In this new and changing environment what is the Financial way forward for hospitals and physicians
In this new and changing environment what is the Financial way forward for hospitals and physicians

In every Health care industry Publication, there are many opinions about what will change and what impact it will have on all providers/clinicians.

The headlines are clear: we may have repeal and replacement of the ACA or we will have bits and pieces. How do we in the industry formulate a strategy to cope.

Dr. Price, the designated leader of HHS, (awaiting his confirmation hearing) seems to be against any mandatory performance requirements for physicians. Yet we hear the words “Patient Centric” mentioned. CMS has been very persuasive about new “Reimbursement” methodologies for both Hospitals and Physicians. We think we have entered the realm of Quality vs Volume or creating ACO’s (Accountable Care Organizations) and we wonder what will really happen now. Forty percent of our physicians are now employed and the question arises, has the health Care Environment affected the ability of Hospitals and Physicians to be Entrepreneurs for both Quality and Revenue without being forced.

We are letting our clients know that we are about to enter a new paradigm and CMS might have to take a step back from many of its experiments in Reimbursement that have had mixed successes.

Because we have been advising clients for thirty years (30) on the Revenue Cycle, we are in a unique position to advise our clients on how to prepare.

To our clients we stay look within at performance of your hospital/ambulatory care services and that physicians look closely as well. If you think you’re the best, think about being better in measuring where you stand in the quality and Revenue Cycle sectors.

Looking inward means looking honestly at cost, efficacy, outcomes and whether your patient/clinical data support your efforts to be “Best Practice” sites. The time has arrived to go back to basics and penetrate the essence of clinical service delivery, cost and efficacy. This is done by looking carefully at basic clinical and financial data elements on the back end and then going to the source of the data, the Medical staff/Ancillary services to determine whether your proposed standards have been met. While Medicare is a large part of the Revenue Stream for many CMS doesn’t have to define who you are as a provider. Quality must be internalized and efficiency must follow on. We are letting our clients know they must look at those elements which give us the most clues and these are: Denied claims from insurers and finding the root causes of such denials. We understand that some payers deny too much without cause and we have to do all of the work. Look closely for the clues that are in the “DATA Set” that comprises a patient encounter/procedure.

We are advising our clients to look at the basics by doing reviews, by implementing “deconstruction” methodologies in an almost forensic frenzy to make sure that no matter what political decisions are made, ultimately everyone will be looking at clean and honest claims data from hospitals and physician practices.

Also, the new administration is clear on its stand to eliminate or reduce fraud and abuse, and therefore, Rac Reviews, overpayment reviews and future decisions about payment will be based on what they can learn from the data.

For those organizations who have implemented an enterprise wide Electronic Health Record and are finding huge losses due to the kind of toll that has cost UMass Memorial Health Care millions of dollars in reimbursement “become granular” in your review of root causes. Why? Because clinical data are the destiny of Health care no matter who is in congress or the White House. Those who recently opened Ambulatory services under the “Provider Based clinics” have real work to do in reviewing data and gaining an understanding of how they can continue to provide that service at a lower cost and keep the Quality high.

We are advising our clients to look very carefully at the Revenue Cycle and not from 35,000 feet but from actual sources, the patient encounter. In our next article, we will spell out what “Deconstruction” means in looking at clinical data.

Cathy Idema, BSN, MPH, FAAHCC

President and CEO



Phone: 866-908-4226

Health Systems Management Network, Inc

A Revenue Cycle Company cited by Modern Health Care magazine as one of the best, largest and longest established in its field.