Better claims and collections in a post-COVID-19 world

No matter how widespread the effects of the COVID-19 pandemic were on the healthcare industry, the challenges faced by independent groups required unique solutions specific to their respective circumstances.

For ONE Pediatrics in Louisville, Ky., the outlook for making it through the roughest months of 2020 meant finding the right revenue cycle key performance indicators (KPIs) that would drive results for the independent group of seven integrated practices consisting of nine locations, more than 40 providers and about 179,000 patient visits in 2019.

Setting up a corporate structure to do many business functions under a single tax ID took about two years before the group’s launch in 2014, according to Lawrence “Larry” Jones, MD, pediatrician and ONE Pediatrics partner. At that time, several hospital corporations started acquiring primary care and pediatric practices in the area, which posed a challenge for Jones and his colleagues, who were “fiercely independent” and hoping to avoid “being outflanked” by the larger organizations.

Upon merging, the practices noticed various challenges:

• Payer contracts were inconsistent and/or outdated.
• Individual practices varied in how well they streamlined areas of operation.
• By March, ONE Pediatrics saw a 60% drop in visits due to the pandemic, plus the added challenges and cost associated with sourcing personal protective equipment (PPE).

Particularly, bringing in cash was a major concern from the loss of productivity. “We were unable sometimes and also unwilling to collect as aggressively as we had done before,” Jones said.

According to Dan Pope, senior vice president and general manager at R1 RCM, each of those challenges needed unique approaches for the seven practices within the group.

Optimizing payer contracts with analytics

As much as there’s truth to the adage of “strength in numbers,” Pope noted that ONE Pediatrics wasn’t helped solely by merging multiple practices into an independent group. “As much as larger practices and a combined group of practices have the ability to negotiate more efficiently, having access to data is equally important,” Pope said.

Using analytics to identify opportunities was crucial, such as determining the volume and combination of HCPCS and CPT® codes by revenue (see Table 1). Another big step in analytics was reviewing capitation rates and the annual bonus incentives offered by payers. “Knowing all of those things allows you as a provider to enter into the negotiations from a much more defensible and strategic position,” Pope added, which lays the groundwork for entering appropriate value-based arrangements.

“Potentially carving out specific groups of high-usage CPT® codes may be an effective strategy … rather than just taking a blanket fee schedule,” Pope said, noting that you could agree to less-favorable rates on lesser-used codes to ensure you get the right reimbursement for your highest-volume codes.

In ONE Pediatrics’ case, the group was able to use data to renegotiate quality metrics used in the capitation program, which led to an additional $110,000 in revenue the first year.

Optimizing operations for simplification and value

Despite various practices operating as different profit centers, ONE Pediatrics sought to work under a single tax ID, which brought specific legal requirements to navigate, Jones said, including a unified benefits plan for hundreds of employees.

Other areas that office managers normally handled or oversaw — such as payroll processing, IT support and practice management (PM) system support — would shift into an enterprise approach for all human resources and IT support functions, with strategically outsourced services to allow office managers to focus attention on other areas.

In particular, Jones noted that the addition of enterprise training for OSHA and HIPAA in conjunction with monthly safety calls across the organization were helpful in streamlining work.

Attaining higher levels of quality

An enterprise approach to quality was another key goal for ONE Pediatrics at the time of its formation, including becoming NCQA-certified as a Level 3 Patient-centered Medical Home (PCMH). In addition to shared intellectual resources among the combined practices, ONE Pediatrics also leveraged a dedicated care coordinator from Pope’s team and a quality director to perform on-site assessments of quality to ensure the group met the criteria for NCQA recognition.

To further support optimization of the entire enterprise, ONE Pediatrics launched biannual, individualized coding audits to boost education of coding staff. The group also engaged a third-party vendor to institute a rules engine within the group’s PM system, which (among other things) would flag certain claims when there are known needs for specific modifiers to be applied.

That combination of coding education and the implementation of a rules engine to ensure better claims submissions to payers resulted in a 99% clean-claims rate on first submission, Pope said.

For the denials that do occur, having the improved analytics that helped optimize payer contracts also helps break down issues with claims based on provider, payer and reason for denial outside of the biannual audits. Providers are provided with a chart review on a monthly basis to help them understand their volumes and where denials occur.

KPI improvements

• Charges per visit: +7% (FY 2015 to FY 2019)
• Collections per visit: +18% (FY 2015 to FY 2019)
• Overall collections: +11% (FY 2016 to FY 2018)
• Average days in A/R: 25 (FY 2019)

Improved schedules via data visualization

Another advantage of the combined ONE Pediatrics group was looking at the historical data of practices’ volumes, RVUs and schedules to find opportunities to improve scheduling and reduce wait times for appointments.

Using a data visualization platform, ONE Pediatrics and R1 RCM evaluated existing scheduling data to find opportunities for physicians to take on new patients and block certain times of the day strategically for walk-in/same-day appointments, which had benefits for patients as well as overall productivity.

Patient communication and marketing

While texted appointment reminders have been a common way for years to ensure patients show up for scheduled visits, ONE Pediatrics also added messaging to patients about outstanding balances owed, paired with a link to a payment site.

As with any new venture, ONE Pediatrics updated the practices’ web presence and commissioned new print ad designs to boost awareness of the new group, along with promotional events in the community. The group also engaged in online reputation management to drive more patient reviews on various review sites, including Google.

Adjusting processes to meet post-pandemic demands

Adjusting A/R and payment plans

The COVID-19 pandemic created a sensitive financial market for many parts of the nation, including ONE Pediatrics’ market in Kentucky. Significant job and insurance coverage losses made it difficult for many patients and guarantors to pay.

Acknowledging those issues, ONE Pediatrics decided to stop all collection efforts for two months (April and May 2020) and worked to train front desk staff on messaging to encourage point-of-service (POS) collections beginning in June.

For any balances under $500, patients were texted about how to make payments. If outstanding balances exceeded $1,200, the practice would attempt to call the patient and set up automatic payments, such as with credit card on file (CCoF).

The group also made a point of targeting accounts that reached 60 to 90 days in A/R, and in some instances offered a 15% discount on a balance for settling the amount in a timely manner. This approach helped reduce days in A/R by 5% to 8% per practice through September 2020.

Adjusting for volumes

With patient volumes down 60% in the early months of the pandemic and shelter-in-place orders limiting office visits, ONE Pediatrics ramped up a wellness campaign, using patient logs to identify those who had not been seen recently and reach out to patients’ parents or guardians via text or calling to explain safety measures in place. Additionally, curbside service was offered for certain types of care, as well as COVID-19 testing.

As school cancellations occurred, the group worked to encourage daytime appointments when children were available, allowing for spreading patients throughout the day (for better social distancing) and accommodating wellness visits early and late in the day.

The group also posted videos on Facebook and TikTok to share how the practices are keeping patients safe. This coordinated outreach led to a 13% year-over-year increase in wellness visits for June 2020, and a 5% year-over-year increase in July.

Adding telehealth

While ONE Pediatrics experimented with telemedicine prior to the pandemic, the stay-home orders in Kentucky necessitated the implementation of a telehealth platform to make up for the loss of in-person visits.

In two weeks, the platform was launched for all seven practices, paired with an online and email promotion campaign. The option of telehealth visits was marketed with a link to schedule an appointment online. The group also set up payer-specific telehealth rules in its claims-scrubbing technology, which would flag claims for pre-submission review.

Conclusion

This analytics-driven approach makes a significant impact on how decision-making is done at the independent group. “Management proposes changes based on data and research,” Jones said. “The owners, the physicians, approve or disapprove it. It is a give and take. Nobody’s telling anybody what to do.”

By leveraging the expertise of individual clinic managers and these data insights, ONE Pediatrics developed a “really effective and elastic model that has allowed us to not only survive in the environment we were in — where hospitals were buying independent practices — but it really did become one of the premier pediatric organizations in our region,” Jones added. “And our PCMH Level 3 certification, I think, speaks to that.”

The group’s response to the challenge of the COVID-19 pandemic, Jones noted, underscores how much stronger they were and is “the proof in the pudding that this model works, and I would encourage anybody who’s out there who’s thinking about this — who wants to move from small, private independent practices into a larger group — you will not lose your independence. You will gain more, and it has been wildly successful from our viewpoint.”