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Conducting a Medical Practice Assessment

Conducting a Medical Practice Assessment. Purpose. To determine the readiness of the medical practice to receive payment by a given reimbursement mechanism i.e. capitation, discounted FFS. Assessment Items. 1. Number of active clients 2. Average visits/client/year

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Conducting a Medical Practice Assessment

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  1. Conducting a Medical Practice Assessment

  2. Purpose • To determine the readiness of the medical practice to receive payment by a given reimbursement mechanism • i.e. capitation, discounted FFS

  3. Assessment Items 1. Number of active clients 2. Average visits/client/year 3. Average number of new clients/year 4. Total referrals from organization/year - Principal resource(s) employed 5. Total clients referred to organization/year - Principal source(s) of referrals

  4. Assessment Items 6. Average referral income/client/year - Principal source(s) of income 7. Average number of in-office ancillary service units/year - i.e. medical emergency 8. Percent (%) active clients/source of payment - i.e. FFS, private pay, commercial insurance, Medicare, Medicaid, managed care, etc.

  5. Assessment Items 9. Average length of time for receipt of A/R - Information subsets: collection rate, bad debt write-off, time difference between date charge generated vs. data billed to payer, ratio of denied claims, etc. 10. Listing of businesses & organizations employing significant number of employees who refer to organization for clinical services - Significant number = 100+

  6. Assessment Items 11. Average number of outpatient clients seen/week - Principal source(s) of referral 12. Average number of inpatient/residential admissions/week & average LOS 13. Average number of hospital consults, physician, psychologist, social worker/week & principal source(s) of referral

  7. Assessment Items 14. Principal CPT codes for which charges are generated & corresponding RBRVS value - Number performed/year - Average charge/treatment - Average allowed charge/year - Average reimbursement/procedure

  8. Assessment Items 15. Comparison of cap rates offered to organization with cost of providing services to clients - RBRVS 16. Relationship of cap rates to total revenues generated/year - If it is a risk assumption contract, must be 20+%

  9. Assessment Items 17. For MCOs employing a withhold, how is it structured - Policy regarding withhold for PCP & specialist 18. Productivity of direct services staff - Average time spent in direct service 19. Results of ongoing client satisfaction surveys

  10. Assessment Items 20. Impact studies of capitation - For each cap rate offered, convert monthly revenue stream to FFS equivalent CCF - e.g. 50K ss x $0.50/ss/month = $25K/month Month #1 = $25K/100 ss = $250/visit rec’d Month #2 = $25K/2K ss = $12.50/visit rec’d

  11. Benchmarking

  12. Benchmarking Defined • Collect data • Analyze data • Trend data • Compare data • Identify best performers

  13. Internal vs. External Benchmarking • Internal Benchmarking • Intra- or interdepartmental • External Benchmarking • Best industry performers • Reluctance of some organizations • Confidentiality agreements

  14. What to Benchmark • Comparative professional liability claims • Number of incidents/year • Number of PCEs/year • Number of claims/year • Number of lawsuits/year

  15. What to Benchmark • Comparative PL claims (cont.) • Number of closed cases • With settlement or judgment • Without settlement or judgment • Amount(s) reserved

  16. Benefits of Benchmarking • Summary reports • Tracking & trending • Average costs incurred as a function of claims • Legal costs vs. plaintiff costs • Number of claims/insured physician • Number of claims/insured bed • Number of claims/1,000 patients

  17. Benchmarking Leads to Studies • Frequency of claims • Aggregate stop loss • Severity of claims • Specific stop loss

  18. Ultimately…Benchmarking Control Costs

  19. Risk Management Areas Applicable to Benchmarking • Employee satisfaction as a function of education & training opportunities • Risk financing cost comparisons • Workers’ compensation claims as a function of implementing an EAP • Infection control as a function of incentives for an infection free environment

  20. Risk Management Areas Applicable to Benchmarking • Incident reporting comparisons per quarter • Productivity measures as a function of incentives for production of billable services • Patient satisfaction as a function of compliance with organizational quality standards

  21. Risk Management Areas Applicable to Benchmarking • Patient complaint resolution • Safety & security compliance

  22. What Must Be in Place to Facilitate Benchmarking Program • Administration support is essential • Must determine in advance what activities or processes are to be benchmarked • Determine processes within activities & processes being benchmarked

  23. What Must Be in Place to Facilitate Benchmarking Program • Determine who performs activity or process well • Develop data collection method(s) • Compare performance against a standard • Determine changes required

  24. What Must Be in Place to Facilitate Benchmarking Program • Plan ways to implement changes • Monitor results of changes which are implemented

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