Healthcare’s Evolving Reimbursement Imperative

By Vasilios Nassiopoulos, Vice President of Platform Strategy and Innovation, Hayes Management
Twitter: @HayesManagement

Embracing the shift from revenue cycle to revenue integrity

Reimbursement is becoming increasingly complex for today’s providers. And while it is fair to say that a certain amount of missed revenue has always been part of the bottom-line equation, healthcare organizations simply cannot afford to leave money on the table in the current market climate.

Already operating within razor-thin margins, today’s hospitals and health systems must now address current and future reimbursement and revenue risks introduced by the COVID-19 pandemic. In a recent study, Strata Decision Technology estimated that 97% of health systems will lose an average of $1,200 per coronavirus case, or as high as $8,000 in some instances—even with the 2% Medicare payment increase.

That loss comes in addition to the revenue fallout associated with elective procedures that were halted for more than a month in most cases—a decision that could be revisited in emerging hot spot areas. Further exacerbating the situation is an expected increase in denials as healthcare organizations navigate a fluid regulatory environment and learn how to interpret new guidance.

Consequently, forward-looking providers are increasingly embracing a shift from revenue cycle management to broader revenue-integrity models to achieve greater efficiency, patient engagement and claims accuracy. The best strategy for implementing this enhanced approach engages collaborative technology-enabled processes with effective governance.

Revenue Integrity: Understanding the Shift
By definition, revenue integrity characterizes a provider’s ability to clearly identify, track and realize the revenues they are due for the care that is provided. This model builds on the traditional revenue cycle management approach—which addresses end-to-end oversight of billing and payment processes—through proactive identification of revenue breakdowns and timely enactment of process improvement measures.

Progressive revenue integrity models integrate systems and processes that create strong partnerships between revenue integrity, revenue cycle and billing compliance teams—professional functions that have often operated in silos creating a fragmented approach. Through these partnerships, a revenue integrity teams can engage in shared monitoring and auditing processes, ultimately streamlining budgets and improving revenue recoupment.

In particular, billing compliance is a very cost-constrained function inside today’s healthcare systems. While addressing this area is a necessary evil, it is often hard for healthcare organizations to justify allocating extra dollars to optimize this area with so many competing priorities. Within a technology-enabled revenue integrity model, the business case for investing in infrastructures and strategies that elevate oversight of this area is easier to make. Revenue integrity teams are able to not only protect an institution from risk but also improve revenue retention and often, identify dollars that might otherwise be left lying on the table.

Once this systematic collaboration and communication is in place, it becomes much easier to eliminate revenue cycle complexities—such as those created by the current pandemic—that can fast become liabilities for providers

Steps to Realizing a Better Bottom Line
Analytics plays a key role in helping lay the groundwork for sound revenue integrity practices. With the right infrastructure in place, revenue integrity teams can engage in two key strategies that will support optimal reimbursement.

  • Continuous auditing of claims
    Auditing of claims for proper coding and clinical documentation should be ongoing to ensure accurate, compliant submission of claims to minimize denials. Analytics driven by artificial intelligence can be a critical enabler of these processes in terms of monitoring updates, staying abreast of changes across payer reimbursement policies and ensuring claims are compliant.

Many healthcare organizations use analytics to engage in risk-based auditing, where they can target areas that have the greatest impact on mission-critical activities. This strategy has been significantly important amid the evolution of COVID-19 reimbursement and increased use of telehealth. Advanced solutions that automatically release new ICD10 codes and telehealth guidance streamline the ability of a providers to operationalize changes and support ongoing monitoring.

  • Monitoring delayed or denied claims immediately for optimal reimbursement
    Incorrect or incomplete claims that require adjudication can wreak havoc on a provider’s revenue stream. Best practices support setting up mechanisms to monitor delayed adjudication to identify the root cause quickly. Then, an optimal corrective action strategy can be put into play to ensure future claims are submitted accurately and completely.

When technology is used to support ongoing monitoring, revenue integrity teams can rapidly analyze data in near real-time to uncover reasons for delayed and denied claims. Advanced solutions allow organizations to set up analytics that encompass different scenarios directly related to COVID-19 services.

The reimbursement landscape is always in a state of flux, and healthcare organization are increasingly higher levels of scrutiny. In late 2019, the OIG reported that Medicare made $54.4 million in improper payments to acute care hospitals due to incorrectly coded claims. It also recommended that CMS direct its contractors to recover the lost money. The time is now for healthcare organizations to get their revenue integrity and billing compliance house in order. And the best approach draws on the power of automation and analytics to bring together compliance and billing functions in a collaborative way.