1 PART 1: REVENUE INTEGRITY PROGRAM DESIGN, PROCESS AND IMPLEMENTATION CAROLINE RADER ZNANIEC OWNER/FOUNDER LUNA HEALTHCARE ADVISORS AHIA 33 rd Annual Conference September 21-24, 2014 Austin, Texas www.ahia.org
Today s Presenter 2 Caroline Rader Znaniec is the founder and owner of Luna Healthcare Advisors LLC, headquartered in Maryland. Her focus is providing high quality healthcare provider integrity consulting services to the nation's top health systems, hospitals and physician groups, and freestanding providers. Caroline has close to 20 years of healthcare experience within the private industry and as a consulting professional. Prior to starting her own company, Caroline was the Revenue Integrity Services National Lead for Grant Thornton, Associate Director of Charge Integrity Services at Navigant Consulting, Corporate Compliance Officer of a large Maryland integrated health system, as well as other positions within the revenue integrity profession. This is her 3rd year speaking for AHIA. She also speaks for other organizations including HFMA, HCCA, AHIMA and ACDIS. caroline@lunahealthcareadvisors.com
Learning Objectives 3 Determine your organization's revenue integrity needs and how to incorporate into an annual work plan Recite key principles in the performance of a revenue integrity review Assess revenue integrity key performance indicators and benchmarks List the stakeholders and processes behind the success of key performance indicators
Today s Session 4 This session will provide for an introduction to a formal revenue integrity process, including: program design staffing key strategies key performance indicators stakeholder involvement
Takeaways 5 Live Participant handouts: sample program and committee charters job descriptions sample work plan Post conference online copies can be accessed at the following link: www.lunahealthcareadvisors.com/ahia2014 Password: Austin
6 Assess your Program or your Expectations...
Question 1 7 1. Where does the Revenue Integrity Program reside? A. Patient Financial Services B. Compliance C. Health Information Management
Question 2 8 2. Within Revenue Integrity, most of the staffs time is spent performing the following: A. Entering charges B. Auditing and monitoring C. Reviewing and correcting accounts
Question 3 9 3. What word best describes the daily operations of the Revenue Integrity Program? A. Reactive B. Proactive C. Random
Question 4 10 4. What defines the overall goals and objectives of the Revenue Integrity Program? A. Volume of accounts not billed B. A formal work plan C. The fire of the moment
Question 5 11 5. The Revenue Integrity Program measures effectiveness utilizing the following: A. Volume of unbilled accounts; monthly B. Measured improvement against benchmarks and goals C. Reductions in requests for assistance from clinical departments
Tally Time! 12 Mostly A s Not Effective. Your program is in a more reactive state. Programs that operate reactively cannot break the cycle. The root cause of the breakdown compounds the issue and prevents other risks from being identified or addressed.
Tally Time! 13 Mostly B s Potentially Effective. Your program has the infrastructure to identify risks, audit and monitor those risks. However, the healthcare environment is ever-changing and the frequency, content and methodologies utilized to administer the program may require substantial efforts to sustain positive momentum.
Tally Time! 14 Mostly C s Not Effective. Your program is not only reactive, but disorganized. Programs that are not formally structured with clear goals, objectives and direction will not affect change in the process and breakdowns will continue.
Defining Revenue Integrity 15 Revenue Integrity can be a stand-alone department, initiative, program or organizational structure. The basis of Revenue Integrity is to prevent recurrence of issues that can cause revenue leakage and/or compliance risk. Activities under Revenue Integrity are expected to focus more on process improvement. A successful revenue integrity program will provide for a holistic view of the revenue cycle, with support from leadership and technology.
Defining Revenue Integrity (CONT) 16 Revenue integrity depends on compliance with proper revenue-cycle processes from the point where the patient is referred to the organization to the payment of the claim. These processes function sequentially to produce the desired patient outcome and to generate the bill for services related to that outcome. If any of these processes are not functioning properly mistakes may become compounded along the way leading to denial of the claim.
Objectives 17 Identification and correction to the processes and systems that lead to lost revenue opportunities through the creation and oversight of processes to ensure the accurate capture and reporting of data, translation of data into useful information and use of data to support strategic initiatives; Assurance that every chargeable procedure, item or service is coded, documented, captured, billed and paid according to the terms of government guidelines and payer contracts;
Objectives (CONT) 18 Assistance in bringing on new service lines and/or offerings, including clinical trials, and Provide for a resource for other staff members on questions or issues related to documentation, coding, charge capture and billing to create, or better foster, an organization-wide understanding of the importance of revenue integrity.
Key Strategies 19 Create staff awareness at all levels on the individual and provider organization s responsibilities through inclusion of responsibilities in job descriptions, on-boarding activities and annual education; Provide tools and/or guidance to the provider organization specific to those processes of the revenue cycle that are specific to front, middle and back-end revenue cycle processes;
Key Strategies (CONT) 20 Design and implement a monitoring program for high risk areas identified to include the development of review tools, analysis of results to identify root causes and develop corrective action plans, track corrective action plan implementation and verify improvement, and Create and maintain a means for oversight and reporting to leadership.
Structure 21 Models can vary based on several factors of the provider organization: Type Size Clinical Services Infrastructure Culture External Forces Examples for discussion provided on following slide
Structure Example 1 22 Type of Provider Large Health System (6) Academic and Community Urban through Rural Settings Size of Provider 163,000 Annual Inpatients 2 million Annual Outpatient Visits 2,000 Physicians Clinical Services Freestanding Radiology Services Physician Offices & Billing Office Durable Medical Equipment Company Clinical Trials Home Care and Home Infusion Services Infrastructure Culture Corporate Function and Oversight Separate Finance, Reimbursement/ CDM, Compliance and Internal Audit Clinically Advanced (overall) High Financial Performance Complicated Communication Channels Reactive External Forces Single Hospital Under OIG Scrutiny
Structure Example 2 23 Type of Provider Integrated Health System Community Provider Size of Provider 300 Inpatient Acute Hospital Beds 50,000 Annual ED visits 5 Radiology Sites 10 Employed Hospitalists 50 Employed Community Physicians Clinical Services Freestanding Radiology Services Physician Offices & Billing Office Inpatient Chemical & Drug Rehabilitation Clinical Trials Home Infusion Services Infrastructure Culture CDM/Compliance Auditors Revenue Integrity Committee Corporate Compliance Officer Corporate Compliance Committee Finance and Audit Committee Hospital Board Oversight Clinically and Technologically Advanced High Financial Performance Collaboration Amongst Key Stakeholders Open Communication Proactive External Forces Post Satisfaction of OIG Corporate Integrity Agreement
Structure Example 3 24 Type of Provider Small Community Health System Size of Provider 100 Inpatient Acute Hospital Beds 35,000 Annual ED visits 2 Free-Standing Radiology Sites 3 Employed Hospitalists 15 Employed Community Physicians Clinical Services Increasing Outpatient Services Freestanding Radiology Services Physician Offices & Billing Office Infrastructure Culture CDM/Charge Capture Manager, also functioning as Educator Corporate Compliance Officer Looking to Advance Clinically and with Addition of Technology Low Financial Performance "Many Hats" Reactive External Forces Looking for Academic Health System Affiliation
Structure Considerations 25 Define Scope Identify Key Stakeholders Understand Current Initiatives (internal and external)
Staffing 26 Better practice has provided for staffing levels that can administer an effective program through the use of dedicated independent staff. Key stakeholders must understand the objectives of Revenue Integrity and what factors are fundamental to its success. Organizations with the greatest success engage key stakeholders through the use of a Revenue Integrity Committee.
Work Plan 27 The two objectives behind the development of an annual work plan are: 1. Correct the processes and systems that lead to lost revenue opportunities, and 2. Ensure every chargeable procedure, item or service is coded, documented, captured, billed and paid according to the terms of government guidelines and payer contracts.
Work Plan (CONT) 28 To meet the work plan objectives, provider organizations should review for policies procedures, practices and/or processes which include, but are not limited to, the following: Maintenance of the Charge Description Master Use of Tools or Technology to Document, Capture Charges, Code and Bill Responsibilities and Required Knowledge of Registration through to Billing Staff
Work Plan (CONT) 29 The work plan should allow for flexibility. The work plan should allow for revision to accommodate additional items. The work plan should be realistic and achievable. Work plans should identify why the review is necessary. For each work plan item, the scope of the review should be determined and specifically outlined.
Performing a Review 30 In reviewing departments or services, a holistic approach is best: Charge Description Master Review Clinical Subsystem Linkage and Usage Review Administrative and Financial Subsystem Linkage and Usage Review Charge Capture Tools Review Documentation Tools or Template Review Baseline Coding and Documentation Assessment Coding, Documentation and Charge Capture Policies and Procedures Analysis and Review of Payer Remittance Concurrent Review of Processes Interviews of Key Stakeholders
Performing a Review (CONT) 31 The deliverables for each work plan item should be individually defined. A time period for the initiation and completion of the work plan item should be defined. Each task delegated should have a separate and distinct date for completion. Audit activities should remain independent. The responsible stakeholder should not be designated as the reviewer.
EXAMPLE Performance Indicators 32 Eligibility Verification Benchmark Monitoring Scheduled Services 98% verified prior to service System generated report F R O N T E N D ED Services 90% verified prior to discharge System generated report Insurance Verification Benchmark Monitoring OP Scheduled Services 95% verified prior to service System generated report Inpatient Services 100% of patients verified System generated report Financial Counseling Benchmark Monitoring Inpatients (uninsured/underinsured) >95% cleared prior to discharge System generated report Inpatient Services 100% of patients verified System generated report Registration Benchmark Monitoring Registration errors <3% error rate System generated report
EXAMPLE Performance Indicators 33 Interface Reporting Benchmark Monitoring Error Reports/Ques <10% of encounters System Generated Report M I D D L E Documentation Quality Benchmark Monitoring Coding Queries Coding Backlog Benchmark Monitoring Transcription Turnaround 30% concurrent 10% retrospective <24 hours H&P, OP <2 days Discharge Summary Coder Productivity Inpatient 24/day Outpatient/Amb Surg 40/day Emergency 120/day Ancillaries 240/day Late Charges Benchmark Monitoring System Generated Report Query Response Rate 86 90% System Generated Report System Generated Report System Generated Report Late Charge Report < = 2% of total gross charges System Generated Report
EXAMPLE Performance Indicators 34 Claim Editing Benchmark Monitoring Electronic claim scrubbing > 95% clean claim submission Daily claims edit report B A C K E N D Claims requiring editing Worked within 24 hours Daily claims edit report Follow-up Benchmark Monitoring Large balance unit Account inventory <1000 Productivity > 50 accts per day Small balance unit Account inventory <3000 Productivity > 90 accounts per day Discharged Not Final Billed Benchmark System generated work lists System generated work lists Monitoring Outpatient 6 hold days System generated report Inpatient 4 hold days System generated report
Ready for the Next Step? 35 Tomorrow... Part 2: Troubleshooting Revenue Integrity Issues for Today and Tomorrow Regular review of integral revenue cycle processes within a healthcare provider's operations is critical to overall revenue integrity. The monitoring of revenue integrity benchmarks such as DNFB can identify potential issues, but then what? Identifying there is an issue is only half the battle. This session will review "hot topic" revenue integrity benchmarks, provide for tips on troubleshooting and will include the review of actual case studies to lead discussion on how to not only identify, but correct the issue(s). Considerations for organizational culture and industry change will also be addressed. This may include the adoption of an EMR, acquisition and regulatory changes such as ICD-10. Participants will be provided with handouts including detail for the case studies discussed, benchmark matrix, and a revenue integrity checklist for ICD-10 preparation.
Save the Date August 30 - September 2, 2015 34 th Annual Conference Portland, Oregon 36