It’s been an exciting ride over the past 15 years, watching our company evolve and adapt to the ever-changing healthcare landscape. Anyone who has been reading our blogs over the past several years can attest to the knowledge we’ve gained by working alongside healthcare professionals to tackle a variety of modern healthcare business challenges: helping department leaders staff teams with qualified professionals; partnering with IT departments to evaluate their systems and implementation strategies; and working with revenue cycle departments to help identify untapped sources of revenue. It has been a tremendous learning process.
Hayes' Healthcare Blog
Healthcare providers are focused on delivering the most effective care for their patients. In recent years, however, it has become increasingly challenging for them to carry out that mission due to the growing regulatory demands and accompanying documentation requirements. Failure to adhere to these requirements can result in painful consequences, such as lost revenue, heavy financial penalties, or significant reimbursements due to poor claims documentation.
Compliance leaders bear the responsibility for ensuring their organizations avoid these adverse consequences by making sure their providers are complying with the mountain of regulatory directives. To carry out their charge, compliance professionals audit the providers to identify areas of risk and remediate any potential non-compliance issues. In many cases this puts physicians and compliance teams at odds, as we've noted in other recent blog posts.
The tools compliance teams use can also create strained relations between these two groups; by focusing attention on claims and coding errors, they can create a negative feedback loop in which auditors circle back to providers to hold them accountable for errors that may have occurred. Frustration between the two groups can grow from there.
Topics: Healthcare Regulatory Compliance
This is the fourth and final post in our series of blogs discussing how a revenue integrity program can help clinical, compliance and revenue cycle teams join forces to address the increasing challenges of compliance. In our first post, we discussed how a revenue integrity program can be a unifying force in the organization. In the second, we explored the impact to physician practices as regulatory demands have grown. In the third post, we showed how the increasing rules and regulatory burden have strained the relationships of the three key stakeholder groups.
In this final installment, we lay out a plan that shows how to break down silos and bring the three groups together under the umbrella of a strong revenue integrity program. Following these steps will not only enhance morale, but will dramatically improve the financial health of your organization.
The provider community has been begging for documentation reform for over 20 years, and there is no question that simplifying the complex requirements of clinical documentation is necessary. Unfortunately, the recent release of the proposed changes from CMS surrounding evaluation and management (E/M) is not the answer. The benefits of the modest reduction in documentation requirements are more than offset by the devastating impact the changes will have operationally, clinically, and financially.
This is the third in a series of four posts discussing how a revenue integrity program can help clinical, compliance and revenue cycle teams join forces to address the increasing challenges of compliance. In our first post, we discussed how a revenue integrity program can be a unifying force in the organization and in the second we explored the growing complexity of physician practices as regulatory demands grow.
In our previous post we discussed the increasing regulatory burden on the healthcare industry, and how it spurred the creation of large physician groups who could afford to staff their organizations with compliance teams and revenue cycle departments. Today we’ll look at how these regulatory demands sometimes put these groups at odds, and how a strong revenue integrity program can help bring them together in a new spirit of cooperation.
Gentlemen, take your corners
The growing oversight by government payers and insurance companies caused a splintering inside healthcare organizations into three groups, each with seemingly different goals and responsibilities:
- Physicians. Practicing clinicians were forced to balance the desire to spend quality time with their patients with the need to fulfill documentation demands.
- Compliance teams. In an effort to avoid the penalties and reimbursement costs associated with compliance violations, compliance professionals became the "watch dogs" – responsible for monitoring clinicians to make sure they were adhering to the new requirements.
- Revenue cycle departments. As clinicians began to “play it safe” and under-code the services they were providing in order to avoid compliance penalties, the revenue streams of their organizations began to suffer. This required establishing another team – the revenue cycle department – to monitor payments to ensure the organization was being properly reimbursed.
Increasing pressures cause tension
As each group diligently attempted to carry out its mandate, it was inevitable that relationships between them would become strained. For example, when Medicare changed the DRG reporting requirements in 2008, another new group was created – Clinical Documentation Improvement (CDI) – to “support” physicians to tell them how to document their services according to the new requirements. However, many clinicians interpreted this as payers dictating to them how to practice medicine in order to be compliant, causing further frustration. At the same time, revenue cycle teams, who were trying to collect for the services provided, would often become irritated when claims were rejected because of improper coding or insufficient documentation.
The shift from fee-for-service to value-based care increased the pressure on all three groups. Because of the additional risks posed by the new requirements, which could result in inadequate reimbursement for services delivered if they didn’t meet certain quality standards, compliance teams now also had to audit clinicians to make sure they were complying with new requirements. They also had to protect the organization from additional penalties for not complying with new mandates.
Increasing cost burden
The costs associated with the additional resources needed to monitor compliance and protect revenue streams - plus the reduction in the time that physicians could spend with patients - all contributed to a hit on both the top and bottom lines, creating a fiscal nightmare for many healthcare organizations. Over the years the mountain of regulations has taken its toll: suppressing revenue; imposing new controls on clinicians and how they practice medicine; inducing fear of financial penalties for non-compliance; and causing conflict across all three groups instead of bringing them together as collaborators.
It doesn’t have to be that way. Focusing the resources and experience of all three groups to provide quality care, to help make the organization profitable, and to remain in compliance can be much more effective approach. In the fourth and final post of the series, we will outline how you can set up a revenue integrity program that will break down silos and get clinicians, compliance groups and revenue cycle teams to work together to reach those common goals.
This is the second in a series of four posts discussing how a revenue integrity program can help clinical, compliance and revenue cycle teams join forces to address the increasing challenges of compliance. In our first post, we discussed how a revenue integrity program can be a unifying force in the organization.
When it comes to medicine, many like to wax poetic over the simpler times of the 1990s. Although we have improved dramatically when it comes to medical advances and quality of care over the past several decades, clinicians sometimes long for a return to certain aspects of those “good old days” when practicing medicine was a much simpler pursuit.
Looking back at the evolution of the physician practice over the past quarter century, you can certainly understand that point of view. One thing is clear: the dramatic changes affecting the health care profession since the 1990s have contributed to a growing regulatory monster, which has negatively impacted the relationship between clinicians, compliance and revenue cycle teams.
With all the hoopla surrounding the recent announcement that CMS is proposing changes to Evaluation & Management (E/M) codes, you would think the government was eliminating documentation requirements altogether. That couldn’t be further from the truth. While the modest proposal impacting 15 E/M office and outpatient visit codes for Medicare is a step in the right direction when it comes to reducing the documentation burden for physicians, it by no means suggests that you should take your eye off the ball when it comes to monitoring and auditing your coding activity.
This is the first in a series of four posts discussing how a revenue integrity program can help clinical, compliance and revenue cycle teams join forces to address the increasing challenges associated with compliance.
Much of the healthcare industry is focused on reaching the goals of the Institute of Healthcare Improvement’s Triple Aim – improving health outcomes, enhancing the patient experience and lowering the per capita cost of healthcare. By any measure, the growing area of telehealth checks all three boxes.
Improved health outcomes? In an American Journal of Critical Care survey, eight out of ten nurses agreed that tele-ICU systems enable them to improve patient care. They said the technology allows them to remotely review patient vital signs, physiological status and laboratory and diagnostic test results to help make better healthcare decisions.
Enhanced patient experience? A study published in the Annals of Family Medicine reports that patients who were offered primary care telemedicine during a pilot program in Pennsylvania experienced high satisfaction. They noted the convenience of eliminating the need to miss work, travel to an office, arrange childcare and change attire as reasons. They also cited decreased wait times compared to in-office visits.
Reduced cost? Spectrum Health, a provider based in Grand Rapids, Michigan, saved insurers nearly $4.1 million from 2014 to 2017 by delivering almost 50,000 virtual visits that avoided more than 11,000 emergency room trips. So far in 2018, Spectrum’s telehealth program has saved insurers almost $1.5 million.
So, telehealth is the perfect solution, right? Not so fast. Especially if you are a provider facing the not-so-small problem of getting paid. While telehealth appears to be a viable healthcare delivery alternative, reimbursement issues continue to be an issue, and if not handled correctly, can adversely affect your organization’s revenue integrity.
In today's challenging financial environment - plagued by shrinking revenue, narrowing margins and tightening regulatory constraints - many healthcare leaders are stepping back to take a more holistic view of their organization’s revenue stream. They understand that the traditional, silo'ed approach to revenue cycle and compliance - in which the two functions operate independently from one another - is not going to help them achieve their goal of optimizing their financial health.
These leaders are beginning to see the value of bringing these disparate groups together to effectively address their top- and bottom-line issues. For many, that means implementing a comprehensive revenue integrity program that can serve as the “backbone” supporting such an effort.
The dictionary defines a “backbone” as “the chief support of a system or organization.” A well-developed revenue integrity program can be the “chief support” that links together revenue cycle and compliance, resulting in a more robust revenue stream, decreased risk of costly non-compliance, and enhanced bottom-line performance.
Here are five benefits that can be achieved by instituting a common revenue integrity backbone in your organization.