deconstructing revenue integrity · cdm charge capture documentation coding • wrong codes...
TRANSCRIPT
Presented by
Revenue Cycle Advancement Center
Building an efficient and effective information chain to
ensure payment accuracy
Deconstructing Revenue Integrity
© 2019 Advisory Board • All rights reserved • advisory.com • WF953632-c 09/11
2
Road mapRoad map
Deconstructing Revenue Integrity1
2 Building an Efficient and Effective Information Chain
3 Coda
© 2019 Advisory Board • All rights reserved • advisory.com • WF953632-c 09/11
3
No market consensus on what revenue integrity (RI) is or what it means
Starting with (what we thought was) an easy question
“Revenue integrity is
the accuracy of
charging and
documentation…it’s
difficult to define.”
“We basically coined
revenue integrity as
a job description
back in 2008.”
“Revenue integrity is not
compliance.”
“Revenue integrity is kind of
the middle part of the
revenue cycle…from the
time the clinician posts
charges all the way up to the
time a claim drops.”
“Revenue integrity is
in the eye of the
beholder. It’s about
protecting the revenue
that you have,
ensuring its compliant
and optimizing it.”
“Revenue integrity is
full revenue cycle
support.”
“Revenue integrity is like cotton candy.
It appears to be exciting, but once you
bite into it, it disappears”
Chief Revenue Officer
Large Northwestern Health System
Revenue Cycle Advancement Center research and insights.
© 2019 Advisory Board • All rights reserved • advisory.com • WF953632-c 09/11
4
RCAC regularly receives questions around revenue integrity programs
Lack of agreed upon definition hasn’t slowed interest
Of Advisory Board member hospitals and
health systems with a revenue integrity function
53%
22%Of Revenue Cycle VPs that say investing in
revenue integrity technology is very important
“Does this require new staff or a
reorganization of existing staff?”
“Do I have to have a revenue integrity function?”
“What results can I expect and how
quickly can I expect them?”
“What are the appropriate KPIs?”
Commonly asked questions
Revenue Cycle Advancement Center research and insights.
© 2019 Advisory Board • All rights reserved • advisory.com • WF953632-c 09/11
5
Much variation, but CDM ubiquitous in revenue integrity programs
Contract managementPhysician advisors
Performance and
Quality Improvement
Compliance and
Auditing Chargemaster
Clinician education
Billing
Denials
Coding
85%48%
40%
24%Analytics
16%
20%EHR Workflow 16%
Pricing
20%
16%
16%
4% 4%
© 2019 Advisory Board • All rights reserved • advisory.com • WF953632-c 09/11
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Programs must strive to maintain the RI information chain
Revenue integrity is the process of ensuring payment accuracy
Factors leading to
payment accuracy
Complete,
comprehensive
documentation
Business OfficeMid-cycle
Timely,
accurate bills
Front Office
Appropriate
coding
Claims not
denied
Correct patient
information
The revenue integrity information chain
Efficient passage from stakeholder to stakeholder is critical
Accurate
charge capture
Revenue Cycle Advancement Center research and insights.
© 2019 Advisory Board • All rights reserved • advisory.com • WF953632-c 09/11
7
Complexity adds challenges as RI programs proliferate
Market forces complicating our path
Regulatory changes and oversight
Contractual complexityAdoption of technology
Evolving health system footprint
Payment accuracy
• Care being delivered across multiple
settings
• Requires disparate payer contracts,
coding requirements
• Payer-specific requirements include
different rates of pay, carve-outs,
exceptions for different services
• Complicates billing accuracy
• EHR implementation
• Expansion of technology into charge
capture and billing processes
• RAC and MAC audits
• Impact of Two-Midnight Rule, Post-
Acute Transfer Policy
1
4
2
3
Revenue Cycle Advancement Center research and insights.
© 2019 Advisory Board • All rights reserved • advisory.com • WF953632-c 09/11
8
Complexity of processes opens doors to vulnerability
Myriad of opportunities for mistakes
CDM Charge
captureDocumentation Coding
• Wrong codes
assigned
• Lack of codes
captured for all
care provided
Claim
denied
• Inaccurate
pricing
• Demographic,
other errors
• Lack of or
inefficient work
flow and work
queues
• Untimely
charge drop
• No concurrent
audit
Lack of knowledge around changes to reimbursement,
documentation/coding requirements, and/or changes to government auditsRegulatory changes
Claim
submission
• Incomplete list of
clinical services
• Duplicate entries
• Inaccurate
assignment of
CPT/HCPCs
• Incomplete or
inaccurate
documentation
• Unresponsive
clinicians
Compliance
risk
Vulnerable
to audit(s)
Revenue
leakage
Revenue Cycle Advancement Center research and insights.
Incorrect
Claim
© 2019 Advisory Board • All rights reserved • advisory.com • WF953632-c 09/11
9
Operational demands negatively impact information chain
Revenue Cycle Advancement Center research and insights.
Lack of oversight and
inflexible program structure
Gaps left by IT
interoperability
No regulatory monitoring or
anticipation of potential changes
Deprioritized CDM and
contracting strategyResources not distributed
according to level of revenue risk
Haphazard, scattershot
performance monitoringInappropriate staff
assigned to tasks
Documentation efforts duplicative,
diminishing of CDI
Clinicians struggle with timely,
efficient charge drop
© 2019 Advisory Board • All rights reserved • advisory.com • WF953632-c 09/11
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Nine imperatives for an efficient and effective information chain
Ensure a strong foundation
through CDM and contracting
Craft a compelling career
opportunity
Establish flexible oversight
Increase scrutiny in areas of
high revenue risk
Engage with, but don’t
corrupt, CDI
Make charge drop easy for
clinicians
Use ROI as the ultimate
performance metric
1
2
3
4
5
6
7
8Monitor regulatory landscape
for potential chain disruptors
Fill the charge capture
gaps with IT support
9
Revenue Cycle Advancement Center research and insights.
Incorrect
Claim
© 2019 Advisory Board • All rights reserved • advisory.com • WF953632-c 09/11
11
Road mapRoad map
Deconstructing Revenue Integrity1
2 Building an Efficient and Effective Information Chain
3 Coda
© 2019 Advisory Board • All rights reserved • advisory.com • WF953632-c 09/11
12
Effective programs provide comprehensive oversight of functions and flow
How do we right-size revenue integrity responsibilities?
Data monitoring Process tracking
Quality assurance
Root cause analysis
Solution implementation Clinical diplomacy
“The easiest way to tell if you’ve left your lane is if you’re working on an account, you should be in
operations. If you’re reviewing, performing oversight, and auditing, you should be in revenue integrity.”
VP of Revenue Cycle and Revenue Integrity, Large Southwestern Health System
Regular monitoring of both key
revenue cycle and revenue
integrity metrics
Oversight of current processes
and workflows/work queues
Deep dives to understand root
of inefficiencies/chain
breakdowns
Responsibility for projects and
initiatives focused on
information chain improvement
Collaboration with key clinical
stakeholders, including service
line leadership; physician
education and training
Regular auditing and
compliance checks
Revenue Cycle Advancement Center research and insights.
© 2019 Advisory Board • All rights reserved • advisory.com • WF953632-c 09/11
13
Program charters prevent scope creep and outline responsibilities of other departments
Establishing and formalizing expectations
Program scope
Revenue integrity
program charter
• Specify sites of care (acute, outpatient,
physician clinics)
• Determine which functions revenue integrity is
able to audit and monitor (CDM, documentation)
Mission statement
Stakeholder expectations
Role delineation
• Prevent overlap between revenue integrity and
similar revenue cycle functions, such as:
— CDI
— CDM
— Nurse auditing
• Outline purpose of revenue integrity program
• Include specifics as to how program’s mission
benefits broader organization
• Clearly outline what support and training
revenue integrity will provide clinicians and
other relevant groups
• Establish expectations of clinicians and other
stakeholders (e.g. charge drop within 12 hours)
Revenue Cycle Advancement Center research and insights.
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14
Contract management, provider enrollment included at Aspirus
System Director, Revenue
Integrity
Chargemaster and FeesContract
Management/Reimbursement
Revenue Cycle Regulatory and
Payer Updates
Coordinator
Provider Insurance
Enrollment
Chargemaster Staff
Fee Analyst
Reimbursement Analysts Revenue Cycle Regulatory
Specialist
Specialists
Revenue Cycle Advancement Center research and insights.
© 2019 Advisory Board • All rights reserved • advisory.com • WF953632-c 09/11
Case in brief
15
• Aspirus’ program was started in 2015 and continues to grow and evolve.
• Its key functions include: supporting the revenue cycle departments by
providing accurate provider insurance enrollment, ensuring accurate and
timely charge capture, ensuring accurate claim reimbursement and
proactive review and readiness of regulatory and payer changes.
• In 2019, Aspirus’ net patient revenue was $1,235,991,551.
8-hospital health system based in Wausau, WI (serves
Wisconsin and Upper Michigan)
Aspirus
Source: American Hospital Directory, “Identification and Characteristics,”
https://www.ahd.com/free_profile/520030/Aspirus_Wausau_Hospital/Wausau/Wisconsin/.
Revenue Cycle Advancement Center research and insights.
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16
Room and Board
Charging
Vice President, Patient Account Services
Revenue Integrity and Utilization Management/Physician Advisor Services OfficerCorporate Compliance Officer Facility CFOs
Corporate Revenue Integrity Data Analytics Corporate Utilization
Management
Physician
Advisors
Underpayments Clinical
Audit
Physician
Practices
Facilities
Appeals
Non-
Clinical
Appeals
Defense
Staff
Corporate
Utilization
Management
Staff
Utilization
Management
– Surgery
Line Service
(Inpatient)
Physician
Advisor
Support Staff
Part-Time
Physicians
1. Pseudonym.
Including denials, appeals and UM at Malone1
Business
Office
Auditors
Revenue Cycle Advancement Center research and insights.
© 2019 Advisory Board • All rights reserved • advisory.com • WF953632-c 09/11
Case in brief
17
• Malone’s program was started in 2008.
• Its key functions are oversight over audits, underpayments and appeals.
• In 2017, Malone’s net patient revenue was around $1.5M.
Health system in the South
Malone1 Health
1. Pseudonym.
Revenue Cycle Advancement Center research and insights.
© 2019 Advisory Board • All rights reserved • advisory.com • WF953632-c 09/11
18
Organizational education critical to mission, goals of program
Revenue Integrity at CoxHealth
Revenue Cycle Advancement Center research and insights.
System Director, Revenue Integrity
Revenue Cycle Education Team Revenue Optimization Team Revenue Cycle Analyst Team
VP, Hospital Revenue
Revenue Cycle Educator
Revenue Cycle Educator
Revenue Cycle Educator
Clinical Liaison
Revenue Optimization Specialist
Revenue Optimization Specialist
Analyst I
Analyst II
Analyst II
Analyst II
Analyst II
Analyst II
Revenue Cycle Educator
Analyst I
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Staff training to prevent gaps in knowledge and performance
Revenue Cycle Education Team
CoxHealth’s revenue integrity program
includes education as one of its core
functions
Four educators provide training and
education on revenue cycle applications,
general revenue cycle topics, new
system policies, and targeted education
for performance improvement
• Health Information Management, Patient Financial Services,
Patient Access and revenue integrity staff receive
onboarding training and ongoing education
• Curriculum is taught using a combination of classroom and
online training as well as ongoing tip sheets and information
updates as needed
Revenue Cycle Staff
• Clinical staff, new and tenured, have the
opportunity to sit in on revenue cycle staff training
• Program hopes to create targeted revenue cycle
training for clinical staff
Clinical Staff
Revenue Cycle Advancement Center research and insights.
© 2019 Advisory Board • All rights reserved • advisory.com • WF953632-c 09/11
Case in brief
20
• CoxHealth’s program was started in 2013, as a component of a broader
revenue integrity program which includes other departments.
• The department was structured specifically to fill gaps and help support
broader revenue cycle needs as a way to limit disruption of day-to-day
operations.
• The program’s key functions include: education and training, system
business development and maintenance, reporting and analytics, pricing,
revenue optimization, and revenue cycle support and/or project facilitation
for issues and improvement initiatives.
• In 2018, CoxHealth’s net patient revenue was $967,278,947.
6 hospitals health system in southwest Missouri
CoxHealth
Source: CoxHealth, “CoxHealth 6 30 18 Operating and Financial DAC
Final,” https://emma.msrb.org/ES1189881-ES929918-.pdf.
Revenue Cycle Advancement Center research and insights.
© 2019 Advisory Board • All rights reserved • advisory.com • WF953632-c 09/11
21
Successful programs predict or mitigate bumps in the road, and pivot to address them
Multitude of factors may disrupt information chain
Renegotiated contracts
Staff turnover
New sites and services
New technology
Regulatory changes
Common chain disruptors
Revenue Cycle Advancement Center research and insights.
© 2019 Advisory Board • All rights reserved • advisory.com • WF953632-c 09/11
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Texas Health Resources’ proactively planned, dedicated resources to potential issues with transition
Identifying risks before switching to new patient accounting system
Current status
• Phase one of conversion scheduled
for completion in September 2019
• After conversion, revenue integrity
and charge capture will pivot to
optimization mode, revisiting work
flows and charge capture decisions
made at conversion to enhance
operational workflow and timeliness
and accuracy of charge capture
Identify gaps
Revenue cycle examined work flows for revenue generating clinical
departments to identify potential charge capture gaps
Texas Health’s process
Went through training with Epic to understand how work flows
would change in an electronic environment
Consult patient accounting vendor
Texas Health enhanced role of revenue integrity department by adding charge
capture review and reconciliation, key components of system conversion.
Revenue integrity analysts and charge capture personnel act as internal
consultants and liaisons to clinical departments on charge capture issues
Enhance RI discipline
Revenue Cycle Advancement Center research and insights.
© 2019 Advisory Board • All rights reserved • advisory.com • WF953632-c 09/11
Case in brief
23
• Texas Health Resources realized that a conversion to Epic’s patient
accounting system would cause charging issues.
• To prepare, revenue integrity was enhanced with the addition of charge
capture.
• Conversion mode will end in September 2019.
• The program will then transition into “optimization mode” and focus more
on compliance, revisiting work flows and charge capture decisions made
at conversion to enhance operational workflow and timeliness and
accuracy of charge capture.
• In 2017, Texas Health’s net patient revenue was $3.8 billion.
27-hospital health system based in Arlington, TX
Texas Health Resources
Source: O’Donnell, Paul, “Texas Health Resources lays off 720 Workers Across North Texas,”
https://www.dallasnews.com/business/health-care/2019/01/24/texas-health-resources-lays-720-workers-across-north-texas.
Revenue Cycle Advancement Center research and insights.
© 2019 Advisory Board • All rights reserved • advisory.com • WF953632-c 09/11
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Source: National Association of Healthcare Revenue Integrity, “2018 State of the Revenue Integrity
Industry Survey Report,” https://nahri.org/resources/2018-state-revenue-integrity-industry-survey-report.
Big picture vision is critical, regardless of prior background
The newest revenue cycle career?
Of revenue integrity professionals have
been in their positions for 5 years or less
62% “You need claims, payer and coding knowledge plus
the ability to do detective work and interact with
different departments.”
Cassi Birnbaum, System-Wide Director,
HIM and Revenue Integrity
UC San Diego Health
“You need someone who is able to think critically; to
identify trends and issues and opportunities. Not
someone who just sticks to the status quo.”
Tracy Cahoon, Director of Revenue Integrity
Southwest General Health Center
Revenue Cycle Advancement Center research and insights.
National Association of Healthcare
Revenue Integrity (founded 2017)
Mission: Enhance revenue integrity profession
through standards, advocacy, networking, and
promotion of shared knowledge and resources
COMPANY IN BRIEF
© 2019 Advisory Board • All rights reserved • advisory.com • WF953632-c 09/11
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1. Pseudonym.
2. Pseudonym.
Effective revenue integrity directors can come from many places
Who should lead the charge?
Patient Financial Services
• CoxHealth’s director formerly led Patient
Financial Services and brought staff with
her into the new department
• Restructure happened after the
organization took over a new hospital
Charge Description Master
• Halpert1 Health System’s director came
from a CDM background
• Started as a CDM analyst and worked his
way up to the director level
• Felt this was the area he was most
comfortable
ICU Nursing
• Hannon2 Health Care System’s director
was an ICU nurse before moving to
revenue cycle
• When the department was first started, it
included the director, appeals
specialists, and other nurses who
worked in charge capture
Benefits from previous experience
• Pre-registration and pre-authorization
knowledge
• Buy-in from front-office staff on
importance of accuracy of patient
information
• Billing and reimbursement knowledge
• Understanding of revenue cycle
workflows, gaps and opportunities
• Buy-in from clinical staff
• Understanding of the challenges of timely
and accurate clinician documentation
Revenue Cycle Advancement Center research and insights.
© 2019 Advisory Board • All rights reserved • advisory.com • WF953632-c 09/11
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1. Pseudonym.
Maximize talent and resources by having well-scoped revenue integrity roles
Clear delineation of roles ensures appropriate staff allocation
Scott Health System’s1 revenue integrity credentialed HB enterprise team
• Performs claim edits
• Work queue upkeep with KPIs
• Executive Revenue Guardians
• “The Doer”
• Charge quality evaluations
• Late charge analysis
• Acts as a hospital and clinical department liaison
• “The Critical Thinker”
• Works in tandem with compliance,
coding, and Revenue Integrity work plans
• Engages with committees, projects and
go-live activities
• Educates coders and departments
• “The Conqueror”
• Charge structure updates
• Epic charge build and testing
• Go-live activities and training
• “The Architect”
Analyst I
Revenue Cycle Advancement Center research and insights.
Analyst II
CDM Epic
AnalystAnalyst III
© 2019 Advisory Board • All rights reserved • advisory.com • WF953632-c 09/11
Case in brief
27
• Scott1 Health System’s program was established in 2015 to identify and
prevent revenue leakage as well as ensure compliance.
• Its key functions include: monitoring mid-cycle activities, maintaining the
chargemaster, tracking data, working on claim edits, and engaging with
business office managers and payer policy.
• To keep staff engaged, four positions requiring a different skillset were
developed. As staff increase their skills, they can move to other positions,
resulting in unified and coordinated team able to avoid duplicative work.
• In 2017, Scott1 Health System’s approximate net patient revenue was $2.1M.
Health system in the Northeast
Scott1 Health System
1. Pseudonym.
Revenue Cycle Advancement Center research and insights.
© 2019 Advisory Board • All rights reserved • advisory.com • WF953632-c 09/11
28
OHSU considers their program to be “a good entry and a good feeder” for analysts
Serving as a training ground for revenue cycle and the organization
Staff begin in billing office
• Many staff become analysts after
working in the billing office
• From these experiences, they become
good candidates to be analysts in the
revenue integrity program
Move into revenue integrity
• Current staff train new employees
• Employees, specifically client service
analysts and revenue recycle analysts
gain a comprehensive understanding
of revenue cycle issues
Grow into leadership
• Analysts can then be considered for
revenue cycle leadership roles given
skillset and problem solving abilities
• Two analysts have even taken
leadership roles in clinical departments
Analyst employee retention rate since 2012
95%
Revenue Cycle Advancement Center research and insights.
© 2019 Advisory Board • All rights reserved • advisory.com • WF953632-c 09/11
Case in brief
29
• OHSU’s program was started in 2012 to provide front-end charge capture
support for the revenue cycle department.
• The program has numerous opportunities to move within the program and
gain important skills.
• Analysts often gain experience in the billing office prior to becoming
analysts. After being an analyst, there is opportunity to move up into
leadership positions.
• Two analysts have taken leadership roles in clinical departments.
• In 2017, OHSU’s net patient revenue was $2,097,255.
2-hospital academic health center based in Portland, OR
OHSU
Source: Oregon Health & Science University, “Financial Statements and Supplementary
Information,” https://www.ohsu.edu/sites/default/files/2018-08/ohsu-financial-stmt-audited-fy17.pdf.
Revenue Cycle Advancement Center research and insights.
© 2019 Advisory Board • All rights reserved • advisory.com • WF953632-c 09/11
30
Metrics should match current initiatives, but ROI is ultimate measure of success
Comprehensive nature of RI makes performance monitoring tricky
?
?
?
Duplicative
CDM entries
Preauthorization
denials
Physician query
response rates
Days in A/R
Medicare
underpayments
Coder edits
How do we measure RI
performance, but not all
revenue cycle performance?
Revenue Cycle Advancement Center research and insights.
How should we gauge
revenue integrity program
success?
How can changing initiatives
and areas of process
improvement be tracked?
? ? ?
© 2019 Advisory Board • All rights reserved • advisory.com • WF953632-c 09/11
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1. Pseudonym.
Successful programs allow RI to go where they see opportunity
Granting RI staff a revenue hunting license
Total FTEs for
underpayment review
Return on investment compared
to baseline, FY 2015 – FY 2017
3
$7.4M
Clear ROI for underpayment review
Before virtual CBO
Wigston Health1 expands underpayment recovery system-wide
Single centralized
underpayment recovery
covers all facilities
With virtual CBO
1/19 Facilities with
underpayment data
tracking and reviews
Revenue Cycle Advancement Center research and insights.
To add staff is like
an act of Congress; we
are constantly told we
are not a revenue
generating department.
© 2019 Advisory Board • All rights reserved • advisory.com • WF953632-c 09/11
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1. Pseudonym.
Increased accuracy reveals history of Medicare underpayments
Cleaning up the chargemaster
• Howard1 Health’s medical group concerned
about their chargemaster's inaccuracy
• Realized they were receiving underpayments
because charges were below Medicare rates
Recognizing incorrect payments Resetting the chargemaster
• With the help of a consultant, Howard1 reset
their chargemaster to match Medicare rates
• Now, with a correct chargemaster, the group
is paid correctly for their Medicare patients
Additional reimbursement per year
after correcting the chargemaster$2M
Revenue Cycle Advancement Center research and insights.
© 2019 Advisory Board • All rights reserved • advisory.com • WF953632-c 09/11
Case in brief
33
• External consultant identified underpayments at Howard Health due to
prices set below Medicare rates in the medical group’s chargemaster.
• Chargemaster was then reset to match appropriate rates. The medical
group is now receiving an additional $2 million dollars in reimbursement
every year.
• In 2017, Howard Health’s approximate net patient revenue was $3.5B
Health system in the Midwest
Howard1 Health
1. Pseudonym.
Revenue Cycle Advancement Center research and insights.
© 2019 Advisory Board • All rights reserved • advisory.com • WF953632-c 09/11
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1. Pseudonym.
Anderson1 Health proactively models impact of new contracts, carve-outs on revenue capture
Planning for reimbursement adjustments
Commercial payer
opened their contract
for new negotiations
two months early
Initial proposal was
complex with several
carve out elements
Used Optum360
Payment Integrity
Compass (PIC) to
model and analyze
payer’s service terms
Reimbursement was
incrementally
increased
Reports available to
validate calculation
results and forecast
expected revenue
Revenue Cycle Advancement Center research and insights.
© 2019 Advisory Board • All rights reserved • advisory.com • WF953632-c 09/11
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Modeling decreases time, increases revenue capture
Manual process5 month-timeframe
Modify counter-proposalsAgree on final terms
with payer
Create full initial proposal,
including carve outs
Modeling3 month-timeframe
Recaptured leakage based on
additional 2% rate increase$428K
Create and analyze
initial model using
spreadsheets
Extract source system
data
Modify counter-
proposals and create
new reports
Agree on final terms
with payer
Revenue Cycle Advancement Center research and insights.
© 2019 Advisory Board • All rights reserved • advisory.com • WF953632-c 09/11
Case in brief
36
• Major commercial payer opened their contract for new negotiation and
delivered the proposal two months earlier than expected with complex
methodology with several carve out elements.
• Contract Negotiation Director used Payment Integrity Compass’ calculation
logic to analyze the payer’s service terms, building iterations of the initial
model to incrementally increase reimbursement and create ad hoc reports
to validate calculation results and forecast expected revenue.
• Anderson1 finalizes rates in three months, securing additional 1% rate
increase above the initial proposal, amounting to $428,000 in potential
annual revenue.
• In 2019, Anderson1’s approximate net patient revenue was $1B.
Hospital in the Midwest
Anderson1 Health System
1. Pseudonym.
Revenue Cycle Advancement Center research and insights.
© 2019 Advisory Board • All rights reserved • advisory.com • WF953632-c 09/11
37
1. HCPCS J-code.
Capitated contract leads to significant unreimbursed revenue for oncology drugs at Memorial
Risk-based payments complicate integrity efforts
Discovered unreimbursed
drug costs due to one plan’s
payment limits
J-code1 level analysis
uncovered thousands of
unreimbursed dollars
resulting from managed
care payment caps on
oncology payments
RIC voices concern about
managed care caps
Pharmacy and managed
care team advocate to
exclude oncology patients
from payment caps with
major payer
Creating an exception
Revenue Integrity Committee (RIC)
1 2 3 4
Revenue Cycle Advancement Center research and insights.
© 2019 Advisory Board • All rights reserved • advisory.com • WF953632-c 09/11
Case in brief
38
• Pharmacists established the Revenue Integrity Committee (RIC) with
members from: pharmacy, nursing, patient financial services, pharmacy
reimbursement specialists, and guest members from: IT, revenue cycle,
practice managers, and medical staff.
• Pharmacy staff manually sorted through J-code level reimbursement
claims to provide medication using evaluations, medication cost,
reimbursement by payer, revenue per dispensation, number of
treatments, and net revenue per treatment plan.
• System-specific reimbursement analysis helps build payer strategy, such
as negotiating disease-specific carve-outs to plans with payment limits.
• In 2017, Memorial Health System’s net patient revenue was $241,175.
6-hospital health system in South Florida
Memorial Health System
Source: Memorial Healthcare System, “Annual Report for the Fiscal and
Quarter Ended April 30, 2018,” https://www.mhs.net/about/finances.
Revenue Cycle Advancement Center research and insights.
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39
Despite CMS’ self congratulation, regulatory landscape remains complicated
Managing the regulatory tentacles
Office of
Inspector General
LCDs
RACs
QIOs
MACs
“We’ve reduced RAC-related provider
burden to an all-time low, as evidenced
by the significant decrease in the number
of RAC-reviewed claim determinations
that are appealed and the corresponding
reduction in the appeals backlog…”
Centers for Medicare and Medicaid Services NCDs
RACs: Making Life Simple?
Revenue Cycle Advancement Center research and insights.
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Several options for preventing revenue leakage to lack of regulatory compliance
Regular monitoring of potential impacts necessary to protect revenue
Biweekly communication
Director of Revenue Integrity has bi-weekly meetings with Director of Government
Managed Care and the Director of Commercial Contracting to identify adjudication
issues. This information is then passed to the specific payer liaison for resolution.
1
Dedicated researcher
Regulatory and payer researcher who tracks regulatory and payer updates and
works with revenue cycle and clinical key stakeholders to ensure readiness.
2
Government Audit Program
Team dedicated to understanding and identifying audit risks, updating clinical
departments to improve work flows before billers or auditors find mistakes.
3
Least to most
resource intensive
Revenue Cycle Advancement Center research and insights.
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Dedicated staff, database allows revenue integrity to stay on top of requests
Overwhelm prompts Cedars-Sinai to find a solution to government audits
1
• Audit requests came from multiple contractors
and entered the organization via many points,
including HIM and PFS
• Revenue integrity program takes comprehensive
responsibility over compliance
• Program includes 3.5 FTEs
• Team implemented database containing records
from all governmental audits of Cedars Sinai
• Metrics around audits monitored monthly, and
generated into report for C-Suite, with success
rates, areas of risk and financial reporting
2
Unable to keep up with requests Government Audit Program (GAP) launched
Revenue Cycle Advancement Center research and insights.
© 2019 Advisory Board • All rights reserved • advisory.com • WF953632-c 09/11
Case in brief
42
• Audit requests entered the organization from multiple sources went to
many departments, including HIM and PFS.
• Revenue integrity program took comprehensive responsibility of
compliance from HIM and purchased a government audit database.
• Using this database, the organization has saved over $76M since 2007.
• In 2017, Cedars-Sinai’s net patient revenue was $3,470,222,000.
1-hospital health system in Los Angeles, CA
Cedars-Sinai
Source: Cedars-Sinai, “Facts and Reports,”
https://www.cedars-sinai.org/about/facts-and-reports.html.
Revenue Cycle Advancement Center research and insights.
© 2019 Advisory Board • All rights reserved • advisory.com • WF953632-c 09/11
43
Diving into GAP database
Includes details from:
• Line item denials on second level
appeals
• Internal self-audits
• External audits (RACs, MACs, etc.)
Contains detailed history and
record of every governmental
audit impacting Cedars-Sinai, for
the last 7 years
ADRs (audit requests) are also
monitored and logged by the team
in the database
Interest payments for appeals won
are included in the monthly report
Monthly report with permanently
saved, permanently lost, and in-
play amounts are included
Revenue Cycle Advancement Center research and insights.
© 2019 Advisory Board • All rights reserved • advisory.com • WF953632-c 09/11
44
Expansion of GAP includes pharmacy, physician billing, other sites of care
Capturing audit history in other areas
Cedars-Sinai
Medical Center
Cedars-Sinai Marina
del Rey Hospital
Start with high
cost drugs
Focus on commercial
audits and denials on
high cost drugs, given
the large risk in this area
1Move to include
physician billing
Physician billing brought
their RACs to GAP,
leading to involvement
with commercial payers
as well
2Expand to other
areas
After testing with the first
hospital, Cedars-Sinai
Medical Center, the
organization is now able
to expand to other areas
and to another hospital
3
Revenue Cycle Advancement Center research and insights.
© 2019 Advisory Board • All rights reserved • advisory.com • WF953632-c 09/11
45
Memorial Healthcare’s Revenue Integrity Committee (RIC) addresses pharmacy charging problems
A multi-departmental response to high drug costs
Identify potential drug
revenue streams
Pharmacy leaders recognize
that drug value analyses
focus primarily on costs.
Involve oncology pharmacists
Involve oncology pharmacists in
reimbursement analysis to focus
on key drug reimbursement
cases to show system impact
and drive cultural support.
Establish Revenue Integrity Committee
Foster system-wide acceptance by inviting a
multidisciplinary group of internal
stakeholders:
• Nursing
• Pharmacy
• Patient financial service representations
• Pharmacy reimbursement specialists
Identify retrospective, drug-level data to
provide a complete picture of cost and
reimbursement, specific to payer mix.
Revenue Cycle Advancement Center research and insights.
© 2019 Advisory Board • All rights reserved • advisory.com • WF953632-c 09/11
Case in brief
46
• Oncology pharmacists recognized drug decisions focused primarily on up-front costs
and lobbied internally to have reimbursement trends included in future strategy and
decision-making.
• Pharmacists established Revenue Integrity Committee (RIC) with members from:
pharmacy, nursing, patient financial services, pharmacy reimbursement specialists,
and guest members from: IT, revenue cycle, practice managers, and medical staff.
• Pharmacy staff manually sorts through J-code level reimbursement claims to provide
medication using evaluations, medication cost, reimbursement by payer, revenue per
dispensation, number of treatments, and net revenue per treatment plan.
• System-specific reimbursement analysis helps build payer strategy, such as
negotiating disease-specific carve-outs to plans with payment limits.
• In 2017, Memorial Health System’s net patient revenue was $241,175 (2017).
Six-hospital health system in South Florida
Memorial Health System
Source: Memorial Healthcare System, “Annual Report for the Fiscal and
Quarter Ended April 30, 2018,” https://www.mhs.net/about/finances.
Revenue Cycle Advancement Center research and insights.
© 2019 Advisory Board • All rights reserved • advisory.com • WF953632-c 09/11
47
Analysis, cooperation with payers leading to increased revenue capture
RIC narrows in on biosimilars to prevent denials
Medication use evaluations
Conducts MUEs to determine if
providers are prescribing according to
Medicare coverage or if treatment
regimens are not included
RIC partnered with Blue Cross Blue
Shield to advocate for the inclusion
of biosimilars in formulary
Goal is to reduce,
eliminate denials stemming
from uncovered biosimilars
Examined biosimilars due to
importance, volatile cost and
reimbursement
AdvocacyAssessing generics Preventing denials
Revenue Cycle Advancement Center research and insights.
© 2019 Advisory Board • All rights reserved • advisory.com • WF953632-c 09/11
48
Organization uses regular meetings, root cause analysis to educate broader organization
Southeast Health creates their own RIC
Oncology
2Weekly meetings
Committee pulls six months of
denials data, begins to work
through each case
Root cause analysis
identifies documentation and
pre-authorization problems
1Oncology Revenue Integrity Committee
Committee representatives:
Insurance
Billing
Physician clinics
Drug replacement
Pre-authorization
3Shared insights
Educate pharmacists to
refrain from substituting drugs
without pre-authorization
Use regular provider meeting
to discuss issues around
documentation
Revenue Cycle Advancement Center research and insights.
© 2019 Advisory Board • All rights reserved • advisory.com • WF953632-c 09/11
Case in brief
49
• Southeast Health noticed an uptick in denials.
• In response, the oncology service line director formed a committee
composed of representatives from insurance, billing, physician offices,
drug replacement, and pre-authorization.
• The committee currently meets monthly to discuss issues related to
denials.
• Since October 2018, the committee has seen a 24% improvement in
collections, about $400K.
• In 2019, Southeast Health’s net patient revenue was $1,839,801,396.
Hospital in Dothan, AL
Southeast Health
Source: American Hospital Directory, “Identification and Characteristics,”
https://www.ahd.com/free_profile/010001/Southeast_Health_Medical_Center/Dothan/Alabama/.
Revenue Cycle Advancement Center research and insights.
© 2019 Advisory Board • All rights reserved • advisory.com • WF953632-c 09/11
50
Success leads to expansion of scope, adoption in other clinical areas
Expanding beyond oncology
Committee started by meeting weekly, but
as issues have been resolved, only needs
to meet monthly
Scope is expanding to not only include
denials, but also underpayments and other
reimbursement challenges
Committee is considering expanding the
practice to other service lines
Of lost revenue avoided
since September 2018
$400K
Revenue Cycle Advancement Center research and insights.
© 2019 Advisory Board • All rights reserved • advisory.com • WF953632-c 09/11
51
1. Pseudonym.
Size of loss lead executives to approve creation of new position at Beesly1 Health
Billing error leads to dedicated RI pharmacist
Found billing error
around pharmacy that
led to underpayments
Executives realize need for special
attention, resources in pharmacy
due to size of revenue risk
Organization hires pharmacist to
serve as revenue integrity specialist
System Director of Pharmacy
and Vice President of Finance
champion a pharmacy revenue
integrity specialist position
Currently working to
extend position to other
service lines
Revenue Cycle Advancement Center research and insights.
© 2019 Advisory Board • All rights reserved • advisory.com • WF953632-c 09/11
Case in brief
52
• Organization found a pharmacy-related billing error that cost the
organization $6 million
• System Director of Pharmacy and Vice President of Finance decided to
hire a pharmacist to oversee pharmacy-related charges.
• The pharmacy revenue integrity specialist has overturned about $13-80K
for different drugs rebilled.
• The service line approach is currently being expanded across the
organization.
• In 2016, Beesly1 Health’s approximate net patient revenue was $2.4M.
Health system in the Northwest
Beesly1 Health
Revenue Cycle Advancement Center research and insights.
© 2019 Advisory Board • All rights reserved • advisory.com • WF953632-c 09/11
53
Concerted focus and oversight leads to significant gains
Functional collaborationWork flow improvement
Assists in clean up of the pharmacy chargemaster
and corrects line items that are billed incorrectly, as
first step of policy and procedure standardization
Standard policy and procedure development
Pharmacy Revenue Integrity Specialist
Revenue Cycle Advancement Center research and insights.
Collaborates with front-end
users on work flows related to
charge capture to ensure clean
claims in billing
Pharmacy revenue practice
team composed of pharmacy
IT build team, billing, and
compliance teams to
determine and solve charge
router issues
© 2019 Advisory Board • All rights reserved • advisory.com • WF953632-c 09/11
54
Position may be created in other areas with significant revenue risk
Clear wins make idea appealing to other service lines
Cardiovascular
Emergency Department
Medical Authorization
Radiology
Upcoming service lines
$13K-$80KSaved per drug rebilled over
period of several months
Revenue Cycle Advancement Center research and insights.
© 2019 Advisory Board • All rights reserved • advisory.com • WF953632-c 09/11
55
Source: Ingenious Med, “Most healthcare execs say charge capture is essential, yet 40 percent
discuss it once a month or less,” https://www.prnewswire.com/news-releases/78-of-healthcare-
execs-say-charge-capture-is-essential-yet-40-discuss-it-once-a-month-or-less-300774051.html.
EHRs widely used for charge capture, but few report satisfaction with current state
A ubiquitous “solution”
10%Of health care organizations
would recommend their current
charge capture solution
84%Of health care organizations rely
at least partly on their EHR
systems for charge capture
50%Of health care organizations
use it exclusively as their
charge capture solution
Revenue Cycle Advancement Center research and insights.
© 2019 Advisory Board • All rights reserved • advisory.com • WF953632-c 09/11
56
RI programs take two approaches to getting what they need from technology
Potential fixes require deep collaboration with IT
• Revenue integrity program hosts regular
workgroups between IT and clinical staff
• Workgroup mitigates issues and helps
financial staff understand clinical modules
• Group of dedicated IT staff report to
revenue integrity department
• IT able to provide any support, fixes
required of revenue integrity
Information
Technology
Solution #1: Dedicated IT support Solution #2: Formalized work groups
Benefits: Clear line of communication,
accountability, and faster time to
improvement
Drawbacks: Expense of adding IT staff
Revenue Cycle Advancement Center research and insights.
Benefits: Bridge between clinical and
financial worlds, eliminate problems due to
miscommunication
Drawbacks: Competing priorities, requires
time, no formal mechanism for accountability
© 2019 Advisory Board • All rights reserved • advisory.com • WF953632-c 09/11
57
CFO buy-in provides OHSU with significant support
Focus on front end workflows necessitates IT staff
Prioritization of work flows
Given revenue integrity’s focus on front
end work flows and the rise of their
EHR, a need for immediate access to
IT staff is determined.
Receive added support
Department continues to
meet with the organization’s
IT team for larger projects
Gain executive advocacy
VP of Revenue Cycle and
Enterprise Revenue Cycle Director
advocated for internal IT staff to sit
within revenue integrity
Centralize IT staff
Three types of IT support are
centralized for revenue integrity
• EHR billing systems
• Revenue integrity support
• Revenue Cycle team
Revenue Cycle Advancement Center research and insights.
© 2019 Advisory Board • All rights reserved • advisory.com • WF953632-c 09/11
58
Support goes beyond just RI program to all of revenue cycle
Technology staff specialized across three teams
Revenue Cycle/IT team divisions
EHR billing systems
• 10 FTEs
• Support professional billing
• Perform system build, maintenance,
upgrades and enhancements
Revenue cycle team
• 11 FTEs
• Provide charge capture support
• Help develop work flows to ensure
compliant billing
• Liaise between the hospital clinics
and the billing office
Revenue Integrity support
• 4 FTEs
• Manages department and provider
master files
• Performs all build maintenance
IT support leads to project success:
• IT teams meet weekly with revenue integrity staff
• Coordinate effort for significant go-lives including two community connect hospitals,
four OHSU clinics on EHR, and a 14-story ambulatory building in three years
Revenue Cycle Advancement Center research and insights.
© 2019 Advisory Board • All rights reserved • advisory.com • WF953632-c 09/11
59
Cedars-Sinai’s difficulties with automated charging triggers formalized workgroups
Connecting revenue cycle, IT, and clinical expertise
• Regular workgroups held by revenue integrity with IT staff
and clinical departments provides answers for each of the
three areas
• Specific to the group’s original problem, pharmacy IT gained
an understanding of the national drug codes required for
outpatient drugs as well as connecting to the system build
After
Access to answers
• Billing edits appear in PFS for missing national drug
code (NDC) claims for outpatient claims
• Pharmacy IT team confirms NDC is in the system
• Billing team confirms NDC is not on claim
• RI gets everyone together via WebEx to solve the issue
Before
Questions galore
“No one in revenue cycle operations and clinical operations was knowledgeable
about the new electronic applications, making it difficult to speak with IT and
clinical partners about charge issues stemming from clinical modules.”
Gretchen Case, Executive Director of Compliance and Revenue Integrity
Cedars-Sinai
Revenue Cycle Advancement Center research and insights.
© 2019 Advisory Board • All rights reserved • advisory.com • WF953632-c 09/11
Case in brief
60
• VP of Revenue Cycle and Enterprise Revenue Cycle Director determined
a need for internal IT support.
• Three IT teams were centralized under Revenue Integrity: EHR billing
systems, revenue integrity support and a revenue cycle team focused on
technology.
• Teams coordinate well with revenue integrity and supported significant
EHR conversions.
• In 2017, OHSU’s net patient revenue was $2,097,255.
2-hospital academic health center based in Portland, OR
OHSU
Source: Oregon Health & Science University, “Financial Statements and Supplementary
Information,” https://www.ohsu.edu/sites/default/files/2018-08/ohsu-financial-stmt-audited-fy17.pdf.
Revenue Cycle Advancement Center research and insights.
© 2019 Advisory Board • All rights reserved • advisory.com • WF953632-c 09/11
61
Responsibility allows RI to gain clinical knowledge, and vice versa
Dedicated RI staffer leads each work group
Delivery system reform
• Different revenue integrity staff are responsible
for running the clinical workgroups
• Workgroups cover both Epic and non-Epic
modules
• Buy-in from clinical areas has been significant
with one group having 27 attendees
Clinical workgroups
Pharmacy
Ambulatory
Imaging
Oncology
Associate Program Director
RI workgroup leader
CDM Analyst
Charge Capture Manager
CDM Analyst
Revenue Cycle Advancement Center research and insights.
© 2019 Advisory Board • All rights reserved • advisory.com • WF953632-c 09/11
62
$76,000,000+
Total amount saved from GAP and
revenue integrity program, October
2007-March 2019
Revenue Cycle Advancement Center research and insights.
© 2019 Advisory Board • All rights reserved • advisory.com • WF953632-c 09/11
63
Comprehensive documentation, educational efforts critical to both entities
Overlap exists between CDI and RI, but functions have distinct goals
Focus on physician documentation to
ensure appropriate care and
comprehensive capture of information
• Comprehensive
documentation
• Physician education
• Source of support for
clinical teams
• Performance monitoring
Clinical Documentation Improvement Revenue Integrity
Focus on comprehensive and accurate
physician documentation (and other
functions) to ensure accurate payment
Revenue Cycle Advancement Center research and insights.
© 2019 Advisory Board • All rights reserved • advisory.com • WF953632-c 09/11
64
Revenue integrity’s hunting license does not extend to CDI
Keep functions separate to avoid corruption of mission
81% Of health systems have an
inpatient CDI program
4%Of revenue integrity
programs include CDI
Most opting for continued separation Appropriate focus of CDI
Completeness of physician documentation
Timeliness of documentation
Physician query response rates
Consistency with coders
Revenue leakage from improper documentation
Revenue Cycle Advancement Center research and insights.
© 2019 Advisory Board • All rights reserved • advisory.com • WF953632-c 09/11
65
1. Pseudonym.
Flenderson1 proactively seeks new executive buy-in on mission and goal of revenue integrity
Extending RI education beyond clinicians
Risk and challenges
• Disparate chargemasters and contracts
• Potential billing and compliance issues
depending upon site of care being onboarded
• New technology/EHR integration
• Different clinical systems and processes
• Normal hiccups associated with mergers
New hospitals integrated into system are
unfamiliar with certain protocols, and EHR1
Revenue integrity department on-boards new
hospitals with a focus on understanding Epic
workflows
2
Department staff meet with executive leadership
to review the transition process3
Department staff meet with service line leaders to
explain clinical areas’ impact on charging and the
importance of accurate information
4
M&A complicates revenue integrity Flenderson1’s introduction to revenue integrity
Revenue Cycle Advancement Center research and insights.
© 2019 Advisory Board • All rights reserved • advisory.com • WF953632-c 09/11
Case in brief
66
• Onboarding of new sites of care as a result of M&A activity present risk
for Flenderson1.
• Revenue integrity program created a robust training process to on-board
new hospitals and executives to the importance of RI, processes around
documentation, and technology for those unfamiliar with Epic.
• In 2016, Flenderson1’s approximate net patient revenue was $2M.
Health system based in the Northwest
Flenderson1 Health System
1. Pseudonym.
Revenue Cycle Advancement Center research and insights.
© 2019 Advisory Board • All rights reserved • advisory.com • WF953632-c 09/11
67
Standardize the processes and expectations
1. #9: Make charge drop easy for clinicians
Source: Ingenious Med, “Most healthcare execs say charge capture is essential, yet 40 percent
discuss it once a month or less,” https://www.prnewswire.com/news-releases/78-of-healthcare-
execs-say-charge-capture-is-essential-yet-40-discuss-it-once-a-month-or-less-300774051.html.
Coders and CDI specialists spend too much time tracking information from physicians
Three steps to greater physician accountability
Share performance data
Observe the status quo
Percentage of coder time
spent tracking down details
of physician documentation
10%-20%
Revenue Cycle Advancement Center research and insights.
© 2019 Advisory Board • All rights reserved • advisory.com • WF953632-c 09/11
68
1. Pseudonym.
Flenderson1 determines the status quo through first-hand observation, before solution implementation
Before attempting a solution, identify the status quo
Understand how clinicians are
providing care and documenting
it through first-hand observation
Ask the end-user what’s missing from
the process or causing them issues Avoid asking questions over
email or phone—observe the
patient workflow in-person
Address the problem in
the front-end
Repeat this process of
determining the status
quo before solution
implementation for any
issues that appear
Revenue Cycle Advancement Center research and insights.
© 2019 Advisory Board • All rights reserved • advisory.com • WF953632-c 09/11
69
Source: Ingenious Med, “Most healthcare execs say charge capture is essential, yet 40 percent discuss it
once a month or less,” https://www.prnewswire.com/news-releases/78-of-healthcare-execs-say-charge-
capture-is-essential-yet-40-discuss-it-once-a-month-or-less-300774051.html; Secan, R, “The Evolution of
Charge Capture Technology,” https://www.physicianspractice.com/blog/evolution-charge-capture-technology.
Complaints on timeliness of charge drop abound among revenue cycle leaders
Overcoming the physician charge capture bottleneck
1. Charge lag
2. General inefficiency
3. Integration with EHR and other technologies
Top 3 charge capture issues ranked
by health care executives
Physicians become busy with other issues,
neglect to drop charge, or capture all care
provided to the patient
Chart lingers for longer than necessary,
ultimately adding to days in A/R and
untimely bills
Revenue Cycle Advancement Center research and insights.
© 2019 Advisory Board • All rights reserved • advisory.com • WF953632-c 09/11
70
Source: pMD, “Hospital Charge Capture, Improve the Process with
pMD,” https://www.pmd.com/case-studies/hospital-charge-capture.
Mobile charge capture reduces physicians’ work and streamlines EHR
Doctor enters charge
on paper
Medical assistant enters
charge into spreadsheet
Billing staff enters charge
into billing software
Charge is on EHR
Doctor enters charge on
mobile deviceMedical assistant
reviews charge
Mobile charge capture
solution sends charge to EHR
Paper charge capture
Mobile charge capture
Revenue Cycle Advancement Center research and insights.
© 2019 Advisory Board • All rights reserved • advisory.com • WF953632-c 09/11
71
“[Mobile charge capture] is very
convenient…I don’t have to worry about
[delayed submission] anymore. My billing
goes out faster with a much greater
likelihood of not missing charges.”
–Dr. Juan Dumois
All Children’s Hospital
Source: pMD, “Hospital Charge Capture, Improve the Process with pMD,”
https://www.pmd.com/case-studies/hospital-charge-capture.
Revenue Cycle Advancement Center research and insights.
© 2019 Advisory Board • All rights reserved • advisory.com • WF953632-c 09/11
72
1. Pseudonym.
Automated flags ensure physicians document need for hospital-based ancillary services
Think globally, act locally
Revenue Cycle Advancement Center research and insights.
Physicians who order a hospital-based ancillary
service must document and code for:
Ancillary services often overlooked in the
physician office settingFlax1’s bolt-on reminds physicians
Medical necessity of the office visit
Medical necessity of ordered
ancillary service
Failure to do so will result in a medical necessity denial
for the ancillary service
System’s EHR bolt-on reviews the faculty’s Medicare
documentation and codes in the moment
When physician orders a hospital-based
ancillary procedure, technology pop-up
reminds physicians to document and code
medical necessity for both settings
Number of times the technology
pop-up was triggered within the first
eight months of implementation
33,000
© 2019 Advisory Board • All rights reserved • advisory.com • WF953632-c 09/11
Case in brief
73
• In 2018, Flax1 built an EHR bolt-on technology to review faculty physician
Medicare documentation and coding in the moment.
• When physicians order a hospital-based ancillary service, technology’s
pop-up reminds the physician to document and code the medical
necessity for both the office visit and hospital service.
• In the first eight months, the flag was triggered 33,000 times.
• Flax1 hopes to expand this technology to all payers soon.
• In 2018, Flax1’s net patient revenue was $2.61B.
Health system in the North
Flax1 Health
1. Pseudonym.
Revenue Cycle Advancement Center research and insights.
© 2019 Advisory Board • All rights reserved • advisory.com • WF953632-c 09/11
74
1. Pseudonym.
And let clinicians know when they’ve achieved notable performance
Make clinical departments aware of RI’s expectations
Flenderson1 Health System’s Revenue Integrity policies
Revenue
integrity
responsibilitie
s
Revenue integrity
responsibilities
Clinical department
responsibilities
• Review documentation before charges
automatically drop
• Properly place patient cases so that
Epic’s algorithm selects the correct code
• Correctly building tables in Epic for
clinical staff to enter data
• Room and board charging including
patient, department, and level of careRegularly share
performance data
with physicians to
demonstrate their
success or areas of
improvement
Revenue Cycle Advancement Center research and insights.
© 2019 Advisory Board • All rights reserved • advisory.com • WF953632-c 09/11
75
Road mapRoad map
Deconstructing Revenue Integrity1
2 Building an Efficient and Effective Information Chain
3 Coda
© 2019 Advisory Board • All rights reserved • advisory.com • WF953632-c 09/11
76
Revenue cycle pushed to weather considerable change while increasing current performance
Dynamic market asking much of our staff
Tackling a lot at once
Concerns about automation,
and potential impact on staff
EHR implementation and
complications from technologyDeep knowledge of insurance
products and coverage required
Integration of departments
across sites of care
Difficult patient financial situations
and pushback around payment
Changing regulatory and
payment environment
Revenue Cycle Advancement Center research and insights.
© 2019 Advisory Board • All rights reserved • advisory.com • WF953632-c 09/11
77
Next session tackles these questions head on
Staff engagement critical to delivering on our initiatives
How do we know whether
our staff is engaged?
? ?What factors impact
engagement, or lead to
disengagement?
Are all of our staff equally
engaged? Which should we
be most concerned about?
?
Revenue Cycle Advancement Center research and insights.
Are we asking too much of
our patient access staff
specifically
?How does pay at our
organization compare with
other organizations?
?
© 2019 Advisory Board • All rights reserved • advisory.com • WF953632-c 09/11
Credits
78
Stefanie Kuchta
Design Consultant
Eric Fontana
Program Leadership
Sophia Duke-Mosier
Research Team
Robin Brand
Project Director
Revenue Cycle Advancement Center
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