Case Study: Managed Care Contracting

Catholic Healthcare West (CHW), headquartered in San Francisco, is a healthcare system including 41 hospitals and medical centers in Arizona, California, and Nevada. It is the eighth-largest healthcare system in the nation and the largest not-for-profit hospital provider in California. MedBill Partner has had the privilege of working with two CHW entities.

In 2002, MedBill Partner was awarded a contract after responding to a Request For Proposal for Billing and Claim Management Services to California Family Care (CFC), a division of California Hospital Medical Center. CFC operated four clinics in Southern California. As the relationship progressed, CFC recommended MedBill Partner to its affiliated entity, St. Mary Medical Center, Long Beach, CA. MedBill Partner responded, and was approved for an RFP of the same caliber for St. Mary’s various clinical operations. Each operation serves a diverse patient base and payor mix with a multi-disciplinary provider network that includes MD, DO, OD, NP, PA, RN, and residency program practitioners.

Both CFC and St. Mary’s rapid expansion of clinical operations had resulted in disparate data systems, poor reporting of business information to CHW executive management, and the inability to create and maintain unified methods of management across the clinic network. This resulted in incomplete charge capture, missed revenue opportunities, and underutilization of clinical resources. Provider participation in many available healthcare programs was non-existent, resulting in lost revenue. Finally, they were struggling to fulfill the unique reporting requirements of operating as licensed Community Clinics and Federally Qualified Health Centers.

With an experienced staff and powerful software application, MedBill Partner was able to implement a program meeting each entity needs:

Centralized point of management and unified operations and reporting
Medi-net Reporting greatly enhanced executive and operational management’s access to business information while giving clinical staff the software tools needed to effectively maximize resource utilization and the patient’s experience.

Highly detailed, divisible reporting
Medi-Net provides for a wide variety of Internet-enabled financial and operational reports that can be filtered creating a user-friendly ad-hoc decision support environment.  All levels of decision makers have been effective in using this software service to enhance their ability to choose the best course of action.

Access to patient populations
We applied for and secured participation in Medicare, Medi-Cal, PPO, and managed care programs, as well as episodic programs including CHDP, CPSP, SOFP, PE, BCEDP, PPP programs.  New and expanded participation in these programs created additional patient and revenue sources

Specialized analysis of operations for PPP, Community Clinics, FQHC
Our MIS team worked closely with CHW leadership to define and implement reporting standards unique to PPP, Community clinic, and FQHC reporting, including specialized OSHPD reporting and cost basis analysis and accounting.

Real-Time data transfer and transformation with various hospital information systems
CHW utilizes the services of Perot Systems to manage its networks and information systems.  Our MIS team worked with Perot Systems’ engineers to develop a real-time, VPN-secured HL-7 data interchange with MedBill Partner’s data base for HIPAA-compliant sharing of patient information.  Data sharing created economies for both companies.

Improved charge capture
Medi-Net’s Appointment application enabled CHW and St. Mary to benefit from better tracking resources.  The process of charge entry automatically ties the new claim with the appointment that generated the superbill.  Available reports, as well as visual inspection of the appointment screen, can be used to track appointments that are not attached to a claim, indicating that billing documentation may be lost.  Medi-Net Appointment creates an audit trail from appointment completion to charge entry.

Improved revenue capture
MedBill Partner provided clinical staff retraining and continued oversight on techniques in information acquisition, such as when to perform eligibility, obtaining correct information from patients to effectively process claims, and billing compliance.  Proper training reduced the number of non-compliant billing documents returned to CHW and the denial ratios on submitted claims.

Resource utilization reporting
MedBill Partner worked closely with CFC and St. Mary management to define which healthcare delivery resources (providers, spaces, and equipment) and visit types required/needed utilization reporting.  Medi-Net Appointment was then configured to these specifications resulting in utilization reporting that presented opportunities to reduce FTE’s without sacrificing service quality.