2021 Performance Period Eligible Professional / Eligible Clinician eCQMs

The document outlines 47 electronic clinical quality measures (eCQMs) for Eligible Professionals/Clinicians for the 2021 performance period. It categorizes various measures based on quality domains, including effective clinical care, community health, and patient safety, while indicating eligibility for telehealth in select measures.

2021 Performance Period Eligible Professional / Eligible Clinician eCQMs
Total number of EP/EC eCQMs: 47

Measure Name	CMS eCQM ID	Quality Domain	NQF ID	MIPS Quality ID	Meaningful Measure Area	Telehealth Eligible*
Adult Major Depressive Disorder (MDD): Suicide Risk Assessment	CMS161v9	Effective Clinical Care	0104e	107	Prevention, Treatment, and Management of Mental Health	Yes
Anti-depressant Medication Management	CMS128v9	Effective Clinical Care	Not Applicable	009	Prevention, Treatment, and Management of Mental Health	Yes
Appropriate Testing for Pharyngitis	CMS146v9	Efficiency and Cost Reduction	Not Applicable	066	Appropriate Use of Healthcare	Yes
Appropriate Treatment for Upper Respiratory Infection (URI)	CMS154v9	Efficiency and Cost Reduction	Not Applicable	065	Appropriate Use of Healthcare	Yes
Appropriate Use of DXA Scans in Women Under 65 Years Who Do Not Meet the Risk Factor Profile for Osteoporotic Fracture	CMS249v3	Efficiency and Cost Reduction	3475e	472	Appropriate Use of Healthcare	Yes
Bone density evaluation for patients with prostate cancer and receiving androgen deprivation therapy	CMS645v4	Effective Clinical Care	Not Applicable	462	Management of Chronic Conditions	Yes
Breast Cancer Screening	CMS125v9	Effective Clinical Care	Not Applicable	112	Preventive Care	Yes
Cataracts: 20/40 or Better Visual Acuity within 90 Days Following Cataract Surgery	CMS133v9	Effective Clinical Care	0565e	191	Management of Chronic Conditions	No
Cervical Cancer Screening	CMS124v9	Effective Clinical Care	Not Applicable	309	Preventive Care	Yes
Child and Adolescent Major Depressive Disorder (MDD): Suicide Risk Assessment	CMS177v9	Patient Safety	1365e	382	Prevention, Treatment, and Management of Mental Health	Yes
Childhood Immunization Status	CMS117v9	Community/Population Health	Not Applicable	240	Preventive Care	Yes
Children Who Have Dental Decay or Cavities	CMS75v9	Community/Population Health	Not Applicable	378	Preventive Care	No
Chlamydia Screening for Women	CMS153v9	Community/Population Health	Not Applicable	310	Preventive Care	Yes
Closing the Referral Loop: Receipt of Specialist Report	CMS50v9	Communication and Care Coordination	Not Applicable	374	Transfer of Health Information and Interoperability	Yes
Colorectal Cancer Screening	CMS130v9	Effective Clinical Care	Not Applicable	113	Preventive Care	Yes
Controlling High Blood Pressure	CMS165v9	Effective Clinical Care	Not Applicable	236	Management of Chronic Conditions	Yes
Coronary Artery Disease (CAD): Beta-Blocker Therapy-Prior Myocardial Infarction (MI) or Left Ventricular Systolic Dysfunction (LVEF <40%)	CMS145v9	Effective Clinical Care	0070e	007	Management of Chronic Conditions	Yes
Dementia: Cognitive Assessment	CMS149v9	Effective Clinical Care	2872e	281	Prevention, Treatment, and Management of Mental Health	Yes
Depression Remission at Twelve Months	CMS159v9	Effective Clinical Care	0710e	370	Prevention, Treatment, and Management of Mental Health	Yes
Diabetes: Eye Exam	CMS131v9	Effective Clinical Care	Not Applicable	117	Management of Chronic Conditions	Yes
Diabetes: Hemoglobin A1c (HbA1c) Poor Control (> 9%)	CMS122v9	Effective Clinical Care	Not Applicable	001	Management of Chronic Conditions	Yes
Diabetes: Medical Attention for Nephropathy	CMS134v9	Effective Clinical Care	Not Applicable	119	Management of Chronic Conditions	Yes
Diabetic Retinopathy: Communication with the Physician Managing Ongoing Diabetes Care	CMS142v9	Communication and Care Coordination	Not Applicable	019	Transfer of Health Information and Interoperability	No
Documentation of Current Medications in the Medical Record	CMS68v10	Patient Safety	0419e	130	Medication Management	Yes
Falls: Screening for Future Fall Risk	CMS139v9	Patient Safety	Not Applicable	318	Preventable Healthcare Harm	Yes
Follow-Up Care for Children Prescribed ADHD Medication (ADD)	CMS136v10	Effective Clinical Care	Not Applicable	366	Prevention, Treatment, and Management of Mental Health	Yes
Functional Status Assessment for Total Hip Replacement	CMS56v9	Person and Caregiver-Centered Experience and Outcomes	Not Applicable	376	Functional Outcomes	Yes
Functional Status Assessment for Total Knee Replacement	CMS66v9	Person and Caregiver-Centered Experience and Outcomes	Not Applicable	375	Functional Outcomes	Yes
Functional Status Assessments for Congestive Heart Failure	CMS90v10	Person and Caregiver-Centered Experience and Outcomes	Not Applicable	377	Functional Outcomes	Yes
Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) or Angiotensin Receptor-Neprilysin Inhibitor (ARNI) Therapy for Left Ventricular Systolic Dysfunction (LVSD)	CMS135v9	Effective Clinical Care	0081e	005	Management of Chronic Conditions	Yes
Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD)	CMS144v9	Effective Clinical Care	0083e	008	Management of Chronic Conditions	Yes
HIV Screening	CMS349v3	Community/Population Health	Not Applicable	475	Preventive Care	Yes
Initiation and Engagement of Alcohol and Other Drug Dependence Treatment	CMS137v9	Effective Clinical Care	Not Applicable	305	Prevention and Treatment of Opioid and Substance Use Disorders	Yes
Oncology: Medical and Radiation – Pain Intensity Quantified	CMS157v9	Person and Caregiver-Centered Experience and Outcomes	0384e	143	Management of Chronic Conditions	Yes
Pneumococcal Vaccination Status for Older Adults	CMS127v9	Community/Population Health	Not Applicable	111	Preventive Care	Yes
Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan	CMS69v9	Community/Population Health	Not Applicable	128	Preventive Care	No
Preventive Care and Screening: Influenza Immunization	CMS147v10	Community/Population Health	0041e	110	Preventive Care	Yes
Preventive Care and Screening: Screening for Depression and Follow-Up Plan	CMS2v10	Community/Population Health	0418e	134	Prevention, Treatment, and Management of Mental Health	Yes
Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented	CMS22v9	Community/Population Health	Not Applicable	317	Preventive Care	No
Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention	CMS138v9	Community/Population Health	0028e	226	Prevention and Treatment of Opioid and Substance Use Disorders	Yes
Primary Caries Prevention Intervention as Offered by Primary Care Providers, including Dentists	CMS74v10	Effective Clinical Care	Not Applicable	379	Preventive Care	Yes
Primary Open-Angle Glaucoma (POAG): Optic Nerve Evaluation	CMS143v9	Effective Clinical Care	0086e	012	Management of Chronic Conditions	No
Prostate Cancer: Avoidance of Overuse of Bone Scan for Staging Low Risk Prostate Cancer Patients	CMS129v10	Efficiency and Cost Reduction	0389e	102	Appropriate Use of Healthcare	No
Statin Therapy for the Prevention and Treatment of Cardiovascular Disease	CMS347v4	Effective Clinical Care	Not Applicable	438	Management of Chronic Conditions	Yes
Urinary Symptom Score Change 6-12 Months After Diagnosis of Benign Prostatic Hyperplasia	CMS771v2	Person and Caregiver-Centered Experience and Outcomes	Not Applicable	476	Functional Outcomes	No
Use of High-Risk Medications in Older Adults	CMS156v9	Patient Safety	Not Applicable	238	Medication Management	Yes
Weight Assessment and Counseling for Nutrition and Physical Activity for Children and Adolescents	CMS155v9	Community/Population Health	Not Applicable	239	Preventive Care	Yes

Carenodes, a Healthcare Infrastructure Developer, Wins Two Best in Class Awards From Health Net and ComPsych for its Pandemic Response

Jan 25, 2021 (AB Digital via COMTEX) — Los Angeles, CA – ComPsych® revealed the 2020 winners for its 16th-annual Health at Work Awards. This award honors organizations that assist employees with outstanding wellness systems. Carenodes was named as the winner of the best-in-class gold award for organizations with less than 100 employees.

In an unprecedented year, Carenodes has created jobs where others have, unfortunately lost jobs. Carenodes has not only grown its team substantially, but it has led through these trying times with award winning performance.

Carenodes has done so by implementing a community-based approach to workforce development, wellness, and resilience. Alex Yarijanian, CEO of Carenodes, stated, “All employers and companies had to make sudden and immediate changes to adapt to the pandemic. Carenodes took the approach of deploying forces to provide business administration support to critical Healthcare provider organizations”. Carenodes partnered with its provider network to help implement administrative supports and workforce development, wellness, and resilience across various sectors of healthcare.

Here are some of the ways Carenodes and its provider network collaborated to scale workplace innovation in wellness:

Overnight attainment of grant funding for a new model of remote staff decentralization, management, and engagement.
Wholistic suicide prevention programs to include staff training, patient engagement, and supports.
Collocation of emergency department and acute-center behavioral health support for patients, healthcare providers, and caregivers.

“…these outstanding organizations for making employee health and wellness top priorities, especially during these difficult times. Given the current climate, employee well-being is more important than ever, and I applaud the exceptional efforts of these companies.”
Dr. Richard Chaifetz, Founder, Chairman and CEO of ComPsych,

Earlier in 2020, carenodes secured a Health Net grant proposal for its behavioral health provider network to expand its virtual healthcare delivery capacity and accessibility. In response to the ongoing COVID-19 pandemic, Carenodes Behavioral, in collaboration with Insight Choices, was awarded $125,000 to rapidly expand its telehealth infrastructure.

The grant was used to help Carenodes Behavioral Health networks launch new telehealth technologies to increase prevention and intervention efforts for patients with mental health conditions.

Furthermore, the availability of funding has enabled the provision of crisis intervention services, mental and substance use disorder treatment, crisis counseling, and other related supportive services for communities impacted by the COVID-19 pandemic.

“Providing increased access to care during this unprecedented time is critical to ensuring our most vulnerable populations stay healthy and safe. The amount of difficult news, confusion and tragedy surrounding all of us in a short period of time can feel insurmountable. Reaching out for help is incredibly important and telehealth is key to ensuring access to care is not interrupted.”
Brian Ternan, President and CEO, Health Net of and California Health & Wellness.

Recognizing the urgency of the situation, Carenodes saw the need to increase its telehealth offering to benefit its patients who are coping with increased anxiety, deep depression and unfortunately, suicidal ideation. The organization also saw an increased need to provide mental health services for health care workers on the frontline of the pandemic.

“Our nation’s health care providers are under incredible, and still increasing, strain as they fight the pandemic. Insight Choices plan for the COVID-19 Telehealth Program is a critical tool to address this national emergency — starting in California and the counties we serve with a focus on mental health care and emotional wellbeing. This grant will provide Insight Choices, and the communities it serves, vital funding to assist in a more robust response to the mental health crisis exasperated by the COVID-19 pandemic,”
Alex Yarijanian CEO of Carenodes and Interim COO of Insight Choices.

Carenodes will support infrastructure modernization efforts to include telecommunications services, information services and devices necessary to enable the provision of telehealth services during this emergency period and beyond. In addition, such capacity-building funds have the potential to substantially stimulate the deployment of innovative access to care models.

ABOUT CARENODES

Carenodes is the delegated authority acting on behalf of providers troubled by the present multi-payer, disjointed, and cumbersome way healthcare has been, as an industry, running payer/provider operations. In partnership with providers (medical and non-medical, behavioral, primary, substance abuse, and others), it has developed community-wide coalition efforts geared towards addressing larger systemic health, infrastructure or social determinant issues with a large impact on health.

ABOUT COMPSYCH

ComPsych® Corporation is the world’s largest provider of employee assistance programs (EAP) and is the pioneer and worldwide leader of fully integrated EAP, behavioral health, wellness, work-life, HR, FMLA and absence management services under its GuidanceResources® brand. ComPsych provides services to more than 53,000 organizations covering more than 118 million individuals throughout the U.S. and 170 countries. By creating “Build-to-Suit” programs, ComPsych helps employers attract and retain employees, increase employee productivity and improve overall health and well-being.

ABOUT HEALTH NET

Health Net believes every person deserves a safety net for their health, regardless of age, income, employment status or current state of health. Founded 40 years ago, we remain dedicated to transforming the health of our community, one person at a time. Today, Health Net’s 3,000 employees and 85,000 network providers serve more than 3 million members. That’s nearly 1 in 12 Californians. Health Net of California, Inc., Health Net Life Insurance Company and Health Net Community Solutions, Inc. These entities are wholly owned subsidiaries of Centene Corporation (NYSE: CNC), a Fortune 100 company providing health coverage to more than 20 million Americans.

This is a newly created article and can now be edited

PIL Letter to the UC Regents

To: Office of the Secretary and Chief of Staff to the Regents
1111 Franklin St.,12th floor
Oakland, CA 94607

Dear

I am writing on behalf of [your organization name], an organization that [insert your mission/vision], to make sure that you are aware of recent regulatory fines and a landmark federal court decision involving health plans’ coverage of mental health and addiction treatment.

As head of [company name] that offers health insurance coverage to its employees and their families, you may be interested in these recent developments, both for their potential legal implications and the possibility that health insurers – including third party administrators of self-funded plans – may be wrongly denying your employees needed care.

A number of state insurance departments and attorneys general have recently issued fines against health insurers for violations of the federal Mental Health Parity and Addiction Equity Act of 2008 (Federal Parity Law) and state-based parity laws that mirror it. The Federal Parity Law and state equivalents require insurers to treat illnesses of the brain, such as depression and addiction, no more restrictively than illnesses of the body, such as diabetes and cancer.

Unfortunately, recent data from the actuarial firm Milliman has found huge disparities between insurers’ coverage of mental health and addiction treatment and their coverage of other medical conditions.[1] The Milliman data is reinforced by findings from state officials who have examined mental health and addiction coverage and found numerous violations. Recent findings and fines include:

California – The Department of Managed Health Care has fined Kaiser Permanente millions of dollars over the past few years for violating parity and other mental health and addiction coverage laws.
Oregon – The Department of Consumer and Business Services fined Pioneer Educato

Similar violations are most certainly happening in other states. In fact, in a recent landmark legal decision, Wit v. United Behavioral Health(UBH), a federal judge in the Northern District of California ruled that UBH violated its fiduciary duty under the federal ERISA law by allowing financial considerations and a desire to “mitigate” the Federal Parity Law to guide the construction of deeply flawed medical necessity criteria that were used to determine coverage for mental health and addiction services. These criteria were inconsistent with generally accepted standards of care and resulted in the denial of mental health and addiction treatment services to more than 50,000 UBH members who were part of the Wit class action lawsuit.

Again, UBH – the largest managed behavioral health care company in the country – is most certainly not alone in its offenses. For [name of company], there could be substantial liability if its health plans are self-funded and its third-party administrator administers benefits in a way that violates federal law. Of course, there are also important questions to ask about the economic cost of employees not being able to seek help for mental health and addiction challenges as well. Mental health conditions such as depression and anxiety take a massive toll in the workplace. And untreated addiction, particularly opioid use disorder, is a major contributing factor to labor shortages. Any company that is not closely examining is mental health and addiction treatment insurance coverage is missing a key opportunity to improve staff well-being and productivity.

[Your organization name], urges you to take these issues seriously and ask your health insurance company or administrator the following questions:

What are you doing to ensure compliance with the federal and state parity laws?
How are you protecting me from legal decisions such as Wit v. United Behavioral Health?
How are you ensuring that my employees and their families have equal access to treatment for mental health and addiction concerns?

Thank you for your attention to this critical issue. For far too long, those with mental health and substance use disorders have faced a separate and unequal system of care. As life expectancy in the U.S. continues to decline largely due to overdoses and suicides, we must all do our part to hold insurers accountable. Nothing should stand in the way of getting help.

Sincerely,

[Your signature]

[Your name and title, organization name]

[Your phone number and email address]

[1] “Addiction and mental health vs. physical health: Analyzing disparities in network use and provider reimbursement rates,” Milliman, December 2017, http://www.milliman.com/uploadedFiles/insight/2017/NQTLDisparityAnalysis.pdf

CWS Data Tool: Demographics of the U.S. Psychology Workforce

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Learn to speak the Managed Care Language (101)

Healthcare flow of funds explained. Managed Care 101 for healthcare entrepreneurs seeking to do business in the California market. Session led by Alex Yarijanian, CEO Carenodes. The aim: providing healthcare entrepreneurs with a framework within which they will find their place in the business value chain.

Everyone should be able to walk out of this session feeling empowered by having learned the basic flow of funds (starting at the payer).

About this Event

Topics covered in this session are as follows:

1. Managed Care Mind

Managed care: ‘utilization management’
Payment: Volume shift to value
Quality (‘value’) measured
Patient experience
Clinical outcomes

2. Lines of Business aka ‘LOB’ (funding source)

Medicare (Traditional Medicare and Medicare Advantage, Parts ABCD)
Medicaid (managed Medicaid, state / federal, Medi-Cal)
Duals (Medicare and Medicaid beneficiaries)
Commercial (on exchange, off exchange)

3. Products (benefit designs)

The spectrum of products: HMO, PPO, POS, EPO, FFS
Business ramifications

4. Difference between ‘LOB’ vs ‘product’

Difference between ‘LOB‘ (Medicare, commercial, etc) vs ‘product‘ (HMO, PPO, etc.)

The video and article link below is of an expanded version of this training https://www.carenodes.com/healthcare-flow-of-funds-explained-healthcare-entrepreneur-bootcamp/

Expert Seminar on Parity Laws and Reimbursement

Learn to speak the Managed Care Language (101)

Getting Paid (more) for Telehealth by Leveraging Mental Health Parity

About this Event

This is an advanced session for healthcare lawyers, general counsel, contracting VPs, C-suite, consultants.

Healthcare providers and technology companies looking to launch a new telemedicine or mHealth program may find an unexpected ally in commercial health plans. Healthcare providers looking to launch a new telemedicine or mHealth program may find an unexpected ally in commercial health plans. But they need to understand how and what mechanisms to trigger. For example, in mental health, most fail since they are unaware of mental health parity leverage points.

A Carenodes Network provider noted that one private payer in Mississippi won’t cover telehealth even though it’s mandated by the state, and another one of our providers said health plans in New York have found a way to reimburse for telehealth at only half the rate of in-person coverage.

We will discuss these cases, outcomes, and how we managed to obtain better reimbursement terms and partnerships — substantially improving client position and patient access.

This method has demonstrated an average of 46% increase in topline payer reimbursement for healthcare providers.

Provider – Contracting: KPIs

KPI / Metric	Formula or Definition	Target	Business Purpose
Gross Revenue	Gross Revenue or “Top Line Revenue” is synonymous with gross charges associated with the provision of services	This is Facility Specific. GR is budgeted at the Financial Class Level based upon historical payer mixes, demographic studies, material managed care contracting changes and other forecasting methods.	From a revenue cycle management perspective, the objective is rapid, compliant conversion of Gross Revenue into Cash (and legitimate associated contractual adjustments) Therefore, GR is a significant input in a number of relevant KPI’s.
Net Revenue	The term Net Revenue has diverse definitions within the industry but is best defined as: The value of the hospitals dollar, less contractuals, less bad debt.Different methods are used to determine both the value of the Active AR and related %’s that are applied to Gross Revenue to determine its Net Revenue.	This is Facility Specific. The NR target is based upon reducing Gross Revenue by anticipated contractual allowances and a Bad Debt Expense target.The contractual allowances and BD%’s are applied by a combination of a calculated model and/or history.	A primary objective of the Revenue Cycle Team is to increase Net Revenue through denial prevention and recovery as the reduction of the Bad Debt Expense through improved Self Pay receivable management strategies.
Net Patient Revenue(Before Bad Debt)	Net Patient Revenue is Net Revenue prior to making deductions for Bad debt Expense and could be defined as “Maximum Net Collectible Value”	Same approach as Net Revenue.	Measure Cash as a % of Net Patient Revenue instead of Cash as a % Net Revenue. This approach is not as common as Net Revenue.
Lag Revenue(Rolling 2,4,6 months)	Most Gross Revenue is converted into cash and associated contractual adjustments with in 45-60 days. As a result, cash targets are based upon a prior month’s revenue or a rolling average of a prior periods revenue. This is referred to as Lag Revenue. Some targets are based upon a 2 month average with a one month lag.	N/A	Lag Revenue is constantly studied, normalized and modeled to help the hospital become increasingly scientific in setting cash and contractual allowance targets.
Modeled Net Revenue (%)(Expected Reimbursement)	Net Revenue Modeling is the practice of converting contract terms(and for Government Payers; DRG and APC Driven reimbursement) into an Expected Reimbursement calculation at the account level. From there, projections can be made based upon “perfection” (not considering denials and underpayments, etc.) from a Reimbursement standpoint. Modeled Net Revenue is usually expressed as a %.	This is Facility and contract specific.	This works if you Net most of the Receivables at the time of Final Billing. Many facilities utilize historical experience for Net Revenue and related contractuals
Experiential Net Revenue % (ENR) Zero Balance accounts for 12-18 months	Experiential Net Revenue (ENR) is best described as Collections against the dollar on a large sample of zero balance accounts.The Formula is Receipts/Charges 12-18 months of zero balance charges. Often expressed as a %	ENR should be as close the the MNR as possible. The Delta between ENR and MNR is the economic opportunity.	ENR% is used to calculate cash target, average daily net revenue and is an input for a host of other critical Key Performance Indicators
Average Daily Gross Revenue	6 months gross revenue/ total number of days in the calculation period. Expressed as a $ amount.	There may be seasonality to consider so 6 months may be a better standard to determine average daily gross revenue. (Industry standards are 3 months)	ADGR is the divisor for a number of other KPI’s. It is conversational language for “how much Business” is being generated on a daily basis.
Average Daily Net Revenue	6 Months net revenue / total number of days in the calculation period. Expressed as a $ amount.	There may be seasonality to consider so 6 months may be a better standard to determine average daily net revenue. (Industry standards are 3 months)	ADNR is the divisor for a number of other KPI’s. It is conversational language for “how much Business” is being generated on a daily basis.
Cash as % of Net Revenue	Cash/Lag net Revenue (Or Net patient Revenue). Expressed as a %	100% or Greater	This is the most important of all KPI’s and measures cash performance against opportunity for cash performance. This KPI increases in value when calculated at the Financial Class Level and allows for team by team organizational goal alignment.
Bad Debt as % of Gross Revenue	(Bad Debt Transfers – Bad Debt Recoveries) / Gross Revenue. Expressed as a % and $ amount.	This is NOT the finance view of Bad Debt Expense (which is out of scope for this document but includes looking at actual BD write offs Less recoveries against the budgeted BD allowance against the value of the Self Pay Receivable)From the Revenue Cycle Perspective, this calculation should be managed daily and if at 3.1% or less, will equate to successful migration of Bad Debt Risk. (% is client specific)	Used to measure the effectiveness of both Front End Financial Securement and Self Pay follow up.It is critical that only qualifying accounts be referred to BD and that the provider continuously look to reallocate High Risk Self Pay to Federal, State, Private and Local or other funding sources.
Charity Care as a % of Gross Revenue	Charity Care Write offs/Gross Revenue. Expressed as a % and $ amounts.	Finance, using primarily volumes and experience, prepares a charity budget.From a Revenue cycle Perspective, charity care write-offs are targeted at 1.9% of Gross Revenue. (% is client specific)	Charity Care is described as the inability to pay for services rendered (whereas Bad Debt is based upon unwillingness to pay)Non Profits maintain their standing through the provision of Community Benefits visa vie Charity Care.Therefore, it is imperative that qualifying Charity Care accounts not be wrongly classified or through fractured process flow to bad debt.
DNFB – Discharged Not Final Billed	DNFB is a term used to define unbilled accounts where the patient has been discharged (for outpatient services the admit and discharge date is one and the same) and the account is either not coded, or pending charges, service documentation or claim holds to be released into the final billed receivable.The Formula for calculating the DNFB target is:ADGR x 4 (4 is an example) … Expressed as $	DNFB Targets are financial class and patient type specific.Example: if your suspense days is 4 for Non Government payers then: 4 X ADGR would be your calculation…If you have a 5 day suspense for Government payers then you would calculate this as: 5 X ADGR for Gov. Payers	It is critical to success that the DNFB be managed and sustained with the targeted range as that with is not coded/released cannot be converted to cash.
Unbilled beyond Suspense	With in the DNFB receivable is a subset of accounts that have moved beyond the targeted date (which is called the Suspense Cutoff date). These receivables represent a direct delay in cash conversion opportunity.	The target for this calculation, whether expressed as Days, Net Days or $ is ZERO	Unbilled beyond Suspense receives high attention from all functional areas within the revenue cycle, tends to represent the exact co-efficient of any cash short fall being expressed during the month.
DNFB Days	DNFB Receivable Outstanding / Average Daily Gross Revenue (Or Net DNFB Receivable Outstanding / Average Daily net revenue)	Fin Class specific, usually 3-5 daysAlso calculated as Net DNFB days	See above
Gross Days In Revenue Outstanding	Active accounts receivable outstanding / Average daily Gross Revenue	Calculations can vary: Gross Days Target at the Financial Class level and then aggregates the total for a more specific (and less anecdotal) approach to managing days.	This KPI is in the top 5 and is a strong “processing KPI” but may not be tied directly to cash performance. (Avoidable write – offs and high bad debt may produce lower AR days while cash performance is at a variance to target.
Net Days in Revenue Outstanding	Active Accounts Receivable / Average Daily Net Revenue	Calculations can vary: Net days target at the financial class level and then aggregates the total for more specific approach to managing days	See above
Days Lower Control Limit	A term used to describe absolute perfection for A/R Days at the Financial Class (and the aggregate) level. For Example, a perfect Medicare Inpatient Claim is Inhouse for 3.2 Days, DNFB for 5 days and the submitted and adjudicated in 14-16 days.	Financial Class Specific	Days LCL, for both Net and Gross, is an input used for several targets and KPI’s within the Revenue cycle.
Held Claims Days	Claim submission date – Final Billed Date expressed as # of calendar days.	No claim should be held longer than 1 business day for correction and submission/re-submission.	This is a standard Claims Management KPI that seeks to place rigid controls on predictable, regular billing porduct in CBO.
Clean Claim Rate	Clean Claims/Total Claims expressed as a %	95-98%	This is a standard Claims Management KPI that seeks to place rigid controls on predictable, regular billing product in CBO
Erosion	As accounts get older, then become less collectible – or “erode” on the Accounts Receivable.
1. A/R > 90	Creditors that loan hospitals money against their A/R asset use A/R > 90 as a critical measure of the health of the accounts receivable	Through the use of Days Lower Control Limitis, Financial class specific targets can be set around tolerable volumes of accounts moving past 90 Days.	Must maintain acceptable targets from an aging perspective to ensure strong cash performance, and avoid Finance “devaluing” the Active A/R based upon volumes moving into this aging category.
2. A/R > 120	Self pay accounts may be deemed worthless (either in A/R or Bad Debt) after valid collection effors for 120 days.	Financial Class Specific and is dependent upon whether SP after Insurance is blended with pure Self Pay.	120 is an important trigger for Mediare Cost Report compliance and set the standard for Bad Debt Transfers on account that are validated to be uncollectible
POS Cash	Cash collected at, or as a direct result of front end functional area efforts (such as Financial Counseling)	Targeting for POS Cash becomes meaningful when measured against an estimated patient portion due.Initiative to implement a Patient Payment Estimator.	POS Cash Management is critical because the psychological opportunity to collect declines rapidly after the Patient leaves.There is a direct correlation between POS Cash performance and bad debt reduction.
POS Cash as % of Self Pay Cash Collected	This Metric measures the overall composition of Self Pay Cash Performance and seeks to understand the contribution of POS Cash Management to the Overall Self pay campaign.	See Above	See above
Percentage of Receivable over 120 Days	Percentage of current total receivables, as defined by amounts owed to the provider/facility by patients, third party payers etc. that is greater than 120 days post discharge	Find this data in your Aged Trial Balance	Benchmarks: Best practice less than 12% Average between 12 and 25% Alarm Greater than 25%
% business in VBC

All Hospitals Response to Health Care Reform Investments

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Author: Alex Yarijanian

2021 Performance Period Eligible Professional / Eligible Clinician eCQMs

Carenodes, a Healthcare Infrastructure Developer, Wins Two Best in Class Awards From Health Net and ComPsych for its Pandemic Response

Here are some of the ways Carenodes and its provider network collaborated to scale workplace innovation in wellness:

ABOUT CARENODES

ABOUT COMPSYCH

ABOUT HEALTH NET

PIL Letter to the UC Regents

CWS Data Tool: Demographics of the U.S. Psychology Workforce

Learn to speak the Managed Care Language (101)

About this Event

Expert Seminar on Parity Laws and Reimbursement

Getting Paid (more) for Telehealth by Leveraging Mental Health Parity

About this Event

This method has demonstrated an average of 46% increase in topline payer reimbursement for healthcare providers.

RELATED FREE CONTENT (ON DEMAND)

Provider – Contracting: KPIs

All Hospitals Response to Health Care Reform Investments

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