Hayes' Healthcare Blog

Building a Denial Management System? Here’s Where to Start

Posted by Sou Chon Young on August 30, 2017 at 9:00 AM

As healthcare costs grow, reimbursement continues to decrease, and margins for providers get smaller, we see the room for error getting smaller as well.  To combat this there has been an increase in mergers and acquisitions (M&A)[1].  As the number of mergers and acquisitions increases, one result is system conversion.  Instead of disparate systems, the newly formed organizations either move to one new system or they consolidate their systems to make their processes more efficient. As more organizations implement new revenue cycle systems, they are faced with many challenges but also many opportunities – one of which is the opportunity to implement a denial management system.

A strong denial management system will help you not only identify issues with your revenue cycle and help you avoid leaving money on the table, but it will also give you the information you need to optimize it.  Below is a quick summary on how to set up a denial management system.

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Topics: A/R management, denial management

Is Biometric Identification the Answer to Patient Data Integrity Issues?

Posted by Leala M. Williams on August 23, 2017 at 9:00 AM

Long gone are the days of standalone demographic and paper medical record files in a physician office.  A patient’s record is now digital and likely exists in multiple hospitals, physician offices, and other ancillary services across cities, states, and countries.  Patients can now access their own records online to view medical results, schedule appointments, request prescription refills, and manage their medical claims.

Despite the sharp rise in dependency on electronics and technology in today’s healthcare industry, ensuring accurate patient identification is still a challenge.  Mismatched patients are the primary cause of data integrity issues and has various causes – from human error to disparate electronic health record (EHR) systems, multiple visits for multiple reasons with multiple providers, etc. In the end, some things just get complicated. The AHIMA reported that 8 - 12% of all patients have a duplicate medical record.

Even with the technology of today, a patient’s identity is commonly confirmed verbally. A patient’s demographic data such as name, date of birth, gender, and social security number are indexed by assigning an MPI (Master Patient Identifier) to each person.  Other validation options have been introduced over time including photo identification, the use of wristbands, and patient smart cards.  Some organizations have implemented software using algorithms to help identify and link duplicate records.   

Looking at the healthcare industry today, we see new shared technology constantly being introduced.  The overall goal is to integrate the patient’s digital data so it can be linked, stored, retrieved, and shared with a few strokes of your fingertips. The success of the technology is dependent upon its optimization, which includes accurate patient records. Organizations with multiple integrated EHR’s or who provide high volume emergency or inpatient services see a higher risk of occurrence.  But in order to address how to resolve these issues, we must first look at their causes.

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Topics: EHR, data integrity

Reimbursement Analysis – A Critical Component to the Implementation of New Services

Posted by Margaret Webb-Nolan on August 16, 2017 at 9:00 AM

In our current competitive healthcare environment, innovative services are an important dynamic to a successful revenue cycle.  Patients want the most current care delivery methods, new technology, pharmaceuticals, and actively seek providers who can supply them. 

Thorough reimbursement analysis which provides an accurate picture of the reimbursement environment as it pertains to your new service is important to ensure your organization will be able to provide new, innovative services like newly released drugs, devices, and implants to patients while still achieving a margin which will allow continued growth.

A comprehensive reimbursement analysis should be conducted with adequate lead time to include an in-depth understanding of payer-mix, the delivery cost of the new service, and the anticipated reimbursement by the designated payer.  Also included should be detailed coding and billing requirements to ensure your organization is prepared before service delivery to process claims.

Those of us who are healthcare professionals have probably been in situations where new services are initiated without the inclusion of the appropriate revenue cycle team members, resulting in denials, delays, loss of revenue, unhappy patients and discontent providers. Multiple departments should be included to ensure a comprehensive approach is conducted.  The service area, coders, reimbursement, billing, and a CDM resource should all be included.  If the new service is a new drug, an appropriate pharmacy resource should be included, as well.

To avoid the need to recover lost revenue and implement service backfill, it’s crucial to have a structured program in place. This program should include a check list and appropriate sign-off from all pertinent staff or departments involved.

Here are the critical components to a successful reimbursement analysis. To spearhead this initiative, many organizations have a reimbursement analyst on staff and others may utilize a CDM resource for managing this activity.

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Topics: revenue cycle management

Are You Ready for Value-Based Care? 7 Things to Consider

Posted by Strategic Planning Team on August 9, 2017 at 9:00 AM

MACRA took effect in January and the march to value-based care (VBC) continues. According to the 2017 HealthLeaders Media Value-Based Readiness Survey, healthcare organizations have been making steady progress in getting ready for the transition.

Three quarters of respondents say their level of preparation is “strong or somewhat strong” up from just over half who made the same claim a year ago. Two thirds report their infrastructure preparation for value-based care is “strong or somewhat strong” up from less than half a year ago.[1]

While a majority of hospitals and physician practices appear to be well on their way to successfully making the transition to value-based care models, there remains many other organizations who still have work to do. Here are seven things to consider as you continue to assess your readiness for the shift from fee-for-service to VBC.

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Topics: strategic planning, value-based care

Overcoming 3 Healthcare Data Analytics Challenges with Intelligent Analysis

Posted by Robert Freedman on August 2, 2017 at 9:00 AM

A recent article in the HealthIT Analytics newsletter noted that most healthcare organizations are looking to launch Big Data analytics projects to “improve clinical quality and reduce inefficiencies.”[1] That’s only natural considering the buzz surrounding the benefits of Big Data analytics.

However, the article goes on to say that many healthcare organizations face major challenges in ramping up their analytics program - specifically lack of qualified talent, issues with system interoperability and the basic question of where to begin the process.

There’s no doubt that Big Data analytics initiatives have proven valuable in uncovering actionable information in nearly every industry. That can also happen in healthcare, but hospitals and physician groups should understand that massive Big Data projects are not the only route to gaining the critical knowledge you need to improve the operation of your organization. You can also obtain significant insights from “little data” information that is readily available if you use the right tool.

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Topics: mdaudit, healthcare compliance, Healthcare Analytics

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