Revenue Cycle Management

New Revenue Cycle Challenges

As more of your hospital Revenue has shifted to the outpatient setting, a new challenge to your revenue cycle has emerged. Coming soon will be an inpatient reimbursement system that will be based on Severity and acuity, requiring much more precision and attention to clinical documentation by your medical staff and those who do the coding. Outpatient procedures are generating five to ten times as many claims as you did five years ago, that number will also increase and will now require much more precision in the supporting clinical documentation and leveling done by your staff.

Restructuring to meet the new Federal Reimbusrsement Challenge

Meeting this challenge requires more skilled and intense labor then ever before. The skill sets are related to acquiring accurate data, providing superb documentation of care with gradations of acuity and severity and then coding them with excellence. The Federal System is always budget neutral and in order not to lose more revenue in these areas you will be forced to think about whether the Revenue Cycle in your organization is structured to meet the next challenge.

Patient Financial Services Center

One approach that the larger systems have used is the creation of a "Patient Financial Services Center," sometimes known as an extended business office. It's focus is to assure that every claim is clean and followed up, that all leveling is optimized and supported with precise clinical documentation and that where required, it works closely with clinicians on education and correction.

Changing the Revenue Cycle Paradigm

Health Systems Management is celebrating its 20th year in assisting hospitals in changing the Revenue Cycle Paradigm with assessment, redesign and management planning. Often clients have asked us to set up and manage an Extended Business Office as a transparent extension of the current business office functions. These offices are set up to be profit centers, funded entirely by the revenue stream gained from what has often been missed by the in house Patient Financial Services.

The challenges are real and time is running out. This is the appropriate moment to begin looking at all of the opportunites that lie behind the numbers in the Aged Trial Balance.

Call us for a consultation and review of your aged trial balance.

Health Systems Management Network, Inc. has provided for its clients assessments of:

• Front to Back end processes affecting Revenue Stream with special focus on Outpatient Revenue.
• Analysis of Revenue-Related Data including, but not limited to, Demographic, Clinical and Financial.
  • Extensive scrutiny of actual cases: clinical records, UBs, 1500s and EOBs, diagnostic and procedure coding and the underlying clinical documentation to evaluate the level of services provided vs. those billed for.
  • A review of charge tools in use (manual and computerized).
  • Processes, procedures accountability and workflows related to the Revenue Cycle.
  • A review of Organizational structure including staffing, skill levels, knowledge/use of tools, staff training and effectiveness.

Medical Staff Relations

• Conduct case conference reviews with leaders of the medical staff on coding and documentation issues.
• Ascertain their level of understanding of what supports levels of service vs. what is reflected in the documentation.
• Provide crossover analysis between Evaluation and Management requirements and what is actually reflected in the hospital documentation; comparisons of how professional fee documentation and hospital documentation by medical staff conform to regulatory requirements.

Financial Impact Analysis

• A comprehensive review of services not reimbursed for all reasons. A detailed report on claims denials and reasons.
  • Focus on Medical Necessity as appropriate and review procedures and tools in use to determine “Upfront Appropriateness.”
  • Develop training.
• An analysis of ungroupable items, those not passing the various edit requirements prior to billing.
• An intense look at the cost of care vs. the reimbursement.
  • This review is done as a dialogue with clinical managers.
• A review of pricing of items.
• A targeted and focused review of Chargemaster items and services actually performed at a particular site: Do they conform and meet payor/regulatory requirements? Are they adequately described in precise coding terms?
• Financial impact of all of the aforementioned categories on the Revenue Stream.

Health Care Organization Revenue Cycle Systems Review

• Determine how well data is moving between and among systems. Validate data items as they pass from front-end systems to back end.
• Review and detail reason for gaps in data transmission that directly affect revenue.
• Review roles of those using systems to determine human error vs. system dysfunction.
• Provide Reconciliation between front end and back end staff, process, and systems through use of the “Case Conference Technique.” Discuss specific cases that epitomize categories of problems that may be endemic to how current systems are functioning.
• Make recommendations on specific system specification aspects affecting the revenue cycle.
• Lay out the short- and long-term changes essential to the financial health of the revenue stream.

Management Plan Design, Training and Implementation

• In dialogue with management and clinical leaders, fashion a plan for performance improvements on all levels.
• Detail tasks, responsibility and timetables in the management plan.
• Identify benchmarks to be achieved for monitoring improvements.
  • Implement management reports to be used by specific levels of management for determining progress.
  • Implement training for the following:
    • Medical/clinical staff and clinical documentation/Resource Use.
    • Front-end staff for demographic and financial data.
    • Use of new processes and workflows.
    • Monitoring benchmarks.