Transcription
Revenue Integrity,Denials Management &Charge Capture BestPractices
Agenda› Revenue Integrity Clinical Revenue Cycle Charge Capture & Reconciliation Other Charge Focused Activities› Denials Management & Denials Prevention2
Revenue Integrity – Clinical RevenueCycle› Clinical Services Documentation3› Business Office Charges› Clear› Timely› Accurate› Appropriate› Compliant› Reconciled› Supports charge(s)› Supported bydocumentation
Revenue Integrity – Clinical RevenueCycle, Continued› Interdisciplinary approach to creating a “clinicalrevenue cycle” (CRC)› HFMA definition of “clinical revenue cycle” –All administrative and clinical functions thatcontribute to the capture, management andcollection of patient service revenue4
Revenue Integrity – Clinical RevenueCycle, Once More› Common CRC Focus Areas IP & OP clinicaldocumentation Patient acuity Coding & CDI Clinicians play an activerole in identifying,preserving and recoveringrevenue UR & Care Management Governance and oversightstructure Denials Culture Charge capture Understand and plan forlinkages across clinicaland financial activities tooptimize workflow andreporting with newtechnologies Chargemaster (CDM)5› CRC Operating Model
Revenue Integrity – Clinical RevenueCycle, FinalPhysician AdvisorClinical DocumentationSpecialistsCase ManagerAppeals TeamClinical and business linkages are fostered Physician engagement Physician Advisor Expert Champion Clinical Documentation Integrity Charge Capture & Reconciliation Interdisciplinary Oversight & Reporting6
Revenue Integrity – Charge Capture &Reconciliation› Charge Capture Timely How charge is posted Appropriate charges for department/location Charge code maintenance Education and training Policies and procedures7
Revenue Integrity – Charge Capture &Reconciliation, Continued› Charge Reconciliation Revenue and usage reports Reconciliation processes› The action of making financial accounts consistent;harmonization Polices, procedures and expectations› Clinic area vs. Pharmacy› Inpatient units vs. Lab8
Revenue Integrity – Charge Capture &Reconciliation, Once More› Charge Reconciliation Examples: Inpatient nursing unit – Daily census to R&B charges,bedside procedures, supplies, sample auditing Pharmacy* & Lab* – Average daily charge volume anddollars, Pyxis reports (cabinet overrides), sampleauditing Operating Room – Schedule to OR charges, implantsand “trunk stock”, sample auditing Radiology* – Average daily charge volume and dollars,schedule to charges, sample auditing Clinic – Schedule to clinic charges, E/M distribution,sample auditing*Interface balancing reports9
Charge Reconciliation Example:2 South Nursing StationDaily Census as of midnight January 17, 2020RevenueIntegrity –ChargeCapture 201/17/20201/17/20201/17/2020Patient NameGeller, RossBing, ChandlerGeller, MonicaGreen, RachelTribiani, JoeyBuffay, atientObservationInpatientObservationInpatientWhat charges should we be looking for?10
Revenue Integrity – Charge Capture &Reconciliation, Final› What charges to reconcile? Is anything missing?Charge Report – 2 South Nursing 1/17/2020Date of Service1/17/2020MRN852963Patient NameGeller, Ross1/17/20201/17/2020159357357951Bing, ChandlerGeller, Monica1/17/2020917382Green, Rachel1/17/2020873264Buffay, 491379123456321479123456698741698741Charge DescriptionMed/Surg Semi-PrivateWound CareWound Dressing KitMed/Surg Semi-PrivateObservation per hourIV Infusion InitialIV Infusion, AdditionalMed/Surg Semi-PrivateVaccine AdminMed/Surg Semi-PrivateWound CareWound CareQuantity111118121111-1Charge Amount 950.00 325.00 76.00 950.00 720.00 285.00 190.00 950.00 75.00 950.00 325.00 (325.00)
Revenue Integrity – Other Focus Areas› CDM oversight and maintenance Pricing› Education and training New hires, transfers, promotions Quarterly or bi-annually training› Auditing› Interdisciplinary team for oversight andaccountability12
Revenue Integrity – Other Focus Areas,ContinuedInterdisciplinary team structure and functions› Structure Revenue integrity CDM Billing Managed carecontracting CDI HIM – coding Physician advisor13› Function Policy andprocedures Pricing strategy &updates Revenue monitoring Documentation andcharging auditoversight Billing issues relatedto charges
Denials Management & Prevention› Denials Management - Retrospective managementof denied claims Partial claim payment Payment less than expected No claim payment› Denials Prevention - Pre-service delivery processesto mitigate a claim denial Technical denials Clinical denials14
Denials Management & Prevention,Continued“The goal is to turn data into information andinformation into insight.” – Carly Fiorina, former CEO of Hewlett Packard› Denials data needed to Monitor Track Report› Data can identify breakdowns in process andopportunities for process improvement15
Denials Management & Prevention,Once More› Denial Root Cause CARC & RARC codes Review and appeals exhausted Initial review Final determination of denial andneed for write-off Initial category assignment Denial worked & resolved Examples: Final category assignment› Timely filing Examples:› Medical necessity not met› COB› Coverage issues› Medical necessity› Prior authorization hospitalvs. prior authorizationphysician16› Denial Write-off Reason› Inappropriate status› No prior authorizationhospital vs. no priorauthorization physician
Denials Management & Prevention, Again17
Denials Management & Prevention,Furthermore› Denials Management Steering Committee – Theleadership to drive the change Monthly meetings Utilize data for target areas and improvement› Denial Management Sub Committee – Theprocess owners to implement the change Weekly meetings Reports to Denials Steering Committee Utilize data for target areas and improvement18
Denials Management & Prevention,Moreover› Clinical staff› Revenue cycle staff › Support staff Physician champion Patient access IT Service line leaders Billing Managed care Department managers Coding/HIM Quality Pharmacy Denials UR/Case management19
Denials Management & Prevention,Final› Identifying those denials that are: Preventable High volume High dollar Process oriented› Reviewing processes, making changes &monitoring outcomes› Creating a sense of accountability20
Summary› Revenue Cycle Management Guide› Revenue Integrity – Working together to providecompliant, complete and accurate documentationto support charges and prompt, appropriatepayment Charge Capture is a central function to RevenueIntegrity› Denials Management & Prevention – Use yourdata to create insight for improvements to reducedenial burden21
Questions?
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DisclosureThis project is supported by the Health Resourcesand Services Administration (HRSA) of the U.S.Department of Health and Human Services (HHS)under grant number U65RH31261, Delta RegionHealth Systems Development, 8,000,000 (0%financed with nongovernmental sources). Thisinformation or content and conclusions are those ofthe author and should not be construed as theofficial position or policy of, nor should anyendorsements be inferred by HRSA, HHS or theU.S. Government.
Revenue Cycle Management Guide Revenue Integrity -Working together to provide compliant, complete and accurate documentation to support charges and prompt, appropriate payment Charge Capture is a central function to Revenue Integrity Denials Management & Prevention -Use your data to create insight for improvements to reduce denial burden 21
