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

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

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

Forgotten A/R: 3 Steps to Getting Beyond “Low Hanging Fruit”

Posted by Paul Allen on March 21, 2018 at 10:34 AM

Low hanging fruit. You likely hear the term nearly every day in the business world. It refers to something easy to reach and therefore should be “picked” first. It has also come to mean an area where you can concentrate your efforts to get the most results.

In healthcare finance, low hanging fruit is often used as a descriptor of the easiest money to collect on outstanding accounts receivable. Revenue Cycle teams focus on Medicare, Medicaid, and specific major payers that make up the majority of their revenue.

Working the payers that will yield 80 percent of your revenue – Medicare, Medicaid, and two or three of your major commercial plans - makes sense and should be the first line of attack when looking to collect outstanding revenue. But what about the “fruit” that is further back and higher up in the “trees?” What about that other 20 percent of your revenue?

You shouldn’t be content with disregarding 20 cents of every dollar. With improvements in automation and technology, it’s time to take another look at this still-very-valuable component of your receivables and begin mapping out a new attack plan to collect it.

 

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Topics: A/R management, Revenue Cycle Health, revenue integrity

3 Keys to Staying on Top of Your Underpayments

Posted by Aaron Wall on February 14, 2018 at 3:29 PM

Research from the Medical Group Management Association (MGMA) estimates that payers underpay practices in the U.S. by an average of 7% – 11%. In a time when budgets are tightening and reimbursements are shrinking, it’s more important than ever to make sure your organization is being paid correctly. Some organizations take this seriously but many don’t spend nearly enough time focusing on underpayments and their bottom lines suffer as a result.

Forward looking healthcare systems that are committed to a robust revenue integrity program, take the time to analyze their revenue and reimbursement details. Based on their success, it is clear that it’s worth the time and effort each year to make sure your contracts are up to date and that that you are monitoring your underpayments on a regular basis.

Staying on top of your underpayment activity is not as difficult as it may seem. There’s a good chance someone at your organization already has the information needed to get this ball rolling.

Here are three key things you need to implement an effective reimbursement analysis program.

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Topics: Data Analysis, Revenue Cycle Health, revenue integrity

Are You Ready for Revenue Cycle Consolidation? A 7 Point Checklist

Posted by Sondra Akrin on November 8, 2017 at 9:00 AM

As the pressure on top and bottom lines grows, many healthcare organizations are focusing on revenue integrity as a way to improve margins. Part of this effort requires lowering overhead costs by driving efficiencies into their revenue cycle operations. These streamlining projects include consolidating business office functions to minimize duplication of effort around registration, insurance assignment and verification and customer service on both the physician and hospital sides of the organization.

An increase in merger and acquisition activity continues in the healthcare industry and this, too, can cause the need for a business office consolidation. 

Whether driven by a cost cutting initiative or merger, the consolidation initiative means merging the entire revenue cycle. Combining tasks, workflows and technology to create economies of scale can result in significant cost savings.

Centralizing business office functions can be challenging. Before you attempt to take on such an ambitious project, you must be sure your organization can carry it out successfully. You need to understand the inherent differences between the organizations or divisions you plan to consolidate. You should start with a comprehensive assessment of your people, process and technology to provide a baseline from which to proceed with the project.

This seven-point checklist will help you determine your readiness and will guide you in focusing on the areas you should be addressing as you begin your consolidation.

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Topics: healthcare mergers and acquisitions, Revenue Cycle Health

4 KPI Focus Areas to Ensure Revenue Integrity

Posted by Sondra Akrin on September 27, 2017 at 9:00 AM

Maintaining your revenue integrity in a time of reduced revenue and shrinking margins has never been more important – or difficult. New reimbursement models, the cost shift to patients, a substantial increase in auditing from a greater number of agencies and continued merger and acquisition activities combine to put enormous stress on the financial condition of healthcare organizations.

Like most other things in business, ensuring revenue integrity comes down to managing the details. Monitoring and measuring day-to-day activity can be the best way to make sure your revenue cycle is operating smoothly and you are identifying, billing and collecting all the revenue you should be.

Developing appropriate Key Performance Indicators (KPI’s) can help guide the daily activities in your organization and keep your revenue cycle on track. Diligently monitoring KPI’s to improve performance becomes a critical task to helping you maintain your revenue integrity.

Here are four key areas on which to focus your KPI efforts.

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Topics: revenue cycle management, Revenue Cycle Health

3 Benefits of a Data Driven Approach to Billing Integrity

Posted by Robert Freedman on September 6, 2017 at 9:00 AM

Six trends affecting the healthcare billing industry in 2017 have been identified by MedicalBillersandCoders.com. They include the transition from ICD-9 to ICD-10, implementation of CPT codes, evolution of EHR management, the rise of money managers, cognitive computing and onset of block chain technology.[1]

As the healthcare industry continues to evolve, more focus is being placed on revenue integrity. This means more intense scrutiny on every element of the revenue cycle from the front end through the mid-cycle to the back office. No aspect of the revenue cycle is receiving more attention than the billing function.

Organizations must deal with these trends while at the same time ensuring the quality of their billing function. Many rely on auditing to monitor their billing processes and make sure billing departments are being run effectively. However, the key to proper billing is identifying root cause issues and applying appropriate corrective action. Auditing is simply a tool to help accomplish that, not an end in itself.

To ensure billing integrity, organizations must develop a process that is supported by a system. Auditing is only one element of an oversight system that also includes analysis and corrective action. Taken together, this system supports a data-driven approach that can enhance billing integrity. The system should effectively translate patient encounters into proper coding to ensure full payment and maintain compliance – making sure you get to keep what you have collected.

The system ultimately needs to be driven by data, since data gives you analysis that provides insight necessary to implement improvement. Here are three key benefits of a data-driven approach to ensuring billing integrity.

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Topics: compliance risk, mdaudit, Revenue Cycle Health, revenue integrity

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