5 pieces of advice on how to improve the revenue mid-cycle

All parts of the revenue cycle management process must work efficiently for hospitals and health systems to receive proper reimbursement.

This includes the front and back ends — before and after the patient receives care — as well as the mid-cycle, which involves crucial components such as clinician documentation, charge capture and coding diagnoses and procedures.

Here, five providers and vendors share their advice for improving mid-cycle performance.

Vasilios Nassiopoulos, vice president and client advocate at Wellesley, Mass.-based Hayes Management Consulting, considers the revenue integrity department the most important one within RCM. Absent a revenue integrity function, "redundant denials will continue to exist, charge capture accuracy will suffer and departmental silos that result to lack of collaboration and communication will continue to deepen," he argues. But he says healthcare organizations can positively affect finances and operations via design and inauguration of a strong revenue integrity department that connects RCM areas, while performing denial related data analysis and trending, auditing and monitoring, problem mitigation and training.

He notes hospitals and health systems may use existing staff, leadership or subject matter experts from different RCM areas for the origin of a revenue integrity department, or design a new department by adding some subject matter experts in areas such as auditing, chargemaster or charge capture review.  

Tom Schaal, director of product management at Emeryville, Calif.-based MedeAnalytics, notes hospitals and health systems face increasing pressure in the mid-cycle to properly document services they're rendering, particularly amid the shift to value-based care. He says some organizations struggle to keep pace with industry changes such as the transition to ICD-10. Additionally, the Medicare Access and CHIP Reauthorization Act further expands clinical documentation to quality of care provided. "It becomes more than coding around claim documentation in general [and instead about] quality and how that leads to reimbursement," he adds.

To help navigate these changes, Mr. Schaal recommends focusing on data analytics to aggregate mass quantities of data and be able to make meaningful use out of that data. Mr. Schaal says some organizations essentially aggregate and benchmark data so they understand how they stack up against their peers. Using data analytics, hospitals and health systems can see the areas where they need to work on coding improvement. Healthcare organizations can use the information to drive value by utilizing it to educate physicians, coders and others on appropriate documentation.

Dan Ward, vice president of strategy at Louisville, Ky.-based ZirMed, recommended using easy steps to begin improving the mid-cycle. He says annual Current Procedural Terminology changes affect various part of the revenue cycle, such as coding, so providers can leverage momentum when these changes are occurring and further drive improvement as they implement the changes/enhancements.

Mr. Ward also addressed the role of health IT in improving the mid-cycle. He says technology can be used to initially push a system to focus on the mid-cycle for the first time and to identify remaining revenue cycle improvement opportunities later on. "In either instance, however, it is essential that the technology not be viewed as a panacea for all challenges at the midpoint of the revenue cycle; rather the technology must supplement people and process as opposed to reverse," says Mr. Ward.

Lori Dixon, director of clinical documentation improvement for Atlanta-based Piedmont Healthcare, recommended hospitals implement solutions that affect the overall organization and not only the mid-cycle. For instance, Piedmont reviewed admissions for all of its hospitals to provide a working principal diagnosis, working diagnosis-related group and the geometric length of stay for case management. The system also began reviewing all DRG payers rather than just Medicare accounts. Ms. Dixon says Piedmont did this by placing staff into multiple teams, an admission team of five clinical documentation improvement specialists and a DRG review team.

"All of these changes have come about because the technology we use has given us new tools to prioritize the cases that we review. The cases with the highest impact come to the top of our worklist and are reviewed first," she added.  

"It's important to not think in traditional ways regarding clinical documentation improvement, but to come up with new solutions that impact the healthcare system as a whole."

Laurie Lamarre, vice president of revenue cycle at Pittsfield, Mass.-based Berkshire Health Systems, notes the importance of data in revenue cycle improvement. She says BHS reports data points, such as time-of-service collections, and assures prior authorizations and referrals are finalized before billing, by organizing outputs into Microsoft Excel and/or through the use of viewing this data in formats utilized by Six Sigma tools. "These formats help our managers within the revenue cycle to prioritize the most important focus areas," adds Ms. Lamarre. "In denial management, unless you have some way to prioritize this, we risk having issues spin and never have the chance [to] make an impact. By looking at the data by both volume and dollars, BHS has been able to target areas."

Ms. Lamarre says BHS operational managers also helm denial management workgroups comprised of staff from multiple specialties. She said the efforts have been successful as far as reducing denials and enhancing team building across departments.

Based on the experiences at BHS, she provided the following advice.

"Gather your data and select a few areas of opportunities to stay focused on, in order to make a positive impact. To this day, the old management adage of, 'you can't manage what you don't measure' is true. I feel by setting priorities in a methodical way, and maintaining our focus, the team is engaged and empowered to make change. We need to continue to listen to the voices of our front-line staff and managers."


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