The sources of data in an organization are critical to determining outcomes, resource use and reimbursement. HSMN has often found that it needs to go to the source of the data creation in order to determine validity. So often we find that the data in a system does not always reflect the reality. The reasons are simple
- Human being collect data and they can make mistakes. With not viewing or hearing or entering properly.
- Much clinical data is contained in the notes written by clinicians and sometimes not legible or not understood.
Our mission is to assure that data collection is accurate because that data flows through the entire episode of care until it meets a claim. Too often correction of data means much rework. Therefore, our first and highest priority in doing any engagement is to make sure that the data are correct and accurate.
Organizations should be shaped based on the goals they must accomplish. Often we find Hospitals and Physician practices where the Organization is shaped by individuals who maintain a role. Often roles are not related to the reality of function and therefore organizations are weakened.
- The shape of the organizational structure must start with assuring that every function essential to carry out its major goal (patient financial services, Coding, registration, insurance verification) are the foundation of the structure. Determining volumes allows for understanding staffing needs built upon function. Technology support and workflows follow.
- HSMN devotes much of its time to understanding the shape and purpose of each structure within the Revenue Cycle.
Clinical Documentation Management
Clinical documentation is the life blood of the revenue cycle and it must reflect accurately what has happened in the patient encounter or procedure. Physicians often do not understand the connection between the clinical and the documentation. This is a process that can be managed but only by working closely with medical staff. HSMN has found in many engagements that physicians do not want to be lectured about documentation; they want to learn but anything that suggests that clinical judgment is questioned is never acceptable. HSMN has developed a strategy of case deconstruction which has been very effective in every setting in which we have worked. Deconstruction is followed by case conferences with medical staff taking the lead on explaining to peers the differences between a clinical action and decision and its documentation. Over 25 years we seem to have had many successes.
The Medical Billing Continuum
The medical billing isn’t only an event which happens when a claim is prepared. It is the cumulative effect of each bit of data that has been gathered from the patient from the first contact by phone or computer. Think of the Billing process as a stream that runs through the entire Practice/hospital while being touched, augmented, changed and finalized over the course of the Encounter(s). We generally call this the Revenue Cycle.
So from the appointment being made to the patient being asked for Demographic data, financial data for insurance, authorization for a procedure from the insurance company and finally the clinical documentation translated into Coding that creates all of the elements for the claim to be filed. None of these steps is unimportant and every one of these has the potential to create a bad claim that won’t be paid or a good clean claim that can be paid. The Medical Billing Continuum needs to be reviewed regularly to determine if all functions are being performed well, whether data are accurate, whether the final codes and diagnoses make sense and whether all of the demographics and financial combine to make an accurate claim. Certainly once a year a review of your Revenue Cycle should be part of the Operating Procedure. As new partners join a practice or new clinicians are added to the practice, the reviews should be repeated. For over 25 years, HSMN have been reviewing Physician Practices and the Revenue Cycle in every setting.
Operational Assessment/Management Plan
When an organization defines its mission and goals and sets out a vision for the staff of the various departments, e.g., Revenue Cycle Operations, the most important and fundamental objective that must be achieved is determining whether the “Structure, staff, workflows and processes, and technology support are all shaped and in tune to carry out the mission and goals. HSMN provides detailed management plans to carry out the recommendations in our assessments of the Revenue Cycle for both the Hospital side and the Physician practice. The Management plan encompasses a timeline, task list, and responsible people for accomplishing the task. The management plan also builds in benchmarks by which one can monitor the progress of the implementation measure the success once it is in place.
The Management Plan encompasses also every aspect of the Revenue Cycle including but not limited to the following:
- Define the purpose/ mission with a design to the Organization’s structure to assure success’
- Define functions, work process and positions/roles for the organizational structure
- Design job competencies to match required organizational functions;
- Define the leadership structure and necessary characteristics for success;
- Screen existing staff and make recommendations for those who can fit into new roles;
- Create detailed workflows and decision trees and organizational charts.
- Create detailed job descriptions/competencies
- Transfer knowledge and assist in the training of existing staff in their new roles.
- Detail the System specifications necessary to support the change in operations.
Revenue Cycle Partnerships
The Revenue Cycle begins with what critical event? At HSMN, we believe this critical event is when the patient calls to make that first appointment. Management of the Revenue Cycle starts here, making the patient your first partner in providing healthcare services.
Customer driven healthcare is one of the most dramatic shifts in healthcare today. Therefore, our performance improvement plan begins with assessing patient satisfaction and access management from the first point of entry. HSMN has helped hospitals, specialized providers and physicians/clinicians to partner in the management of the revenue cycle through an array of strategies that include integrating the three silos of the Revenue Cycle:
- Access Management,
- Patient-Provider Interaction, and
- Claims Management
Our goal is to help the provider manage the entire transaction to allow the patient to move through the healthcare process efficiently, effectively and satisfied.
Third Party Payer Contract Review
For specialized care providers, the “Contract” between the Third party payers and these entities is the basis for reimbursement. The truth is that only 60% of the payers in our country actually pay what to pay to that which they have agreed. In other words Third party payers whether by omission or design take discounts. Also the basis for denials should be plainly spelled out but new ones often are found to impede payments to the providers. HSMN for over 25 years have reviewed contracts against actual payment performance by Third party payers. Our methodology employs both Retrospective reviews of the clinical data in support of the service, the claim sent out by the provider, the EOB which describes what the payment is for. It is critical that we determine whether there are internal Revenue Cycle problems or whether true discounts are being taken by the Third party payers. In many of our engagements this has turned out to be both a financial gain and an awakening of the Revenue Cycle departments to be more sensitive and careful about comparing remittances to Claims.
Peer Performance Review
Physician leaders must think about where their practices are going but that cannot be done unless you know where you have been. It is critically important that Practice Leaders create bench marks to measure the performance based on the Plan for growth. What you do not have a plan for growth? Why not? A very rudimentary plan would suffice, one which embodies the hopes, goals, the objective and some solid performance measurements.
It isn’t just nice to have these but essential. Not only do you want to see the data in aggregate but you want to determine what is working and what is not. You want to be able to eyeball who is a Champion and who is a laggard. Without measurements it is impossible to make any judgments about how well your practice is doing.
Once you have both aggregate data (Volume is holding, expense is higher, our bottom line is smaller) one needs to focus in on causes. Some of the issues may lie in the performance of the individuals in the Practice. The billing lady is out sick and we are way behind; Dr. Smith saw fewer patients last month. Why? He was at a conference. We are backed up in the scheduling; people are waiting 3 weeks for an appointment and goal was no longer than 2 days. These all matter when running a practice.
Presenting findings to peers can be sensitive and difficult. Presentation of Aggregate data breaks the ice and allows the partners to have a context for the Peer report. In a small group practice, once a month everyone as to view each participants’ performance on volume and revenue without varnish. When it come to the problems related to clinical documentation and coding, that can presented by giving each doctor an anonymous identification after which the Practice Manager or billing person can work with the individuals. This is not about Peer pressure; it is about understanding where your practice relative to where you want it to be. This exercise also leads to other Practice decisions: is it time for another partner? Is it time to lose a partner who is not performing? Numbers are information; numbers are not personal. For over 25 years HSMN has worked with Practices in every discipline on the issues we have discussed.