High Value Revenue Cycle Audits AHIA 2009 Annual Conference September 1, 2009
Speakers Richard Williams Richard is a Director in Protiviti s Dallas office and a key leader in Protiviti s Healthcare Revenue Risk Solutions practice. Richard has more than 11 years professional experience providing operational, financial, and regulatory consulting and internal audit services to the healthcare industry. Prior to joining Protiviti, Richard was a Project Manager at Arthur Andersen focusing on healthcare internal audit and risk consulting. Don Billingsley Don is a Senior Manager in Protiviti s Dallas office and a key leader in Protiviti s national healthcare practice. Don has more than 16 years experience working in the healthcare industry and has worked with numerous healthcare providers to assess and improve their revenue cycle operations and processes. Prior to joining Protiviti, Don worked as a revenue cycle consultant at Arthur Andersen and held a position as a care manager and compliance auditor for one of the largest diversified specialty healthcare management organizations. 1
Agenda Obtain an understanding of the key activities performed, risks and typical deficiencies that exist within the following revenue cycle components: Access & Utilization Review Charge Capture Billing / Collections & Denials Management Discuss audit methodology, approach, and scope setting considerations. 2
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Obtain an Understanding of Key Revenue Cycle Components and Risks
The Revenue Cycle Healthcare providers typically fail to realize as much as five percent in net revenue due to a lack of effective internal controls mitigating g financial, regulatory and operational risks. 5
Key Challenges Information is traditionally managed in isolation by different departments with very little integration Multiple points of patient entry Numerous managed care contracts and lack of familiarity with requirements Legacy technology solutions and workflow limitations Multiple constituencies require consensus and tend to resist change Adequacy of training programs Payer stall tactics and decreasing reimbursement Poor auditing, reconciliation, and monitoring processes Unequal priority for administrative responsibilities as that placed on patient care 6
Access & Utilization Review Patient access is one of the most important areas that impact patient satisfaction and hospital reimbursement. Ineffective processes typically result in patient dissatisfaction, billing problems, excessive insurance denials, and extensive rework activity. Scheduling gathering patient information to schedule a patient s test, procedure or stay Admissions/Registration verifying benefits to validate insurance coverage, obtaining pre-treatment authorizations and any remaining information not captured during scheduling/pre-admission process Utilization Review the managing of admission reviews, precertification reviews, medical necessity reviews, continued stay reviews, patient care reviews and retrospective reviews 7
Charge Capture On average, organizations are losing one percent of revenue to errors in the chargemaster and/or charge capture and many hospitals are not aware of the degree to which they may be missing charges. Charge Capture documentation, posting and reconciliation of charges for services rendered Chargemaster listing of charges for procedures, medications, supplies and services rendered Charge Validation / Integrity ensuring charges posted are complete and accurate 8
Billing / Collections & Denials As much as 25% - 30% of all claims are rejected or denied at some point in the collection process with 5% - 9% of net revenue being directly impacted, a large portion of which is lost and never recovered. At least 90% of all denials considered unrecoverable can be prevented with improved controls. Billing sending a bill to a patient and/or a claim to a third-party payer for reimbursement Collections / Cash Posting verifying the status of outstanding claims and posting payments received Denials / Underpayments Management the process of collecting, tracking, reporting, trending, forecasting, measuring and managing denied or underpaid claims One of the best indicators to help determine the effectiveness of a provider s revenue cycle is to look at denied claims. 9
Methodology and Scope Considerations
Methodology The Protiviti Key represents our overarching Methodology that we apply to every engagement in order to unlock value and ingrains concepts of problem solving and benchmarking. 11
Methodology We commonly use the Six Elements of Infrastructure for categorizing operational practices, potential issues, understanding where problems either exist or may occur within the organization, and drawing conclusions to form the basis for recommendations. Business Policies Business Processes People and Organization Management Reports Methodologies Systems and Data Risk if element is deficient: Process does not carry out established policies or achieve intended result People lack the knowledge and experience to perform process Reports do not provide information for effective management Methodologies do not adequately analyze data and information Information is not available for analysis and reporting 12
Audit Objective The primary objective of performing a revenue cycle audit should be to evaluate the effectiveness of internal controls surrounding existing revenue cycle processes in order to identify business process and/or system improvement opportunities within existing operations that, when implemented, would lead to enhanced profitability and strengthened compliance practices. In addition, an entity and process level view should be considered. 13
Audit Approach The approach should be designed to gain an understanding of the business as a means to identify, source and measure risk at both the entity and process level. What are the key business risks that impact the process? How and how well are those risks being controlled? What key measures are used to monitor the process and are they the right ones and reliable? How efficient is the process in operation? How can the process be improved to bring its performance closer to leading standards? 14
15 Control Framework Example
Scoping Considerations Design Review vs. Operating Effectiveness Testing Documentation ti Review vs. Observations Regulatory Compliance Revenue Cycle Systems and Application Controls New System Implementations Net vs. Gross Revenue Impact Data Analysis / Sampling Indicators of Need / Benchmarking Revenue Cycle Diagnostic Frameworks / Tools 16
Please feel free to contact us if you have additional questions. Thank you again for your time! Richard Williams Protiviti Director and Healthcare Revenue Risk Solutions Leader Direct: 469.374.2469 Email: richard.williams@protiviti.com Don Billingsley Protiviti Senior Manager and Healthcare Revenue Risk Solutions Leader Direct: 469.374.2519 Email: don.billingsley@protiviti.com 17