deconstructing revenue integrity · cdm charge capture documentation coding • wrong codes...

Presented by

Revenue Cycle Advancement Center

Building an efficient and effective information chain to

ensure payment accuracy

Deconstructing Revenue Integrity

© 2019 Advisory Board • All rights reserved • advisory.com • WF953632-c 09/11

2

Road mapRoad map

Deconstructing Revenue Integrity1

2 Building an Efficient and Effective Information Chain

3 Coda

http://www.advisory.com/



3

No market consensus on what revenue integrity (RI) is or what it means

Starting with (what we thought was) an easy question

“Revenue integrity is

the accuracy of

charging and

documentation…it’s

difficult to define.”

“We basically coined

revenue integrity as

a job description

back in 2008.”

“Revenue integrity is not

compliance.”

“Revenue integrity is kind of

the middle part of the

revenue cycle…from the

time the clinician posts

charges all the way up to the

time a claim drops.”


in the eye of the

beholder. It’s about

protecting the revenue

that you have,

ensuring its compliant

and optimizing it.”


full revenue cycle

support.”

“Revenue integrity is like cotton candy.

It appears to be exciting, but once you

bite into it, it disappears”

Chief Revenue Officer

Large Northwestern Health System

Revenue Cycle Advancement Center research and insights.




4

RCAC regularly receives questions around revenue integrity programs

Lack of agreed upon definition hasn’t slowed interest

Of Advisory Board member hospitals and

health systems with a revenue integrity function

53%

22%Of Revenue Cycle VPs that say investing in

revenue integrity technology is very important

“Does this require new staff or a

reorganization of existing staff?”

“Do I have to have a revenue integrity function?”

“What results can I expect and how

quickly can I expect them?”

“What are the appropriate KPIs?”

Commonly asked questions





5

Much variation, but CDM ubiquitous in revenue integrity programs

Contract managementPhysician advisors

Performance and

Quality Improvement

Compliance and

Auditing Chargemaster

Clinician education

Billing

Denials

Coding

85%48%

40%

24%Analytics

16%

20%EHR Workflow 16%

Pricing

20%

16%

16%

4% 4%




6

Programs must strive to maintain the RI information chain

Revenue integrity is the process of ensuring payment accuracy

Factors leading to

payment accuracy

Complete,

comprehensive

documentation

Business OfficeMid-cycle

Timely,

accurate bills

Front Office

Appropriate

coding

Claims not

denied

Correct patient

information

The revenue integrity information chain

Efficient passage from stakeholder to stakeholder is critical

Accurate

charge capture





7

Complexity adds challenges as RI programs proliferate

Market forces complicating our path

Regulatory changes and oversight

Contractual complexityAdoption of technology

Evolving health system footprint

Payment accuracy

• Care being delivered across multiple

settings

• Requires disparate payer contracts,

coding requirements

• Payer-specific requirements include

different rates of pay, carve-outs,

exceptions for different services

• Complicates billing accuracy

• EHR implementation

• Expansion of technology into charge

capture and billing processes

• RAC and MAC audits

• Impact of Two-Midnight Rule, Post-

Acute Transfer Policy

1

4

2

3





8

Complexity of processes opens doors to vulnerability

Myriad of opportunities for mistakes

CDM Charge

captureDocumentation Coding

• Wrong codes

assigned

• Lack of codes

captured for all

care provided

Claim

denied

• Inaccurate

pricing

• Demographic,

other errors

• Lack of or

inefficient work

flow and work

queues

• Untimely

charge drop

• No concurrent

audit

Lack of knowledge around changes to reimbursement,

documentation/coding requirements, and/or changes to government auditsRegulatory changes

Claim

submission

• Incomplete list of

clinical services

• Duplicate entries

• Inaccurate

assignment of

CPT/HCPCs

• Incomplete or

inaccurate

documentation

• Unresponsive

clinicians

Compliance

risk

Vulnerable

to audit(s)

Revenue

leakage


Incorrect

Claim




9

Operational demands negatively impact information chain


Lack of oversight and

inflexible program structure

Gaps left by IT

interoperability

No regulatory monitoring or

anticipation of potential changes

Deprioritized CDM and

contracting strategyResources not distributed

according to level of revenue risk

Haphazard, scattershot

performance monitoringInappropriate staff

assigned to tasks

Documentation efforts duplicative,

diminishing of CDI

Clinicians struggle with timely,

efficient charge drop




10

Nine imperatives for an efficient and effective information chain

Ensure a strong foundation

through CDM and contracting

Craft a compelling career

opportunity

Establish flexible oversight

Increase scrutiny in areas of

high revenue risk

Engage with, but don’t

corrupt, CDI

Make charge drop easy for

clinicians

Use ROI as the ultimate

performance metric

1

2

3

4

5

6

7

8Monitor regulatory landscape

for potential chain disruptors

Fill the charge capture

gaps with IT support

9


Incorrect

Claim




11

Road mapRoad map



3 Coda




12

Effective programs provide comprehensive oversight of functions and flow

How do we right-size revenue integrity responsibilities?

Data monitoring Process tracking

Quality assurance

Root cause analysis

Solution implementation Clinical diplomacy

“The easiest way to tell if you’ve left your lane is if you’re working on an account, you should be in

operations. If you’re reviewing, performing oversight, and auditing, you should be in revenue integrity.”

VP of Revenue Cycle and Revenue Integrity, Large Southwestern Health System

Regular monitoring of both key

revenue cycle and revenue

integrity metrics

Oversight of current processes

and workflows/work queues

Deep dives to understand root

of inefficiencies/chain

breakdowns

Responsibility for projects and

initiatives focused on

information chain improvement

Collaboration with key clinical

stakeholders, including service

line leadership; physician

education and training

Regular auditing and

compliance checks





13

Program charters prevent scope creep and outline responsibilities of other departments

Establishing and formalizing expectations

Program scope

Revenue integrity

program charter

• Specify sites of care (acute, outpatient,

physician clinics)

• Determine which functions revenue integrity is

able to audit and monitor (CDM, documentation)

Mission statement

Stakeholder expectations

Role delineation

• Prevent overlap between revenue integrity and

similar revenue cycle functions, such as:

— CDI

— CDM

— Nurse auditing

• Outline purpose of revenue integrity program

• Include specifics as to how program’s mission

benefits broader organization

• Clearly outline what support and training

revenue integrity will provide clinicians and

other relevant groups

• Establish expectations of clinicians and other

stakeholders (e.g. charge drop within 12 hours)





14

Contract management, provider enrollment included at Aspirus

System Director, Revenue

Integrity

Chargemaster and FeesContract

Management/Reimbursement

Revenue Cycle Regulatory and

Payer Updates

Coordinator

Provider Insurance

Enrollment

Chargemaster Staff

Fee Analyst

Reimbursement Analysts Revenue Cycle Regulatory

Specialist

Specialists





Case in brief

15

• Aspirus’ program was started in 2015 and continues to grow and evolve.

• Its key functions include: supporting the revenue cycle departments by

providing accurate provider insurance enrollment, ensuring accurate and

timely charge capture, ensuring accurate claim reimbursement and

proactive review and readiness of regulatory and payer changes.

• In 2019, Aspirus’ net patient revenue was $1,235,991,551.

8-hospital health system based in Wausau, WI (serves

Wisconsin and Upper Michigan)

Aspirus

Source: American Hospital Directory, “Identification and Characteristics,”

https://www.ahd.com/free_profile/520030/Aspirus_Wausau_Hospital/Wausau/Wisconsin/.





16

Room and Board

Charging

Vice President, Patient Account Services

Revenue Integrity and Utilization Management/Physician Advisor Services OfficerCorporate Compliance Officer Facility CFOs

Corporate Revenue Integrity Data Analytics Corporate Utilization

Management

Physician

Advisors

Underpayments Clinical

Audit

Physician

Practices

Facilities

Appeals

Non-

Clinical

Appeals

Defense

Staff

Corporate

Utilization

Management

Staff

Utilization

Management

– Surgery

Line Service

(Inpatient)

Physician

Advisor

Support Staff

Part-Time

Physicians

1. Pseudonym.

Including denials, appeals and UM at Malone1

Business

Office

Auditors





Case in brief

17

• Malone’s program was started in 2008.

• Its key functions are oversight over audits, underpayments and appeals.

• In 2017, Malone’s net patient revenue was around $1.5M.

Health system in the South

Malone1 Health

1. Pseudonym.





18

Organizational education critical to mission, goals of program

Revenue Integrity at CoxHealth


System Director, Revenue Integrity

Revenue Cycle Education Team Revenue Optimization Team Revenue Cycle Analyst Team

VP, Hospital Revenue

Revenue Cycle Educator



Clinical Liaison

Revenue Optimization Specialist

Revenue Optimization Specialist

Analyst I

Analyst II

Analyst II

Analyst II

Analyst II

Analyst II


Analyst I




19

Staff training to prevent gaps in knowledge and performance

Revenue Cycle Education Team

CoxHealth’s revenue integrity program

includes education as one of its core

functions

Four educators provide training and

education on revenue cycle applications,

general revenue cycle topics, new

system policies, and targeted education

for performance improvement

• Health Information Management, Patient Financial Services,

Patient Access and revenue integrity staff receive

onboarding training and ongoing education

• Curriculum is taught using a combination of classroom and

online training as well as ongoing tip sheets and information

updates as needed

Revenue Cycle Staff

• Clinical staff, new and tenured, have the

opportunity to sit in on revenue cycle staff training

• Program hopes to create targeted revenue cycle

training for clinical staff

Clinical Staff





Case in brief

20

• CoxHealth’s program was started in 2013, as a component of a broader

revenue integrity program which includes other departments.

• The department was structured specifically to fill gaps and help support

broader revenue cycle needs as a way to limit disruption of day-to-day

operations.

• The program’s key functions include: education and training, system

business development and maintenance, reporting and analytics, pricing,

revenue optimization, and revenue cycle support and/or project facilitation

for issues and improvement initiatives.

• In 2018, CoxHealth’s net patient revenue was $967,278,947.

6 hospitals health system in southwest Missouri

CoxHealth

Source: CoxHealth, “CoxHealth 6 30 18 Operating and Financial DAC

Final,” https://emma.msrb.org/ES1189881-ES929918-.pdf.





21

Successful programs predict or mitigate bumps in the road, and pivot to address them

Multitude of factors may disrupt information chain

Renegotiated contracts

Staff turnover

New sites and services

New technology

Regulatory changes

Common chain disruptors





22

Texas Health Resources’ proactively planned, dedicated resources to potential issues with transition

Identifying risks before switching to new patient accounting system

Current status

• Phase one of conversion scheduled

for completion in September 2019

• After conversion, revenue integrity

and charge capture will pivot to

optimization mode, revisiting work

flows and charge capture decisions

made at conversion to enhance

operational workflow and timeliness

and accuracy of charge capture

Identify gaps

Revenue cycle examined work flows for revenue generating clinical

departments to identify potential charge capture gaps

Texas Health’s process

Went through training with Epic to understand how work flows

would change in an electronic environment

Consult patient accounting vendor

Texas Health enhanced role of revenue integrity department by adding charge

capture review and reconciliation, key components of system conversion.

Revenue integrity analysts and charge capture personnel act as internal

consultants and liaisons to clinical departments on charge capture issues

Enhance RI discipline





Case in brief

23

• Texas Health Resources realized that a conversion to Epic’s patient

accounting system would cause charging issues.

• To prepare, revenue integrity was enhanced with the addition of charge

capture.

• Conversion mode will end in September 2019.

• The program will then transition into “optimization mode” and focus more

on compliance, revisiting work flows and charge capture decisions made

at conversion to enhance operational workflow and timeliness and

accuracy of charge capture.

• In 2017, Texas Health’s net patient revenue was $3.8 billion.

27-hospital health system based in Arlington, TX

Texas Health Resources

Source: O’Donnell, Paul, “Texas Health Resources lays off 720 Workers Across North Texas,”

https://www.dallasnews.com/business/health-care/2019/01/24/texas-health-resources-lays-720-workers-across-north-texas.





24

Source: National Association of Healthcare Revenue Integrity, “2018 State of the Revenue Integrity

Industry Survey Report,” https://nahri.org/resources/2018-state-revenue-integrity-industry-survey-report.

Big picture vision is critical, regardless of prior background

The newest revenue cycle career?

Of revenue integrity professionals have

been in their positions for 5 years or less

62% “You need claims, payer and coding knowledge plus

the ability to do detective work and interact with

different departments.”

Cassi Birnbaum, System-Wide Director,

HIM and Revenue Integrity

UC San Diego Health

“You need someone who is able to think critically; to

identify trends and issues and opportunities. Not

someone who just sticks to the status quo.”

Tracy Cahoon, Director of Revenue Integrity

Southwest General Health Center


National Association of Healthcare

Revenue Integrity (founded 2017)

Mission: Enhance revenue integrity profession

through standards, advocacy, networking, and

promotion of shared knowledge and resources

COMPANY IN BRIEF




25

1. Pseudonym.

2. Pseudonym.

Effective revenue integrity directors can come from many places

Who should lead the charge?

Patient Financial Services

• CoxHealth’s director formerly led Patient

Financial Services and brought staff with

her into the new department

• Restructure happened after the

organization took over a new hospital

Charge Description Master

• Halpert1 Health System’s director came

from a CDM background

• Started as a CDM analyst and worked his

way up to the director level

• Felt this was the area he was most

comfortable

ICU Nursing

• Hannon2 Health Care System’s director

was an ICU nurse before moving to

revenue cycle

• When the department was first started, it

included the director, appeals

specialists, and other nurses who

worked in charge capture

Benefits from previous experience

• Pre-registration and pre-authorization

knowledge

• Buy-in from front-office staff on

importance of accuracy of patient

information

• Billing and reimbursement knowledge

• Understanding of revenue cycle

workflows, gaps and opportunities

• Buy-in from clinical staff

• Understanding of the challenges of timely

and accurate clinician documentation





26

1. Pseudonym.

Maximize talent and resources by having well-scoped revenue integrity roles

Clear delineation of roles ensures appropriate staff allocation

Scott Health System’s1 revenue integrity credentialed HB enterprise team

• Performs claim edits

• Work queue upkeep with KPIs

• Executive Revenue Guardians

• “The Doer”

• Charge quality evaluations

• Late charge analysis

• Acts as a hospital and clinical department liaison

• “The Critical Thinker”

• Works in tandem with compliance,

coding, and Revenue Integrity work plans

• Engages with committees, projects and

go-live activities

• Educates coders and departments

• “The Conqueror”

• Charge structure updates

• Epic charge build and testing

• Go-live activities and training

• “The Architect”

Analyst I


Analyst II

CDM Epic

AnalystAnalyst III




Case in brief

27

• Scott1 Health System’s program was established in 2015 to identify and

prevent revenue leakage as well as ensure compliance.

• Its key functions include: monitoring mid-cycle activities, maintaining the

chargemaster, tracking data, working on claim edits, and engaging with

business office managers and payer policy.

• To keep staff engaged, four positions requiring a different skillset were

developed. As staff increase their skills, they can move to other positions,

resulting in unified and coordinated team able to avoid duplicative work.

• In 2017, Scott1 Health System’s approximate net patient revenue was $2.1M.

Health system in the Northeast

Scott1 Health System

1. Pseudonym.





28

OHSU considers their program to be “a good entry and a good feeder” for analysts

Serving as a training ground for revenue cycle and the organization

Staff begin in billing office

• Many staff become analysts after

working in the billing office

• From these experiences, they become

good candidates to be analysts in the

revenue integrity program

Move into revenue integrity

• Current staff train new employees

• Employees, specifically client service

analysts and revenue recycle analysts

gain a comprehensive understanding

of revenue cycle issues

Grow into leadership

• Analysts can then be considered for

revenue cycle leadership roles given

skillset and problem solving abilities

• Two analysts have even taken

leadership roles in clinical departments

Analyst employee retention rate since 2012

95%





Case in brief

29

• OHSU’s program was started in 2012 to provide front-end charge capture

support for the revenue cycle department.

• The program has numerous opportunities to move within the program and

gain important skills.

• Analysts often gain experience in the billing office prior to becoming

analysts. After being an analyst, there is opportunity to move up into

leadership positions.

• Two analysts have taken leadership roles in clinical departments.

• In 2017, OHSU’s net patient revenue was $2,097,255.

2-hospital academic health center based in Portland, OR

OHSU

Source: Oregon Health & Science University, “Financial Statements and Supplementary

Information,” https://www.ohsu.edu/sites/default/files/2018-08/ohsu-financial-stmt-audited-fy17.pdf.





30

Metrics should match current initiatives, but ROI is ultimate measure of success

Comprehensive nature of RI makes performance monitoring tricky

?

?

?

Duplicative

CDM entries

Preauthorization

denials

Physician query

response rates

Days in A/R

Medicare

underpayments

Coder edits

How do we measure RI

performance, but not all

revenue cycle performance?


How should we gauge

revenue integrity program

success?

How can changing initiatives

and areas of process

improvement be tracked?

? ? ?




31

1. Pseudonym.

Successful programs allow RI to go where they see opportunity

Granting RI staff a revenue hunting license

Total FTEs for

underpayment review

Return on investment compared

to baseline, FY 2015 – FY 2017

3

$7.4M

Clear ROI for underpayment review

Before virtual CBO

Wigston Health1 expands underpayment recovery system-wide

Single centralized

underpayment recovery

covers all facilities

With virtual CBO

1/19 Facilities with

underpayment data

tracking and reviews


To add staff is like

an act of Congress; we

are constantly told we

are not a revenue

generating department.




32

1. Pseudonym.

Increased accuracy reveals history of Medicare underpayments

Cleaning up the chargemaster

• Howard1 Health’s medical group concerned

about their chargemaster's inaccuracy

• Realized they were receiving underpayments

because charges were below Medicare rates

Recognizing incorrect payments Resetting the chargemaster

• With the help of a consultant, Howard1 reset

their chargemaster to match Medicare rates

• Now, with a correct chargemaster, the group

is paid correctly for their Medicare patients

Additional reimbursement per year

after correcting the chargemaster$2M





Case in brief

33

• External consultant identified underpayments at Howard Health due to

prices set below Medicare rates in the medical group’s chargemaster.

• Chargemaster was then reset to match appropriate rates. The medical

group is now receiving an additional $2 million dollars in reimbursement

every year.

• In 2017, Howard Health’s approximate net patient revenue was $3.5B

Health system in the Midwest

Howard1 Health

1. Pseudonym.





34

1. Pseudonym.

Anderson1 Health proactively models impact of new contracts, carve-outs on revenue capture

Planning for reimbursement adjustments

Commercial payer

opened their contract

for new negotiations

two months early

Initial proposal was

complex with several

carve out elements

Used Optum360

Payment Integrity

Compass (PIC) to

model and analyze

payer’s service terms

Reimbursement was

incrementally

increased

Reports available to

validate calculation

results and forecast

expected revenue





35

Modeling decreases time, increases revenue capture

Manual process5 month-timeframe

Modify counter-proposalsAgree on final terms

with payer

Create full initial proposal,

including carve outs

Modeling3 month-timeframe

Recaptured leakage based on

additional 2% rate increase$428K

Create and analyze

initial model using

spreadsheets

Extract source system

data

Modify counter-

proposals and create

new reports

Agree on final terms

with payer





Case in brief

36

• Major commercial payer opened their contract for new negotiation and

delivered the proposal two months earlier than expected with complex

methodology with several carve out elements.

• Contract Negotiation Director used Payment Integrity Compass’ calculation

logic to analyze the payer’s service terms, building iterations of the initial

model to incrementally increase reimbursement and create ad hoc reports

to validate calculation results and forecast expected revenue.

• Anderson1 finalizes rates in three months, securing additional 1% rate

increase above the initial proposal, amounting to $428,000 in potential

annual revenue.

• In 2019, Anderson1’s approximate net patient revenue was $1B.

Hospital in the Midwest

Anderson1 Health System

1. Pseudonym.





37

1. HCPCS J-code.

Capitated contract leads to significant unreimbursed revenue for oncology drugs at Memorial

Risk-based payments complicate integrity efforts

Discovered unreimbursed

drug costs due to one plan’s

payment limits

J-code1 level analysis

uncovered thousands of

unreimbursed dollars

resulting from managed

care payment caps on

oncology payments

RIC voices concern about

managed care caps

Pharmacy and managed

care team advocate to

exclude oncology patients

from payment caps with

major payer

Creating an exception

Revenue Integrity Committee (RIC)

1 2 3 4





Case in brief

38

• Pharmacists established the Revenue Integrity Committee (RIC) with

members from: pharmacy, nursing, patient financial services, pharmacy

reimbursement specialists, and guest members from: IT, revenue cycle,

practice managers, and medical staff.

• Pharmacy staff manually sorted through J-code level reimbursement

claims to provide medication using evaluations, medication cost,

reimbursement by payer, revenue per dispensation, number of

treatments, and net revenue per treatment plan.

• System-specific reimbursement analysis helps build payer strategy, such

as negotiating disease-specific carve-outs to plans with payment limits.

• In 2017, Memorial Health System’s net patient revenue was $241,175.

6-hospital health system in South Florida

Memorial Health System

Source: Memorial Healthcare System, “Annual Report for the Fiscal and

Quarter Ended April 30, 2018,” https://www.mhs.net/about/finances.





39

Despite CMS’ self congratulation, regulatory landscape remains complicated

Managing the regulatory tentacles

Office of

Inspector General

LCDs

RACs

QIOs

MACs

“We’ve reduced RAC-related provider

burden to an all-time low, as evidenced

by the significant decrease in the number

of RAC-reviewed claim determinations

that are appealed and the corresponding

reduction in the appeals backlog…”

Centers for Medicare and Medicaid Services NCDs

RACs: Making Life Simple?





40

Several options for preventing revenue leakage to lack of regulatory compliance

Regular monitoring of potential impacts necessary to protect revenue

Biweekly communication

Director of Revenue Integrity has bi-weekly meetings with Director of Government

Managed Care and the Director of Commercial Contracting to identify adjudication

issues. This information is then passed to the specific payer liaison for resolution.

1

Dedicated researcher

Regulatory and payer researcher who tracks regulatory and payer updates and

works with revenue cycle and clinical key stakeholders to ensure readiness.

2

Government Audit Program

Team dedicated to understanding and identifying audit risks, updating clinical

departments to improve work flows before billers or auditors find mistakes.

3

Least to most

resource intensive





41

Dedicated staff, database allows revenue integrity to stay on top of requests

Overwhelm prompts Cedars-Sinai to find a solution to government audits

1

• Audit requests came from multiple contractors

and entered the organization via many points,

including HIM and PFS

• Revenue integrity program takes comprehensive

responsibility over compliance

• Program includes 3.5 FTEs

• Team implemented database containing records

from all governmental audits of Cedars Sinai

• Metrics around audits monitored monthly, and

generated into report for C-Suite, with success

rates, areas of risk and financial reporting

2

Unable to keep up with requests Government Audit Program (GAP) launched





Case in brief

42

• Audit requests entered the organization from multiple sources went to

many departments, including HIM and PFS.

• Revenue integrity program took comprehensive responsibility of

compliance from HIM and purchased a government audit database.

• Using this database, the organization has saved over $76M since 2007.

• In 2017, Cedars-Sinai’s net patient revenue was $3,470,222,000.

1-hospital health system in Los Angeles, CA

Cedars-Sinai

Source: Cedars-Sinai, “Facts and Reports,”

https://www.cedars-sinai.org/about/facts-and-reports.html.





43

Diving into GAP database

Includes details from:

• Line item denials on second level

appeals

• Internal self-audits

• External audits (RACs, MACs, etc.)

Contains detailed history and

record of every governmental

audit impacting Cedars-Sinai, for

the last 7 years

ADRs (audit requests) are also

monitored and logged by the team

in the database

Interest payments for appeals won

are included in the monthly report

Monthly report with permanently

saved, permanently lost, and in-

play amounts are included





44

Expansion of GAP includes pharmacy, physician billing, other sites of care

Capturing audit history in other areas

Cedars-Sinai

Medical Center

Cedars-Sinai Marina

del Rey Hospital

Start with high

cost drugs

Focus on commercial

audits and denials on

high cost drugs, given

the large risk in this area

1Move to include

physician billing

Physician billing brought

their RACs to GAP,

leading to involvement

with commercial payers

as well

2Expand to other

areas

After testing with the first

hospital, Cedars-Sinai

Medical Center, the

organization is now able

to expand to other areas

and to another hospital

3





45

Memorial Healthcare’s Revenue Integrity Committee (RIC) addresses pharmacy charging problems

A multi-departmental response to high drug costs

Identify potential drug

revenue streams

Pharmacy leaders recognize

that drug value analyses

focus primarily on costs.

Involve oncology pharmacists

Involve oncology pharmacists in

reimbursement analysis to focus

on key drug reimbursement

cases to show system impact

and drive cultural support.

Establish Revenue Integrity Committee

Foster system-wide acceptance by inviting a

multidisciplinary group of internal

stakeholders:

• Nursing

• Pharmacy

• Patient financial service representations

• Pharmacy reimbursement specialists

Identify retrospective, drug-level data to

provide a complete picture of cost and

reimbursement, specific to payer mix.





Case in brief

46

• Oncology pharmacists recognized drug decisions focused primarily on up-front costs

and lobbied internally to have reimbursement trends included in future strategy and

decision-making.

• Pharmacists established Revenue Integrity Committee (RIC) with members from:

pharmacy, nursing, patient financial services, pharmacy reimbursement specialists,

and guest members from: IT, revenue cycle, practice managers, and medical staff.

• Pharmacy staff manually sorts through J-code level reimbursement claims to provide

medication using evaluations, medication cost, reimbursement by payer, revenue per

dispensation, number of treatments, and net revenue per treatment plan.

• System-specific reimbursement analysis helps build payer strategy, such as

negotiating disease-specific carve-outs to plans with payment limits.

• In 2017, Memorial Health System’s net patient revenue was $241,175 (2017).

Six-hospital health system in South Florida

Memorial Health System

Source: Memorial Healthcare System, “Annual Report for the Fiscal and

Quarter Ended April 30, 2018,” https://www.mhs.net/about/finances.





47

Analysis, cooperation with payers leading to increased revenue capture

RIC narrows in on biosimilars to prevent denials

Medication use evaluations

Conducts MUEs to determine if

providers are prescribing according to

Medicare coverage or if treatment

regimens are not included

RIC partnered with Blue Cross Blue

Shield to advocate for the inclusion

of biosimilars in formulary

Goal is to reduce,

eliminate denials stemming

from uncovered biosimilars

Examined biosimilars due to

importance, volatile cost and

reimbursement

AdvocacyAssessing generics Preventing denials





48

Organization uses regular meetings, root cause analysis to educate broader organization

Southeast Health creates their own RIC

Oncology

2Weekly meetings

Committee pulls six months of

denials data, begins to work

through each case

Root cause analysis

identifies documentation and

pre-authorization problems

1Oncology Revenue Integrity Committee

Committee representatives:

Insurance

Billing

Physician clinics

Drug replacement

Pre-authorization

3Shared insights

Educate pharmacists to

refrain from substituting drugs

without pre-authorization

Use regular provider meeting

to discuss issues around

documentation





Case in brief

49

• Southeast Health noticed an uptick in denials.

• In response, the oncology service line director formed a committee

composed of representatives from insurance, billing, physician offices,

drug replacement, and pre-authorization.

• The committee currently meets monthly to discuss issues related to

denials.

• Since October 2018, the committee has seen a 24% improvement in

collections, about $400K.

• In 2019, Southeast Health’s net patient revenue was $1,839,801,396.

Hospital in Dothan, AL

Southeast Health

Source: American Hospital Directory, “Identification and Characteristics,”

https://www.ahd.com/free_profile/010001/Southeast_Health_Medical_Center/Dothan/Alabama/.





50

Success leads to expansion of scope, adoption in other clinical areas

Expanding beyond oncology

Committee started by meeting weekly, but

as issues have been resolved, only needs

to meet monthly

Scope is expanding to not only include

denials, but also underpayments and other

reimbursement challenges

Committee is considering expanding the

practice to other service lines

Of lost revenue avoided

since September 2018

$400K





51

1. Pseudonym.

Size of loss lead executives to approve creation of new position at Beesly1 Health

Billing error leads to dedicated RI pharmacist

Found billing error

around pharmacy that

led to underpayments

Executives realize need for special

attention, resources in pharmacy

due to size of revenue risk

Organization hires pharmacist to

serve as revenue integrity specialist

System Director of Pharmacy

and Vice President of Finance

champion a pharmacy revenue

integrity specialist position

Currently working to

extend position to other

service lines





Case in brief

52

• Organization found a pharmacy-related billing error that cost the

organization $6 million

• System Director of Pharmacy and Vice President of Finance decided to

hire a pharmacist to oversee pharmacy-related charges.

• The pharmacy revenue integrity specialist has overturned about $13-80K

for different drugs rebilled.

• The service line approach is currently being expanded across the

organization.

• In 2016, Beesly1 Health’s approximate net patient revenue was $2.4M.

Health system in the Northwest

Beesly1 Health





53

Concerted focus and oversight leads to significant gains

Functional collaborationWork flow improvement

Assists in clean up of the pharmacy chargemaster

and corrects line items that are billed incorrectly, as

first step of policy and procedure standardization

Standard policy and procedure development

Pharmacy Revenue Integrity Specialist


Collaborates with front-end

users on work flows related to

charge capture to ensure clean

claims in billing

Pharmacy revenue practice

team composed of pharmacy

IT build team, billing, and

compliance teams to

determine and solve charge

router issues




54

Position may be created in other areas with significant revenue risk

Clear wins make idea appealing to other service lines

Cardiovascular

Emergency Department

Medical Authorization

Radiology

Upcoming service lines

$13K-$80KSaved per drug rebilled over

period of several months





55

Source: Ingenious Med, “Most healthcare execs say charge capture is essential, yet 40 percent

discuss it once a month or less,” https://www.prnewswire.com/news-releases/78-of-healthcare-

execs-say-charge-capture-is-essential-yet-40-discuss-it-once-a-month-or-less-300774051.html.

EHRs widely used for charge capture, but few report satisfaction with current state

A ubiquitous “solution”

10%Of health care organizations

would recommend their current

charge capture solution

84%Of health care organizations rely

at least partly on their EHR

systems for charge capture

50%Of health care organizations

use it exclusively as their

charge capture solution





56

RI programs take two approaches to getting what they need from technology

Potential fixes require deep collaboration with IT

• Revenue integrity program hosts regular

workgroups between IT and clinical staff

• Workgroup mitigates issues and helps

financial staff understand clinical modules

• Group of dedicated IT staff report to

revenue integrity department

• IT able to provide any support, fixes

required of revenue integrity

Information

Technology

Solution #1: Dedicated IT support Solution #2: Formalized work groups

Benefits: Clear line of communication,

accountability, and faster time to

improvement

Drawbacks: Expense of adding IT staff


Benefits: Bridge between clinical and

financial worlds, eliminate problems due to

miscommunication

Drawbacks: Competing priorities, requires

time, no formal mechanism for accountability




57

CFO buy-in provides OHSU with significant support

Focus on front end workflows necessitates IT staff

Prioritization of work flows

Given revenue integrity’s focus on front

end work flows and the rise of their

EHR, a need for immediate access to

IT staff is determined.

Receive added support

Department continues to

meet with the organization’s

IT team for larger projects

Gain executive advocacy

VP of Revenue Cycle and

Enterprise Revenue Cycle Director

advocated for internal IT staff to sit

within revenue integrity

Centralize IT staff

Three types of IT support are

centralized for revenue integrity

• EHR billing systems

• Revenue integrity support

• Revenue Cycle team





58

Support goes beyond just RI program to all of revenue cycle

Technology staff specialized across three teams

Revenue Cycle/IT team divisions

EHR billing systems

• 10 FTEs

• Support professional billing

• Perform system build, maintenance,

upgrades and enhancements

Revenue cycle team

• 11 FTEs

• Provide charge capture support

• Help develop work flows to ensure

compliant billing

• Liaise between the hospital clinics

and the billing office

Revenue Integrity support

• 4 FTEs

• Manages department and provider

master files

• Performs all build maintenance

IT support leads to project success:

• IT teams meet weekly with revenue integrity staff

• Coordinate effort for significant go-lives including two community connect hospitals,

four OHSU clinics on EHR, and a 14-story ambulatory building in three years





59

Cedars-Sinai’s difficulties with automated charging triggers formalized workgroups

Connecting revenue cycle, IT, and clinical expertise

• Regular workgroups held by revenue integrity with IT staff

and clinical departments provides answers for each of the

three areas

• Specific to the group’s original problem, pharmacy IT gained

an understanding of the national drug codes required for

outpatient drugs as well as connecting to the system build

After

Access to answers

• Billing edits appear in PFS for missing national drug

code (NDC) claims for outpatient claims

• Pharmacy IT team confirms NDC is in the system

• Billing team confirms NDC is not on claim

• RI gets everyone together via WebEx to solve the issue

Before

Questions galore

“No one in revenue cycle operations and clinical operations was knowledgeable

about the new electronic applications, making it difficult to speak with IT and

clinical partners about charge issues stemming from clinical modules.”

Gretchen Case, Executive Director of Compliance and Revenue Integrity

Cedars-Sinai





Case in brief

60

• VP of Revenue Cycle and Enterprise Revenue Cycle Director determined

a need for internal IT support.

• Three IT teams were centralized under Revenue Integrity: EHR billing

systems, revenue integrity support and a revenue cycle team focused on

technology.

• Teams coordinate well with revenue integrity and supported significant

EHR conversions.

• In 2017, OHSU’s net patient revenue was $2,097,255.

2-hospital academic health center based in Portland, OR

OHSU

Source: Oregon Health & Science University, “Financial Statements and Supplementary

Information,” https://www.ohsu.edu/sites/default/files/2018-08/ohsu-financial-stmt-audited-fy17.pdf.





61

Responsibility allows RI to gain clinical knowledge, and vice versa

Dedicated RI staffer leads each work group

Delivery system reform

• Different revenue integrity staff are responsible

for running the clinical workgroups

• Workgroups cover both Epic and non-Epic

modules

• Buy-in from clinical areas has been significant

with one group having 27 attendees

Clinical workgroups

Pharmacy

Ambulatory

Imaging

Oncology

Associate Program Director

RI workgroup leader

CDM Analyst

Charge Capture Manager

CDM Analyst





62

$76,000,000+

Total amount saved from GAP and

revenue integrity program, October

2007-March 2019





63

Comprehensive documentation, educational efforts critical to both entities

Overlap exists between CDI and RI, but functions have distinct goals

Focus on physician documentation to

ensure appropriate care and

comprehensive capture of information

• Comprehensive

documentation

• Physician education

• Source of support for

clinical teams

• Performance monitoring

Clinical Documentation Improvement Revenue Integrity

Focus on comprehensive and accurate

physician documentation (and other

functions) to ensure accurate payment





64

Revenue integrity’s hunting license does not extend to CDI

Keep functions separate to avoid corruption of mission

81% Of health systems have an

inpatient CDI program

4%Of revenue integrity

programs include CDI

Most opting for continued separation Appropriate focus of CDI

Completeness of physician documentation

Timeliness of documentation

Physician query response rates

Consistency with coders

Revenue leakage from improper documentation





65

1. Pseudonym.

Flenderson1 proactively seeks new executive buy-in on mission and goal of revenue integrity

Extending RI education beyond clinicians

Risk and challenges

• Disparate chargemasters and contracts

• Potential billing and compliance issues

depending upon site of care being onboarded

• New technology/EHR integration

• Different clinical systems and processes

• Normal hiccups associated with mergers

New hospitals integrated into system are

unfamiliar with certain protocols, and EHR1

Revenue integrity department on-boards new

hospitals with a focus on understanding Epic

workflows

2

Department staff meet with executive leadership

to review the transition process3

Department staff meet with service line leaders to

explain clinical areas’ impact on charging and the

importance of accurate information

4

M&A complicates revenue integrity Flenderson1’s introduction to revenue integrity





Case in brief

66

• Onboarding of new sites of care as a result of M&A activity present risk

for Flenderson1.

• Revenue integrity program created a robust training process to on-board

new hospitals and executives to the importance of RI, processes around

documentation, and technology for those unfamiliar with Epic.

• In 2016, Flenderson1’s approximate net patient revenue was $2M.

Health system based in the Northwest

Flenderson1 Health System

1. Pseudonym.





67

Standardize the processes and expectations

1. #9: Make charge drop easy for clinicians

Source: Ingenious Med, “Most healthcare execs say charge capture is essential, yet 40 percent

discuss it once a month or less,” https://www.prnewswire.com/news-releases/78-of-healthcare-

execs-say-charge-capture-is-essential-yet-40-discuss-it-once-a-month-or-less-300774051.html.

Coders and CDI specialists spend too much time tracking information from physicians

Three steps to greater physician accountability

Share performance data

Observe the status quo

Percentage of coder time

spent tracking down details

of physician documentation

10%-20%





68

1. Pseudonym.

Flenderson1 determines the status quo through first-hand observation, before solution implementation

Before attempting a solution, identify the status quo

Understand how clinicians are

providing care and documenting

it through first-hand observation

Ask the end-user what’s missing from

the process or causing them issues Avoid asking questions over

email or phone—observe the

patient workflow in-person

Address the problem in

the front-end

Repeat this process of

determining the status

quo before solution

implementation for any

issues that appear





69

Source: Ingenious Med, “Most healthcare execs say charge capture is essential, yet 40 percent discuss it

once a month or less,” https://www.prnewswire.com/news-releases/78-of-healthcare-execs-say-charge-

capture-is-essential-yet-40-discuss-it-once-a-month-or-less-300774051.html; Secan, R, “The Evolution of

Charge Capture Technology,” https://www.physicianspractice.com/blog/evolution-charge-capture-technology.

Complaints on timeliness of charge drop abound among revenue cycle leaders

Overcoming the physician charge capture bottleneck

1. Charge lag

2. General inefficiency

3. Integration with EHR and other technologies

Top 3 charge capture issues ranked

by health care executives

Physicians become busy with other issues,

neglect to drop charge, or capture all care

provided to the patient

Chart lingers for longer than necessary,

ultimately adding to days in A/R and

untimely bills





70

Source: pMD, “Hospital Charge Capture, Improve the Process with

pMD,” https://www.pmd.com/case-studies/hospital-charge-capture.

Mobile charge capture reduces physicians’ work and streamlines EHR

Doctor enters charge

on paper

Medical assistant enters

charge into spreadsheet

Billing staff enters charge

into billing software

Charge is on EHR

Doctor enters charge on

mobile deviceMedical assistant

reviews charge

Mobile charge capture

solution sends charge to EHR

Paper charge capture

Mobile charge capture





71

“[Mobile charge capture] is very

convenient…I don’t have to worry about

[delayed submission] anymore. My billing

goes out faster with a much greater

likelihood of not missing charges.”

–Dr. Juan Dumois

All Children’s Hospital

Source: pMD, “Hospital Charge Capture, Improve the Process with pMD,”

https://www.pmd.com/case-studies/hospital-charge-capture.





72

1. Pseudonym.

Automated flags ensure physicians document need for hospital-based ancillary services

Think globally, act locally


Physicians who order a hospital-based ancillary

service must document and code for:

Ancillary services often overlooked in the

physician office settingFlax1’s bolt-on reminds physicians

Medical necessity of the office visit

Medical necessity of ordered

ancillary service

Failure to do so will result in a medical necessity denial

for the ancillary service

System’s EHR bolt-on reviews the faculty’s Medicare

documentation and codes in the moment

When physician orders a hospital-based

ancillary procedure, technology pop-up

reminds physicians to document and code

medical necessity for both settings

Number of times the technology

pop-up was triggered within the first

eight months of implementation

33,000




Case in brief

73

• In 2018, Flax1 built an EHR bolt-on technology to review faculty physician

Medicare documentation and coding in the moment.

• When physicians order a hospital-based ancillary service, technology’s

pop-up reminds the physician to document and code the medical

necessity for both the office visit and hospital service.

• In the first eight months, the flag was triggered 33,000 times.

• Flax1 hopes to expand this technology to all payers soon.

• In 2018, Flax1’s net patient revenue was $2.61B.

Health system in the North

Flax1 Health

1. Pseudonym.





74

1. Pseudonym.

And let clinicians know when they’ve achieved notable performance

Make clinical departments aware of RI’s expectations

Flenderson1 Health System’s Revenue Integrity policies

Revenue

integrity

responsibilitie

s

Revenue integrity

responsibilities

Clinical department

responsibilities

• Review documentation before charges

automatically drop

• Properly place patient cases so that

Epic’s algorithm selects the correct code

• Correctly building tables in Epic for

clinical staff to enter data

• Room and board charging including

patient, department, and level of careRegularly share

performance data

with physicians to

demonstrate their

success or areas of

improvement





75

Road mapRoad map



3 Coda




76

Revenue cycle pushed to weather considerable change while increasing current performance

Dynamic market asking much of our staff

Tackling a lot at once

Concerns about automation,

and potential impact on staff

EHR implementation and

complications from technologyDeep knowledge of insurance

products and coverage required

Integration of departments

across sites of care

Difficult patient financial situations

and pushback around payment

Changing regulatory and

payment environment





77

Next session tackles these questions head on

Staff engagement critical to delivering on our initiatives

How do we know whether

our staff is engaged?

? ?What factors impact

engagement, or lead to

disengagement?

Are all of our staff equally

engaged? Which should we

be most concerned about?

?


Are we asking too much of

our patient access staff

specifically

?How does pay at our

organization compare with

other organizations?

?




Credits

78

Stefanie Kuchta

Design Consultant

Eric Fontana

Program Leadership

Sophia Duke-Mosier

Research Team

[email protected]

Robin Brand

Project Director

Revenue Cycle Advancement Center



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