Quality Management is a familiar concept in healthcare, especially when it comes to organizational excellence and patient safety. Minimizing risks and ensuring safe outcomes for those under your care are critical goals in every healthcare setting.
But patient care isn’t the only area where quality management matters. An effective quality management system is an essential element of a revenue integrity program. In order to provide the best healthcare to your patients, you must build a strong revenue integrity foundation that ensures a financially viable organization. To reach that goal, you need a quality management approach that incorporates auditing and corrective action to optimize every aspect of your business and revenue cycle operations.
Revenue integrity – getting paid for everything you do and keeping it – is a key focus area for many healthcare organizations. But ensuring the revenue integrity of your organization is not an isolated task. The responsibility for appropriate revenue recognition and collection cannot rest with one group; it must be a coordinated effort across the entire spectrum of your organization – front end to back office.
Similarly, the compliance function – the area responsible for ensuring that the policies and procedures that have been set up are understood and followed – likewise can’t be an isolated responsibility. To achieve the goals of revenue integrity, a comprehensive quality management program – plan, do, check, act – must be embedded in the four key components of the revenue cycle.
The first step in the revenue cycle, patient access, is critical for ensuring that you bill – and get paid for – all the services you provide to patients. Strict procedures and processes must be in place to ensure that the front office team properly collects all insurance documentation and pre-certifications, and enters them correctly into the electronic billing system. Mistakes at this step can derail any hope of fully collecting on your claim.
You should regularly audit this process for adherence to documented procedures so you can initiate corrective action to address any breakdowns that you find.
Once the patient encounter is complete, the physician must document the visit appropriately by translating the description of the encounter into the appropriate five-digit CPT code that the payer can consume and remit payment against. In hospitals, clinicians will use a DRG code for their billing.
Quality management is crucial in this area as well. Choosing the incorrect code could result in over-billing –which could lead to payer reimbursements – or under-coding, which could deprive the organization of recognizing the full revenue to which it is entitled. Using the auditing-corrective action methodology at this stage will often lead to additional education and training for clinicians to ensure proper understanding and use of these important codes.
Once the code for a patient visit is submitted, it moves to the coding team, where it goes through a series of reviews designed to detect errors and anomalies that could result in payment issues.
CMS encourages the coding team to verify that all conditions that co-exist at the time of the encounter and require or impact patient care, treatment or management are documented. They suggest using the "MEAT" process, which stands for Monitor, Evaluate, Address/Assess, and Treat. Following this process ensures that the description of the visit will be complete and accurately documented.
Billing and revenue collection
The final step in the revenue cycle process is billing and revenue collection. This crucial step ensures that your organization collects all the revenue to which it is entitled for the care provided. Regular monitoring of this function is critical, since a lack of proper follow-up can significantly degrade collections.
Denials management – a key responsibility for the billing and collections team – is in fact a shared responsibility that can benefit greatly from a quality management approach. A typical denials management process focuses on fixing specific, individual transactions. A quality management approach, in contrast, means going beyond simply fixing transactions to identifying the root cause and applying corrective action to improve the associated processes. This enables you to prevent issues from happening before they occur, rather than trying to catch and repair them after the fact, or correcting and resubmitting them when payment has been denied.
An effective quality management system encompasses all four phases of the revenue cycle. Transaction issues that arise at any step are simply an indicator or a symptom of an underlying problem. You need a comprehensive auditing platform that can take these symptoms, dig deeply into your data, analyze them, and fix the problems at their root.
Revenue integrity is an important goal for any organization. To achieve it requires a comprehensive quality management program…at every step of the process.
To learn more about revenue integrity and how it applies to your organization, please download our infographic, The Who, What, Why, Where and How of Revenue Integrity