Revenue Cycle Define Production Cycle Role of HIM in the Revenue Cycle Metrics/Benchmarking Future

"All administrative and clinical functions that contribute to the capture, management, and collection of patient service revenue."  - HFMA

Successfully managing the revenue cycle is the blood line of an organization

The are a number of Revenue Cycle stakeholders throughout the cycle…

PatientAccess

Case Manage-ment

Clinical Documentation & Charge Capture

Medical Record Completion & Coding

Billing & Collection

Denial and Contract Management

Scheduling Medical necessity reviews

Patient care documentation

Discharge/encounter reconciliation

Claims Processing

Claims analysis

Pre-registration

Documenta-tion reviews

Charge capture

Record Assembly (scanning) and Completion

Insurance Follow Up

Appeals

Insurance verification

Financial Counseling

Clinical Criteria monitoring

Chargemaster maintenance

Obtaining complete physician documentation

Collections

Payment posting

Recoveries

Payer contract analysis

Authorization/Pre-certification

Payer Communica-tion

Diagnosis and Procedure Coding

Developing Payer Network

Up-front cash collections

Utilization Review

DNFB management

Revenue Cycle Organizational Chart

Metrics Driven Leadership Team

Process Improvement Teams

High Dollar/High Risk Account Meetings

Cross Functional Team Meetings

Denial Prevention Team Meeting

Patient Access 2.25- 6.75%◦ Scheduling/IV, Pre-registration, Registration, ED

Processes HealthCare Billing 1.7- 4.05%

◦ Charge Control, Documentation, Coding, Patient Status

Patient Accounting 1.5- 4.25%◦ Cashiering, Claims Processing, Follow-up, Secondary

Billing, Support Areas .02- 4.5%

◦ Chargemaster, Pricing, Contracting Support, Reimbursement Management,

Business owner of the legal record Discharged Not Final Billed (DNFB) Documentation management/improvement Coding Revenue Integrity Denial Management Regulatory compliance

Traditionally an HIM function Only Record completion Stratify priorities Coding complete Best practice measure: < 2 days from bill

hold

Timely and accurate coding Identifying missing documentation Trending and analyzing case mix Post discharge queries Auditing Education Impacts:

◦ Core measures◦ Quality◦ Reimbursement◦ Denials

Define requirements by patient type CDI Specialists;

◦ Concurrent chart review◦ Physician queries◦ Provider education◦ Ensure compliance◦ Core measures

Provide data, feedback and education Design/redesign forms Impacts:

◦ Coding/severity of Illness◦ Case Mix Index◦ Readmissions◦ Quality management ◦ Accreditation◦ Reimbursement

Liaison Between Clinical and Revenue Cycle Partners

Charge Capture and Auditing◦ Observation Carve Outs◦ IV/ Infusion◦ Late Charge Management

Pre-form Pre Bill Claims Review;◦ CCI, Medical Necessity , Revenue Code Mismatch

Chargemaster Owner/Maintenance Pricing Optimizing Payer Contracts

Clinical:◦ Lack of precertification ◦ Medical necessity

Technical:◦ Incorrect code assignment◦ CCI edits◦ Missing or incorrect modifiers◦ Incorrect patient identification◦ No response to record request◦ Documentation does not support charge

Denial Management Team Track and trend HIM denials Reporting and feedback to providers and

staff Record request TAT Monitor DNFB for timeliness Know payer filing limits Participate appeal process

◦ Ensure correct MR included with appeal◦ Assist in writing appeal letters for coding changes

Why establish and monitor metrics and benchmarks? Measure Performance

Consensus on Revenue Cycle excellence Trending

Compare Performance How do we compare to our peers

Improving Performance What are the targets To identify and implement best practices

KPI Best PracticeStandard

KPI Best PracticeStandard

Days in Accounts Receivable

45-50 days % Insurance Verification

100% of patients with insurance

% Bad Debt 2% (percentage of gross revenue year to date)

% Pre-authorization / Certification

100% of scheduled patients

Discharged Not Final Billed(DNFB)

<2 days beyond bill hold Denial Rate Goal: < 2%

Coding/DRG/APC Accuracy Rate

>95% At least one annual external audit

% of Clean Claims 95 – 97%

Liquidation 101% -103% of expected Net Revenue

% of Accounts Receivable > 90 days

< 20%

19

KPI Best PracticeStandard

KPI Best Practice Standard

LOS, by DRG < or = DRG average Late Charges as % of Total Charges

= or < 2%

ACD Call Abandonment Rate

=< 2% Lost Charges as % of Total Charges

= or < 1%

Rate increases compared with CPI medical-care component

> or = CPI MCC Chart Delinquency Rate beyond 30 days (Joint Commission)

< 5%

Readmissions < or = DRG average Total Chart Delinquency

<10%

A/R cash as a % of net revenue

= or > 100% POS Collection Rate =or > 20% of Total Patient Payments(Cash)

Increasingly insured population Delivery model redesign Payment transformation

◦ Expansion of P4P◦ Bundled payments◦ Value Based Purchasing

Standardized charge reporting Increased government oversight

◦ RAC/Medicaid Integrity Audits/Pre-Payment Requirements for tax-exempt hospitals