EMERGING TRENDS IN REVENUECYCLE MANAGEMENT

 

Presented byDavid Nordella

 HSM 571 – Clinical and Financial Management

Department of Health Services ManagementUniversity of La Verne

 James Peelgren

InstructorFall Term

November 6, 2010 

Presentation OverviewHistory of Revenue Cycle Management (RCM)

Changing Definition of RCMGoals of new RCM

Motivations for changes in RCMImprovements in hospital processes

Implementation Benefits

Impact on employees SummaryQuestions

Tedious manual laborPatient discharged

Pre-bill Editing, BillingWork-list for editingClaim generated

Claim logged into the general ledgerElectronic claim file produced

Edited claim is sent to a clearinghousePaper report for rejected claim

Corrections made for remittanceClaim is resubmitted

Collection and posting of payment

Changing DefinitionPrevious definition concentrated on the back-end of

the cycle and correcting discrepancies caused by problems in the front-end

“All administrative and clinical functions that can contribute to the capture, management and collection of patient service revenue “, Healthcare Financial Management Association

Motivations for changes in RCM practices

Labor is expensive Demands from payers for coding and documentation

increased with costsUnsustainable and rising increases in U.S

expenditures as a % of the Gross Domestic ProductDemographics are driving growth in use

Improving net collections and prompt payments improve cash flow

Use of technology can improve collection of unrecovered amounts by large %

Goals of emerging RCM Generate charges from Computerized Physician

Order Entry (CPOE)Automated performance with bi-directional feeds

Positive patient experience from registration through payment

Increased physician and nursing productivityCo-ordination of payment processing with payers

Advance Beneficiary Notice (ABN)“Connected patient “ with administrative supportUse of Enterprise Patient Index (EPI) for unique

identifiers

Improvements in hospital processesDashboard access to RT data

Powerful analytic tools for managementRules-driven workflow with management by exception

Single databaseIntegrated solution with capacity for bolt-ons

Reduction of system complexity (user friendly)Manual tasks frequently reviewed for conversion to

automationLow cost of ownership

Improvements in other services

ImplementationStrategic review

Team process with integrated clinical and business teams.

Shared responsibilities No “silo” perspectives

Processes>personnel>technology

Key Performance Indicators (KPI)Implementation of Data Marts for high level data

Beware of acronyms –what is ROI?“Ideal” solution should be mapped

“Pragmatic” solution should be mapped for fallback if resources are limited Maps reviewedMaps finalized

Maps distributedResults measured by metrics

Reapply process

BenefitsCo-ordination with payers reduces claims, reduces

administrative expenses, improves cash flowKnowledge of criteria for prompt payments

Reduction of coding errors that produce denialsEasier collection of denials when an error is made

by payerEasier distribution of work when an error is identified

by payerDemonstration of goodwill by identifying over-

payments as well as under-payments

Benefits (continued)Easier audits of denials

Earlier recognition of Present on Admission (POA) for reduction of Re-Admissions

Added protection against Recovery Audit Contractors compensated on contingency by

Centers foe Medicare & Medicaid Service (CMS)Proper RCM will complement the transition to ICD-

10-CMHigher employee morale from respect for career,

education, compensation

SummaryImprove cash flow- reduction of denials, decreasing bad

debt, prompt payments and postingsComputerized manual tasks under rule-driven work by

exception Reduction of system complexity

Improves high-level review of structures and activityPromotes transformative care by assembling all patient

documents and dataAligns the interests of patient, hospital, payers, MedicareComplements rather than compete with other technology

initiatives

Questions?

Contact David Nordella805.991.6001dnordella@sbcglobal.net