701. Home Health Summer Camp 2013

Transcription

Pre-Conference 2
Presented by
Tom Boyd, MBA, CFE
Melinda Gaboury, COS-C
Principal
Boyd & Nicholas, Inc.
Rohnert Park, CA
[email protected]
Chief Executive Officer
Healthcare Provider Solutions, Inc.
Nashville, TN
[email protected]
M. Aaron Little, CPA
William Simione, III
Director
BKD, LLP
Springfield, MO
[email protected]
Principal
Simione Healthcare Consultants, LLC
Hamden, CT
[email protected]
Agenda
Sunday, July 28, 2013, 9:00 a.m. – 3:00 p.m.
9:00 a.m.
9:25 a.m.
10:20 a.m.
Current Medicare reimbursement issues (Gaboury)
Billing oversight and compliance processes (Gaboury)
Break
10:35 a.m.
11:05 a.m.
12:00 p.m.
Using the Medicare cost report as a management tool (Boyd)
Essential management benchmarking data (Little)
Lunch
1:00 p.m.
1:15 p.m.
2:00 p.m.
3:00 p.m.
Reporting Medicare organizational changes (Boyd)
Achieving compliance in organizational changes (Simione)
Feasibility analysis practices for business expansion (Simione)
Adjourn
Pre-Conference 2
Current Medicare Reimbursement Issues &
Billing Oversight & Compliance Processes
July 28, 2013
Home Health PreConference 2013
Current Reimbursement Issues
Proposed 2014 Payment Rates
Home Health
 Base rate of $2,860.20 (increase from $2,137.73)
BUT
– CMS’s proposed rebasing changes are the most complex factor of the new
rule. As stated in the proposed regulation: “rebasing must be phased-in
over a four-year period in equal increments.” So, starting with the
2014 proposed HHPPS rule, CMS has chosen to begin this four-year
process with a -3.5 percent rebasing adjustment in 2014. This 3.5
percent reduction is based on CMS projection of an average home
health margin of 13.63 percent in 2013 (the difference between the
average national episode revenue in home health and the average
national episode cost) using 2011 Cost Report Data. This data
appears to be skewed and is under intense review.
– Labor Rate Increase from 77.082 to 78.535 percent changing the
non-labor rate from 22.918 to 21.465 (good for agencies whose wage
index is 1.0 or greater)

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Proposed 2014 Payment Rates
Home Health
• CMS arrived at its CY 2014 proposed case mix weights
by dividing the CY 2013 case mix weights (which are
the same weights as those finalized in the CY 2012
rulemaking) by 1.3517.
• To offset the effect of re-setting the case mix weights
such that the average is 1.00, CMS increased the
proposed CY 2014 national, standardized 60-day
episodic payment rate by the same factor used to
decrease the weights (1.3517).
• The proposed rule suggests that the rebasing of the
HHPPS payment rates and case mix weights do not
require a “case-mix creep” adjustment.
Case Mix Weight Changes 2012
Weight
Weight
Variance
2011
2012
In Payment
1AFKS
0.5827
0.8186
473.27
1AFLS
0.8507
0.9793
229.46
1AFMS
1.0599
1.1401
114.75
2BHLS
2.2074
2.2145
-103.02
2BHMS
2.3445
2.4691
140.91
2CFKS
2.1524
2.0453
-344.30
5CFKS
3.0835
2.7140
-955.30
5CGKS
3.2730
2.8712
-1034.53
5CHKS
3.4872
3.0014
-1225.63
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Case Mix Weight PROPOSED
Changes 2014
Weight
Weight
Proposed
2011
2012
2014
1AFKS
0.5827
0.8186
0.6056
1AFLS
0.8507
0.9793
0.7245
1AFMS
1.0599
1.1401
0.8435
2BHLS
2.2074
2.2145
1.6383
2BHMS
2.3445
2.4691
1.8267
2CFKS
2.1524
2.0453
1.5131
5CFKS
3.0835
2.7140
2.0078
5CGKS
3.2730
2.8712
2.1241
5CHKS
3.4872
3.0014
2.2205
LUPA
HHA
MSS
OT
PT
SN
SLP
2012
$ 51.13
$180.96
$124.26
$123.43
$112.88
$134.12
FINAL
2013
$ 51.79
$183.31
$125.88
$125.03
$114.35
$135.86
Proposed
2014
$ 54.91
$194.34
$133.46
$132.56
$121.23
$144.03
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Non-Routine Medical Supplies
FINAL - 2013
Nonroutine
Medical Supplies
Severity Level
Points
2013 – FINAL
Urban
2014
PROPOSED
Urban
1
0
$14.56
$14.53
2
1 – 14
$52.68
$52.45
3
15 – 27
$144.16
$143.82
4
28 – 48
$214.19
$213.67
5
49 – 98
$330.29
$329.49
6
99+
$568.06
$566.69
Case-Mix Reform - 2014
• Proposed case-mix refinement
–Expanded set of case-mix variables
• 153 case mix groups – weights changed on all
• CMS states that Category 1 codes likely reflect conditions the
patient had prior to the home health admission (for example,
while being treated in a hospital setting). Conditions coded
under this category are anticipated to have progressed to a less
acute state, or are completely resolved for the patient to be
cared for in the home setting, thus meaning that another
diagnosis code would likely have been a more accurate
reflection of the patient’s condition in the home.
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Case-Mix Reform - 2014
• CMS proposes to remove Category 2 codes from the HHPPS
Grouper based upon clinical judgment that the condition would
not require home health intervention, would not impact the home
health plan of care (POC), or would not result in additional
resource use when providing home health services to the
patient.
• There are 170 ICD-9-CM codes that CMS proposes to remove
from the HHPPS grouper, effective January 1, 2014.
• Finally, the proposed rule confirms that ICD-10-CM diagnosis
codes are set to be adopted by October 1, 2014 for use by
entities covered under the Health Insurance Portability and
Accountability Act of 1996 (HIPAA), such as home health
agencies.
Therapy – FINAL 2013
• CMS proposes that if a qualified therapist missed a
reassessment visit, therapy coverage would resume with
the visit during which the qualified therapist completed the
late reassessment, not the visit after the therapist
completed late reassessment.
• CMS proposes that if multiple therapy disciplines are
involved, if the required reassessment visit was missed
for any one of the therapy disciplines for which therapy
services were being provided, therapy coverage would
cease only for that particular therapy discipline.
• CMS proposes to revise the assessment timing for
individuals receiving more than one type of therapy. The
reassessment could occur during the 11th, 12th, or 13th
visit for the required 13th visit reassessment and on the
17th, 18th, or 19th visit for the required 19th visit
reassessment.
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New Codes for Billing HH
July 2013
EFFECTIVE DATE: July 1, 2013 (HH episodes beginning on or after this date.)
IMPLEMENTATION DATE: July 1, 2013
•
HHAs must report where home health services were provided on home health
claims, using the Q codes:
– Q5001 - HOME
– Q5002 – ASSISTED LIVING FACILITY
– Q5009 – NOT OTHERWISE SPECIFIED
Home Health PreConference 2013
Billing Compliance Oversight
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Billing Performance

Job Descriptions:




Do they exist for all positions?
Do Employees have a copy?
Do Employees truly understand what they are responsible for?
Are positions over/under-staffed?
 Develop measures to monitor staff performance
 Review measures in team meetings
 Set reasonable expectations/goals
 Require staff to be accountable
Deal with low performance
Set limits for time allowed to perform at these levels
Reward high performance
Who Does What?
 Billers – Collectors – Cash Posters –
Managers/Supervisors
Do you have separate designations or does
one person wear all four hats?
Does each employee understand his/her
responsibilities?
Who is the leader/manager/supervisor?
Is there required reporting in place to monitor
progress?
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Prebilling Audit
 Audit 100% of Charts
 Catch Compliance Issues
 Catch Issues Associated w/PPS
 Avoid unnecessary denials
 Who should conduct these audits?
 Billing or Clerical Staff are sufficient – it
is not a clinical audit
Prebilling Audit
 When do we conduct these audits?
End of episode – no need to audit prior to
end of episode or discharge
 What do you need for audit?
Patient Chart
Audit Tool
Trial Bill (Pre-bill)
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Prebilling Audit
 Face To Face Compliance
 Quick Review of 485
 All Blanks Completed, Signed & Dated by Clinician
 Signed & Dated by Physician
 Supplies ordered on 485
 Supplemental Orders Signed & Dated by Physician
 Clinical Note for every visit
 Frequency & Duration Match Visits provided
 Therapy ReAssessment Visits
 Correct G code usage
 Supplies billed correctly
 OASIS transmitted to the state
Recommendations
 Recommend that Agencies do the following:
 Send Billers/Collectors to Billing Workshops at least once per
year
 Join List Serves/Participate in Webinars/Teleconferences
frequently
 Have someone in agency closely monitor the Medicare MAC
websites/newsletters
 Update PreBilling Audit Tools as necessary
 Have peers within agency randomly pull prebilling audits and
double check the accuracy
 Billing/Reimbursement Review by Third Party at least every
two years
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Faculty Contact Info
Melinda A. Gaboury, COS-C
Chief Financial Officer
Healthcare Provider Solutions, Inc.
810 Royal Parkway, Suite 200
Nashville, TN 37214
615-399-7499
[email protected]
www.healthcareprovidersolutions.com
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Pre-Conference 2
Medicare Cost Report
July 28, 2013
NAHC Financial Management
Conference & Exposition
“Using the Medicare Cost Report for
Management Information, Benchmarking
and Competitive Knowledge”
July 28, 2013
Presented by: Thomas E. Boyd, Principal Boyd & Nicholas, Inc.
Benchmarking & Productivity
 Evaluate Your Data
 Illuminate the Results
 Improve Your Business
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THE MEDICARE COST REPORT CAN BE
USED FOR BENCHMARKING DATA
A COMPLETED AND ACCURATE
MEDICARE COST REPORT will permit an
organization to benchmark their PPS data
against the information provided by ALL
the cost reports for the nation and for
their state.
Management Use of Cost Report
The MCR is NOT just a “compliance” requirement that
must be filed with CMS but can be a valuable tool to
assist in budgeting, pricing and strategic analysis.
Direct and indirect costs by discipline
(per hour and per visit)
Fixed and variable costs
Non-routine medical supplies
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NAHC Cost Report Data Compendium
(All States)
Item Number: M-083, All States
The NAHC COST REPORT DATA COMPENDIUM is an in-depth analysis of
Medicare cost reports filed by home health agencies since the beginning of the
HH PPS payment system in October 2000. NAHC has acquired over 20,000 filed
cost reports to develop this Compendium. Cost reports contain a wealth of data.
For purposes of this compendium, NAHC used data on per unit costs, supply
costs, service utilization, and Medicare PPS episodes. In addition, overall HHA
cost and revenue data is used to calculate overall financial margins. The
geographic location of the HHA and its categorizations also is utilized. The
Compendium is a valuable tool for providers of services, consultants, health
policy planners, home care advocates, investors, and trade associations looking
to gain an understanding of the financial status of home health agencies.
FOIA

Freedom of Information Act
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Direct Cost Per Visit
SN
PT
OT
ST
MSW
HHA
2012
2011
2010
$ 59.31
$ 86.47
$ 80.69
$ 110.64
$ 85.54
$ 26.42
$ 50.70
$ 81.56
$ 73.45
$ 97.42
$ 75.98
$ 23.77
$ 51.94
$ 67.77
$ 59.44
$ 72.84
$ 53.66
$ 21.63
Salaries of worksheet A, column 1, lines 6-11,
divided by the visits of worksheet S-3 Part 1, column 5, lines 1-6
Total Cost Per Visit
2012
SN
PT
OT
ST
MSW
HHA
$
$
$
$
$
$
113.65
165.70
154.62
212.01
163.90
50.63
2011
$
$
$
$
$
$
116.44
187.34
168.72
223.77
174.51
54.59
2010
$
$
$
$
$
$
123.33
160.90
141.13
172.95
127.41
51.37
Nevada
National
$
$
$
$
$
$
$
$
$
$
$
$
147.38
193.70
180.60
198.97
209.35
78.50
130.81
137.11
135.22
147.80
201.54
60.71
Worksheet C, Part 1, column 4, lines 1-6
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Statistics - Average Visits Per Episode
2012
SN
PT
OT
ST
MSW
HHA
11.12
4.18
1.35
0.17
0.23
2.57
2011
11.58
4.18
1.35
0.04
0.24
2.44
2010
Nevada
National
9.8
3.2
0.8
0.1
0.2
2.7
9.9
4.1
0.7
0.1
0.1
3.9
11.51
3.07
0.98
0.07
0.21
2.6
Worksheet S-3 Part IV, visits column 7, divided by total episodes of lines 45 & 46 column 7
Visits Per Full Episode
2012
SN
PT
OT
ST
MSW
HHA
Total
10.49
4.67
1.47
0.16
0.25
2.83
19.87
2011
10.50
4.62
1.47
0.05
0.26
2.61
19.50
2010
10.41
4.14
1.07
0.08
0.22
2.77
18.69
Nevada
National
8.40
3.60
0.90
0.10
0.20
3.00
16.10
8.30
4.70
0.80
0.10
0.20
4.10
18.20
Worksheet S-3 Part IV visits column 1 divided by total episodes column 1 line 45
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Episodes By Type
Full w/o
Outliers
Full with
Outliers
Your Agency
84.83%
Nevada
National
LUPA
PEP
3.27%
8.97%
2.65%
82.91%
3.22%
10.24%
2.71%
80.59%
4.00%
11.38%
2.29%
Average Per Episode
Revenue
Cost
Profit
Visits
2012
2011
2010
Nevada
National
$ 3,095.84
$ 2,369.85
$ 725.99
19.63
$ 3,138.47
$ 2,544.17
$ 594.30
19.83
$ 2,734.15
$ 2,326.04
$ 408.11
19.07
$ 2,764.84
$ 2,149.91
$ 614.93
16.70
$ 2,527.78
$ 2,007.20
$ 520.58
19.00
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Payment Per Full Episode
2012
2011
2010
Nevada
National
$ 3,382.38
$ 3,366.64
$ 2,967.26
$ 3,009.68
$ 2,752.65
Worksheet D Part II line 12.01, total of columns 1 & 2
divided by Worksheet S-3 Part IV, column 1 line 45
Cost Report Indicators
Profit By Episode Type
Full w/o
Outliers
Full with
Outliers
LUPA
PEP
Total
Revenue
$600,270
$26,195
$14,789
$8,353
$649,607
Cost
$444,324
$35,096
$12,822
$5,755
$497,997
Profit
$155,946
($8,901)
$ 1,967
$2,598
$151,610
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• Cost Analysis
Capital Costs
Plant Operation / Maint
Administration
Total Overhead Costs
Direct Costs
Total Costs
Total Patient Revenue
$ 55,500
$ 10,400
$ 464,218
$ 530,118
$1,222,646
$1,752,764
$1,809,392
Admin Costs as % of Revenue
26.48%
30.24%
69.76%
25.66%
All Costs from Worksheet A column 10
• Medicare Profit Margin
Medicare PPS Reimbursement
$649,607
Medicare PPS Cost
Visit Cost
NRS Cost
Total Cost
$491,437
$ 6,560
$497,997
Medicare Profit Margin
$151,610
Medicare Margin %
23.3%
PPS reimbursement from Worksheet B Part II total of lines 28 columns 1 & 2
PPS costs from Worksheet C Part IV line 19 column 6
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ZPIC REQUESTS COST REPORT INFORMATION
FROM HOME HEALTH AGENCY
Home Health Alert, Volume 13.03
April 10, 2013
www.healthgroup.com
Contact Information
Tom Boyd, MBA, CFE
Principal
877-424-6527
[email protected]
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Pre-Conference 2
Essential Benchmark Data
July 28, 2013
Pre-Conference 2
CPAs & ADVISORS
July 28, 2013
9:00 a.m. – 3:00 p.m.
Washington, DC
BKD, LLP | Director
[email protected]
OBJECTIVES
2
1
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OBJECTIVES
Evaluating home health (HH) performance
using key metrics
Comparing HH performance using key
benchmarks
3
EVALUATING PERFORMANCE
4
2
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Identify
Gather
Measure
• key metrics
• raw performance
data
• performance data
Compare
Examine
Implement
• performance results
• processes driving
performance
• action &
accountability plan
5
Identify key metrics
Are metrics meaningful, objective & measurable, &
comparable?
Is data available & obtainable?
Are data management requirements sustainable?
Gather raw performance data
Internal data
Billing, accounting & operations systems, CASPER, cost reports, etc.
External data
Publicly available &/or reported data, benchmarking & market
analysis vendors, government or advocacy organizations, etc.
6
3
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Measure performance data
Are industry benchmarks available?
Relevant & comparable to your organization?
Do personnel know how to measure & manage
performance data?
Compare performance results
Is data comparable?
Are data sources comparable?
Are time periods measured comparable?
7
Examine process drivers
What are processes responsible for performance?
What are primary improvement opportunities?
How will action plan address opportunities?
Implement action & accountability plan
What are reasonable timelines & performance milestones?
What will be used to monitor & manage accountability?
With what frequency will performance be monitored?
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COMPARING PERFORMANCE
9
COMPARING PERFORMANCE
Quality
Financial & cash flow
Volume
Revenues
Expenses
Compliance
10
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QUALITY
Patient perception & satisfaction
HH Consumer Assessment of Healthcare Providers &
Systems (CAHPS) data
Publicly reported & quantifiable
Available to all Medicare providers
How often HH team gives care in professional way?
How well did HH team communicate with patients?
Did HH team discuss medicines, pain, & home safety with patients?
How do patients rate overall care from HH agency?
Would patients recommend HH agency to friends & family?
11
QUALITY
Outcome & Assessment Information Set
(OASIS) data
Outcomes
Publicly reported & quantifiable
Available to all Medicare providers
How often patients got better at walking or moving around?
How often patients got better at getting in & out of bed?
How often patients got better at bathing?
How often patients had to be readmitted to hospital?
Outcome-Based Quality Improvement & Outcome-Based
Quality Monitoring
12
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Outcomes
80%
60%
40%
20%
0%
Rehospitalization
Ambulation
Transferring
Bathing
Patient Satisfaction
90%
85%
80%
75%
70%
Professionalism
13
State
Nation
Communication
Meds, pain,
safety
Care rating
We're
recommended
Per Centers for Medicare & Medicaid
Services (CMS) Home Health Compare
website
QUALITY
Other metrics to consider
Admission response time
Referral intake time
Referral source satisfaction
Impact of telemonitoring or other specialty programs, etc.
Post-discharge patient activities
Disease-specific outcomes
Specialty-specific program outcomes
14
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FINANCIAL & CASH FLOW
Benchmark sources
BKD analyzed & compiled
Medicare cost report data obtained directly from CMS
Freestanding & hospital-based agencies
Excludes skilled nursing facility-based agencies
Fiscal years ended in 2011
15
Strategic Healthcare Programs, LLC (SHP) analyzed &
compiled
Study conducted by SHP of its user database to determine its
Benchmark Leaders
Based on outcomes & compliance indicators
Benchmarking Leaders financial performance then analyzed by BKD
using Medicare cost report data
OCS HomeCare Elite
Study conducted by OCS to determine its HomeCare Elite
Based on outcomes & financial indicators
Top 100 agencies
HomeCare Elite Medicare cost report data analyzed by BKD
16
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Margins
Gross margin
Margin after direct costs
Data not available for hospital-based agencies
Medicare margin
Includes traditional Medicare only
Excludes Medicare Advantage
Based on average episode payment & average episode cost
17
Overall margin
Includes all payers & programs
HH, hospice, private duty, etc.
Cash flow
Days in accounts receivable (AR)/days sales outstanding
(DSO)
18
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OCS Top 1001
Metric
Gross
margin3
Medicare
margin
Overall
margin3
Days in AR
1Per
19
2Per
SHP/BKD1
Nation2
Median
Best 25%
Median
Best 25%
Median
Best 25%
52%
61%
47%
55%
51%
61%
19.7%
29.0%
20.9%
28.3%
10.5%
23.3%
10.5%
19.2%
7.5%
18.4%
2.8%
10.8%
52
37
53
41
54
38
BKD study of 2011 Medicare cost report data of OCS HomeCare Elite Top 100 & SHP Benchmark Leaders
BKD study of Medicare freestanding & hospital-based cost reports with fiscal years ended in 2011
only available for freestanding agencies
3Data
Profitability
Margins by program, i.e., HH, hospice, private duty, etc.
Margins by payer, i.e., Medicare, Medicaid, commercial, etc.
Earnings before interest, taxes, depreciation & amortization
(EBITDA)
Return on assets
Liquidity
Current ratio
Quick ratio
Leverage ratio
20
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Cash flow
Percent of AR older than 90 or 120 days
Collections as a percent of net revenues
Write-offs as percent of net revenues
Average days to bill
Medicare requests for anticipated payments (RAPs)
Medicare final claims
Non-Medicare claims
21
VOLUME
Net revenues
Includes all payers & programs
Visits
Includes all HH visits
Patients
Includes all HH unduplicated patients
22
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VOLUME
Medicare patient percentage
Traditional Medicare only
Medicare episodes
Medicare revenues
23
VOLUME
OCS Top 1001
Metric
Net revenues3
SHP/BKD1
Nation2
Median
Best 25%
Median
Best 25%
Median
Best 25%
$2.1 mil.
$3.5 mil.
$3.3 mil.
$7.4 mil.
$1.4 mil.
$3.2 mil.
Visits
10,115
16,643
19,263
39,965
9,062
19,432
Patients
318
562
949
1,708
250
628
Medicare
patients3
78%
94%
64%
Medicare
episodes
461
907
822
Medicare
revenues
$1.3 mil.
$2.3 mil.
$2.2 mil.
79%
1,516
$3.3 mil.
86%
100%
371
772
$0.9 mil.
$2.0 mil.
1Per
24
3Data only available for freestanding agencies
2Per
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VOLUME
Current census
Volume by program & payer & by diagnosis/disease
Number of referrals by source & by diagnosis/disease
Number of new admissions vs. readmissions
Number of non-admissions
Market assessment
25
REVENUES
Visits
Percent of traditional Medicare visits
Medicare low utilization payment adjustments
(LUPAs)
Medicare episodes per patient
Average Medicare case-mix weight
Includes full episodes only
Excludes LUPAs, partial episode payments, & outliers
26
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REVENUES
Average therapy visits per Medicare episode
Includes physical therapy (PT), occupational therapy (OT), &
speech therapy (ST)
Average of all episodes
Average Medicare episode payment
Includes all payment adjustments
27
REVENUES
OCS Top 1001
Metric
Visits
Medicare visits
Medicare episodes
Median
Best 25%
SHP/BKD1
Median
Best 25%
Nation2
Median
Best 25%
10,115
16,643
19,263
39,965
9,062
19,432
84%
96%
69%
79%
86%
100%
461
907
822
1,516
371
772
LUPAs
5.1%
2.8%
9.5%
5.1%
6.5%
2.9%
Episodes per
patient
1.6
2.3
1.3
1.6
1.6
2.3
Case-mix weight
1.3300
1.5395
1.3444
1.4722
1.3133
1.5193
Therapy visits per
episode
5.1
7.6
5.4
7.2
5.3
7.6
$2,648
$3,148
$2,708
$3,141
$2,670
$3,115
Average episode
payment
1Per
28
2Per
14
Pre-Conference 2
July 28, 2013
REVENUES
Revenues by program & payer/plan & diagnosis/disease
Average payment per episode per referral/admission
source
Average payment per visit &/or per patient
For all per-visit payers/plans
Average payment per Medicare episode dimension
Clinical, functional & service utilization
Nonroutine medical supplies
Average case-mix weight & payment adjustments per
clinician
29
EXPENSES
Cost per visit
Includes hospital-based overhead
Visits per Medicare episode
Includes all episodes
Cost per Medicare episode
Includes hospital-based overhead
Labor costs as a percent of revenues
Includes compensation, contract labor & benefits
30
15
Pre-Conference 2
July 28, 2013
EXPENSES
Administrative & general (A&G) costs as a
percent of revenues
Hours per visit
Includes all personnel hours worked
Total hours
A&G hours
31
EXPENSES
OCS Top 1001
Metric
Cost per visit
Median
$125
Best 25%
$101
SHP/BKD1
Median
$136
Best 25%
$116
Nation2
Median
$136
Best 25%
$106
Hours per visit
3.3
2.3
3.0
2.3
3.2
2.5
Visits per episode
16.9
14.5
14.9
13.7
16.9
14.3
$2,196
$1,888
$2,127
$1,900
$2,405
$1,953
Labor percent of
revenues3
68%
61%
72%
64%
75%
65%
A&G cost percent of
revenues3
36%
32%
35%
26%
39.2%
30%
1.2
0.9
1.2
0.8
1.3
0.9
Cost per episode
A&G hours per visit
1Per
32
2Per
16
Pre-Conference 2
July 28, 2013
EXPENSES
Discipline-specific drill-down
Visits per episode
Cost per visit
Without hospital-based overhead
Direct
Indirect
Hospital-based overhead
Hours per visit
Visits per day per full-time equivalent (FTE)
33
EXPENSES
Skilled Nursing
Metric
Visits per
episode
visit3
OCS Top 1001
SHP/BKD1
Nation2
Median
Best 25%
Median
Best 25%
Median
Best 25%
8.4
6.9
7.7
6.5
8.5
6.9
$142
$97
$135
$118
$137
$107
Direct only
$74
$50
$78
$62
$69
$50
Indirect
$52
$37
$56
$39
$63
$43
Overhead
$42
$29
$34
$25
$43
$28
Cost per
Hours per visit
2.3
1.3
2.0
1.5
2.0
1.2
Visits per day
3.7
6.9
4.5
5.9
4.5
6.8
1Per
34
2Per
17
Pre-Conference 2
July 28, 2013
EXPENSES
Physical Therapy
Metric
Visits per
episode
visit3
SHP/BKD1
Nation2
Median
Best 25%
Median
Best 25%
Median
Best 25%
4.4
6.2
4.2
5.5
4.3
6.1
$134
$110
$141
$118
$159
$126
Direct only
$72
$60
$81
$70
$83
$69
Indirect
$54
$34
$56
$37
$72
$46
Overhead
$30
$18
$32
$25
$36
$24
Cost per
Visits per day
1Per
35
OCS Top 1001
2Per
6.2
9.0
5.5
6.7
6.1
8.7
3Data
EXPENSES
Occupational Therapy
Metric
Visits per
episode
visit3
OCS Top 1001
SHP/BKD1
Nation2
Median
Best 25%
Median
Best 25%
Median
Best 25%
0.5
1.1
1.2
1.8
0.6
1.4
$135
$107
$139
$113
$158
$124
Direct
$77
$60
$76
$64
$80
$64
Indirect
$55
$31
$59
$38
$73
$47
Overhead
$26
$16
$31
$24
$37
$24
Cost per
Visits per day
5.6
8.5
5.3
7.3
5.2
8.4
1Per
36
2Per
18
Pre-Conference 2
July 28, 2013
EXPENSES
OCS Top 1001
Aide
Metric
Visits per
episode
visit3
SHP/BKD1
Nation2
Median
Best 25%
Median
Best 25%
Median
Best 25%
1.6
0.8
1.4
0.7
1.8
0.8
$54
$41
$57
$46
$55
$41
Direct
$27
$21
$30
$24
$27
$20
Indirect
$24
$14
$24
$16
$26
$16
Overhead
$13
$5
$12
$8
$16
$10
Cost per
Hours per visit
1.9
1.2
1.8
1.2
1.6
1.1
Visits per day
4.8
7.2
4.9
6.7
5.5
8.0
1Per
37
2Per
3Data
EXPENSES
Transportation expenses
Per visit, personnel, patient
Costs per referral/admission source & diagnosis/disease
Supply costs per patient & per diagnosis/disease
Productivity standards
Per visit vs. per case-load
38
19
Pre-Conference 2
July 28, 2013
COMPLIANCE
Payment per episode
Case-mix weight
Therapy visits per episode
Episodes per patient
Outliers
LUPAs
Outcomes
39
COMPLIANCE
Metric
Average episode payment
Provider OCS Top 1001
$3,502
$2,648
SHP/BKD1
$2,708
Nation2
$2,670
Case-mix weight
1.8616
1.3300
1.3444
1.3133
Average therapy visits per
episode
11.5
5.1
5.4
5.3
1.2
1.6
1.3
1.6
Episodes per patient
Outliers
1.7%
0.4%
0.5%
0.8%
LUPAs
6.5%
5.1%
9.5%
6.5%
Ambulation3
55%
Not available
Not available
58%
Transfers3
67%
Not available
Not available
55%
Bathing3
70%
Not available
Not available
66%
1Per
40
3Per CMS Home Health Compare
2Per
20
Pre-Conference 2
July 28, 2013
COMPLIANCE
Other considerations
Frequency of additional development requests & denials
Regulatory survey results
Program integrity actions
Patient &/or personnel complaints
Average Medicare payment per beneficiary
Frequency of Medicare HIPPS codes
41
MANAGING PERFORMANCE
42
21
Pre-Conference 2
July 28, 2013
Patient Satisfaction & Clinical Outcomes
100%
50%
0%
Professional care
Patient rating
Patient
recommendations
Rehospitalizations
Ambulation
Transfers
Bathing
Census Mix
Census
YTD visits
YTD non-admits
4%
YTD patients
45%
Medicare
55%
YTD episodes
0
500
1,000
YTD non-Medicare
0
5,000 10,000 15,000 20,000
Visits Per Episode
1,500
Skilled
Case-mix
Revenue Mix
LUPAs
31%
Episodes/patient
0.00
0.50
1.00
1.50
4%
Aides
65%
Medicare
2.00
Therapies
Total
0
Pay per episode
2%
16%
Cost per episode
$0
43
5
10
15
20
$50
$100
$150
$200
Per-visit revenue
75 days
Per-visit cost
$0
$1,000 $2,000 $3,000 $4,000
Us
State
Them
Nation
44
22
Pre-Conference 2
July 28, 2013
45
46
23
Pre-Conference 2
July 28, 2013
Pre-Conference 2
CPAs & ADVISORS
July 28, 2013
9:00 a.m. – 3:00 p.m.
Washington, DC
BKD, LLP | Director
[email protected]
24
Attachment A
Formula Key
Current Ratio
Quick Ratio
Gross Profit Margin
Net Profit Margin
Inventory Days
Accounts Receivable Days
Accounts Payable Days
Interest Coverage Ratio
Debt-to-Equity Ratio
Return on Equity
Return on Assets
Fixed Asset Turnover
Sales per Employee
Profit per Employee
Profit Growth
Sales Growth
=
=
=
=
=
=
=
=
=
=
=
=
=
=
=
Total Current Assets / Total Current Liabilities
(Cash + Accounts Receivable) / Total Current Liabilities
Gross Profit / Sales
Adjusted Net Profit before Taxes / Sales
(Inventory / COGS) * 365
(Accounts Receivable / Sales) * 365
(Accounts Payable / COGS) * 365
EBITDA / Interest Expense
Total Liabilities / Total Equity
Net Income / Total Equity
Net Income / Total Assets
Sales / Gross Fixed Assets
Sales / Total Employees (FTE)
Adjusted Net Profit before Taxes / Total Employees (FTE)
(Current Period Adjusted Net Profit before Taxes - Prior Period
Adjusted Net Profit Before Taxes) / Prior Period Adjusted Net Profit
before Taxes
= (Current Period Sales - Prior Period Sales) / Prior Period Sales
Attachment B
Sample Home Care & Hospice
Overall Financial Dashboard
Monthly Dashboard
Key Performance Indicators
Prior
Year
January
February
March
April
May
June
July
August
September
October
November
December
YTD
Profitability
Contribution Margin %
Home Health
38.0%
40.7%
56.0%
36.9%
48.4%
31.7%
34.9%
47.9%
43.4%
Hospice
29.6%
23.5%
28.2%
30.8%
45.5%
44.7%
35.8%
33.7%
35.8%
Private Duty
24.4%
22.2%
33.0%
33.6%
43.8%
50.1%
38.9%
45.5%
42.2%
Net Profit %
-3.3%
4.3%
27.5%
-1.3%
35.3%
2.7%
1.3%
10.2%
11.6%
EBITDA %
-2.0%
5.7%
28.8%
0.1%
36.5%
3.9%
2.4%
11.0%
12.8%
Return on Assets
-4.2%
0.5%
3.2%
-0.1%
3.9%
0.3%
0.2%
1.4%
-18.6%
2.0%
13.9%
-0.6%
15.6%
1.1%
0.6%
5.2%
40.9
47.1
45.7
39.5
39.5
49.9
43.3
45.3
41,096
45,976
53,603
42,552
26,267
15,868
63,839
81,061
Return on Net Assets
Cash Flow
Days in AR
AR over 90 Days
Cash Collections as a % of Revenue
Days to RAP Billing
79.9%
77.4%
79.0%
106.3%
87.1%
71.3%
60.2%
78.3%
9
7
5
6
4
4
6
4
Liquidity
Current Ratio
1.57
1.57
1.58
1.68
1.86
1.95
2.10
2.00
Quick Ratio
1.40
1.32
1.35
1.33
1.52
1.58
1.71
1.69
22.5%
22.6%
25.9%
22.3%
20.3%
19.7%
18.8%
22.4%
Leverage Ratio
79.2%
Target
Sample Home Care & Hospice
Home Health Financial Dashboard
Monthly Home Health Dashboard
Prior
Year
Key Performance Indicators
Volume
Census - Beginning of Period
Admissions
Discharges
Census - End of Period
January
February
March
April
May
June
July
August
September
October
November
December
YTD
113
710
701
122
122
97
74
145
145
81
80
146
146
70
94
122
122
76
93
105
105
79
60
124
124
70
81
113
113
86
68
131
Non-Medicare Payer Mix
35.3%
39.3%
35.1%
38.7%
29.1%
30.1%
35.6%
34.8%
34.9%
Medicare Recertification Rate
13.6%
26.4%
22.2%
15.8%
19.2%
25.7%
20.1%
9.1%
19.5%
Revenue
Avg Medicare Payment per Episode
$
Avg Case Mix Weight
$
Visits Per Medicare Episode
Labor as a % of Revenue
$
33.90
2,288
$
1.2287
24%
Expense
Gross Profit %
Overall Direct Cost per Visit
$
1.3339
% of Episodes Adjusted
Avg Non-Medicare Payment Per Visit
3,298
40.81
$
1.3758
11%
$
2,560
29.51
$
1.4714
15%
$
2,484
67.39
$
1.4439
18%
$
2,622
64.34
$
1.5825
20%
$
2,835
37.88
$
1.3415
16%
$
2,508
35.05
$
1.5188
17%
$
2,693
1.4536
10%
$
35.76
2,563
15%
$
43.39
38.0%
40.7%
56.0%
36.9%
48.4%
31.7%
34.9%
47.9%
43.4%
24.21
17.42
20.60
23.49
21.67
20.73
14.77
19.13
19.67
60.51
85.3%
$
62.12
86.1%
$
50.17
63.8%
$
58.09
90.1%
$
59.21
75.9%
$
75.05
95.3%
$
84.15
93.0%
$
66.96
75.0%
$
63.45
81.2%
Target
Attachment C
07/17/2013
Medicare Home Health Operations Detail Dashboard Report
Measure
Number of Agencies
Total home health visits
Total visits for other services4
Total net patient revenue4
Total Medicare episodes
Total Medicare home health revenue
Total home health unduplicated patients4
Total unduplicated patients for other services4
Payer mix, measured on total visits
Medicare
Other
Payer mix, measured on unduplicated patients4
Medicare
Other
Visits per Medicare episode (all episodes)
Skilled nursing
Physical therapy
Occupational therapy
Speech therapy
Medical social services
Home health aide
Total visits per episode
Total therapy visits per episode
Visits per Medicare full episode (including outliers)
Skilled nursing
Physical therapy
Speech therapy
Home health aide
Total visits per episode
Total therapy visits per episode
Visits per Medicare LUPA episode
Health Care Group
|
Peer Group Data1
State Data1
National Data1
BKD Analysis of
OCS HomeCare Elite,
Top 100
BKD Analysis of
SHP Benchmark
Leaders
All United States
Medicare Certified
Agencies
Lower
Upper
Lower
Upper
Quartile
Median
Quartile
Quartile
Median
Quartile
Total agencies in peer group data: 88
Total agencies in peer group data: 65
Service Delivery Dashboards
5,815
10,115
16,643
11,165
19,263
39,965
$ 1,161,534 $ 2,123,723 $ 3,450,816 $ 1,914,427 $ 3,315,397 $ 7,440,538
250
461
907
495
822
1,516
$ 724,736 $ 1,252,870 $ 2,320,513 $ 1,356,623 $ 2,172,526 $ 3,994,875
197
318
562
558
949
1,708
-
Lower
Upper
Quartile
Median
Quartile
Total agencies in national data: 9,510
$
$
4,213
672,662
174
433,839
105
-
9,062
$ 1,445,622
371
$ 939,215
250
-
19,432
$ 3,229,937
772
$ 2,013,330
628
-
69.1%
4.5%
83.4%
16.6%
95.5%
30.9%
60.6%
19.9%
68.5%
31.5%
80.1%
39.5%
63.0%
0.0%
85.7%
14.3%
100.0%
37.1%
63.4%
6.6%
77.7%
22.3%
93.5%
36.6%
53.7%
21.3%
63.8%
36.2%
78.7%
46.3%
61.5%
0.0%
86.3%
13.7%
100.0%
38.5%
6.9
2.9
0.1
0.0
0.8
14.5
3.8
8.4
4.4
0.5
0.1
0.0
1.6
16.9
5.1
10.4
6.2
1.1
0.2
0.1
2.8
18.7
7.6
6.5
3.5
0.7
0.1
0.1
0.7
13.7
4.7
7.7
4.2
1.2
0.1
0.1
1.4
14.9
5.4
8.9
5.5
1.8
0.3
0.2
2.2
17.5
7.2
6.9
2.9
0.2
0.8
14.3
3.5
8.5
4.3
0.6
0.1
0.1
1.8
16.9
5.3
10.6
6.1
1.4
0.2
0.1
3.8
20.3
7.6
7.4
3.1
0.1
0.0
0.9
15.7
4.0
2.6
8.9
4.7
0.5
0.1
0.0
1.8
17.9
5.6
2.8
10.7
6.8
1.2
0.3
0.1
3.3
20.0
8.4
3.0
7.2
3.9
0.7
0.1
0.1
0.8
15.0
5.2
2.5
8.3
4.7
1.3
0.2
0.1
1.6
16.6
6.1
2.7
9.6
6.2
1.9
0.3
0.2
2.4
19.1
8.1
2.9
7.6
3.1
0.2
0.9
15.5
3.8
2.5
9.0
4.7
0.7
0.1
0.1
2.0
18.2
5.8
2.7
11.2
6.6
1.5
0.2
0.2
4.1
21.7
8.3
2.9
www.bkd.com
Questions? Contact M. Aaron Little at [email protected].
1 of 7
07/17/2013
Measure
Peer Group Data1
State Data1
National Data1
BKD Analysis of
OCS HomeCare Elite,
Top 100
BKD Analysis of
SHP Benchmark
Leaders
All United States
Medicare Certified
Agencies
Lower
Quartile
Upper
Lower
Median
Quartile
Quartile
Median
Service Delivery Dashboards (Continued)
1.3
1.6
2.3
1.2
1.3
Number of episodes per Medicare patient
Estimated number of hours per visit
Direct nursing service (based on SN visits)
Home health aide service (based on HHA visits)
Administrative staff
Total staff
Estimated number of visits per day per FTE5
Direct nursing service
Physical therapy service
Occupational therapy service
Speech therapy service
Home health aide service
Cost Per Visit
Skilled nursing
Salaries4
Employee benefits4
Contract services4
Total labor
Transportation
Other direct costs
Total direct care costs
Indirect agency costs
Total agency cost per visit
Provider-based overhead costs3
Total cost per visit
Health Care Group
|
$
$
1.3
1.2
0.9
2.3
2.3
1.9
1.2
3.3
2.7
4.5
4.4
3.8
3.1
3.7
6.9
6.2
9.0
5.6
8.5
5.4
6.9
0.6
2.8
4.8
7.2
Operating Dashboards
33.32
3.68
47.27
50.05
37.25
97.14
29.09
99.56
$
$
58.04
7.48
70.86
0.52
73.68
52.01
141.51
41.76
141.96
3.2
2.7
1.7
4.1
$
$
73.69
10.63
0.16
96.98
5.56
100.64
82.58
166.78
50.59
187.30
www.bkd.com
$
$
Upper
Quartile
Lower
Quartile
Upper
Quartile
Median
1.6
1.3
1.6
2.3
1.5
1.2
0.8
2.3
2.0
1.8
1.2
3.0
2.9
2.3
1.4
3.4
1.2
1.1
0.9
2.5
2.0
1.6
1.3
3.2
2.8
2.2
1.9
4.2
3.2
4.5
4.3
3.3
1.0
3.9
4.5
5.5
5.3
5.7
2.5
4.9
5.9
6.7
7.3
7.7
5.4
6.7
3.2
4.4
3.9
3.4
3.8
4.5
6.1
5.7
5.2
0.7
5.5
6.8
8.7
8.4
7.6
3.5
8.0
49.77
5.85
57.91
62.17
39.41
118.39
24.97
120.32
$
$
60.72
8.86
71.47
3.56
77.89
56.38
135.14
33.90
137.40
$
$
74.84
15.47
0.19
96.98
5.54
102.32
67.42
166.44
42.54
166.44
$
$
35.00
1.28
47.89
49.66
42.91
107.46
28.16
109.24
$
$
51.77
6.25
65.72
68.83
62.51
136.77
42.83
140.10
$
$
69.36
10.99
1.71
89.39
4.61
94.17
90.44
173.54
60.16
179.86
2 of 7
07/17/2013
Measure
Peer Group Data1
State Data1
National Data1
BKD Analysis of
OCS HomeCare Elite,
Top 100
BKD Analysis of
SHP Benchmark
Leaders
All United States
Medicare Certified
Agencies
Lower
Quartile
Cost Per Visit (Continued )
Physical therapy
Salaries4
Employee benefits4
Contract services4
Total labor
Transportation
Other direct costs
Salaries4
Employee benefits4
Contract services4
Total labor
Transportation
Other direct costs
Health Care Group
|
$
$
$
$
Upper
Lower
Median
Quartile
Quartile
Operating Dashboards (Continued)
0.03
58.21
60.40
34.38
109.95
18.45
113.77
$
59.88
60.20
31.02
107.06
16.39
112.42
$
$
$
53.83
71.68
72.28
54.29
133.86
30.01
140.59
$
55.44
72.64
77.05
55.12
135.35
26.04
135.79
$
$
$
50.32
7.62
69.90
83.61
1.22
87.85
83.86
161.56
47.47
167.41
$
52.51
8.78
75.54
90.40
0.51
91.54
91.55
176.33
39.12
182.22
$
www.bkd.com
$
$
Upper
Quartile
Median
27.92
2.78
2.44
66.84
70.28
36.89
117.98
25.20
120.78
$
9.57
62.96
64.09
38.46
113.31
24.02
114.18
$
$
$
50.30
7.02
15.19
76.53
1.41
81.37
56.45
140.55
32.06
142.39
$
43.76
5.96
3.29
74.51
0.44
75.81
59.31
138.54
31.06
142.12
$
$
$
Lower
Quartile
61.96
11.27
36.54
90.16
3.83
94.42
72.00
165.00
44.26
168.96
$
71.56
8.69
44.10
88.09
2.85
92.03
78.95
167.90
36.50
174.71
$
$
$
Upper
Quartile
Median
4.93
67.86
69.42
46.14
126.32
24.31
130.72
$
62.19
63.69
46.67
124.03
23.87
127.35
$
$
$
2.96
54.64
80.95
83.01
72.02
159.35
36.26
163.50
$
48.50
79.03
80.17
73.03
158.11
36.83
161.92
$
$
$
57.07
7.84
80.15
95.15
2.42
97.65
116.20
206.82
50.10
210.09
59.66
7.82
78.85
94.20
2.28
96.76
116.01
203.98
52.16
207.97
3 of 7
07/17/2013
Measure
Peer Group Data1
State Data1
National Data1
BKD Analysis of
OCS HomeCare Elite,
Top 100
BKD Analysis of
SHP Benchmark
Leaders
All United States
Medicare Certified
Agencies
Lower
Quartile
Speech therapy
Salaries4
Employee benefits4
Contract services4
Total labor
Transportation
Other direct costs
Salaries4
Employee benefits4
Contract services4
Total labor
Transportation
Other direct costs
Health Care Group
|
$
$
$
$
Upper
Lower
Median
Quartile
Quartile
63.72
63.86
34.31
108.31
18.99
112.23
$
58.05
59.93
57.79
134.56
44.71
139.48
$
$
$
61.43
76.23
81.15
56.09
150.96
34.89
151.15
$
23.50
83.64
84.50
104.00
188.38
60.59
188.38
$
$
$
21.30
0.88
87.38
100.69
99.09
110.89
192.93
43.26
207.46
$
84.38
12.48
65.84
116.53
5.07
116.53
162.94
266.08
90.39
266.08
$
www.bkd.com
$
$
Upper
Quartile
Median
61.76
64.55
40.70
107.70
21.15
107.70
$
35.77
72.96
78.79
50.71
140.27
41.43
146.40
$
$
$
53.73
4.84
4.37
77.27
0.49
79.26
57.38
148.93
46.73
148.93
$
68.65
8.71
88.02
2.28
97.02
74.37
176.60
48.53
190.19
$
$
$
Lower
Quartile
80.52
12.17
54.49
108.23
5.90
113.23
92.49
180.62
54.11
183.18
$
92.23
15.86
4.09
118.05
8.15
124.42
99.94
227.06
53.35
228.66
$
$
$
Upper
Quartile
Median
63.68
65.00
46.96
124.69
25.04
128.53
$
67.38
70.00
59.13
142.57
34.51
144.34
$
$
$
53.18
81.26
83.85
73.25
162.14
36.24
165.70
$
31.42
86.80
90.00
94.78
194.00
60.02
197.19
$
$
$
61.84
7.89
81.95
100.92
2.63
104.70
116.23
214.30
53.63
219.09
81.06
12.33
78.00
124.00
4.82
129.84
156.28
275.50
99.59
285.10
4 of 7
07/17/2013
Measure
Peer Group Data1
State Data1
National Data1
BKD Analysis of
OCS HomeCare Elite,
Top 100
BKD Analysis of
SHP Benchmark
Leaders
All United States
Medicare Certified
Agencies
Lower
Quartile
Home health aide
Salaries4
Employee benefits4
Contract services4
Total labor
Transportation
Other direct costs
Overall agency cost per visit (all disciplines)
Medical Supplies
Non-routine medical supplies
Medicare Episode Payments
Estimated average case-mix weight2
Average payment ratio2
Medicare episode mix by payment type
Unadjusted episodes
LUPA episodes
PEP episodes
Outlier episodes
Average payment per episode by payment type
Unadjusted episodes
LUPA episodes
PEP episodes
Outlier episodes
Health Care Group
|
$
Upper
Lower
Median
Quartile
Quartile
$
$
$
12.14
0.46
16.92
20.77
14.32
41.34
5.40
41.85
101.04
$
0.71
1.1940
1.1184
87.1%
2.8%
0.8%
0.0%
$ 2,458.92
288.27
868.09
2,770.30
$
$
$
18.84
2.91
23.02
26.60
24.09
54.03
12.60
55.08
124.83
$
2.01
1.3300
1.2535
90.6%
5.1%
1.6%
0.4%
$ 2,941.02
321.83
1,011.82
3,810.96
$
$
$
26.90
4.88
37.04
4.42
39.96
37.10
68.38
16.37
70.61
163.88
$
3.27
1.5395
1.4527
94.1%
9.1%
2.3%
1.8%
$ 3,368.09
378.67
1,508.78
5,490.54
www.bkd.com
$
$
$
15.70
1.62
19.38
24.06
16.00
46.18
8.72
46.64
115.74
$
1.34
1.2588
1.1102
83.7%
5.1%
1.6%
0.2%
$ 2,788.27
311.59
960.55
2,752.89
Upper
Quartile
Median
$
$
$
21.81
3.70
28.35
3.02
30.24
24.15
57.09
12.17
59.35
135.65
$
2.34
1.3444
1.1944
86.5%
9.5%
2.3%
0.5%
$ 3,039.38
347.84
1,071.28
3,307.33
Lower
Quartile
$
$
$
28.51
5.73
39.31
5.45
42.45
34.43
76.03
30.64
76.03
157.97
$
3.63
1.4722
1.3817
91.0%
12.5%
3.4%
1.3%
$ 3,349.99
383.64
1,246.43
4,377.80
$
$
$
13.10
17.95
20.00
16.25
40.91
9.91
41.82
105.85
$
0.94
1.1564
1.0720
83.7%
2.9%
0.9%
0.0%
$ 2,481.72
291.29
919.16
2,897.57
Upper
Quartile
Median
$
$
$
19.69
2.38
24.91
27.47
25.57
55.32
16.10
56.92
136.09
$
$
27.04
4.31
35.36
4.27
38.52
41.03
77.53
24.62
80.01
172.20
$
2.26
$
4.16
1.3133
1.2180
88.6%
6.5%
1.8%
0.8%
$ 2,883.22
328.24
1,169.59
3,679.16
1.5193
1.4200
93.1%
11.0%
3.0%
3.1%
$ 3,315.64
370.90
1,490.63
5,034.59
5 of 7
07/17/2013
Measure
Peer Group Data1
State Data1
National Data1
BKD Analysis of
OCS HomeCare Elite,
Top 100
BKD Analysis of
SHP Benchmark
Leaders
All United States
Medicare Certified
Agencies
Lower
Quartile
Medicare Episode Profitability
Average payment per episode
Direct costs per episode
Salaries4
Employee benefits4
Contract services4
Total labor
Transportation
Other direct costs
Nonroutine supplies
Total direct care costs per episode
Direct profit (loss) per episode
Direct profit (loss) margin per episode
Indirect agency costs per episode
Total agency cost per episode
Profit (loss) per episode based on total agency costs
Profit (loss) margin per episode based on total agency costs
Provider-based overhead costs per episode3
Total costs per episode
Overall profit (loss) per episode
Profit (loss) margin per episode
Health Care Group
|
$
2,328
554
73
26
869
919
1,141
45.1%
555
1,806
437
16.1%
387
1,888
266
9.8%
Upper
Lower
Median
Quartile
Quartile
$
2,648
784
116
148
1,147
33
9
1,241
1,365
55.1%
903
2,062
588
23.1%
619
2,196
540
19.7%
$
3,148
968
176
354
1,489
79
26
1,570
1,707
63.8%
1,258
2,435
833
30.6%
779
2,573
776
29.0%
www.bkd.com
$
2,501
687
81
38
969
1
2
1,025
1,228
48.0%
558
1,812
482
18.3%
384
1,900
384
16.1%
Upper
Quartile
Median
$
2,708
769
125
104
1,122
47
18
1,170
1,507
54.4%
814
2,051
705
25.7%
494
2,127
540
20.9%
$
3,141
990
177
276
1,344
71
29
1,379
1,742
61.8%
1,006
2,396
928
30.9%
770
2,501
846
28.3%
Lower
Quartile
$
2,285
512
46
50
936
991
1,056
44.0%
727
1,894
(22)
-0.9%
499
1,953
(111)
-4.3%
Upper
Quartile
Median
$
2,670
734
97
219
1,170
15
8
1,243
1,409
54.1%
1,066
2,336
337
12.7%
675
2,405
279
10.5%
$
3,115
1,003
169
473
1,455
70
27
1,536
1,770
62.3%
1,601
2,914
678
25.0%
993
2,984
637
23.3%
6 of 7
07/17/2013
Measure
Peer Group Data1
State Data1
National Data1
BKD Analysis of
OCS HomeCare Elite,
Top 100
BKD Analysis of
SHP Benchmark
Leaders
All United States
Medicare Certified
Agencies
Lower
Quartile
Gross profit (loss) margin4
Agency profit (loss) margin4
Salaries as a % of total costs4
Salaries as a % of total revenue4
Employee benefits as a % of total salaries4
Total salaries & employee benefits as a % of total costs4
Total salaries & employee benefits as a % of total revenue4
Purchased services as a % of total costs4
Purchased services as a % of total revenue4
Total labor as a % of total costs
Total labor as a % of total revenue4
Direct labor as a % of total costs4
Direct labor as a % of total revenue4
Indirect labor as a % of total costs4
Indirect labor as a % of total revenue4
Transportation as a % of total costs
Transportation as a % of total revenue4
Other costs as a % of total costs
Other costs as a % of total revenue4
Administrative & general costs as a % of total cost
Administrative & general costs as a % of total revenue4
Capital & plant costs as a % of total cost4
Capital & plant costs as a % of total revenue4
Days in accounts receivable4
Current ratio4
Quick ratio4
Return on equity4
Return on assets4
35.3%
1.8%
50.4%
45.9%
13.5%
56.0%
47.9%
2.7%
3.3%
73.5%
61.2%
38.9%
31.1%
19.2%
17.6%
0.2%
0.1%
10.4%
10.5%
29.5%
31.6%
2.0%
1.8%
36.5
1.4
1.0
8.2%
2.4%
Upper
Lower
Median
Quartile
Quartile
52.0%
60.8%
34.0%
10.5%
19.2%
4.7%
59.7%
67.6%
52.6%
50.8%
61.0%
47.7%
18.0%
22.3%
13.5%
70.1%
78.3%
62.6%
60.7%
70.8%
55.0%
7.8%
14.9%
2.2%
6.2%
13.0%
2.1%
81.3%
86.5%
74.2%
68.1%
77.3%
63.9%
50.8%
60.8%
46.8%
41.6%
56.4%
39.9%
27.7%
35.7%
16.4%
25.9%
29.9%
14.6%
2.3%
4.4%
1.8%
2.1%
3.8%
1.6%
15.9%
25.0%
12.2%
17.2%
24.5%
10.4%
39.0%
47.7%
29.1%
36.0%
42.0%
26.2%
2.8%
4.2%
2.4%
2.8%
4.1%
2.1%
52.3
78.1
41.4
3.4
8.3
1.1
3.0
5.5
1.0
28.8%
76.4%
3.6%
28.6%
87.5%
6.4%
Median
46.5%
7.5%
58.8%
53.9%
18.3%
72.3%
64.3%
5.2%
4.9%
80.5%
71.5%
53.1%
47.9%
24.4%
21.0%
3.1%
2.9%
15.2%
15.5%
37.6%
34.7%
2.9%
2.7%
53.1
2.4
1.9
19.9%
16.6%
Upper
Quartile
55.3%
18.4%
66.9%
61.1%
22.8%
79.1%
73.9%
12.6%
10.7%
85.1%
80.8%
62.6%
59.1%
33.3%
29.8%
4.1%
3.6%
22.2%
20.7%
44.5%
41.4%
4.1%
3.8%
75.7
4.9
3.5
45.9%
50.5%
Lower
Quartile
39.0%
-3.2%
47.5%
43.9%
11.0%
50.8%
46.4%
3.2%
3.1%
72.3%
64.7%
36.9%
34.6%
19.3%
17.6%
0.0%
0.0%
12.2%
12.9%
30.7%
29.5%
2.4%
2.3%
38.1
0.9
0.8
-6.1%
-9.5%
Median
51.0%
2.8%
57.1%
54.4%
15.2%
65.0%
61.3%
10.3%
10.2%
79.6%
74.8%
47.5%
44.6%
27.8%
26.8%
1.9%
1.5%
18.3%
18.9%
39.8%
39.2%
3.5%
3.4%
53.5
1.8
1.5
13.9%
8.7%
Upper
Quartile
61.0%
10.8%
65.0%
64.5%
20.1%
74.6%
73.4%
21.3%
21.0%
85.3%
84.3%
58.0%
55.3%
38.7%
39.5%
3.8%
3.4%
26.0%
27.1%
48.7%
48.9%
5.1%
5.2%
77.6
4.9
3.9
77.1%
51.9%
1
Data compiled using all Medicare cost reports available from CMS with fiscal years ending in 2011.
Estimated based on payment rates effective for the location of the agency rather than service area.
3
Dashboard indicator only applies to hospital-based agencies, and accounts for costs allocated to the agency from the provider.
4
Dashboard indicator only includes freestanding agencies as hospital-based agency data is not available from CMS data sets.
5
Estimated based on 230 work days per year.
2
Health Care Group
|
www.bkd.com
7 of 7
Pre-Conference 2
Reporting Medicare Organizational Changes
July 28, 2013
NAHC Financial Management
Conference & Exposition
855A Requirements & Revalidation
July 28, 2013
Presented by: Thomas E. Boyd, Principal Boyd & Nicholas, Inc.
Requirements for Filing
•
•
•
•
•
New Location
New Business Name/add LLC or Inc.
Change in ownership
Acquisition/merger or stock transfer
Additional Branch office
1
Pre-Conference 2
July 28, 2013
Individual Updates/Changes
• If they have a 5 percent or greater direct or
indirect ownership interest in the provider
• If (and only if) the provider is a corporation
(whether for-profit or non-profit), all officers
and directors of the provider
Individual Updates/Changes
• All managing employees of the provider
• All individuals with a partnership interest in
the provider, regardless of the percentage of
ownership the partner has
• Authorized and delegated officials
2
Pre-Conference 2
July 28, 2013
Timeline for Submission
√ Change of ownership
√ Acquisition/Merger
√ Asset Sale
√ Stock Transfer
Timeline for Submission
√ Updates to the provider – ie: change of
information
3
Pre-Conference 2
July 28, 2013
Revalidation Project
• If you enrolled in the Medicare Program
before March 25, 2011 you will get a letter by
March of 2015.
• DO NOT respond until you get your letter.
• You have 60 days from the date of your letter
(not two months) to submit your 855A
revalidation.
4
Pre-Conference 2
July 28, 2013
• Be watching for your letter. Many
are not addressed to a specific
person.
5
Pre-Conference 2
July 28, 2013
You must submit a paid receipt with your
revalidation letter and 855A
https://pecos.cms.hhs.gov/pecos/FeePaymentWelcome.do
• MACs are requesting your NPI email assigning
your NPI – most went out in 2006. If you
don’t have a copy of the email:
• Contact NPPES customer service at 800-4653203 OR if you remember your user ID and
password go to website and login, check that
info is current and proceed to end and submit.
• You will get a new email in 24-36 hours.
https://nppes.cms.hhs.gov/NPPES/Welcome.do
6
Pre-Conference 2
July 28, 2013
We recommend at this time NOT to submit your
855As or Revalidation 855As in PECOS. There are
many bugs in the PECOS system causing hardship to
providers and delaying the submission. Instead
complete the CMS downloaded pdf form:
https://www.cms.gov/cmsforms/downloads/cms855a.pdf
This form was updated in July 2011. Make sure you are using the
correct form as above.
Who Has Questions ???
7
Pre-Conference 2
July 28, 2013
Contact Information
Tom Boyd, MBA, CFE
Principal
877-424-6527
[email protected]
8
Pre-Conference 2
Compliance in Organizational Change
July 28, 2013
2013 Financial Management
Conference
Home Health Summer Camp 2013
William J. Simione, III
Principal
Value Driven Health Care Environment
What do we know & what do we need to know
1. Do we truly understand our costs & how they relate to
patient care?
2
1
Pre-Conference 2
July 28, 2013
A. Do we truly understand our cost and how they
relate to patient care?
① What do I need to get myself ready?



Do I have the data?
Do I understand the data?
Do I know how to react to the data?
② Understanding the Gross Margin





Direct Salaries & Benefits
Contracted Services
Transportation
Medical Supplies
Other Direct Care Costs
3
B. Do we truly understand our cost and how they
relate to patient care?
③ Payer Analysis


GM Profitability
Net Margin Profitability
④ Can we measure the true value of our services?





Difficult many times to truly qualify the value of Home
Health
Need to demonstrate that we are operating efficiently
Need to have the seat at the table to educate all parties
All indicators need to be positive
Know the “Pain Points” of our referral sources
“Home Care is not an adjunct service, but a key component in
the health care continuum”
4
2
Pre-Conference 2
July 28, 2013
INTEGRATING CLINICAL
&
FINANCIAL MANAGEMENT
Integrating Clinical & Financial Management
• The need for both clinical and financial
information is becoming more important to
home care agencies.
→Recognize key clinical and financial indicators
that can be used daily, weekly, etc.
→Analyze trends by comparing to previously run
data.
→Use data to integrate and educate your clinical
and financial teams; and
→Report to senior managers and Board of
Directors
6
3
Pre-Conference 2
July 28, 2013
Key Financial Indicators
•
•
•
•
•
•
Gross Margin
Net Margin
Payer Mix
Liquidity Ratios
Cost Per Visit
Days Sales
Outstanding
• Case Weight Mix
• Episode Distribution
• Reimbursement per
Episode
• Cost Per Episode
• Indirect Cost as a
Percentage of Revenue
7
Integrating Clinical & Financial Management
How does this relate back to Clinical?
How do I share this data?
Where do I begin?
8
4
Pre-Conference 2
July 28, 2013
STEP #1
Dive Into The Data
• Maximize your EMR system?
• Do we truly understand all of the reports?
• What reports are the Clinical
Director/Supervisors currently using?
Are they meeting their needs?
What information could they use?
• Can we do a data Dump? Is this the only way?
10
5
Pre-Conference 2
July 28, 2013
Dive Into The Data
• Understand your business
What makes up your revenue?
How are we providing services?
Does the data tell/confirm the story?
Do we truly understand what is happening?
11
Dive Into The Data - Episodic Payers
• Can we determine the following?
# of Episodes per admission
• Can we determine outliers?
– Try and understand the reasons
# of visits per Episode by type of Episode
• How/Does this change for subsequent episodes?
• How/Does this change by diagnosis?
• Duals vs. Regular admissions
12
6
Pre-Conference 2
July 28, 2013
Life Of An Admission
Column Labels
Count of SOC/Re-Cert
Row Labels
1
January-12
72
February-12
60
March-12
55
April-12
73
May-12
72
June-12
78
July-12
57
August-12
72
September-12
70
October-12
69
November-12
58
December-12
51
January-13
40
February-13
43
March-13
24
April-13
7
Grand Total
901
2
30
25
17
29
22
25
17
12
17
15
14
13
4
2
3
10
5
9
8
6
7
3
1
4
1
3
4
3
2
6
2
1
1
242
57
18
5
6
7
4
2
2
4
2
2
1
1
1
13
Life of an Admission - Visits Per Episode
Carrier
Active/D/C
5/1/2013
Medicare/OH
D/C
(All)
Average of Tot Visits Column Label
Row Labels
1
January-12
25.31
February-12
24.18
March-12
23.98
April-12
21.10
May-12
20.06
June-12
22.05
July-12
18.53
August-12
16.97
September-12
19.67
October-12
20.16
November-12
17.47
December-12
19.02
Grand Total
20.74
2
22.27
17.92
21.00
15.90
14.00
16.24
14.06
14.50
19.53
11.87
20.36
11.15
16.95
3
15.90
14.80
21.44
12.50
16.67
16.14
7.33
30.00
18.25
4.00
20.67
16.32
4
5
6
7 Grand Total
14.67
23.42
5.50
21.57
17.83 14.00 21.50 13.50
22.13
9.50
18.93
1.00
18.35
10.00
20.26
17.10
20.00
16.81
3.00
19.40
18.51
1.00
17.91
17.42
12.00 14.00 21.50 13.50
19.53
14
7
Pre-Conference 2
July 28, 2013
Life of an Admission - Therapy Visits
Carrier
Active/D/C
5/1/2013
Medicare/OH
D/C
(All)
Average of Tot Ther Column Label
Row Labels
1
January-12
11.72
February-12
11.50
March-12
10.11
April-12
8.88
May-12
8.36
June-12
9.13
July-12
7.47
August-12
7.00
September-12
7.81
October-12
8.83
November-12
7.28
December-12
8.61
Grand Total
8.89
2
3
4
5
6
7 Grand Total
8.70
2.50
5.33
9.97
3.92
8.57
8.76
5.78
6.17 1.00 0.50
8.41
3.66
1.38
4.00
6.90
4.68
4.17
7.23
2.80
1.00
7.11
3.47
6.30
3.67 20.00 11.00
6.73
2.59
2.00
6.51
2.20
7.55
3.50
6.20
2.00
7.27
4.42
2.60
4.00 1.00 0.50
7.47
15
Life of an Admission (cont’d)
Carrier
Active/D/C
5/1/2013
Medicare/OH
D/C
(All)
Column Label
Average of RAP_HHRG$
Row Labels
1
2
January-12
$ 2,559.62 $ 2,903.91
February-12
$ 2,646.29 $ 2,402.44
March-12
$ 2,374.75 $ 2,865.41
April-12
$ 2,666.44 $ 2,235.19
May-12
$ 2,539.27 $ 2,578.12
June-12
$ 2,646.97 $ 2,407.64
July-12
$ 2,537.08 $ 2,354.05
August-12
$ 2,500.09 $ 2,243.65
September-12 $ 2,642.28 $ 2,173.58
October-12
$ 2,749.82 $ 2,127.41
November-12 $ 2,715.61 $ 2,492.54
December-12 $ 2,674.99 $ 2,354.92
Grand Total
$ 2,606.21 $ 2,453.11
3
$ 2,064.69
$ 1,762.56
$ 2,567.85
$ 1,819.60
$ 2,651.51
$ 2,135.56
$ 1,922.95
$ 1,382.59
$ 1,995.42
$ 2,246.49
$ 1,959.17
4
5
6
7
$ 1,500.42
$ 2,381.42
$ 2,828.32 $ 2,049.48 $ 2,212.65 $ 1,928.71
$ 1,968.26
$ 2,191.38
$ 1,519.37
$ 5,021.68
$ 1,930.76
$ 2,127.06 $ 2,401.98 $ 2,049.48 $ 2,212.65 $ 1,928.71
16
8
Pre-Conference 2
July 28, 2013
Life of an Admission (cont’d)
Carrier
Active/D/C
5/1/2013
Medicare/OH
D/C
(All)
Average of Final$
Row Labels
January-12
February-12
March-12
April-12
May-12
June-12
July-12
August-12
September-12
October-12
November-12
December-12
Grand Total
Column Label
1
$ 3,519.29
$ 3,469.40
$ 3,280.92
$ 3,074.99
$ 2,888.30
$ 3,192.65
$ 2,780.47
$ 2,756.39
$ 2,811.06
$ 3,037.20
$ 2,582.81
$ 2,908.78
$ 3,031.03
2
$ 2,946.86
$ 2,208.85
$ 3,096.30
$ 2,216.64
$ 2,426.47
$ 2,196.92
$ 2,226.55
$ 2,119.28
$ 2,278.84
$ 2,028.13
$ 2,516.43
$ 1,567.54
$ 2,378.97
3
$ 1,740.26
$ 1,466.77
$ 2,606.69
$ 1,774.89
$ 2,290.80
$ 2,129.69
$ 1,444.45
$ 2,151.45
$ 439.73
$ 1,745.18
$ 1,962.66
4
5
6
7 Grand Total
$ 2,052.73
$ 3,174.00
$ 1,546.77
$ 2,976.23
$ 2,200.32 $ 2,054.67 $ 2,324.32 $ 2,112.23 $ 3,033.96
$ 1,639.72
$ 2,731.17
$ 107.92
$ 2,724.68
$ 1,527.34
$ 2,886.35
$ 2,606.12
$ 3,055.33
$ 2,669.96
$ 439.73
$ 2,663.83
$ 2,838.10
$ 2,561.40
$ 2,724.69
$ 1,815.49 $ 2,054.67 $ 2,324.32 $ 2,112.23 $ 2,818.32
17
Dive into the Data - Other Payers
• Look at the visit volume
Do we know visits per admission
Does this differ by Payer
• Can we drill down to the diagnosis?
• What is the trend?
Medicaid volume
• Duals
• Traditional
• Move to Managed – What does this mean?
18
9
Pre-Conference 2
July 28, 2013
Dive into the Data - Other Payers
• What is our census
Need to know by payer
• Do we have patients with no visits within the last 30
days?
• Are we tracking admission by payer, by month,
by referral source?
Grow Market Share through strategic
alliances
Is there a trend? How should we react?
19
Dive into the Data - Episodic Payers
• Meet with staff to understand what is happening
What is the story
Is it helpful
• Why is this important to understand the data
Financial
Clinical
20
10
Pre-Conference 2
July 28, 2013
STEP #2
Staffing
• Understand how admissions and Episodes
equate to staffing
Direct
Indirect
• Develop Productivity expectations throughout
the organization
Productivity should be consistent and
measurable
22
11
Pre-Conference 2
July 28, 2013
Methodology Options - Weighted Calculation
• Weight types of visits based on length of visits
and documentation time
SOC
Resumptions
Recertifications
Discharge
High mileage
High tech/high skill
• Weighted visits not consistent in the industry difficult to compare
23
Methodology Options - Direct Calculation
# visits in a given time
# Visits/Day
# FTE’s x # Days
24
12
Pre-Conference 2
July 28, 2013
Methodology Options - Direct Calculation
# of visits
# FTE’s x # Days
# Visits/Day
• Number of visits
In a given time (week, month)
By individual
By discipline (RN include LPN, PT include PTA)
By team
• Number of FTE’s
Sum of full time equivalents NOT employees
• Number of days available to work
After benefit and meeting time
25
Number of Days Available to Work - Example
Example
Payroll Time
Paid Time Off
Time Available to work
Mandatory In-Service/Education
Required Staff Meetings
Total Time Available to Visit
Hours
2,080
240
1,840
12
72
1,756
Days
260
30
230
1.5
9
219.5
%
100%
11.5%
88%
0.5%
3.5%
84%
• In order to meet national productivity
benchmarks, staff must have at least 80 - 85%
of their time available to visit.
26
13
Pre-Conference 2
July 28, 2013
Productivity Forces
• Motivation
Economic
Career development
Management practices
• Impact of culture, conflicts and trust
• Efficiency
Effective tools
Skills development
Education and training
• Utility
Measure of satisfaction or impact the work
27
Factors Impacting Productivity
• Average miles per visit
• Time available to visit
• Agency Patient-Related Characteristics Casper
Report
•
•
•
•
•
Prior conditions
Hospitalization risks
Needs help with ADL’s/IADL’s but none is available
Stage IV pressure ulcers
Significant differences in
– Acute Conditions
– Chronic Conditions
– Home Care Diagnosis
28
14
Pre-Conference 2
July 28, 2013
Staff Collaboration
•
•
•
•
Setting expectations
Historical performance
Performance reports and feedback
Team productivity
Team building activities
Trust and collaboration
Success of the unit vs. success of the individual
29
BALANCING ACT
Optimal
Outcomes
Productivity
Expectations
Patient
Expectations
Patient Needs
30
15
Pre-Conference 2
July 28, 2013
Financial & Clinical Reporting
• How do I compare my metrics?
Internal Data
•
•
•
•
Trending
Locations
Teams
Providers
External Data
• Benchmarks
–
–
–
–
National
Regional
State
Agency Attributes
31
• How can I measure my performance?
Key Indicators
Dashboards
Benchmarks
• What performance indicators should I use?
Agency must evaluate what is important
• Revenue Drivers
• Cost Drivers
• Quality Drivers
• How often should I be reporting my
performance?
32
16
Pre-Conference 2
July 28, 2013
Financial Reporting
• Internal Data
Track through dashboard for each location
Trending data (weekly, monthly, quarterly)
Financial Statements
• Operating Revenue
• Operating Expenses
• General and Administrative Expenses
Gross Margin
• Operating Revenue minus Operating Expenses
• Operating Margin
33
Example of Dashboard
Monthly Admissions Report for Billing Date: Thursday, February 28, 2013
ADMISSIONS AND DISCHARGES
2/28/13
Budget
Variance
1/31/13
12/31/12
Last 5 Months
11/30/12 10/31/12
9/30/12
8/30/12
YTD
Totals
Budgeted YTD
Totals
Admissions Home Health 1
Medicare
139
145
(6)
139
130
139
143
137
135
962
1,015
Medicaid
50
40
10
50
50
50
50
50
50
350
280
Blue Cross
25
20
5
25
25
25
25
25
25
175
140
Private Insurance
35
40
(5)
35
35
35
35
35
35
245
280
Other
15
10
5
15
15
15
15
15
15
105
70
264
255
9
264
255
264
268
262
260
1,837
1,785
Medicare
2,453
2,559
(106)
2,453
2,295
2,453
2,524
2,418
2,383
16,979
17,915
Medicaid
750
600
150
750
750
750
750
750
750
5,250
4,200
Blue Cross
200
160
40
200
200
200
200
200
200
1,400
1,120
Private Insurance
280
320
(40)
280
280
280
280
280
280
1,960
2,240
Other
120
80
40
120
120
120
120
120
120
840
560
3,803
3,719
84
3,803
3,645
3,803
3,874
3,768
3,733
26,429
26,035
Grand Total
Visits Home Health 1
Grand Total
34
17
Pre-Conference 2
July 28, 2013
PPS SUMMARY
1/31/13
2/28/13
12/31/12
Last 5 Months
11/30/12 10/31/12
9/30/12
Year to Date
Totals
8/30/12
Episodes
Beginning
166
154
171
162
161
161
180
1,155
Ending
150
152
166
152
170
163
158
1,111
Budgeted
Average Visits Per Episode
2/28/13
Budget
Variance
YTD Average
YTD
Skilled Nursing
7.20
7.00
0.20
6.30
6.80
6.80
7.20
6.40
6.50
6.74
7.00
Physicakl Therapy
4.90
5.00
(0.10)
5.20
5.10
5.70
5.20
4.70
5.10
5.13
5.00
0.70
0.75
(0.05)
0.70
0.70
0.90
0.90
0.80
0.50
0.74
0.75
Speech Therapy
0.20
0.15
0.05
0.20
0.20
0.10
0.10
0.30
0.10
0.17
0.15
Medical Social Service
Home Health Aide
0.10
0.10
-
0.10
0.10
0.10
0.10
0.10
0.10
0.10
0.10
1.90
1.50
0.40
1.80
1.10
1.90
1.60
1.70
1.50
1.64
1.50
15.00
14.50
0.50
14.30
14.00
15.50
15.10
14.00
13.80
14.53
14.50
20
18
20
18
21
22
32
PEP
2
2
2
2
3
1
3
Outlier
2
-
-
-
-
1
1
1
33
48
51
34
44
33
39
40
Therapy Upcode
46
38
43
39
50
52
39
44
Unadjusted
47
46
50
59
52
54
44
50
150
152
166
152
170
163
158
159
1.1800
1.1900
1.3200
1.2500
1.3300
1.1844
Last 5 Months
11/30/12 10/31/12
9/30/12
8/30/12
Grand Total
YTD Average
Episodes Ending
LUPA
Therapy Downcode
Grand Total
Case Mix
2/28/13
Budget
1.2000
Variance
1.1900
22
2
YTD Average
0.0100
1.2363
Budgeted
1.2000
35
Financial Summary
2/28/13
Budget
Variance
1/31/13
12/31/12
Budgeted
YTD
Revenue
Medicare
425,788
425,788
-
425,788
425,788
425,788
425,788
425,788
425,788
11
Medicaid
63,750
51,000
12,750
63,750
63,750
63,750
63,750
63,750
63,750
11
Blue Cross
2,625
2,100
525
2,625
2,625
2,625
2,625
2,625
2,625
10
Private Insurance
4,375
5,000
(625)
4,375
4,375
4,375
4,375
4,375
4,375
1
Other
1,500
1,000
500
1,500
1,500
1,500
1,500
1,500
1,500
0
6 $ 498,032 $ 498,038 $ 498,038 $ 498,038 $ 498,038 $ 498,038 $ 498,038
35
Total Revenue
$ 498,038 $
Gross Margin
Home Health 1
42.00%
43.00%
-1.00%
43.00%
42.00%
40.00%
45.00%
45.00%
40.00%
42.43%
43.00%
10.00%
10.00%
0.00%
8.00%
9.00%
9.00%
10.00%
10.00%
10.00%
9.43%
10.00%
Net Margin
Home Health 1
36
18
Pre-Conference 2
July 28, 2013
Financial Summary
DSO
Medicare
54
49
5
54
54
54
54
54
54
Medicaid
68
64
4
68
68
68
68
68
68
Blue Cross
70
66
4
70
70
70
70
70
70
Private Insurance
75
58
17
75
75
75
75
75
75
Other
75
58
17
75
75
75
75
75
75
Total DSO
65
55
10
65
65
65
65
65
65
Day to RAP
8
6
2
6
6
6
6
6
6
6
6
Days to Final
15
15
-
14
18
17
14
15
16
16
15
Days Orders Outstanding
20
20
-
20
22
25
21
21
21
21
20
Days F2F Outstanding
25
25
-
22
24
23
20
21
25
23
25
YTD Total
Claims
YTD Budget
Orders
37
Clinical Productivity
2/28/13
Skilled Nursing
Physical Therapy
Speech Therapy
Home Health Aide
4.50
5.25
5.00
5.00
4.00
3.00
Last 5 Months
Budget Variance 1/31/13 12/31/12 11/30/12 10/31/12 9/30/12 8/30/12
5.00
5.00
5.00
5.00
4.00
4.00
(0.50)
0.25
(1.00)
4.50
5.00
5.00
5.00
4.00
3.00
4.50
5.00
5.00
5.00
4.00
3.00
4.50
5.00
5.00
5.00
4.00
3.00
4.50
5.00
5.00
5.00
4.00
3.00
4.50
5.00
5.00
5.00
4.00
3.00
4.50
5.00
5.00
5.00
4.00
3.00
YTD Budgeted
Totals
YTD
4.50
5.04
5.00
5.00
4.00
3.00
5.00
5.00
5.00
5.00
4.00
4.00
38
19
Pre-Conference 2
July 28, 2013
• External Benchmark Data
Compare to changes in industry
• Reimbursement changes
• State legislative changes
• Clinical performance measures
Monitor performance and goals
• Use benchmarks as goals
• Evaluate management and staff performance on
constant basis
• Evaluate whether weakness is an internal issue or
industry issue
• Ability to make better business decisions
39
Financial Reporting
• Break out Direct Cost vs. Indirect Costs
Direct - Patient Costs
Indirect - Support Costs
• Gross Margin
Operating Revenue minus Operating Expenses
Operating Margin
• Net Margin
Operating Revenue minus Direct Expenses and
General and Administrative Expenses
40
20
Pre-Conference 2
July 28, 2013
Things To Consider
•
Revenue
 Rate per Episode, Visit, Hour or Day is lower than
what you budgeted
 Shift in utilization of services
 Home Health Aide vs. Nursing Visits
 Payer Shift
 Per Visit vs. Per Episode
 Lower Rates
•
Anticipated increases in volume did not
occur
41
Things To Consider
• Productivity not in line with budget
• Staffing Capacity - Over/Under Staffed
• Transportation/Mileage Expense
Eliminate paying from Home to First Visit
Rate
• Medical Supplies
Closet vs. Drop Ship
• Service Utilization
 Frequency of visits
 Types of visits per Episode
• Schedule Based on Location of Patient
42
21
Pre-Conference 2
July 28, 2013
Things To Consider
• Hiring restrictions based on Caseload
 RN Case Managers - 25 to 30 Cases
 One Team Per 350-375 Patients
 10 -15 RN Case Managers Per Team
 One Clinical Supervisor Per Team
 One Clinical Assistant Per Team
• Increase Competition
 Loss of Market Share
 Mergers/Acquisitions
 Referral Sources getting into Home Care and Hospice
43
Things To Consider
•
•
SEMI-VARIABLE EXPENSES
Staff







•
•
Home Care Coordinators/Liaison Nurse
Intake Nurse
Billing/Collectors
Clinical Supervisor
Clinical Assistant
Insurance Case Manage
Administrative Assistants
Develop and Monitor Staffing Ratios
Develop and monitor Key Performance
Indicators
44
22
Pre-Conference 2
July 28, 2013
 SIMIONE.COM
Simione™ Healthcare Consultants provides solutions for your core home
care and hospice challenges – organizational, financial, sales & marketing,
technology, and mergers & acquisitions. Over 1000 organizations use our
practical insight and tools to reduce costs, mitigate risk and improve
efficiencies to steward the way they conduct business.
4130 Whitney Avenue
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800.949.0388
[email protected]
45
PROPERTY OF SIMIONE HEALTHCARE CONSULTANTS
23
Pre-Conference 2
Feasibility Analysis Practices
July 28, 2013
2013 Financial
Management Conference
Home Health Summer Camp 2013
Principal
UNDERSTAND YOUR MARKET
1
Pre-Conference 2
July 28, 2013
Elements of a Feasibility Study
A. Understand your market
① ACO Developments
 Who is forming ACO’s in your Market


Health Systems / Hospitals
Physicians
 Are we in a position organizationally and
financially to accept risk and/or integrate with these
organizations?
② Alignment of care
 Mergers and Acquisitions Activity





Health Systems / Hospitals
Physician Practices
Long Term Care (SNF, ALF, ILF)
Home Health
Etc.
3
A. Understand your market
③ Population Health Management
④ Who’s entering into risk share contracts
 Medicaid
 Dually Eligible
 Bundling
⑤ Health Transitions
4
2
Pre-Conference 2
July 28, 2013
A. Understand your market - What questions do
we need to answer?
1. Who will be our key Partners?
2. How do we get a seat at the table?

“C” Suite to “C” Suite
3. What will be our value proposition?


What value can we provide to our partner?
How will we solve our partner’s problems?
 What is important?
 What is your Strategy?
4. How do we get and keep our partners?

Customer Relations
5. Revenue Stream

What value are our partner’s willing to pay
5
DEVELOP THE FEASIBILITY
STUDY
3
Pre-Conference 2
July 28, 2013
Understand Revenue
• Know the measurable indicators that build
Revenue
Home Health
• Episodes Per Month
• Visits - FFS
Hospice
• Days by Level of Care
Private Duty
• Hours
7
Understand Revenue
• Know what Indicators drive revenue
Home Health
• Episodes Per Month
– Admissions
– Re-Certifications
• Types of Episodes
– Full
– LUPA
– Outliers
• Visits Per Episode
– By Type of Episode
 Other Payers
• Visits by Discipline
• Revenue by Discipline
8
4
Pre-Conference 2
July 28, 2013
How to Develop - Revenue
• Each indicator should be automated
 Easy to use
 Easy to obtain
 Reliable
• Information Technology and Finance should Partner to
ensure Success
• Resources need to be available
• All Indicators need to have an audit trail
• Who will be responsible to:
 Generate
 Summarize
• What will be the timing of the reports
9
How to Develop - Net Income
• Can the budget be built by team or location
• Make sure everyone’s aware of their expectations
• MOST IMPORTANT
MAKE SURE YOU HAVE BUY IN
• Revenue should be the driver of all Expenses
Direct
Indirect
10
5
Pre-Conference 2
July 28, 2013
How to Develop - Revenue
• Know your Information System
Standard Reports
Custom
Outside Package
11
Medicare Episodes
Medicare PPS Statistics
Month
January
February
March
April
May
June
July
August
September
October
November
December
Total
# Days
31
30
31
31
28
31
30
31
30
31
31
30
365
•
•
•
Medicare Episodes
Current Year FY 2011 Annualized Episodes
Increase /
Regular
LUPA
Outlier
Total
Based
Decrease by
86.23%
13.77%
0.00%
Episodes
Episodes
108
17
125
136
102
16
118
136
106
17
123
136
108
17
125
136
1
113
18
131
136
1
113
18
131
136
1
119
19
138
136
2
122
20
142
136
2
116
19
135
136
2
116
19
135
136
4
119
19
138
136
4
117
19
136
136
4
1,360
Total Episodes
Recertification Rate
Admissions
217
-
21%
79%
1,577
1,632
21
Total
Episodes
136
136
136
137
137
137
138
138
138
140
140
140
1,653
4.82%
Projected FY 2012 Episodes
Regular
LUPA
86.23%
13.77%
117
19
117
19
117
19
118
19
118
19
118
19
119
19
119
19
119
19
121
19
121
19
121
19
1,425
228
Outlier
0.00%
-
1,653
347
1,306
12
6
Pre-Conference 2
July 28, 2013
Medicare Visits Per Episode
Medicare Visits
Discipline
SN
PT
OT
ST
MSW
HHA
Annual
Visits
13,028
5,431
1,596
71
442
2,894
Total
23,462
•
•
Regular
Budgeted Actaul FY 11
Visits Per
Visits Per
Episode
Episode
9.14
9.14
3.81
3.81
1.12
1.12
0.05
0.05
0.31
0.31
2.03
2.03
16.46
16.46
Current
Visits Per
Episode
501
75
9
5
7
LUPA
Targeted Actaul FY 11 Current
Visits Per Visits Per Visits Per
Episode
Episode
Episode
2.20
2.16
0.33
0.33
0.04
0.04
0.02
0.02
0.03
0.20
596
2.62
2.75
Outliers
Targeted Actaul FY 11
Visits Per Visits Per
Episode
Episode
-
-
-
-
Important to know where you are today
Make your assumptions realistic
13
Medicare Visits
Full Episodes
Discipline
January
February
March
April
May
June
July
August
September
October
November
December
Total
Skilled
Nursing
1,072
1,072
1,072
1,080
1,080
1,080
1,088
1,088
1,088
1,103
1,103
1,103
13,028
Physical Occupational
Therapy
Therapy
447
131
447
131
447
131
450
132
450
132
450
132
453
133
453
133
453
133
460
135
460
135
460
135
5,431
1,596
Speech
Therapy
6
6
6
6
6
6
6
6
6
6
6
6
71
LUPA Episodes
Medical
Social Home Health
Services
Aide
Total Visits
36
238
1,930
36
238
1,930
36
238
1,930
37
240
1,945
37
240
1,945
37
240
1,945
37
242
1,959
37
242
1,959
37
242
1,959
37
245
1,987
37
245
1,987
37
245
1,987
442
2,894
23,462
Skilled
Nursing
41
41
41
42
42
42
42
42
42
42
42
42
501
Physical
Therapy
6
6
6
6
6
6
6
6
6
6
6
6
75
Occupational
Therapy
1
1
1
1
1
1
1
1
1
1
1
1
9
Medical
Social
Services
Speech
Therapy
-
0
0
0
0
0
0
0
0
0
0
0
0
5
Home Health
Aide
Total Visits
1
49
1
49
1
49
1
49
1
49
1
49
1
50
1
50
1
50
1
51
1
51
1
51
7
596
Total Visits
July
January
February
March
April
May
June
July
August
September
October
November
December
Total
Skilled
Nursing
1,113
1,113
1,113
1,121
1,121
1,121
1,129
1,129
1,129
1,146
1,146
1,146
13,529
Physical Occupational
Therapy
Therapy
453
132
453
132
453
132
456
133
456
133
456
133
460
134
460
134
460
134
466
136
466
136
466
136
5,506
1,606
Speech
Therapy
6
6
6
6
6
6
6
6
6
6
6
6
71
Medical
Social Home Health
Services
Aide
Total Visits
37
239
1,979
37
239
1,979
37
239
1,979
37
240
1,994
37
240
1,994
37
240
1,994
37
242
2,008
37
242
2,008
37
242
2,008
38
246
2,038
38
246
2,038
38
246
2,038
446
2,900
24,058
14
7
Pre-Conference 2
July 28, 2013
Medicare Revenue
Medicare Case Mix Weight
Jan-12
CBSA Code
CY
Budget
Feb-12
1.2800
1.2800
Mar-12
1.2800
1.2800
Apr-12
1.2800
1.2800
May-12
1.2800
1.2800
Jun-12
1.2800
1.2800
Jul-12
1.2800
1.2800
Aug-12
1.2800
1.2800
1.2800
1.2800
Sep-12
1.2800
1.2800
CBSA CODE
SN
CBSA Code
Localized National Rate
Targeted Rate
$
$
2,514.85 $
3,219.01
Avg. per Day Unadjusted for CM
$
41.91
PT
132.74 $
OT
145.15 $
ST
146.13 $
MSW
157.72 $
HHA
212.81 $
60.13
May-12
94,854
227,852
124,951
-
Jun-12
95,551
220,502
117,601
-
447,657
433,655
Revenue Recognition:
60 days
Method
All episodes will be assumed to begin on
the 15th of the month.
15
Medicare Revenue
Episode Start Date (15th of month)
Full Medicare Episodes
Nov-11
Dec-11
Jan-12
Feb-12
Mar-12
Apr-12
May-12
Jun-12
Jul-12
Aug-12
Sep-12
Oct-12
Nov-12
Dec-12
Jan-13
Feb-13
# Episodes
Beginning
138
136
136
136
136
137
137
137
138
138
138
140
140
140
Case Mix
Weight
1.2800
1.2800
1.2800
1.2800
1.2800
1.2800
1.2800
1.2800
1.2800
1.2800
1.2800
1.2800
1.2800
1.2800
Nov-11
118,460
-
Total
•
Revenue Calculation
Medicare Episodes
138
X Episodic Base Rate Daily
53.65
X Total Days in the Month
16
= Medicare Revenue
$118,460
Dec-11
229,516
124,039
-
Jan-12
96,248
226,189
124,039
-
446,477
Revenue Recgonized in Period
Feb-12
Mar-12
Apr-12
87,557
211,596
102,150
109,446
226,189
102,150
124,039
218,893
117,601
-
408,600
(Daily Rate x
($41.91
x
452,378
438,644
Case Mix)
1.2800)
16
8
Pre-Conference 2
July 28, 2013
Medicaid Revenue
Medicaid Visits & Revenue
2011 Actual Visits
Skilled Nursing
Physical Therapy
Speech Therapy
Home Health Aide
2012 Budgeted Visits
Skilled Nursing
Physical Therapy
Speech Therapy
Home Health Aide
Total Visits
70.53%
18.98%
4.10%
0.20%
0.00%
6.18%
100.00%
Budgeted
Increase
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
Mnthly Avg
31
Jan-12
406
109
24
1
36
576
31
Feb-12
406
109
24
1
36
576
30
Mar-12
406
109
24
1
36
576
31
Apr-12
406
109
24
1
36
576
30
May-12
406
109
24
1
36
576
31
Jun-12
406
109
24
1
36
576
Jan-12
426
115
25
1
37
604
Feb-12
426
115
25
1
37
604
Mar-12
426
115
25
1
37
604
Apr-12
426
115
25
1
37
604
May-12
426
115
25
1
37
604
Jun-12
426
115
25
1
37
604
Current
Trend
576
Budgeted Total Monthly
Increase
Visits
5%
604
17
Medicaid Revenue
Medicaid Visits & Revenue
Adjustments
to
Distribution
2012 Budgeted Visits
Skilled Nursing
0.00%
Physical Therapy
0.00%
0.00%
Speech Therapy
0.00%
0.00%
Home Health Aide
0.00%
Total Visits
Jan-12
426
115
25
1
37
604
Revenue
Net
Skilled Nursing
Physical Therapy
Speech Therapy
Home Health Aide
Net Medicaid Revenue
37,076 $
7,835
1,763
89
948
47,712 $
$
$
$
$
$
$
86.99 $
68.30
71.20
72.88
25.38
$
Feb-12
426
115
25
1
37
604
37,076 $
7,835
1,763
89
948
47,712 $
Mar-12
426
115
25
1
37
604
Apr-12
426
115
25
1
37
604
May-12
426
115
25
1
37
604
Jun-12
426
115
25
1
37
604
37,076 $
7,835
1,763
89
948
47,712 $
37,076 $
7,835
1,763
89
948
47,712 $
37,076 $
7,835
1,763
89
948
47,712 $
37,076
7,835
1,763
89
948
47,712
18
9
Pre-Conference 2
July 28, 2013
SN Staffing Requirements
Normal Work Week
Number of hours worked per year
Number of hours in work week
Number of hours worked per day
Number of days worked per week
Overtime Rate
2,080
40.00
8.00
5.00
2.50%
Paid Time Off (PTO)
Sick Days
Vacation Days
Admin
Holidays
Total PTO Days
Estimated PTO %
Days
%
20
20
6
5
51
Productivity
Hours per Visit
Visits per Day
Miles per Visit
Admin Time per Day (hours) - Full Time Hourly Staff
20% Admin Time per Days (hours) - Per Visit Staff
SN Visit SN Admit
5.00
7.00
-
19
Total Days
Total Days in Month
Non-Work Days
Workdays
Jan-12
FTE Hours per Month
Grand Total Visits
Apr-12
May-12
Jun-12
31
9
22
30
9
21
31
8
23
30
9
21
176
168
176
168
184
168
Feb-12
Mar-12
Apr-12
May-12
Jun-12
2,771
2,771
2,771
2,793
2,793
2,793
110
88
105
84
110
88
105
84
115
92
105
84
Productivity Expectations - Gross
Productivity Expectations - Net
Productivity Calculation
 Days Available to Work 22
 Daily Productivity
5
 Gross Productivity
110
 PTO %
80%
 Productivity Net
Mar-12
29
8
21
Jan-12
Total Visits
•
Feb-12
31
9
22
88
 Year Expectations Gross1,310
 Year Expectations Net 1,053
20
10
Pre-Conference 2
July 28, 2013
Skilled Nursing
Visits - by Location
Full Time Staff
Location #1
Location #2
Jan-12
Full Time Staff Needed- By Location
Full Time Staff
Location #1
Location #2
Full Time Staff FTEs - By Location
Full Time Staff
Location #1
Location #2
•
FTE



Calculation
Visits
Visits Per FTE
Needed FTE’s
Feb-12
Mar-12
Apr-12
May-12
Jun-12
1,801
970
2,771
1,801
970
2,771
1,801
970
2,771
1,815
977
2,793
1,815
977
2,793
1,815
977
2,793
20.37
10.97
31.33
21.34
11.49
32.82
20.37
10.97
31.33
21.51
11.58
33.09
19.64
10.57
30.21
21.51
11.58
33.09
15.27
8.22
23.50
15.27
8.22
23.50
15.27
8.22
23.50
15.27
8.22
23.50
15.27
8.22
23.50
15.27
8.22
23.50
2,771
88
31.33
21
Per Diem Staff Visits - By Location
Full Time Staff
Location #1
Location #2
Skilled Nursing
Per Diem Rate
Full Time Staff
Location #1
Location #2
•
450
242
693
$
Jan-12
55.00
24,762
13,333
38,095
512
275
787
Feb-12
28,138
15,151
43,290
450
242
693
Mar-12
24,762
13,333
38,095
526
283
809
Apr-12
28,934
15,580
44,515
403
217
620
May-12
22,181
11,944
34,125
526
283
809
Jun-12
28,934
15,580
44,515
Per Diem Calculation
 FTE’s Required 31.33
 Current FTE’s
23.50
 Per Diem Need
7.83
 Visits Per FTE
88
 Per Diem Visits
693
22
11
Pre-Conference 2
July 28, 2013
Budgeting
• Visits Should drive Medical Supply and Transportation
Costs
Medical Supply cost per Visit
# of Miles Per Visit Times Reimbursement Per Mile
• Revenue Indicators will drive Indirect FTE requirements
Examples
•
•
•
•
•
•
Clinical Supervisor
Patient Accounting
Performance Improvement
Intake
Coding
Etc.
23
Budgeting
• Monitor current results to budgeted
expectations
Share these results each month with the stakeholders
Know what the variances mean
24
12
Pre-Conference 2
July 28, 2013
 SIMIONE.COM
Simione™ Healthcare Consultants provides solutions for your core home
care and hospice challenges – organizational, financial, sales & marketing,
technology, and mergers & acquisitions. Over 1000 organizations use our
practical insight and tools to reduce costs, mitigate risk and improve
efficiencies to steward the way they conduct business.
4130 Whitney Avenue
Hamden, CT 06518
203.287.9288
800.949.0388
[email protected]
25
PROPERTY OF SIMIONE HEALTHCARE CONSULTANTS
13

701. Home Health Summer Camp 2013

Transcription

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