Revenue Cycle Management
The sources of data in an organization are critical to determining outcomes, resource use and reimbursement. HSMN has often found that it needs to go to the source of the data creation in order to determine validity. So often we find that the data in a system does not always reflect the reality. The reasons are simple:
- Human beings collect data and they can make mistakes with not viewing or hearing or entering properly.
- Much clinical data is contained in the notes written by clinicians and sometimes not legible or not understood.
Our mission is to assure that data collection is accurate because that data flows through the entire episode of care until it meets a claim. Too often correction of data means much rework. Therefore, our first and highest priority in doing any engagement is to make sure that the data are correct and accurate.
Organizations should be shaped based on the goals they must accomplish. Often we find Hospitals and Physician Practices where the Organization is shaped by individuals who maintain a role. Often roles are not related to the reality of function and therefore organizations are weakened.
- The shape of the organizational structure must start with assuring that every function essential to carry out its major goal (patient financial services, Coding, registration, insurance verification) are the foundation of the structure. Determining volumes allows for understanding staffing needs built upon function. Technology support and workflows follow.
- HSMN devotes much of its time to understanding the shape and purpose of each structure within the Revenue Cycle.
Clinical documentation is the life blood of the Revenue Cycle and it must reflect accurately what has happened in the patient encounter or procedure. Physicians often do not understand the connection between the clinical and the documentation. This is a process that can be managed but only by working closely with medical staff.
HSMN have found in many engagements that physicians do not want to be lectured about documentation; they want to learn but anything that suggests that clinical judgment is questioned is never acceptable.
HSMN has developed a strategy of Case Deconstruction which has been very effective in every setting in which we have worked. Essentially our methodology the clinicians and the Coding Analyst staff who each present their version of the case and compare the documentation issues and their effect on the ultimate DRG or diagnosis and reimbursement.
Once documentation is translated someone or the system creates a claim. The claim must encompass all of the following elements:
1. Accurate Procedures and Diagnoses 2. Supportive Documentation 3. Procedure/Service Authorized 4. Accurate Primary and Secondary Payors 5. Ensure Claim is NOT a Duplicate 6. Assure that for hardcoded procedures in the CDM, the code is appropriate.
The PFS department must focus on the quality of the claim because denials mean rework, lack of payment, or no payment. Many departments often want to have claims go out the door within a certain time period. This helps the AR. A track record in timely claims is meaningless in the face of denials. HSMN provides an assessment of the PFS operation, its structure, organization and leadership. HSMN also provides an Interim Management plan in order to implement the recommendations and help screen candidates for the revised roles and structure that have been approved.
In many large Academic Medical Centers and indeed in Practices all over the country, Pro fee billing has become a very sensitive issue. As reimbursement is squeezed down by third party payors, and as those payors pay with a “silent discount”, they also find more and more ways to deny claims, it isn’t enough anymore to just get the claim out the door.
Instead, knowledgeable staff must be on board and understand the contracts, the documentation issues, the authorization and verification processes for services. Getting clean claim out the door is no longer what it used to be. It is difficult. Many practices turn to outside services for billing support but not all outside services are excellent. It is important that at least once a year, claims are reviewed to see what service was provided, what was documented, what was submitted and what was reimbursed. To do that, a knowledgeable team must understand the practice and know the rules and the nuances. This isn’t just about playing it safe and not falling under OIG scrutiny, but rather figuring out how to optimize payment to match the resources that have been used for the care. HSMN has worked with physician practices in every setting to support the staff and train them after assessment to make sure that physicians are receiving what they fairly deserve in reimbursement; and that the professional billing speaks the same language as the services provided.
The Management Plan:
HSMN provides detailed management plans to carry out the recommendations in our assessments of the Revenue Cycle for both the Hospital side and the Physician practice.
The Management plan encompasses a timeline, task list, and responsible people for accomplishing the task. It also builds in benchmarks by which one can monitor the progress of the implementation and measure the success once it is in place.
The Plan encompasses the following:
- Define the purpose/ mission with a design to the Organization’s structure to assure success’
- Define functions, work process and positions/roles for the organizational structure
- Design job competencies to match required organizational functions;
- Define the leadership structure and necessary characteristics for success;
- Screen existing staff and make recommendations for those who can fit into new roles;
- Create detailed workflows and decision trees and organizational charts.
- Create detailed job descriptions/competencies
- Transfer knowledge and assist in the training of existing staff in their new roles.
- Detail the System specifications necessary to support the change in operations.
The Revenue Cycle begins with what critical event?
At HSMN, we believe this critical event is when the patient calls to make that first appointment. Management of the Revenue Cycle starts here, making the patient your first partner in providing healthcare services. Customer driven healthcare is one of the most dramatic shifts in healthcare today. Therefore, our performance improvement plan begins with assessing patient satisfaction and access management from the first point of entry.
HSMN has helped hospitals, specialized providers and physicians/clinicians to partner in the management of the revenue cycle through an array of strategies that include integrating the three silos of the Revenue Cycle:
- Access Management,
- Patient-Provider Interaction, and
- Claims Management
Our goal is to help the provider manage the entire transaction to allow the patient to move through the healthcare process efficiently, effectively and satisfied
Summary of 2012 Outpatient Payment Prospective System (OPPS) Final Rule
- The 2012 conversion factor is $70.016. CMS will use a reduced conversion factor of $68.616 for calculating payments for hospitals that fail to comply with the Hospital Outpatient Quality Reporting requirements. The conversion factor for 2011 was $68.876.
- CMS allocates 1.0% of total OPPS payments to make outlier payments. For 2012 the total outlier threshold will be $1,900. This represents a 6.2% reduction from 2011. (CMS pays outlier payments under OPPS at “50% of the amount by which the cost of furnishing the service exceeds 1.75 times the APC payment amount when both the 1.75 threshold and the fixed-dollar threshold are met.”)
- In 2012 CMS will no longer pay Transitional Outpatient Payments (TOPs) to rural hospitals with 100 or fewer beds, rural sole community hospitals (SCHs) and essential access community hospitals (EACHs).
Based on a review of a 2011/2012 Ambulatory Payment Classification (APC) payment comparison, HSMN has noted that facilities can expect a payment decrease, especially for services performed in the Emergency Room in 2012 compared to 2011. While we understand that APCs have been around since 2000, facilities still need to assess their outpatient business annually to mitigate any financial impact as a result of annual changes to the OPPS. HSMN’s "Assess, Prepare and Communicate" approach to APC revenue impact analysis helps organizations define and understand their outpatient business, understand the financial implications of the annual OPPS payment changes, anticipate compliance exposure, improve outpatient data management, and identify outpatient resource, quality and utilization management issues. HSMN’s approach to the project includes:
- A review of APC service-mix and revenue cycle assessment;
- Observation of charge capture processes and technical hospital billing logics;
- Practice management assessment;
- A review of charge capture tools, systems and processes;
- Review of key policies, procedures and practices;
- Coding and documentation review; and
- Participation in the case management process.