Hayes' Healthcare Blog

Rules, Regulations, and Reimbursement: Straining Relationships Among Clinicians, Compliance and Revenue Cycle Teams

Posted by Vasilios Nassiopoulos on August 15, 2018 at 2:00 PM

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.

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Topics: Revenue Cycle Health, Healthcare Regulatory Compliance, Telehealth

From Simple Practices to Physician Conglomerates: The Burdensome Journey of the Practicing Physician

Posted by Vasilios Nassiopoulos on August 8, 2018 at 2:00 PM

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.

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Topics: Revenue Cycle Health, revenue integrity

Be Wary: Proposed CMS Changes to E/M Codes Don’t Minimize the Need for Vigilant Review and Monitoring

Posted by Vasilios Nassiopoulos on July 27, 2018 at 9:00 AM

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.

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Revenue Integrity: A Unifying Force for Overcoming Compliance Challenges

Posted by Vasilios Nassiopoulos on July 11, 2018 at 9:00 AM

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. 

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Topics: Revenue Cycle Health, Telehealth

Overcoming the Revenue Integrity Challenges of Telehealth

Posted by Vasilios Nassiopoulos on June 13, 2018 at 9:00 AM

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.[1]

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.[2]

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.[3]

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.

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Topics: Revenue Cycle Health, Telehealth

5 Benefits of a Common Revenue Integrity Backbone

Posted by Vasilios Nassiopoulos on May 17, 2018 at 9:00 AM

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.

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Topics: healthcare compliance, revenue cycle management, revenue integrity

Developing a Revenue Integrity Program? Get Help with the Right Partner

Posted by Vasilios Nassiopoulos on May 10, 2018 at 9:00 AM

You’ve been struggling with the need to improve your bottom line while reducing organizational costs. New financial models, increased cost shifts to patients and continued merger and acquisition activity are leading to an increased focus on your organization’s overall financial health. Up until now, you’ve likely relied on revenue cycle management (RCM) which has served you well, but you now recognize that RCM doesn’t go far enough. You need something more, so you’ve decided to implement a more holistic revenue integrity program.

Revenue Integrity – getting paid for everything you do, and keeping it – takes a broader view of the organization’s revenue stream. A revenue integrity program evaluates many of the same people, processes and technology as RCM, but goes a step further by understanding how these various disparate processes can be connected to optimize the entire revenue cycle.

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Topics: vendor selection, Change management, revenue integrity

Revenue Integrity Leaders Gather to Find Solutions to Healthcare’s Financial Challenges

Posted by Peter J. Butler on May 2, 2018 at 3:00 PM

By Peter Butler, President and CEO, Hayes Management Consulting

As part of our commitment to helping healthcare organizations optimize their business processes to achieve greater revenue integrity, Hayes has recently formed a Revenue Integrity Advisory Council (RIAC), a small group of revenue cycle and compliance executives who understand the real-world financial challenges associated with running a large, complex organization. We held our first meeting on March 20th in Chicago, where leaders from some of the nation’s most prestigious healthcare organizations gathered for an afternoon to discuss issues, exchange ideas and develop new solutions for overcoming some of their most pressing concerns.

So what was on their minds? Not surprisingly, the topics covered a range of issues including telehealth, quality-based reimbursement, and high-cost drug reimbursement, as well how to organize the coding function and managing compliance issues.

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Topics: Thought Leaders, Hayes Thought Leadership Blog Series, revenue integrity, Revenue

11 Ways to Make Sure Your Contract Management Process is Meeting Your Organization’s Needs

Posted by Margaret Webb-Nolan on April 5, 2018 at 9:00 AM

Managed care contracts make up a significant amount of a healthcare organization’s revenue stream.  The impact these contracts can have on your top and bottom lines makes managing them appropriately one of your top priorities. Those organizations that have realized this and have an effective, efficient contract management process in place have a reasonable upper hand over those that don’t.

Staying on top of your managed care contracts is critical to maintaining a sound financial foundation. Managing these contracts successfully can help drive additional revenue through new insurance products. Properly handled managed care contracts can also increase patient satisfaction by enabling patients to obtain the treatment they need.

If you have challenges in keeping track of and managing your contracts, you are not alone; it is an all too common problem in hospitals and healthcare organizations across the county.

Here are 11 things to consider that can help you develop and administer a successful contract management process.

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Topics: Revenue, Managed Care Contracts, Contract Management

8 Tips to Help Understand and Avoid Denials

Posted by Susan Eilman on March 29, 2018 at 9:00 AM

Are you drowning in claim denials and rejections?  Are your denial rates high? It is inevitable for healthcare organizations to experience denials in today’s complex billing arena. Industry standards for denial rates are between 5-10 percent.  If your denial rate is above 10 percent, then "Houston you have a problem!” It is time to build a strategy to reduce your denial rate.

Claims denial avoidance processes should be proactive but in most healthcare organizations, they are more reactive. It is important to be proactive from a revenue integrity perspective at the front-end, and accurately collect and report patient and insurance information before or at the point-of-service. There are ways to be proactive from the billing side as well.

As you develop your action plan, it’s important to define your terms. You and your staff need to understand the difference between a claim rejection and a claim denial.

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Topics: reduce denials, claims denials, denial management, Revenue Cycle Health

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