As hospitals merge, acquire new providers, and navigate the changing payer landscape, revenue cycle management is increasingly challenging for health systems.
A recent HIMSS Analytics survey found that more than 76% percent of health systems found denials to be their biggest revenue cycle challenge with revenue integrity (36.8%) and patient pay (34.2%) following. With competing pressures, it’s easy for the healthcare C-suite to get caught up in the complexities of the revenue cycle and miss the big picture. To ensure financial success, consider these five tips for effective revenue cycle and business office management.
Business office staff can become overwhelmed with high volumes of claim denials. What may be happening is that registrars and appointment call representatives are simply not collecting accurate insurance data during patient onboarding, leading to false denials. When booking appointments, make sure call-center staff collect and accurately input patient insurance information. Moreover, at least one week before the appointment, utilize a financial clearance team and verify insurance on all scheduled encounters. Later, during face-to-face registration, ensure staff check for expired patient identification and insurance cards following a basic registration checklist. Combine these simple steps with re-education, emphasizing the importance of accurate insurance data, and how much errors can cost the organization. Just 10 more minutes spent by front-end registration staff can eliminate several hours wasted on follow-up work on preventable denials and unnecessary claim resubmission.
2. Copay collection
When a health system has multiple clinic locations, consistency in copay collection often falters over time. To regain lost traction, create easy reference sheets with standardized documentation of the proper copay workflow, noting particular transaction codes needed for correct system posting. Across the health system, create and distribute a monthly report on rate of copay collection per clinic location. The monthly reports will hold each clinic accountable by direct comparison to their peers and the national benchmark for copay collection, which is 98 percent of all scheduled appointments. Consider a quarterly prize competition that awards the clinic location with the most improved rate of collection to reach your organization’s goal.
3. Charge capture
Many healthcare organizations still lack a formal charge-capture policy. When charges are posted more than five days after the patient visit or discharge, the risk for lost revenue rises. Documentation gets misplaced, and memories of the clinical visit fade. For establishing the timeframe for late-charge write offs, select a lag day’s value that allows for roughly 95 percent of charges to be posted prior to the initial claim generation step. Keep in mind the industry standard for late charges should be no more than 2 percent of total charges. This measure helps identify opportunities to improve revenue capture, reduce unnecessary cost and accelerate cash flow. Hold one-on-one meetings or perform a detailed analysis for departments turning in late charges consistently.
4. Claims data submission
Many times, payers deny claims simply for a lack of needed information. Instead of wasting valuable time resubmitting claims, strive for proper workflow from the start. For example, if patients seek treatment under workers’ compensation or an auto accident, make sure all the necessary documentation accompanies the initial claim submission. Business office staff should be familiar with the requirements of their major payers. Ensure claims are coded correctly in compliance with ICD-10 and within coverage regulations. Reduce time spent on A/R follow-up and manual edits by integrating an automated coding tool and scrub claims with strategic oversight.
5. Maximize MACRA reimbursement potential
With year 2 of the Medicare Access and CHIP Reauthorization Act (MACRA) Quality Payment Program (QPP) well underway, Merit-based Incentive Payment System (MIPS)-eligible clinicians have the potential to gain or lose 5 percent in Medicare reimbursement. With year 1 as precedence, participating providers should strategically approach measurement selection and data submission for the Quality, Improvement Activities (IA) and Advancing Care Information (ACI) categories. For example, within the ACI category, participating clinicians need to report on all base measures. If not, they will receive a score of zero for the category, eliminating the chance to report on ACI performance measures to build up additional category points. The total possible base and performance measures also depend on certified EHR technology (CEHRT). Using 2015 CEHRT presents an additional base measure requirement, but offers the opportunity to earn 10 bonus points. The goal is to rack up at least 100 ACI category points to reach the full 25-percent ACI score toward the MIPS total score.
From pre-registration processes to MACRA reporting strategy, these five tips will help maximize payer reimbursement and establish strong revenue cycle workflow to smooth the claims management process for healthcare organizations.
About the author:
Joncé Smith is Vice President of Revenue Cycle Management at Stoltenberg Consulting. With over 35 years of healthcare experience, Joncé’ has worked with a wide range of facility types, leading legacy support management, implementation, strategic planning and revenue cycle management projects. She excels with business office transformation, MACRA road mapping and financial data analytics for operational efficiency and financial alignment.
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