Making improvements to the revenue cycle is an evergreen effort for health care providers who understand the importance of continual outcome growth and patient satisfaction. Key to strengthening revenue cycle performance is a strong revenue integrity program. Here, we suggest seven key strategies in the middle of the health care revenue cycle that, when implemented to tackle issues, result in accurate and true reimbursements, consistent compliance and positive quality reporting.
Specifically, the seven strategies lie within Clinical Documentation Improvement (CDI), Charge Description Master (CDM) and Charge Capture Audit or Improvement (CCA OR CCI).
Why focus on these three areas?
CDI Technology is a fundamental cornerstone for data quality, accurate reporting, appropriate reimbursement, and robust public health information tracking. Clinical denials can quickly erode the margins of any health care organization. The #1 reason for poor clinical denial management can be attributed to physician documentation, according to ICD-10 Monitor.
A current and accurate Charge Description Master (CDM) is vital to your health system; it promotes proper reimbursement and compliance and serves as a key revenue cycle performance indicator. Without it, your medical organization runs the risk of missed charges and overcharges that can lead to claim denials, fines, and potentially an unhappy patient population.
Charge Capture Audit (CCA) aims to improve and streamline charge capture processes to help a health system improve patient solutions, improve profitability, and ensure compliance with regulatory rules. Many health systems are aware that not all patient charges are being captured, so they conduct self-audits or spot checks to catch the big mistakes. But without an airtight process and knowledge of thousands of possible clinical scenarios, however, it is nearly impossible to keep up. Millions of dollars can be lost in missed charges, overcharges and health care noncompliance errors because of ineffective health information technology solutions.
The following health information management insights include the three areas of Revenue Integrity with seven productive strategies – all within reach, all practiced by leading health systems and all offering positive results. See which of these insights you can implement or improve within your health care organization for dramatic progress in revenue cycle management performance.
The seven strategies for revenue cycle performance
Fix the incomplete and inaccurate clinical documentation.
More than an essential component of the health care system, clinical documentation quantifiably affects the revenue cycle. DRG assignments and medical coding affect medical billing and, if assigned erroneously, can lead to denied claims or inaccurate reimbursements. Truth time – how thorough is your physicians’ documentation?
A strong collaboration between CDI specialists (CDIS), medical coders and physicians is essential to a successful CDI program. The CDI specialist reviews all clinical documentation and queries physicians to recommend potentially missed clinical indicators or documents lacking required specificity that, if caught early, can lead to more accurate medical coding, higher levels of care and Case Mix Index (CMI), better quality reporting, and appropriate reimbursement.
Clean up the non-coded and correct inaccurate charge code descriptions.
In a typical Charge Description Master, about 30 percent of items are coded and about 70 percent are not, creating the potential for lost revenue. It is possible that some non-coded items should be coded. Tap sources such as clinical consultants, who review all active inpatient and outpatient charge items and use charge descriptions and supplemental information to build links to your practice model. They can provide specific and actionable compliance information on all your chargemaster line items, including non-coded charges, such as OR time and room charges, to promote accurate charging and reimbursement for the entire CDM. The vendor you partner with should be able to analyze your entire CDM as well as standardize medical billing and technical descriptions across your health care organization and provide pricing benchmarks not available in public sources.
Valid codes are only half the answer to a best-in-class CDM. The other half is ensuring codes are correct, which can be an overwhelming task, given their number and constantly-changing nature. Use a tool that combines proprietary pricing benchmarks, regulatory documentation and coding research into a single source and is updated frequently – we suggest weekly – to reflect ongoing regulatory changes and new devices, drugs and procedures. A practice model program empowers your health system to normalize your CDM to best practice content and achieve accurate, compliant billing and prevent lost revenue. It ought to detect and correct miscoded issues by providing context when more specificity than what is provided by Current Procedural Terminology (CPT®) descriptions is needed. It can also ensure that pricing benchmarks are relevant or Centers for Medicare & Medicaid (CMS) bulletins are published.
Close the gaps between costs and the Charge Description Master (CDM).
Most patient accounting systems (PAS) lack the ability to link the cost of supplies to the CDM, resulting in missed revenue opportunities. It’s a known deficiency that health systems have tolerated because creating one data source of truth is difficult. Disparate databases and operating silos, however, are not acceptable when every dollar counts. As an alternative to investing your own time and staff to connect the supply chain to the revenue cycle, your health system can leverage outside resources and expertise from firms to provide analytics for supplies, linking the item master to the CDM to:
- enable all chargeable items being accounted for in the CDM and priced above cost
- support defensible pricing based on true cost rather than across-the-boards or percentiles
- reduce manual work by consolidating data from multiple sources
- maintain consistent pricing to meet your revenue goals
Lack of mapping between pharmacy costs and the CDM could mean your health system is missing out on revenue due to missing or incorrect pharmacy codes and billing units. Many health systems are adapting crosswalk technologies, specific to pharmacy, to ensure correct descriptions and dosages in the CDM and formulary, pricing based on true charges and a defensible and consistent markup strategy.
Update obsolete pricing benchmarks.
There is plenty of health care pricing data available publicly; the problem is that most of it is 12 to 18 months old. To establish a defensible pricing strategy, your health system is better served by accessing current, relevant data that enables custom comparison-to-market pricing results. This helps your health care organization quantify the revenue impact of pricing scenarios and establish your audit trail to substantiate pricing changes.
A sound pricing strategy compares pricing to CMS, national and custom benchmarks; CMS national, state and hospital benchmarks, cost and relative value unit (RVU Medical Data) and fee schedules. New codes should be introduced in your system annually.
Eliminate manual processes and workflow; cleanse data before installing technology.
The CDM is a complex, dynamic part of the revenue cycle that must be continually tracked, updated and accessed by multiple departments. Manual processes are inefficient, error-prone and can lead to delayed or incorrect reimbursement; improve performance through automation. With automation, your staff can request changes and additions to the CDM, streamline approval and tracking processes, consolidate multiple CDM information sources, and track and audit requests status and change history.
Data cleansing before a CDM conversion is always recommended, but many providers don’t have the resources to do it. A reputable vendor can provide expert consultants and advisory services to conduct a CDM Compliance Review and determine whether your descriptions are accurate, codes are appropriate and data integrity is maintained. A thorough review includes the CDM, supply and pharmacy data.
Catch the big and small charge mistakes every day.
A Charge Capture Improvement Program automates the review of 100 percent of your patient bills to look for missing charges, overcharges and coding errors on services rendered before claims are submitted. When errors are found, the technology suggests changes, quantifies potential revenue impact to aid prioritization and connects the right parties to solve problems before billing – thus avoiding rework and late charges. Best practice processes and reporting open the door for your revenue integrity staff to identify trends upstream in the billing process so they can prevent future issues – an important feature in adapting to regulatory changes.
Keep on top of industry rule changes.
A charge capture improvement program does what a thousand nurse auditors cannot, using guidelines from multiple sources to provide standard and custom rules, implement as-needed rule modifications, add new rules regularly and maintain the specialized coding rules, including Medicare Recovery Audit Contractor (RAC) focus areas.
Fix your CDI and Charge Integrity issues and you improve Revenue Integrity. Improve Revenue Integrity and enhance your revenue cycle, positioning your organization to step up your quality of patient care and health solutions – a critical differentiating factor in this value-based health care arena. Collaborate with a proven partner to drive higher performance and greater financial health.