The provider community has been begging for documentation reform for over 20 years, and there is no question that simplifying the complex requirements of clinical documentation is necessary. Unfortunately, the recent release of the proposed changes from CMS surrounding evaluation and management (E/M) is not the answer. The benefits of the modest reduction in documentation requirements are more than offset by the devastating impact the changes will have operationally, clinically, and financially.
Hayes' Healthcare Blog
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.
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.
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.
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.
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.
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.
Each year, the American College of Healthcare Executives surveys healthcare industry CEO's, CFO’s, COO's, Revenue Cycle Managers and Compliance Leaders to name their top concerns. For the past 12 years, financial concerns have topped the list.
That should not come as a surprise considering the turbulent environment healthcare organizations face today. Pressure on top and bottom lines, transition to value-based care, growth of consumerism in the industry and tightened oversight by outside entities are forcing healthcare organizations to change the way they operate.
Organizations have been focusing on revenue cycle management for years, but forward thinking leaders are reexamining this siloed approach. They are coming to recognize that ensuring revenue integrity requires considering the entire revenue cycle – front end, mid-cycle, back office – to more appropriately address the challenges they face today.
But where do you start? Here is a six-step process for establishing an effective revenue integrity program.
Google the term “revenue integrity” and you get 790,000 results. Refining it to “revenue integrity in healthcare” narrows it down to 380,000 results. That still doesn’t help much. The fact is there isn’t one, universally accepted definition of the term.
One thing that isn’t in question is the importance of revenue integrity to healthcare organizations in the current difficult environment. Financial challenges headed the list of hospital leaders’ top concerns in 2016, according to the American College of Healthcare Executives annual survey. It was the twelfth consecutive year CEO’s identified finance issues as their most pressing worry.
That should come as no surprise in a time when hospitals and physician practices are facing shrinking top and bottom lines. The crushing weight of financial worries continues to increase because of the many challenges organizations face in the uncertain healthcare landscape.
New value-based care financial models, increased payment responsibility for patients, more intense regulations and the auditing that goes with it and continued merger and acquisition activity are squeezing the resources of healthcare organizations and jeopardizing their overall financial health.
Which brings us back to revenue integrity. According to an HFMA Survey of 125 hospital and health system CFOs and revenue executives, only 44 percent of respondents say their organizations have established revenue integrity programs. This forward-thinking group has benefited significantly. The result of these revenue integrity programs has been a 68 percent increase in net collection, 61 percent overall gross revenue capture and 61 percent reduction in compliance risk. 
We know revenue integrity programs are effective, but there are still multiple definitions of what it is. Here are how some healthcare leaders view revenue integrity.
Merger and acquisition activity, the demand for cost reduction, and the need for better efficiencies have forced many healthcare organizations to implement a business office consolidation. While this may appear to be a logical step to meet the budgetary challenges facing hospitals and physician practices, you will still likely need to justify the disruption and expense of implementing the project. Before taking the plunge, you will need to calculate the ROI for the move.
Here are five questions to ask to help you develop the ROI for your business office consolidation project.