So Now You`re In-Charge of the Pro-Fee CBO……

So Now You’re In-Charge of the
Pro-Fee CBO……
Charlotte L. Kohler
Carolyn S. Tuttle
September 2011
The Days of Referring the Problems to
“Them” is Over ….. We are “Them”
Goals for Session
Review purpose of MSO and CBO
Evaluate differences between a hospital (or facility
based) CBO and a pro-fee services MSO
Evaluate why the pro-fee CBO should or should not
be separate from Hospital CBO
Update key factors and considerations for success
Understand of the marketplace and
reimbursement factors causing this physician
Review case studies
Some of the Lingo
MSO – Management
Services Organization
Generally the overall
management of the
medical practices
Including contracting,
staffing, practice
Can include centralized
scheduling, etc.
CBO -- Centralized
Business Office
Encompasses the backend of the revenue
BUT may include the
charge capture and
“access” activities
Can be stand alone or
be part of the MSO
What Do You Need To Know?
As per the ad for “Director MSO Central Business
Office” for Texas Children’s Hospital
“To direct and lead operations of the CBO…including
patient billing, collections, refunds, coding/compliance,
standard fee schedules, transaction entry, customer
service, and account follow up”
“Knowledge and Skills: word processing, databases,
spreadsheet, and physician billing software; Medicaid
reimbursement…., printed and oral
communications…., administrative management of a
business office….
What Do You Need To Know?
Revenue Cycle of pro-fee services, including those
in the “private practice settings”
Drivers of the physicians Revenue Cycle
– Physicians
– Office staff
– Provider-based (called “regulated” in Maryland)
– How they differ from facility (hospital)
– Billing/Payment impacted by POS and type of entity
Core Elements of the CBO
Consider the cost/benefit of performing tasks
Outsourcing can be effective or a disaster – can
allow you to focus on “big issues” even if you’ll
want to bring in house later
What is not a “core function”?
Medicaid enrollment
Self pay collections
Key Considerations – Should the Pro-Fee
MSO be Separate from the Hospital CBO?
 Same system
 Can handle all
problems with a
patient on one call
 Better use of resources
 Eliminate redundant
 Skill sets are different
 Split should be by
 Different Systems
 Pro-fee staff don’t
understand UB billing
and vice -versa
Challenges: Reporting Data to
Understand the specific terms of the physician
contract before the billing starts.
Understand reporting requirements – match up to
set of charge capture and billing data collection.
Benchmarking and productivity analysis – may be
part of CBO or part of MSO management – but
data comes from MSO.
Challenges: 3 Day Window
2012 proposed regulations regarding employed or
owned Practices
– Rolls all diagnostic services into inpatient invoice
– Pays physician services using place of service 22
Coordination between Pro-Fee CBO and Hospital
– Change lag time for billing?
– Non-Medicare?
– RVUs used for physician compensation?
Challenges: Compliance & Coding
Multiple Provider Number attached to multiple Tax
ID numbers
Provider-based space – 2 co-pays
Payers that ignore the “provider based status”
Loss of volume due to provider-based status
Do you have the physicians do the coding and then
you review for compliance, or do you code the
Challenges: Getting the Right
Demographic Information
Challenges of going across system – hospital to
pro-fee and/or multiple pro-fee systems.
What ordering/ How to control updating of
Insurance information -- Hospital vs. Pro-fee
insurance requirements may be different and may
cover different components of service.
Challenges: One Payment to Allocate
Combined – Patient - Friendly Billing
Physician – if paid based on collections – want their
money first – EACH of them
Handling inquiries and process
Case Study #1
Multiple primary care and specialty care Practices.
Hospital buying Practices at clip of one a Quarter – size
from one (1) doctor to five (5) doctors.
All Practices must convert to CBO ‘EHR’ and Billing
Discussion now going on with eight (8) doctor
cardiology practice that wants to keep own systems.
What issues are you facing?
How can you deal with this politically? (You’re still
responsible for revenue cycle performance.)
Case Study #2
Freestanding Cancer Center brought in as part of
the Hospital and physicians employed.
Covers RadOnc and Medical Oncology.
All staff at Cancer Center stays.
Systems at Cancer Center used for clinical (and
billing) aspects do not interface.
What are the factors that need to be considered in
making this a successful transition?
Thank You
Reach us at:
Charlotte Kohler – 443-956-1434
[email protected]
Carolyn Tuttle – 301-992-5877
[email protected]

similar documents