Revenue Enhancement reviews cover the period beginning with patient access through collections and final disposition of accounts. These areas are some of the core strengths upon which we have built our national reputation of success. Our projects integrate revenue cycle, medical group operations, coding, compliance, reimbursement and physician training expertise to achieve the maximum bottom line results that matter.
By addressing the front, middle and back ends of the revenue cycle typically yields the highest benefit and immediate return on investment. We typically use a mixture of HFMA and HARA benchmarks and best practice standards in our evaluations.
We have found that the best method to effectively evaluate the revenue cycle is to spend time onsite interacting with staff involved in the detailed processes. Our engagement would include onsite time to shadow and interview staff, review processes and to analyze and gather additional information. Following that, our team will work offsite to complete the evaluation and accompanying findings and recommendations report - key components include:
Revenue Cycle Front End
Revenue Cycle Middle
> Charge Capture Process
> Inpatient/Outpatient Coding Validation
> Charge Description Master (CDM)
> Market-Based Strategic Pricing
Revenue Cycle Back End
> Reports and Metrics
> Denials Management
Revenue Cycle Front End
The front end of the revenue cycle serves as the financial gatekeeper for all healthcare providers. It is essential that organizations have the workflows, systems and processes in place to perform the critical functions required to financially secure patient accounts. The front end of the revenue cycle, however, is not just about the financial and operational functions of outpatient or inpatient services. While comprehensive, efficient and accurate front end processes improve an institutions financial performance, they also improve the overall patient experience and customer service.
Healthcare payors have introduced new product offerings into the marketplace in recent years. These new insurance plans, such as high deductible health plans, have placed increased strain and importance on the key gatekeeper functions of insurance verification, co-pay and deductible collections. Providers that have not modified their front end business practices to coincide with the changing payor landscape are at risk for reduced collections.
Many clients have found that problems in the back end of their revenue cycle (e.g., denials, write-offs, etc.) can be directly attributed to process breakdowns on the front end. Addressing the front end opportunities will improve billing quality, accelerate cash collections and reduce adjustments and write-offs.
Assessment of the front end of the revenue cycle workflow processes, technology and systems and the corresponding controls.
Evaluation of processes and effectiveness of scheduling, registration, admissions, insurance verification and securing financial sponsorship.
Evaluation of the processes to capture accurate registration data.
Evaluation of the auditing and monitoring systems in place to ensure the accuracy of data capture at all points of service.
Evaluation of key indicators for front-end related denials, timeliness, etc.
Evaluation of the curriculum and effectiveness of staff training for all front end staff.
Revenue Cycle Middle
Our approach is designed to provide your organization with education and effective solutions to ensure accurate departmental charge capture and coding of line items from both the CDM and Health Information Management (HIM), determine CDM line items that assess the overall pricing structure within the CDM, and create appropriate ongoing monitoring activities.
We will assess and document the effectiveness of the process to ensure that all appropriate services with corresponding codes are captured and billed for key departments. All areas of the charge capture process, from the time services are ordered to patient billing, will be reviewed to determine whether the processes are effective to capture all charges and to reconcile lost or late charges. The end goal of this portion of the assessment is to identify ways to enhance the hospitals charge capture and billing processes and to identify processes whereby the hospitals can reduce the high volume of late charges.
Departmental functions such as charge ticket maintenance, order entry screen maintenance, charge entry, supply item entry and reconciliation are reviewed. The scope of work includes a review of existing policies and procedures, interview key personnel, and perform on-site analysis of charge data and workflow processes from registration to billing for charges.
Charge Capture Process
The charge capture assessment involves the following activities:
Establish pre-site data request for organization charts, policies and procedures, system error reports, trending information and statistics, denial reports and trends;
Establish kick-off conference call date and customize departmental interview questionnaire for assessment;
Assess current charge capture tools utilized (i.e. forms, systems, technology);
Inventory and review of the current charge capture and billing policies and procedures;
Review and observe current processes and identify discrepancies between existing practices and policies and procedures;
Review workflow processes for charge capture to verify if the process is timely, efficient, and well controlled;
Assess information systems capabilities for capturing accurate charges, correction of missing or late charges, and posting to patient accounts;
Assess what tools are currently in place to assist managers and departments in monitoring and charge error resolution;
Process map the current charge capture data/information flow from Registration to Billing;
Review processes for lost and late charges;
Analyze current remittance advice, reconciliation and appeals processes;
Identify key business risks within the charge capture process that require strengthened or improved controls; and
Interview key personnel to determine current charge capture edit applications, billing practices and data/information flow:
>Departmental director, clinical and clerical charge processing personnel
>Information systems manager and/or applications analyst of applications used for charge capture and billing
>Registration and admitting
>Health Information Management
>Patient Accounting/Business Office/ Finance
Inpatient/Outpatient Coding Validation
We assess the coding accuracy of prospective claims by reviewing a sample of inpatient and outpatient claims. We utilize certified coding professionals to evaluate and record the organizations coding accuracy.
As part of the coding review process, we perform the following activities:
Review a random sample of inpatient and outpatient claims from the organization. Two types of visits will be evaluated in these reviews: 1)Medicare/Medicaid inpatient visits, and 2) Medicare/Medicaid Outpatient visits.
Evaluate each claim and associated medical record documentation for technical coding appropriateness, completeness of documentation to support code selection, and compliance with Centers for Medicare and Medicaid (CMS) Current Coding Initiatives.
Inpatient Coding Review - We perform quality control ("QC") on the coding assigned by the HIM department. The "QC" of inpatient medical record review would consist of claims where the coding was assigned by the HIM department and will be conducted on-site by experienced HRS Health Information Management (HIM) consultants. HRS will perform the "QC" in the following manner:
Identifying ICD-9-CM coding issues including selection of accurate principal and secondary diagnoses, sequencing, and missing or inappropriate code selection;
Assessing the documentation supporting selection of principal diagnosis, procedure codes, co-morbid conditions and complications;
Verifying the accuracy of the selected ICD-9-CM procedure codes;
Verifying the DRG assignment; and
Evaluating the appropriateness of selected discharge disposition codes.
The reviewers will validate the coding accuracy and DRG assignment and record any comments or changes in spreadsheet format. We will assess the medical record documentation for comprehensiveness in compliance with CMS Current Coding Initiatives and to ensure the accuracy of listed codes. All proposed changes, along with the nature and magnitude of the data quality issues identified, will be discussed with the HIM Director and hospital coding staff. HRS will use various reference materials to accomplish the validation review, including but not limited to 3M coding software, AHA Coding Clinics, CMS/AMA publications and Diagnosis Related Groupings.
Outpatient Coding Review - In addition to the Inpatient Coding Review listed above, we perform a chart Outpatient Coding Review. The Outpatient Coding Review will cover all ancillary departments as well as the Emergency Department. The outpatient charts should be randomly selected and demonstrate a good cross section of the types of cases seen within the system. The focus of this review will be to determine outpatient technical coding accuracy and completeness of the documentation supporting code selection.
HRS will complete the coding validation review in accordance with Centers for Medicare and Medicaid Services (CMS), AHA Coding Clinic, CPT-4 Assistant, and AMA and AHIMA ethical coding guidelines. We will assess the medical record documentation for comprehensiveness with CMS Current Coding Initiatives and to ensure accuracy of listed codes.
HRS will identify and report on coding and documentation issues for each case, such as:
ICD-9-CM coding issues including sequencing, incorrect, missing or inappropriate code selection.
Accurate assignment, based upon coding guidelines and bundling requirements of CPT/HCPCS codes as assigned by the CDM.
Health Information Management Department assigned CPT/HCPCS coding accuracy based upon coding guidelines and bundling requirements.
Correct selection of ICD-9-CM and CPT/HCPCS procedure codes and modifiers.
Appropriate abstraction of discharge disposition codes.
Correct abstraction of data required for UB-04 coding related elements.
Accuracy of ICD-9-CM and CPT/HCPCS codes and discharge disposition to be assigned to the UB-04 billing form.
Review of facility-specific coding policies and guidelines.
Completeness of medical record documentation to support code assignment; coding variances may reflect underpayment, overpayment, or no change in reimbursement.
Operative report dictation timeliness and completeness supporting code selection.
Charge Description Master
Using our proprietary software developed for charge description master editing purposes, HRS will perform the following activities for the high level outpatient CDM review. The high level computerized review will include all line items within the charge description master to evaluate your hospitals CDM for:
Invalid/Obsolete CPT/HCPCS codes compared to current CPT/HCPCS codes
Invalid/Obsolete UB-04 revenue codes compared to current UB-04 revenue codes
CPT/HCPCS to UB-04 revenue code mismatching
UB-04 revenue codes that require HCPCS codes
Identification of PT/OT/Speech Medicare line items that require specific modifiers
Evaluation of the accuracy and completeness of the coding assignments for select high volume/high reimbursement procedures
Identification of CDM line item prices found below the Medicare and/or Medi-Cal fee schedules
Identification of zero usage line items and zero dollar amount line items
CDM Deliverable - We create a detailed report listing potential variances by department and line item in an effort to assist to identify and implement correct coding within the CDM. We summarize the findings and will discuss potential compliance and/or revenue opportunities based on this high level CDM review.
Revenue Cycle Middle: Market-Based Strategic Pricing - Charge structure by reviewing CDM line items for compliant maximization of net revenue through selective changes in prices. During this assessment we create a work plan for a Market-Based Strategic pricing initiative. That detail will be the work effort and work plan to provide detailed, empirical information to support third-party contract negotiations and to address the increasing scrutiny by Patients, Regulators, Centers for Medicare and Medicaid Services (CMS), self-pay advocates and the media.
A typical Market-Based Pricing Initiative is comprised of the following components:
Reports summarizing the output for the overall charge structure and detailed charge item analysis;
Various scenario models including a detail report presenting the charge changes by procedure based on the parameters that you have set;
A detailed market and (optional) cost comparison analysis;
An assessment of the change in gross and net revenue changes by payer, procedure, and department; and
Reports of the expected effect of the rate changes on charges for various payers, when required by contract filing terms.
Revenue Cycle Back End
The back end of an organization is typically the area where revenue cycle issues have the highest visibility. Key indicators such as accounts receivable balance, A/R Days and denials often point to inefficiencies or breakdowns in processes both in the business office and throughout the revenue cycle. As these indicators trend in the wrong direction, they are an early warning sign that revenue cycle managers should diagnose the cause of the issues and remediate them.
Given the large volumes of accounts and increasing complexity of billing and follow-up, many of our clients are faced with overwhelming back end revenue cycle issues. Our clients have engaged us to perform a wide range of evaluation and remediation services in the areas of bad debt write-offs and recoveries, collection workflows and processes, billing processes, denials management, claims preparation, patient billing and staff training. Evaluation of current performance is the critical first step to identifying root causes for process issues that may lead to full remediation projects to increase revenue performance.
HRS can perform an assessment of the patient accounting operations for hospitals in order to evaluate the current operational performance and to recommend ways that these hospitals could streamline processes and maximize collections.
Reports and Metrics
Overall assessment of the back end of the revenue cycle workflow processes and systems.
Evaluation of revenue cycle reporting tools, dashboards and detailed reports.
Evaluation of key indicators for denials, adjustments, write-offs, etc.
Evaluation of the current bad debt levels and the performance of the bad debt recovery performance.
Evaluation of billing processes with particular attention to billing accuracy and third party billing processes.
Evaluation of the billing technology, billing edits and associated workflows.
Evaluation of unbilled claim levels and recommendations to remediate the root causes of unbilled claims.
Evaluation of collection performance, timeframes, workflows and technology.
Evaluation of processes to identify and pursue underpayments.
Evaluation of payment processing.
Evaluation of current processes in place to identify, track and respond to claim denials.
Evaluation of the effectiveness of the appeal process and identification of opportunities to improve performance.
Identification of root causes for denials and recommendations to remediate those root causes.
Evaluation of patient billing, collections and payments.
Evaluation of the curriculum and effectiveness of staff training for all patient accounting staff.