TAKING A FRESH APPROACH TO HEALTH INFORMATION CAN REVITALIZE YOUR REVENUE CYCLE How financial leaders use health information management to maintain a sustainable revenue cycle Presented by Optum360
PATIENT CARE CLINICAL DOCUMENTATION IMPROVEMENT CODING CODING SERVICES REIMBURSEMENT 100 % AUTOMATIC CONCURRENT CASE REVIEW 2.4 % -4 % INCREASE IN MEDICARE CMI 0 STAFFING CHALLENGES RECOVERING LOST REVENUE IS THE FIRST STEP TO A STRONGER FUTURE. In today s health system, leaders have to make difficult choices among many urgent financial necessities. They need to do more with less and find ways to solve daily cash demands while keeping an eye fixed on the future. By using next-generation health information management (HIM) strategies, it s possible to recover lost revenue today and build the financial security your organization will need to thrive tomorrow. The right combination of HIM technologies and services, adapted to the unique needs of your organization, can help you achieve fair, accurate and complete revenue capture. 2
REVENUE AT RISK HOW MUCH OF YOUR ORGANIZATION S REVENUE IS AT RISK? Right now, providers lose too much of the revenue they earn, simply because they believe it s too difficult and too costly to recover. Much of that lost revenue falls through the gaps between legacy health information systems and the modern revenue cycle. COMBAT DECLINING REVENUES WITH OPTIMIZED HIM Even organizations who have made immense investments of capital and talent in developing EMR systems and preparing for ICD-10 may still be losing revenue that they could capture. Hospital revenues are at an all-time low, and costs are rising even faster leading to historic operating losses. 1 And pressure on the top line is only increasing as providers move toward value-based care. The good news is that strategic investments in the HIM portfolio can help health care organizations cut costs and reveal vital revenue that s being lost to incomplete clinical documentation and inaccurate coding. Historic operating losses Regulatory pressures Self-pay balances Providers assume increasing risk Revenue through optimized HIM Improved Medicare CMI Smart cost savings More complete charge capture LEGACY REVENUE REVEALED REVENUE 1 Beth Kutscher, Hospitals squeezed as revenue growth slows to all-time low, Modern Healthcare (27 Aug. 2014), http://www. modernhealthcare.com/article/20140827/news/308279955/hospitals-squeezedas-revenue-growth-slows-to-all-time-low. 3
HIM INVESTMENT REVENUE INTEGRITY THROUGH HIM START GETTING RETURNS ON YOUR HIM INVESTMENT. Despite making substantial investments in health information technology, many health care organizations still haven t maximized the potential of the HIM portfolio the vital link between front-end and back-end revenue cycle processes. And as a result, many providers aren t taking complete advantage of the information they already have and the investments already made to improve efficiency, lower costs and improve the patient experience. 4
HIM INVESTMENT REVENUE INTEGRITY THROUGH HIM FIND THE GAPS. Improvements in clinical documentation and coding can help organizations reduce costs and improve cash flow, ensuring that providers stay financially strong enough to care for patients. Most providers now have a clinical documentation improvement (CDI) program in place, and any organization s financial and HIM leadership will certainly agree that improving the accuracy of coding is essential. INADEQUATE CDI AND CODING EFFORTS LEAD TO: LOST REVENUE and OUT-OF-CONTROL COSTS REVENUE COSTS But old health information habits legacy technology systems, out-of-date workflows, or consulting arrangements that have stopped showing benefits can undercut even the best clinical documentation and coding programs. INCREASED ADMINISTRATIVE OVERHEAD STAFFING CHALLENGES 5
HIM INVESTMENT REVENUE INTEGRITY THROUGH HIM RECOVER LOST REVENUE THROUGH STRATEGIC HIM INVESTMENT. With the right strategy, your HIM portfolio can be transformative: patient care, properly documented and coded, yields the revenue that will strengthen your organization. Providers who have invested in NLP-enabled CDI and CAC technologies have realized results like these: Three optimizations can yield the greatest returns: Clinical documentation improvement (CDI) Computer-assisted coding (CAC) 26 % INCREASE CDI PRODUCTIVITY 10 % INCREASE INPATIENT CODER PRODUCTIVITY 2.7 DAYS REDUCTION IN DNFB CASES Coding services 100 % AUTOMATIC CDI REVIEW 60 % REDUCTION TIME FROM CODING TO FINAL BILLING 2.4 % -4 % INCREASE MEDICARE CMI 6
CDI ACCELERATING CASH FLOW THROUGH HIM NEXT-GENERATION CDI. The importance of electronic documentation goes far beyond proving meaningful use of EMRs. Electronic documentation is the mainspring of today s revenue cycle as a whole. Yet most CDI efforts are limited to catching specificity problems, missing clarification opportunities in clinical documentation. Today s most sophisticated natural-language processing (NLP) technology applies clinically based algorithms that are adapted to the mix of semi-structured and structured content within electronic documentation, and links clinical indicators across a patient s complex medical record. A leading-edge CDI system reviews cases automatically, leverages NLP to identify specificity problems and clinical clarification opportunities, and uses intelligent case-finding logic to identify the specific cases that present the greatest possibilities for improvement. Capabilities like these help ensure that your organization accurately captures the care provided in every case. By investing in a smarter CDI system, providers can catch not only specificity errors but also gaps in clinical clarity. 7
CDI ACCELERATING CASH FLOW THROUGH HIM Next-generation CDI programs with NLP can: Reduce A/R days and DNFB cases by facilitating case review during a patient s stay to empower your staff to correct documentation issues before the patient is discharged. Automatically review every record for specificity and gaps in clinical clarity, increasing your ability to identify and act on the cases with the greatest opportunity for improvement. Improve your clinical and business intelligence through informative reporting that helps your program s effectiveness by identifying opportunities for improvement. Contribute to the successful use of the ICD-10 code set. 8
CDI WORKFLOW ACCELERATING CASH FLOW THROUGH HIM HOW LEADING-EDGE NLP POWERS ACCURATE AND COMPLETE CLINICAL DOCUMENTATION. CLINICAL DOCUMENTATION IMPROVEMENT ENTRY MEDICAL RECORD LEADING-EDGE NLP IMPROVEMENT ACCURATE CLINICAL DOCUMENTATION Clinicians document each case with a focus on patient care, not revenue capture Complex medical records can contain errors and gaps that staff are unable to catch NLP engine applies clinically based algorithms adapted to the mix of content within medical records Opportunities for improvement flagged for review both specificity errors and gaps in clinical clarity Accurate and completely documented cases are ready for coding 100% automatic case review occurs concurrently with patient care 9
CODING REDUCING THE COST OF RCM COMPUTER-ASSISTED CODING. Complete clinical documentation helps enable more accurate coding to achieve appropriate capture of revenue, but CDI alone is not enough. When up to 5% of claims are denied by payers, it s imperative to ensure that you re coding every claim as accurately as possible. 2 The ICD-10 era of coding promises to improve the potential for providers to be fairly compensated for the care they provide but only if they have systems in place to use the complexity of ICD-10 in powerful and cost-effective ways. Fortunately, financial leaders can take advantage of recent advances in technology to transform ICD-10 from a burden to a benefit. Today s most sophisticated computer-assisted coding (CAC) uses NLP technology to parse documentation, automatically reading clinical documentation to identify diagnoses and procedures and recommending codes to be assigned to clinical cases. Leading-edge CAC provides quick, accurate and consistent interpretation of clinical documentation making the coding process a powerful lever of revenue. 2 American Medical Association, 2013 National Health Insurer Report Card, http://www.ama-assn.org/resources/doc/psa/2013-nhirc-results.pdf 10
CODING REDUCING THE COST OF RCM Today s best CAC technology has been shown to: INCREASE PRODUCTIVITY Increase productivity by allowing coders to complete more cases in less time, decreasing or eliminating coding backlog and staff overtime costs and reducing A/R days and DNFB cases. IMPROVE ACCURACY Improve accuracy by ensuring that all diagnosis and procedure codes are captured correctly, reducing the chance of denials and rework, improving reimbursement and driving CMI. Enhance consistency by using NLP relieving coders with varying levels of experience from the frustrating task of interpreting puzzling documentation. DRIVE EFFICIENCY Ensure coding traceability by linking all assigned codes to clinical documentation, which provides an improved audit trail. 11
CODING REDUCING THE COST OF RCM HOW NLP ENABLES PRECISE AND EFFICIENT CODING. COMPUTER-ASSISTED CODING LEADING-EDGE NLP MEDICAL RECORD CODES ACCURATE CODING NLP engine parses clinical documentation to identify diagnoses and procedures Recommended codes are automatically generated, leveraging the entire code set All assigned codes linked to clinical documentation for complete traceability Completely and accurately coded cases generate cleaner claims, reducing risk of denial and accelerating reimbursement Coders with varying levels of skill can complete more cases, more consistently, in less time 12
CODING SERVICES REDUCING THE COST OF RCM CODING SERVICES. As the capital costs and regulatory burdens of the changing health system impose increasing weight on providers balance sheets, 90% of financial leaders worry that they simply won t be able to fund the cost of upgrading their in-house RCM systems. 3 Their worries make sense especially when it comes to the vital and increasingly costly RCM process of coding. Containing costs is an urgent necessity, and the challenge of finding a qualified coding workforce is becoming acute. Consequently, the financial leaders of some organizations are making the strategic decision to trust the increasingly complex and expensive functions of coding to outside experts. For these providers, using a coding services partner makes financial sense: it diminishes the challenges of recruiting and retaining qualified coders and significantly reduces administrative overhead expenses. And these benefits come without requiring the substantial and ongoing capital costs of supporting an in-house coding team. A coding services partner can enable your organization to enjoy the benefits of the best coding talent available. 3 Providers embracing RCM outsourcing, Healthcare IT News (26 Nov. 2014), http://www.healthcareitnews.com/news/providers-embracing-rcm-outsourcing. 13
CODING SERVICES REDUCING THE COST OF RCM The right coding services partner can help you: Reduce overall coding costs and eliminate the challenge of finding, retaining and supporting qualified local coders. Achieve consistent coding quality without the high overhead costs of coder training, ongoing education and monitoring. Ensure seamless coverage, even during unanticipated spikes in volume, with scalable support. Maintain accurate and consistent code assignment and establish a coding audit trail. 14
CODING SERVICES REDUCING THE COST OF RCM HOW A CODING SERVICES PARTNER CAN REDUCE THE COST OF RCM. STAFFING CHALLENGES EXPERT CODING SERVICES Staffing challenges and legacy technology can make in-house coding inefficient and unsustainably costly Partnership with the right outside expert can solve coding challenges Coders with ICD-10 expertise increase coding quality, even during spikes in demand Reducing in-house coding operations eliminates staffing problems Expert coding staff can make the most of existing coding systems or use leading-edge CAC technology 15
PARTNERSHIPS THE RIGHT RELATIONSHIP IS EVERYTHING. Since your HIM systems are at the center of your revenue cycle, choosing the right partner to provide your CAC, CDI or coding services solutions takes care and discernment. The right partner will understand that your organization is both a business, with very real capital constraints and financial targets and also a provider of care, with a profound and unshakeable responsibility to care for the health and wellness of individual patients. In practice, you can recognize the best CAC, CDI or coding services partners for your organization by ensuring that they: Bring deep and specialized expertise in health care, rather than providing generalized services across several unrelated industries. Provide the support and expertise you need to integrate nextgeneration CAC and CDI capabilities with your existing systems. Understand the complex and sometimes difficult dynamics of outsourcing, providing support and resources to help you communicate with your team and the community you serve. Provide effective training for your clinical and administrative staff. Maintain open channels of communication to ensure quality processes and transparency. 16
HIM INVESTMENT THE RETURNS ON HIM PORTFOLIO INVESTMENTS ARE MORE THAN JUST FINANCIAL. As a financial leader, it s your responsibility to make sure that every investment your organization makes achieves the greatest possible return. For the vast majority of providers, strategic investment in coding and CDI solutions will pay for itself many times over. The benefits of investing in clinical documentation improvement and accurate coding go far beyond improved financial performance. The technology and services that drive financial performance for providers benefit patients as well. As your organization integrates patients health information more deeply into the revenue cycle, you improve the patient experience and lay the foundation for a thriving future.