Wednesday, May 18, 2016

Stop Revenue Leaks in your Medical Practice

Managing your healthcare revenue cycle is never easy.  Revenue leaks can create havoc with your organizations financial viability.  The root cause of revenue leaks are generally internal, with someone in the system or the system itself, not performing correctly or efficiently.  According to Marc Lion, CEO of Lion & Company CPAs, the average medical practice has a 10 to 15 percent profit leak.
However, the good news is that revenue leaks are preventable with analytics and diligence. Given below are three ways to stop revenue leaks in your medical practice.
Monitor your payments
It is very important to monitor your payments regularly – in fact; it should be part of a weekly schedule.  Despite all the advancements in information technology, errors on medical claims by commercial insurance companies average7.1%, according to the AMA (American Medical Association).  Medical business office associates will key into the billing system what is written on the paper.  Any mistake or undercharge made at your end is going to be reflected as it is and that will definitely hurt your bottom line.  One way to ensure that there are no underpayments is by obtaining the rates directly from the insurance company.  Make sure that you are aware of each rate at the time of negotiating the contract and also when your renewal comes up.  Ask the insurers representative to clarify all your doubts and answer all your queries regarding the reimbursements.
If the rates offered do not match your expectations, negotiate with the insurance company.  You can always get better rates for services that few can perform in your area.  Be sure to check the accuracy of every payment at the CPT code level.  Your system needs to be fed the current fee schedules for you to benefit from them.
Review your denials regularly
It is so much easier to write-off denied payments than to pursue them – and this does happen.  The only way to ensure that your denials keep reducing is to review them regularly.  Is there a pattern to your denials?  If yes, what steps can be taken to ensure that they are not repeated.  Each and every denial needs to be reviewed and pursued; even better if you can do this on a weekly basis.  Bring everyone connected with the denials into the loop and chalk out steps that will ensure that the same mistake is not repeated.  Only if you find that the denial cannot be pursued any further, allow it to be written off.  It is also important to remember that there are time limits for appealing denials.  Make sure that you do not allow this travesty to take place.
Set guidelines in place for everyone involved with medical billing and claims.  Establish a medical claim denial management procedure that has to be followed to the letter.
Time is money
You have worked hard to reach where you are and your time is your biggest asset.  Time is money and wasted time means lost revenue.  Ensure that your office is prepared to fully utilize the time of the day – set up a system that makes efficient use of everyone’s time.  Time lost in searching for something that is not where it should be, hunting for records after a patient is sitting in front of you, trying to find an associate when you already knew that he would be needed – all of these activities cost you precious time and even more precious revenue.
Create a work flow for your staff, make sure that your supplies are all kept in the appropriate place; records need to be placed in the proper files and drawers – these all seem like basic tasks, but believe me, this is where a lot of practices lose time.  It pays to train your staff to work at the peak of their license – from receiving phone calls to preparing the patient for an examination.  The smoother things move, the more number of patients can be accommodated and more patients translate into more revenue.
In a nutshell
These are the key steps to ensure that you do not leak revenue in your medical practice.

  1. Identify all factors involved with your revenue generation and review them regularly.
  2. Mark control points in your revenue stream.
  3. Establish guidelines and measures and make sure they are followed.
  4. Monitor denials regularly and set up a denial management program.
  5. Optimize solutions and execute them.
While it may take time to stem the revenue leakage, it is worth the time and effort required to put these steps in place.  Managing your revenue is an ongoing process that requires regular interventions and changes to match the requirements of the marketplace.  In the end you will find that the results far outweigh the work put into it.

Monday, May 16, 2016

Florida Hospital Gains $72.5 Million Courtesy its Clinical Documentation Improvement Program


Once an informal process that received significant attention at just a few hospitals; Clinical Documentation Improvement (CDI) is now the backbone of an organizations financial viability.  Essential for patient safety, proper and accurate reimbursement, quality ratings and more, a strong CDI program will ensure documentation integrity – a key factor in the ICD-10 transition.  Organizations that seek to improve the efficiency and effectiveness of their CDI programs will find that the rewards are immense.  The benefits received by Florida Hospital stands testimony to this fact.
Healthcare IT News reports that Florida Hospitals implemented the CDI program in 2014 and by May 2015 and completed an expansion across eight affiliated hospitals.  Pre 2014, the observed-to-expected mortality rates for the hospital stood well above the national average.  According to the hospital this was due to gaps and errors in clinical documentation.  Within a year of implementing CDI, the mortality rates were reduced by a whopping 48% – a result of accurate documentation of the disease acuity of the patients at the hospital.  Today, the hospital stands in the top quartile of the industry average.
Florida Hospital aimed towards improving their case mix index by eight basis points through the implementation of more accurate and complete clinical documentation of care delivered to its patients.  By fall 2015, the hospital’s case mix index basis points, which are worth approximately $2.5 million a year for the hospital, had risen to 1.88 basis points from 1.59.  This increase in the case mix index basis points translated to an increase of $72.5 million in appropriate reimbursement.
In a nutshell, Florida Hospital reduced mortality rates by 48%, improved its case mix index, achieved ICD-10 compliance and increased its reimbursement earnings by $72.5 million – all due to its CDI program.  According to the hospital, increased integrity of its clinical documentation, better accuracy and physician engagement are the reasons for their clinical and financial improvement.
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This documentation initiative was driven by educating and engaging 20% or 2,200 medical staff at the hospital.  Physician response rates to CDI clarifications stood between 87 and 92 percent.
Florida Hospital plans to expand their CDI program, using the framework to provide a more efficient workflow for their clinicians and clinical documentation specialists.  Integrated into Cerner’s Document Quality Review platform, computer assisted physician documentation technology will provide physicians with automated CDI clarifications.
According to the American Health Information Management Association (AHIMA), “Successful CDI programs facilitate the accurate representation of a patient’s clinical status that translates into coded data.  Coded data is then translated into quality report cards, physician report cards, reimbursement, public health data and disease tracking and trending.”
Florida Hospital would agree with that.

Thursday, May 5, 2016

ICD-10 codeassist services


The main reason for the transition from ICD-9 to ICD-10 was greater documentation precision.  However, if the diagnostics is documented by clinicians at a lower level than what ICD-10 supports, it may result in submission of financial claims that are lower.  Such documentation will also cause a patient’s medical record to lack details, resulting in incomplete information for future providers.  In order to help resolve these problems, a clinical decision support (CDS) system can be designed for ICD-10 awareness which improves coding data capture and helps deliver ICD-10 specific clinical documentation improvement (CDI). Here are some highlights from a  recent article published in ADVANCE by Dr. Strongwater.

Why do you need a CDS system for ICD-10?
The biggest advantage of a CDS system is that it rides on top of the EMR system where it can align clinical decision making with evidence based best practices, thus strengthening the documentation at the very moment that it is recorded into the EMR.  With capabilities to align clinical documentation with ICD-10 at the time of recording and alerting clinicians of the chance to utilize more specific ICD-10 codes; the CDS system is a great help to clinicians as it does not require them to memorize and remember the current expanded ICD-10 code set.
The CDI helps in creating a more specific medical record of the patient and allows for submission of a cleaner and complete claim to help the provider with receiving their just dues.
Required CDS capabilities for ICD-10 CDI
In order to be accurate with its CDI, the CDS system must have the ability to not only read, but also interpret structured documentation as well as unstructured free text notes in the patient’s EMR, along with the capability to collect and interpret information coming from test labs and imaging departments.  While the ability to read clinical documentation at the recording stage is important, it is more important for the CDS to analyze this documentation relative to its knowledge of the patient and issue corrections to the clinician in real time.  A great addition would be providing a pop-up suggestion box within the EMR screen, if there is a need for more details or a change in the reimbursable code.  This pop-up box should have the correct code or higher level of detail that can be captured by the clinician from here itself.
One of the biggest advantages of the CDS system is alleviating the need for clinicians to master ICD-10 codes.  However, what would help enhance the system even more would be the ability to generate a report that indicates which documentation suggestions were ignored by the clinician.  Not only would this help the billing department close any ICD-10 gaps that remain, but would also help in procedure improvements and help the facility to adjust to ICD-10 completely.
Value of the CDS system
The EMR which just records and acts as a repository mechanism for a patient’s medical data is elevated to become a real time advisory system by adding the CDS system.  This allows for streamlining the processes, improving patient safety and result in less time taken and lower costs.  The CDS system delivers value by providing suggestions of best practices along with a complete clinical record of the patient, thus delivering quantifiable clinical and operational benefits to the organization.

Wednesday, May 4, 2016

5 Commonly Used Healthcare Revenue Cycle Management Terms



One of the key components for healthcare providers and facilities, healthcare revenue cycle management can be intimidating and confusing for a lot of people.  Statutory requirements, coding and billing, payments and denials – add to these the various terms and acronyms that are used – and you have a mine-field on your hands.  Given below are five commonly used healthcare revenue management terms along with a short description of what they mean.

02 5 Commonly Used Healthcare Revenue Cycle Management Terms_MedConverge 04-29-16Alternative Payment Models
The traditional method of paying healthcare providers through a ‘fee for service’ model, allowed the system to be misused.  Payments under the ‘fee for service’ model were made for any tests conducted or any service provided, at a pre-negotiated rate for each activity.  This created an incentive for healthcare providers to ask patients to undergo tests or services, which they may not have required for their treatment.  A simple example is a patient who comes with a coughing problem – the first tests that could be asked for is a chest X-ray and a complete blood test, which may not be required at all in this case.  In order to put a stop to this financially draining and open to abuse system, alternative payment models have been developed by healthcare reformers.  Creating incentives that favor quality of service over quantity, these models include bundled payments, ACOs and value based reimbursements.
Bundled PaymentsAs the term denotes, this is a single payment covering all services and tests delivered to a patient suffering from certain acute medical conditions, over a specific time period, covering the full episode of care.  One of the key components of this model is the sharing of a single payment by multiple providers for the different services they administer in a single episode of care.  The healthcare reformers believe that this will bring about better and more dynamic relationships between different providers.  Organ transplants, knee and hip replacement and other similar procedures are some of the many services that are being paid by insurers under the bundled payment model.
Accountable Care OrganizationA coming together of different members of the healthcare community like hospitals, testing labs, doctors etc, under a single umbrella to share responsibility and provide care to a population of patients, an Accountable Care Organization(ACO) delivers coordinated care, which can result in a reduction of unnecessary medical tests and services, higher savings for providers and better health outcomes for patients.  Value based payment models tied to quality metrics, create incentives to provide cost effective and quality healthcare.
Value based reimbursementDriven by Medicaid, Medicare and other commercial payers, value-based reimbursement is directly linked to quality of care and patient outcomes.  Under this system, costs related to unnecessary or excessive tests and services shifts back onto the healthcare providers – thus ensuring that they have no incentive to ask for or provide more than what is required.  Healthcare reformers believe that this will eventually result in superior quality healthcare minus the inefficiencies, redundancies and fraudulent services.
Price transparencyConsumers are becoming more demanding about knowing in details how much the treatment would cost, as it would allow them to take better informed decisions regarding their treatment.  With increasingly high deductibles and out-of-pocket copayments, consumers want accurate data about the costs involved in their treatment.  However, in many cases, it becomes difficult for the healthcare provider to offer this data as they need to negotiate with payers on pricing.  An ACO for example, would be dealing with multiple payers and different price variations.  Price transparency is becoming an important aspect of the healthcare industry revenue cycle.  The lack of price transparency will eventually lead to trust issues between everyone involved.  Healthcare reformers feel that price coordination between payers and providers is as important as care coordination – something that can be achieved through Accountable Care.

Tuesday, May 3, 2016

Benefits of Outsourcing Provider Credentialing And Enrollment Services



Healthcare facilities address the health needs of people and are supposed to treat the sick under all circumstances.  However, for any organization to remain viable and continue to provide services, it needs to be paid for the services provided – fully and in time.  In order to receive their just dues, organizations have to work with various payers, for example payers like Medicare and Medicaid.  Payer enrollment, till a few years back, was not considered necessary by healthcare professionals as important for building their practice.  Today, however, it is not just necessary, but nearly imperative for clinicians to be enrolled with insurance companies.
With the coming into being of the Affordable Care Act, people who were previously without any health insurance, now have access to healthcare coverage.  This, along with the desire and demand of the majority of patients and their families to utilize their health insurance to pay for healthcare services received rather than paying it out of their own earnings, has made it crucial for healthcare providers to enroll themselves with the payers.
Unfortunately, provider credentialing and enrolling with the payers is becoming more difficult with each passing day.  With most insurance panels getting overloaded due to the spurt in membership applications and a lot of them being selective about enrolling providers, the process of enrolling your facility is becoming more challenging.  Under the circumstances, outsourcing your credentialing and enrollment not only looks as an attractive option but also makes financial sense.

Benefits of Outsourcing Credentialing and Enrollment Services:
  • Reduces operating costs which can typically be around 30-40%.
  • Eliminates errors which could lead to delays in your enrollment.
  • Gives you the advantage of getting experts to do the job.
  • Allows your staff to concentrate on billing and collections.
  • Gives you more time to concentrate on your patients and building your practice.
  • Saves you tons of paperwork and hours of frustration.
Remember, enrollment is necessary to remain monetarily viable, however, your practice was started to treat patients.  That is the core competency of your business and anything else can and should be outsourced to allow you maximum time to do what you do best – help sick people get better.


Difference Between Provider Credentialing and Provider Enrollment


Hiring incompetent healthcare providers or allowing them to remain with your facility can lead to increased liabilities in malpractice suits.  In order to ensure that your facility does not suffer from this, it is important that credentialing and enrollment of your providers is managed properly and kept up to date.  Failure to do so can and will have a negative impact on your revenue cycle.  Add to this, the regulatory requirements under which your facility can be at risk of compliance violations.
To ensure that your provider credentialing and enrollment processes are managed properly, it is important to understand the difference between the two.
Provider Credentialing
Credentialing refers to the process of verifying the proven skills, training and education of healthcare providers.  Verification of the providers credentials are done by contacting the “Primary Source”, which has provided the license, training and education.  The credentialing process is used by healthcare facilities as part of their hiring process and by insurance companies to allow the provider to participate in their network.  Credentialing is also the validation of a provider in a private health plan and the approval to join the network.
Provider Enrollment
Enrollment refers to the process of requesting participation in a health insurance network as a provider.  The process involves requesting participation, completing the credentialing process, submitting supporting documents and signing the contract.  Enrollment is also the validation of a provider in a public health plan and the approval to bill the agency for services rendered.
Importance of Provider Credentialing
Provider credentialing dates back to 1000 BC, and has been an important if not critical part of healthcare services.  The process of credentialing has undergone many changes over the centuries; however, the content of credentialing has remained the same – a verification of the education, training, experience, expertise and willingness to provide medical services by the provider.  It was around 1990, that national organizations started which were dedicated to the credentialing of medical providers.  Around the same time, the National Committee for Quality Assurance (NCQA) set guidelines on the process and method of credentialing medical providers.
These guidelines ensure that healthcare providers have undergone stringent scrutiny with regards to their ability and competence, thus making sure that the patients receive the highest level of healthcare.  For a patient, it is assuring and confidence boosting to know that your healthcare provider’s credentials are certified as through the credentialing process, thus ensuring that you are in good and competent hands.  For the provider, it states that their colleagues are held to the same standards as them.  For the healthcare facility, it shows that they value quality care and place the patient’s well being as a primary goal.
It is very important to remember that in today’s world of health insurance and revenue cycles, improper credentialing can lead to delayed or denied reimbursement for services provided.  Worse, it could lead to serious consequences for all concerned in terms of statutory compliance violations, which can result in monetary damages and criminal charges.
Provider credentialing and enrollment has been overlooked as an important component of healthcare management practices for years.  However, their impact on compliance issues and financial aspects to a practice has ensured that these are now key components to any thriving practice.
MedConverge Provider Enrollment and Credentialing Services can help you reduce your on-hold claim values, streamline and standardize administration processes as well as save time while ensuring compliance.  For further information, please contact: info@MedConverge.com