Payment Posting: A Crucial Link to Efficient Revenue Cycle Management

Posted on October 19, 2016 at 9:00 AM, Sou Chon Young

“For the want of a nail the shoe was lost,
For the want of a shoe the horse was lost,
For the want of a horse the rider was lost,
For the want of a rider the battle was lost,
For the want of a battle the kingdom was lost,
And all for the want of a horseshoe-nail.”

- Benjamin Franklin

What’s a horseshoe-nail story got to do with healthcare revenue cycle management? It illustrates that the smallest detail can ultimately make the difference between success and failure. In revenue cycle management, that detail is payment posting. Posting errors can lead to all the major revenue cycle issues: understated accounts receivable, mounting denials, false credits and inaccurate patient statements.

Payment posting has never been a glamourous position – considered a simple “heads-down” data entry job with little impact on the revenue cycle. If that was ever true, it certainly isn’t today.

The massive changes in the healthcare landscape have dramatically affected the professionals responsible for posting payments. Sophisticated new technologies, multiple new payment models and organizations transitioning from one billing system to another means today’s payment posters must handle a much wider range of scenarios.

The bottom line: take your payment posting operation for granted at your own peril. Here are some of the major new competencies you should be looking for in your payment-posting professionals.


Topics: revenue cycle management, Payment Posters

DSRIP: A Major Step Toward Reinventing Medicaid

Posted on October 12, 2016 at 9:04 AM, Kelly Barland, CIO

By Kelly Barland, Chief Information Officer, St. John’s Episcopal Hospital, New York City

The pros and cons of the Affordable Care Act (ACA) continue to be debated, but one point appears to be beyond dispute: the ACA has significantly contributed to the explosive growth of the Medicaid program. In FY 2015 – the first full year of ACA coverage expansion – enrollment and spending in Medicaid across the 50 states and DC increased by an average of nearly 14%.[1] Combined federal and state spending for Medicaid was more than $500 billion in 2015 and is projected to reach $750 billion by 2020.[2]

Many initiatives are being implemented to help stem the rising costs and improve patient outcomes including increasing the value and quality in managed care contracts, instituting home health for individuals with chronic conditions, and testing innovative delivery and payment models.

One of the more promising efforts has been the Delivery System Reform Incentive Payment program (DSRIP). Rolled out in 2010-11 in California, Texas, and Massachusetts followed by New Jersey and Kansas, in 2012, DSRIP originally focused on funding for safety net hospitals and resulted from negotiations between HHS and the states on how to pay for hospital care. The program has evolved into a way to initiate payment and delivery system reforms and provide the states with funding to support hospitals and other providers in changing methods of providing care to Medicaid beneficiaries.


Topics: Medicaid, Hayes Thought Leadership Blog Series, DSRIP, ACA

Amidst the Angst, Value-Based Care Is Working

Posted on October 5, 2016 at 9:00 AM, Don Michaels, Ph.D.

“It’s not the strongest of the healthcare organizations that survive, nor the most intelligent, but the ones most responsive to change.”

–With apologies to Charles Darwin

People – and organizations – tend to fear and therefore avoid change. That often applies to healthcare organizations facing the new reality of value-based care reimbursement models. As a result, many are holding back trying to maintain the status quo against the rising tide of inevitable change.

On the other hand, some organizations have embraced and committed fully to the change. They have implemented various versions of value-based care programs, been patient and as a result, are starting to reap rewards. They are proving the truth of Darwin’s “repurposed” statement above, and have the best chance to survive – and thrive – because they have been the most responsive to change.

The changes these organizations are going through are not only succeeding in strictly financial terms. They are also increasingly meeting the other major goal of value-based care – better patient outcomes.

Here are three examples of the kinds of positive change possible in the new value-based care environment.


Topics: value-based care

False Claims Act Penalties Doubling: Time to Beef Up Your Compliance Program

Posted on September 28, 2016 at 9:00 AM, Robert Freedman

If you mistakenly submit a single claim that results in a $100 government over reimbursement, you could now be subject to a penalty of over $20,000, according to the lawyers at Mintz Levin, specialists in healthcare law.[1] And that’s for every single claim.

To quote Alec Baldwin’s character in the famous Glengarry Glenn Ross monologue, “Have I got your attention now?”

The Department of Justice recently passed an interim final rule that has nearly doubled the civil penalties under the False Claims Act (FCA) from an already oppressive $5500 minimum to $11,000 maximum per claim to a minimum of $10,781 and maximum of $21,562. The increases – which went into effect August 1 - are the result of a “catch-up” clause in the 2015 Adjustment Act that amended the Federal Civil Penalties Inflation Adjustment Act of 1990.

The act mandates agency heads to adjust civil monetary penalties based on the difference between the Consumer Price Index in October of the year they were established and October 2015. After this initial catch-up, agencies must make additional annual adjustments, so the costs are only going to increase from these new dizzying heights.

The impact for the healthcare industry is seismic. The cost of any slip up in Medicare and Medicaid claims can be financially disastrous and the doubling of penalties means a doubling of “whistleblower” rewards, so organizations can expect increased scrutiny from employees, former employees and competitors looking to cash in.

To make matters worse, because of the sharing of Medicaid costs, the act incentivizes individual states to pass FCA laws in addition to Federal statutes. The pressure on healthcare organizations to “get it right” when it comes to claims submittal has never been greater. With the financial stakes ratcheted even higher, it may be time to refocus your efforts on compliance.

Here are five ideas to help strengthen your compliance program.


Topics: billing compliance software, mdaudit, compliance programs

3 Ways Technology Must Show Up in the Consumerization of Healthcare

Posted on September 21, 2016 at 9:00 AM, Don Lewis, VP/CTO, Group Health Cooperative

In a recent survey, eight out of 10 consumers believe taking a greater, more active role in their healthcare is a positive. Nearly nine of 10 reported feeling a need to be more proactive in managing their own healthcare.[1] The sea change that has since washed over the healthcare industry over the past few years has only served to strengthen those opinions.


Topics: healthcare IT, Hayes Thought Leadership Blog Series

Keys to a Successful Project: Define Before You Jump into Planning

Posted on September 14, 2016 at 9:00 AM, Mike Tagliento

In most organizations when a new project is about to get underway whether internal or with an outside vendor the first question asked is, “Do you have a project plan yet?”  While the project plan is a valuable document in the project manager’s tool kit, it’s not the only one.  Prior to building a stable and workable project plan, the project manager needs to work with stakeholders, possible team members, vendor(s), ancillary resources, and resource managers to define the project as whole and how it aligns to the organization’s goals.

The need to identify core project resources can be a large challenge initally.  Understanding existing time commitments to daily work tasks and existing project work allows the project manager to better plan on how/when the core team will be allocated to best use the needed resources. 

The Core Team should be made up of project leads and core team members.  Project leads should be comprised of departmental managers impacted by the new project and the core team members will be executing on the plan (once completed) with input from the leads.


Topics: project management, Change management, strategic planning

Leading the Path with Information Governance

Posted on September 7, 2016 at 9:00 AM, Johanna Legaspi

Security Issues

When hearing the words "information governance", at first glance, you think 'does this deal with the government'? In fact, it is a part of something larger than we expected: healthcare information and data security. Lately in the healthcare news, we have been hearing a significant increase surrounding cyber security threats to healthcare industry most especially in patient data breach or ransomware. Why is this happening? Security breaches are what we have been dealing with since healthcare has become digitalized. There has been a significant surge in patient data collected, shared, and analyzed on a daily basis.

Ransomware is a type of malware that prevents or limits users from accessing the system with encrypted files.  Then forces the victims to pay ransom via online to grant them access. Hospitals are the perfect mark for this kind of extortion because they provide critical care and rely on up-to-date information from patient records. 

These types of attacks create fear and anxiety. And if we’re educating our healthcare leaders to today's best standards then we can take appropriate actions as opposed to reaction. It is the responsibility of the executive in charge of information security at a healthcare organization to help C-suite executives understand and digest technical and threat assessments, which can be quite complex. The appropriate answer is to build an information governance program.


Topics: Information Governance, Healthcare Regulatory Compliance, Cybersecurity

The Importance of Optimizing Operational Business Processes

Posted on August 31, 2016 at 9:00 AM, Rosie Montemayor

Prior to becoming a healthcare consultant, I was an operations manager for an academic medical organization for over 20 years.  During my tenure, my main focus was to ensure all areas of the business process were in place and adhered to by the staff.   My goal was to work towards making processes more efficient.  This was an ongoing effort that I think too many organizations have lost sight of today.   I wanted to become a consultant to share with other organizations how to improve upon their day-to-day struggles.

This blog focuses on the areas that I have experienced to be key business processes that still challenge organizations today. So, what can optimization do for you?  “Optimization can make something better, more efficient, improve outcomes/results that will set the bar to establish best practice.”

There are two major areas that are frequently targeted for optimization within a healthcare organization: clinical and revenue cycle.  These areas have a significant impact on an organization’s bottom line as it relates to patient satisfaction and revenue.  The goal when looking at optimization is to improve upon processes and workflows that have an impact to these two key areas.  So with this in mind, when was the last time your organization conducted an optimization project to review business practices?  Was it recently?  If no, then please read on to learn more about key processes to review.  If you conducted one recently, use this as a checklist to see if there is an area that you might have missed in your optimization project.


Topics: EHR optimization, system change management

How to Effectively Manage Your Optimization Process after Go-Live: MOP IT UP!

Posted on August 24, 2016 at 9:00 AM, Tamarah Alexander

A new system implementation can really stir up a lot of dust within your organization!  Between trying to mitigate risks,
 complete required tasks, consolidate and contain the limits of the scope, reduce redundancy, design new workflows, and reconciliation, it really can feel like the needs of your end users are being sucked into a vacuum. An implementation is not “one size fits all” but it can feel like it in the beginning when you are introduced to the new technology and learn how others are using it in the industry.

Once you have completed the “hammering of the nails” behind the build, it is important to evaluate what has been done and what is not truly completed yet.  Once the dust of the go-live has fallen and settled on the floor, it’s time to “M.O.P. I.T.” up and begin the optimization process.


Topics: EHR go-live support tips, Change management, System optimization

The 21st Century Revenue Cycle Leader: 3 Key Factors for Success in the Evolving Healthcare Environment

Posted on August 17, 2016 at 9:00 AM, Steven M. Wagner, PH.D., M.P.A,

By Steven M. Wagner, PH.D., M.P.A, Executive Director Medical Practice Income Plan; Clinical Instructor in Health Policy, Finance and Administration, Department of Medical Education, Texas Tech Health Sciences Center El Paso at the Paul L. Foster School of Medicine, faculty instructor for Independence University, and Research Fellow at the Centers for Healthcare Research in the School of Advance Studies for the University of Phoenix.

Healthcare leaders need to look at the bigger picture of healthcare reform rather than narrowly focusing on its separate components. Fragmented legislation and grants led us to where the healthcare industry stands today, and only integrating networks of components in healthcare can lead us to successful reform. Success means that healthcare becomes accessible and affordable with or without insurance to all payors, quality outcomes take into account the functional and holistic health of the patient, and patients are satisfied and feeling well.

The hard reality is that in the end, everyone in the industry will be dealing with less revenue because the over-arching goal for the US government is cost containment. Only when leaders take all the changes into account will we, as an industry, be able to facilitate truly beneficial change. To make that happen, revenue cycle leaders need to be able to integrate cost, quality, and access into our routine processes of patient care, frequently analyze outcomes including the patients’ self-perceived health statuses, and develop actionable solutions.


Topics: revenue cycle management, value-based care, Hayes Thought Leadership Blog Series


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