The Supreme Court has just upheld the new Affordable Care Act; as a result, APC payments and revenue will be more carefully scrutinized than ever. The reasons are clear: in an effort to provide incentive for EMRs, ACO payments to groups and other experiments in reimbursement, the money must be found in existing programs. Denials and rejections under APC will multiply under the new scenario. However, this may present a new opportunity for providers with large ambulatory operations and even those who are doing private ambulatory surgery centers.
Where is the opportunity to optimize revenue when CMS is doing everything in its power to find dollars in the APCs? There is no magic bullet nor is there a software program that can replace the critical thinking skills of those who see the patient, create the documentation and those who code the events along with the groups who scrutinize claims. There must be a synergy among those groups who focus on the details of the medical encounter, the documentation/coding, and the claim. Until recently, these groups all developed finger pointing skills employed in deflecting responsibility for their part in the denials. That energy must now be devoted to creating a program in which denials are analyzed, statistically reported into categories, and then refined by provider and discipline. The information must then come back to the providers in order for them to ascertain the goals of the APC. For example, not wanting to pay for the same thing twice in a bilateral knee repair, now CMS sees the opportunity to fine tune the APCs as it has with DRGs. This includes a “Case Mix Indexing” quotient that will impact payment.
It is essential to create an internal “Case Mix Manager” or a sub-director under revenue management as it will help keep a focus on how well the organization is doing in the aggregate. Work with individual providers should be benchmarked to determine where the improvements are needed and where they need to be directed. The real work in this process is in the detail.
Organizations must study and understand denials, and their sources. It is essential to categorize the denials by the appropriate group, and their value in dollars and cents, then develop a baseline from which to begin the process. The organization must then get at the root cause of the declining revenue in the aggregate, then create a plan to improve the possibility of optimization.
One of the key components of a good strategy is to work closely with each of the groups: the medical staff, coders, financial services and even patients. This entails breaking silos out into synergistic teams that collaborate to attack internal issues and understand the changes in rules that CMS promulgates each year.
HSMN has been pioneers in developing the processes that help institutions optimize their revenue since the inception of APCs. HSMN sends teams to hospitals, ambulatory surgical centers and other providers to jump-start the process. A buddy system is used to transfer the knowledge immediately to the internal staff who have a profound impact on revenue.