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John W. Ruth, MBA, RHIADirector, Revenue Integrity DepartmentStony Brook University HospitalStony Brook, N.Y.john.ruth@stonybrookmedicine.eduNew York Health InformationManagement AssociationRevenue Integrity and the HIMProfessional’s Role in the RevenueCycle6/06/20176/6/20171New York Health InformationManagement Association AHIMA Weighs In—”Shake-up, Wake-up” HIM Professionals Supporting Opportunities in RevenueCycle Sample Alternative Roles for HIM Non-traditional Employers Weigh In Revenue Integrity—What IS It? Stony Brook University Hospital Fast Facts Revenue Integrity/HIM-Revenue Cycle Opportunities Embracing Revenue Cycle Functions Summarize Your Questions6/06/2017Agenda21
6/6/2017Shake-up, Wake-upNew York Health InformationManagement Association According to AHIMA, Bureau of Labor Statistics estimatesdemand for HIM professionals to grow by 22% by 2022 HOWEVER: Demand for coding professionals may DECREASEsignificantly during the same time period AHIMA: We all need to consider where we are in our careersand where we want to be in the future—and take actionablesteps to attain the goals6/06/2017Journal of AHIMA, May, 20163Shake-up, Wake-up HIM departments have downsized with advent of EMRs HIM professionals must update their skills and education tocontinue their employment and to provide added value to theirorganizations Hospital “systems” are transitioning to “shared service center”models in which each facility focuses on one type of HIM servicefor the entire enterprise Information Governance is taking a more central role amonghealthcare administrations—are we making sure that we’re seenas the leaders in this arena, or will IG be delegated to the ITdepartment?New York Health InformationManagement Association AHIMA provided a “reimagined HIM profession” in the abovenoted Journal6/06/2017Journal of AHIMA, May, 201642
6/6/2017 Helps their organizations avoid penalties for not meeting variousquality metrics Assists with meeting compliance initiatives Ensures appropriate reimbursement while improving patientoutcomesNew York Health InformationManagement Association According to AHIMA, HIM professionals play an increasinglyvital role in the revenue cycle. As reimbursement is shiftingfrom volume of patients treated to value and quality ofservices provided, opportunities have significantly increasedfor HIM professionals to play a meaningful part in healthcarerevenue cycle management. Increasing involvement by HIM professionals:6/06/2017HIM Profession-Expanding Into Critical RolesSupporting the Revenue Cycle5 “National and regulatory trends in public reporting, deployment of Web sitesfeaturing care comparisons by outcome and cost, and pay-for-performanceinitiatives have dramatically escalated the importance of aggregating, analyzing,and reporting accurate statistical data, both internally and externally. Proactive management of continual process improvement and benchmarkingagainst national best practice standards has risen in prominence and recognitionthroughout the industry as a major contributing factor in becoming andremaining a top ranked institution in comparison databanks and in pay-forperformance areas. Healthcare facilities must now pay attention to a number of new external andinternal HIM-related pressures that can adversely affect the revenue cycleAnderson, Gail; Underwood, Mal. "HIM: the Underrated and Seldom Stated Driver of Revenue CycleSuccess." AHIMA's 77th National Convention and Exhibit Proceedings, October 2005New York Health InformationManagement Association “Professionals specializing in revenue cycle management work in a variety ofroles including billing management for hospitals and health systems, revenuerelated data analysis, medical practice business management, and auditingcoding and billing for accuracy and compliance,” says Rosann O’Dell, MS, DHSc,RHIA, Clinical Assistant Professor, Kansas University6/06/2017HIM Profession-Expanding Into Critical RolesSupporting the Revenue Cycle(Continued)63
6/6/2017New York Health InformationManagement Association “The integrity of the information in the electronic health record is a criticalcomponent in helping to ensure patient safety as well as to ensure thatquality increases while driving down an organizations cost.”-Siemen’s Corp. “With the complexity of provider Pay for Value program designs and theemergence of “big data” as the foundational epi-center to guide and informprovider performance efforts, the legislative/regulatory data /technology,data/ technology, quality/coding, and quality management/ populationmanagement knowledge and expertise of the HIM professional is relevantand a necessary addition in the health insurance payer realm. An RHIAprofessional has brought strength and leadership in all areas to strategicallyadvance [Our] Pay for Value programs.”-Highmark Medical “Given the rigor with which Health Information Management (HIM)professionals learn about data and information structures in healthcare,there are opportunities within the (pharmaceutical) industry (given the HIMskillset), specifically clinical trial information management, understanding ofthe healthcare delivery system, and assistance in building the industry’s rolein the health information technology environment.”-Pfizer Medical6/06/2017What Non-traditional Employers Are Saying7AHIMA Pamphlet: “HIM Professionals, Your Best Investment”HIM Leadership RolesInformation Governance Officer(IGO)/ Chief of InformationGovernance (CIG)Chief of Information Intelligence(CII)/Business Intelligence Officer (BIO)Chief/Director of InformationExchange ManagementPrivacy & Security Assurance OfficerChief/Director of EnterpriseInformation ManagementChief/Director of Information & DataAnalyticsInofmration ResearchDirector/Manager/AnalystConsumer Informatics/AdvocacyManager/SpecialistEnterprise ApplicationDirector/Manager/AnalystBusiness IntelligenceDirector/Manager/AnalystNew York Health InformationManagement AssociationInformation Asset Officer (IAO) /Information Integrity Officer (IIO)/Director of Information Access (DIA) Director of Information Integrity (DII)6/06/2017Chief/Director of Health Informatics Chief Inormation Strategy OfficerAdministration(CISO)8AHIMA Pamphlet: “HIM Professionals, Your Best Investment”4
6/6/2017New York Health InformationManagement Association6/06/2017What IS Revenue Integrity?9What IS Revenue Integrity? (Cont.)“Results of a 2012 national healthcare industry survey revealed that 60percent of hospital executives believe revenue integrity is essential totheir organization’s financial health. The November 2011 Cranewaresurvey found that operational efficiency, compliance and legitimatereimbursement (the holy trinity of revenue integrity) rank highest onthe list of concerns currently plaguing hospital financial managers.”“Revenue integrity tops list of concerns for hospital executives”, HealthcareFinance, 4/9/2012New York Health InformationManagement AssociationCaroline Rader Znaniec, Healthcare Revenue Integrity AdvisorLuna Healthcare Advisors, Posted On “LinkedIn”, June 13, 2014.6/06/2017“To many, ‘revenue integrity’ is new, its catchy, it’s what is hot inhealthcare revenue cycle, audit and compliance. "I WANT IT! . . . . Butwhat is it?" Really, it can depend on who and when you ask.”105
evenue-integrity-in-healthcareRevenue integrity is the organization’s desire to completely capture allpossible opportunities for reimbursement, in a manner which iscompliant with all applicable rules and regulations. It is a holisticapproach that guides an organization toward achieving operationalefficiency, complete regulatory compliance, and total reimbursement.New York Health InformationManagement AssociationApplied to the healthcare industry, revenue integrity is the achievement ofoperational efficiency, compliance, and legitimate reimbursement. Revenueintegrity can be achieved only with the proper processes, tools, and relatedexpertise aimed at effectively pricing, charging, and coding for services andsupplies related to patient care.6/06/2017What IS Revenue Integrity (Continued):11New York Health InformationManagement Association6/06/2017HIM Systems Are Integral to Revenue Cycle Integrity126
New York Health InformationManagement Association6/06/2017New York Health InformationManagement Association6/06/20176/6/2017Another Theory of The Revenue Cycle 13HIM Systems Are Integral to Revenue Cycle Integrity(cont.)147
6/6/2017New York Health InformationManagement Association6/06/2017The New Elephant In The Room!15New York Health InformationManagement Association We’ll take the next while discussing some of the processeswhich SBUH has implemented in the R.I./HIM Department tosupport R.C. functions The following is meant to provide examples of ideas that maybe implemented in our respective organizations Most important, I’d like the participants to leave with thefollowing thoughts: “What else can I do to embrace andadditionally contribute to the Revenue Cycle process? Is theHIM Department in my organization positioned to be includedas an integral part of the process within my organization?”6/06/2017Some Examples of R.I./HIM R.C. Related Processes168
6/6/2017New York Health InformationManagement Association2016 Statistics: Beds: 603 Inpatients (excludingnewborns): 31,715 Emergency Departmentvisits: 108,936 Outpatient visits: 940,404 Births: 4,169 Surgeries (cases): 24,620 Imaging studies: 315,755 Laboratory tests: 6,200,688 Researchexpenditures: 86,953,916 Employees: 6,501 Physicians: 1,221 Volunteers: 1,3786/06/2017Stony Brook University Hospital Fast Facts17New York Health InformationManagement Association Level 1 Trauma Center and Tertiary CareCenter Level 4 (Most Advanced) RegionalPerinatal Center Children’s Hospital State-designated AIDS Center State-designated Burn Center State-designated ComprehensivePsychiatric Emergency Program Accredited Ventricular Assist DeviceProgram Kidney Transplantation Program Bone Marrow and Blood Stem CellTransplantation Program Accredited Chest Pain Center withPercutaneous Coronary Intervention (PCI) Advanced Cerebrovascular ResearchCenter with dedicated biomedicalengineering lab ALS (Lou Gehrig’s disease) AssociationCertified Center of ExcellenceSM Alzheimer’s Disease Assistance Center6/06/2017Stony Brook University Hospital Fast Facts(cont.)189
6/6/2017iCARESBUH Statement of Values:Accountability – We hold ourselves accountable to our community, toour organization and to each other for our performance and behaviors.Respect – We foster an environment of mutual respect and trust,embracing diversity in people and thinking.New York Health InformationManagement AssociationCompassion – We provide empathic care with attentive listening andaffirmation.6/06/2017Integrity – We are honest and ethical in all our interactions.Excellence – We set the highest standards for safety, clinical outcomesand service.19SBUH Revenue Integrity/HIM DepartmentNew York Health InformationManagement Association SBUH determined in late 2013 that an emerging “best practice” inthe healthcare industry for assuring collaboration between functionsof coding, clinical documentation, billing compliance, finance, andadministration could be best achieved through an overall RevenueIntegrity departmental structure Today’s discussion will focus on areas in which RevenueIntegrity/HIM collaboration has resulted in significant “return oninvestment”, including compliant code assignment, improved denialsmanagement processes, accurate clinical quality metrics (HACs,PSIs), and detailed reporting to Hospital Administration, as well asbeginning to advance Information Governance awareness throughthe HIM Operations Division. These are areas that enhance the traditional HIM functions, andprovide opportunities for the HIM professional to meet newchallenges, and, in some instances, reflect future roles for the HIMprofession.6/06/2017Revenue Integrity/HIM Facilitates Collaboration2010
6/6/2017Revenue CycleDirectorDirector ofRevenue IntegrityNew York Health InformationManagement AssociationCFO6/06/2017SBUH Revenue Integrity/HIMDepartment21 Inpatient Coding-also appeal of coding denials from RAC, commercialsAmbulatory Coding-responsible for 26 hospital servicesClinical Documentation Improvement-also collaborates with Q.M.Health Information Management (Information Access,, document scanning,advancing ‘Information Governance’ concepts and ensuring EMR integrity;assisting patients with Patient Portal, etc.) R.I. Staff Development-Coding & CDI staff training and ongoing education Additional Revenue Integrity Department responsibilities, coordinated by theAssociate Director, Revenue Integrity : Revenue Integrity ROI process for requests related to Hospital revenue (e.g.insurance DRG verification, RAC, MAC, CERT requests, etc.) Denied & Delayed Claims Analysis & Reporting Process for Administration; reviewof ambulatory departments for missed billing opportunities New Initiative: Revenue Integrity Claim Scrubber Validation and ReviewNew York Health InformationManagement Association Department reports to Director of Revenue Integrity who reports toRevenue Cycle Director who reports to CFO Formed in November 2013 Department consists of several division working in concert:6/06/2017Revenue Integrity/HIM DepartmentBackground2211
6/6/2017 Identifies cases for DRG validation Flags AHRQ, PSI and HAC cases for pre-bill review by CDI All mortalities are reviewed by CDI Associate Director andInpatient Coding Associate Director prior to billing 3M CDIS system was implemented for CDI use during May2017 99% of all reviews are conducted “pre-bill” Focus is quality of coded and documented record, movingbeyond “CC/MCC” to metrics and quality scoresNew York Health InformationManagement Association CDI and Coding processes utilize 3M/HDM product for bothInpatient and Ambu
Revenue Integrity and the HIM Professional’s Role in the Revenue Cycle John W. Ruth, MBA, RHIA Director, Revenue Integrity Department Stony Brook University Hospital Stony Brook, N.Y. john.ruth@stonybrookmedicine.edu 6/06/2017 n 1 Agenda AHIMA Weighs In—Shake-up, Wake-up HIM Professionals Supporting Opportunities in Revenue Cycle
