Like most industries, healthcare is experiencing an increase in pressure to reduce cost and boost their margins. It isn’t surprising to see healthcare organizations turn to acquisitions and mergers in an effort to increase the services they offer or to reduce their competition. According to the Healthcare Finance Management Association, the trend is likely to continue as claim reimbursement rates continue to fall and payers continue to alter their billing rules and develop alternative payment systems.

But adding services or service locations is not a panacea to the growing economic pressures faced by healthcare systems. Adding a new pool of patients or services is likely to carry with it a corresponding increase in the resources needed to assure that potential new revenue is maximized. Adding unfamiliar procedures, new patient populations, and potential new regional payers can all contribute to a chaotic environment for the newly formed organization, making it difficult to achieve the desired fiscal results.

In order to really boost their margins, organizations will need to explore new strategies and new workflows to reduce inefficiencies and cost across all clinical departments. To do so, they will need to implement “Best Practices” across the entire system while creating processes that continually strive to improve those inefficiencies. In short, organizations looking to “add more stuff” should be looking to do so without a corresponding increased resource expenditure. An organization’s economy of scale can be achieved through the consolidation of effort or volume and enhanced automation. The scalability of your systems and workflows becomes paramount.

Scalability

When capturing professional charges, a large contributor to the accuracy and timeliness of charges is the established workflow at the organization. Problems can arise when two disparate organizations merge or consolidate and their workflows, language, or integration capabilities differ sharply. Couple that with equally disparate EHR’s or billing systems, and the desired economy of scale becomes extremely difficult. Establishing the technology being used as the source of truth, best practice workflows, and centralized resources across all departments can minimize the risk of inaccurate data, missing charges, unnecessary charge lag and miscommunication across the revenue cycle. As an organization grows—adding more patients, providers, or services—these scalability methods allow for a more efficient process.

The Gap

At complex healthcare organizations it is not uncommon for each clinical department to use a different method of charge entry or charge reconciliation or documentation. Perhaps all three utilize different systems, which can often be the result of healthcare mergers and acquisitions. There may be separate coding teams for professional and facility charges, or for each department. There may be separate payor teams, or teams based on provider specialties. They could also be using different technology solutions—or no technology solutions—for their revenue cycle needs, making the charge process more resource-intensive than is optimal. And the greater the variation in process among departments and resources, the greater the chance for errors and the more difficult the ability to track and correct those errors. The more steps there are in a process the harder it is to figure out why that process is breaking down.

Correcting those errors and repairing a flawed process requires a robust feedback loop between revenue cycle resources, providers, and administration. That communication will suffer under differing and multiple workflows. Unfamiliarity between organizations can also contribute to hesitancy in the feedback loop.

System and workflow processes are not the only areas affected by this gap. System data, including registration, documentation, and coding can all be impacted by differing terminology or organizational requirements. Perhaps due to regional or specialty-specific requirements, important information for one location or department might not be a priority for another. Administratively, inconsistent data could easily cause problems down the line, resulting in additional denials or resource-heavy re-work.

For example, integrating incomplete EHR registration data into a billing system ultimately responsible for a claim might overlook critical data required to create an accurate charge. The result might be a denial or the incorrect payment for the service rendered. Perhaps there is no ability to set up indicators to alert caregivers when specific information is required for the patient. Even with appropriate feedback to the source of the error, it is possible that nothing can be done since the capability to “flag” the account is not available. Coding can be a complex process with differing regional or payor rules or organization-specific requirements due to payor contracts. If your front-line workers do not have consistent access to that information at the time of the service, there can be no efficient feedback that will correct the problem at its origin.

The downstream impact can be substantial. For providers, compensation is often tied directly to their productivity. If they are not coding correctly or charges are lost during timely filing it can have a major impact on their work RVU’s causing revenue leakage. It may also lead to increased workloads for already stressed providers seeking to improve their bottom line.

Addressing the Gap

Ideally, all of the above concerns are addressed and corrected prior to organizational change. In practicality however, leadership tends to address the “bigger issues” during the change process which may leave little time for revenue cycle administrators to fully evaluate existing workflows and implement new systems. Left with having to “figure it out”, there are steps that can be taken to address the gap and create scalable solutions to resolve the inevitable problems.

First, fully document all existing workflows in all areas. Comparing workflow steps line by line will illuminate best practices and provide context for differing requirements. Steps required for outpatient infusion coding, for example, might not be necessary for hospitalist charging. Note those differences and evaluate them against workflow steps for other departments. Patterns will emerge that can provide direction when adding services or incorporating new specialties, allowing solutions to be more easily implemented.

Also be sure to associate workflows and their overall performance against your KPI’s. Take note of strong performers as they are more apt to provide your best practices. Determine weak performers and research their bottlenecks and issues. Can your weak performers benefit from the same workflow as your strong performers? Maybe, but there may be a specific rule or requirement that is leading to a weaker performance. Detecting and isolating those circumstances will lead to improved workflows that can be implemented enterprise-wide.

Leverage existing expertise. Differing workflows does not always mean the existence of a problem. As noted, differing requirements will lead to differing workflows, so be sure to consult the experts when evaluating processes. There may be very good reasons for adding specific steps to a workflow. Be sure to identify those areas where this is the case, and adjust your best practices to accommodate them. Be wary of the “Silo” effect, where workflows and processes are so specialized

Evaluate and implement available technology that will provide integration across multiple systems and a consistent workflow and terminology across all departments. Technology should be flexible enough to allow for differing requirements and workflows. It should be able to help identify bottlenecks and issues as they are happening, with a strong reporting component and robust messaging capability.

Refine revenue cycle choke areas through analytics and reporting. Relying on month-end data to isolate and correct issues could be too late. Look to implement technology that allows a real-time view of current charges and charge opportunities. It is much more difficult to detect a problem many days or weeks after it happens.

Impact of Addressing Gap

Streamlining your revenue cycle operation by integrating all disparate data into one system allows for a standardization of the data and ensures that information needed for complete and compliant claims is easily accessed. Performance can be compared across multiple specialties, groups, locations, institutions, and providers. Automated real-time reports can identify problem areas and bottlenecks and their sources. Communication between coders, providers, and revenue cycle team members occurs immediately, allowing claims to be corrected prior to being sent. And, when new services or providers or specialties are added, appropriate workflows can be implemented quickly with fewer resources and your organization becomes much more efficient.

Centralizing charge capture and reconciliation programs allows organizations to leverage resources in multiple different areas, lessening the risk of denials, inaccurate billing, and potential missed revenue for providers.

A charge management system with robust communication capability will help eliminate the “Silo” effect. Providers, coders, 3rd party workers, nurses, and administrators all have a stake in getting paid appropriately for their services. An effective communication tool, allowing questions and requirements to be shared among care team members helps prevent the “That’s Not My Job” mentality.

Steps to Take Right Now

If your organization is involved in a merger or significant expansion, you should consider the following steps for your revenue cycle organization.

  • Evaluate all of your existing revenue cycle workflows, noting differences and their reasons
  • Create best practice workflows, starting with the least complex scenario
  • Implement best practice workflows and evaluate performance in real time
  • Review your KPI’s for outlier data which will indicate a problem or bottleneck
  • Evaluate available technology to centralize your revenue cycle processes such as charge management, reconciliation, robust reporting, flexibility, and communication across care teams in real time
  • Automate everything you can

EHRs were never designed to ensure effective charge capture documentation and communication. Centralizing your revenue cycle management processes can help you diagnose problem areas and allow corrections to happen quickly and across all departments. Automating as many processes as practical reduces resources required to manage your operation. Establish your best practice workflows—and update them continually as new rules, regulations, and requirements become necessary. Implementing a centralized revenue cycle management system can make these tasks easier and should allow you to scale your system efficiently during organizational change.

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How to fill mid-revenue cycle gaps in your EHR – Part 1: Reconciliation

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