it appears client is still waiting to be seen. Stacey/Vanessa leads.
This is a function of moving through the service from scheduling, checking in, kept appointment or no show. When a
client is at the appointment front desk marks “checked in”. This then has to move to kept appointment. Front desk and
the Clinical Director need to check the status daily before they leave. The Program Directors will be viewing the Front
Desk schedule every day for the day to address any appointments that were scheduled but not kept, and addressing that
with their staff. The No Status report goes out daily and is also addressed daily with the Program Director, Clinical
Supervisor and program staff. Program is expected to act on the no status report within 24 hours. Plan – cheat sheet,
quick training and monitoring for this.
•
Incomplete client demographics – Stacey/Vanessa leads.
o
Example: Missing client’s city or state associated with address
A physical home address and mailing address are required. Carelogic is not sure why this is missing unless staff are
skipping the “mailing address.” Client can have two addresses a physical one which is used for the CRF and the Mailed
address is use for billing. You can fill out the physical one and not fill out the mailing one and still get a billing error. This
can also occur when someone changes a client’s address. Address verification can happen at HUB, front desk and MOA
levels. We will use our addresses for homeless clients. Mail struggles need to be fixed also as we will have client mail
coming. Plan – cheat sheet, quick training and monitoring for this.
•
Incorrect Place of Service code associated with actual service provided – Stacey/Vanessa
o
Example: Place of Service 11 (in office/in person) with activity associated with telehealth and Telehealth
Place of Service associated with an office-based service.
Carelogic stated that we can change how Activities are set up instead of separating office and telehealth, but ultimately
would be up to the employee to click the qualifier (if the telehealth was done via phone or zoom). We can make it
simpler by changing names, so it is not too techie. ServLoc “dummy code” already in place to so if wrong activity is
pulled – this will be seen in failed claims. Stacey and Vanessa to work on plan for July 20th. Plan – cheat sheet, quick
training and monitoring for this.
•
Providers billing for services they are not eligible to bill for Stacey/Vanessa leads
o
o
Billing for providers that are not eligible to be listed on claim fixed no bill to without supervision
Counselors billing under their own name instead of the LCSW
Carelogic stated we can rebuild the back end (employee credential groups, and activities) and would require a lot of
work and suggested if this is what is wanted to pick a date in the future and push to get the build done. This would be
every activity, program, credential group in the system on the back end. Stacey and Vanessa to review to delete what is
no longer used, and to rename activities so it’s simpler to understand what should be selected. Stacey and Vanessa to
work on plan for July 20th. Plan – cheat sheet, quick training and monitoring for this.
RESOLVED
•
Mass reversing and rebilling claims that are already paid. 6/1/23
8
o
This has been addressed with termination of employee from Vanessa’s team and access removed from
the front-end