A/R Management to Revenue Cycle Excellence Kathleen Bourgault, MS, CPAM VHIMA May 8, 2013

1. A/R Management to Revenue Cycle ExcellenceKathleen Bourgault, MS, CPAMVHIMAMay 8, 2013

2. Overview • Revenue Cycle Define • Production Cycle • Role of HIM in the Revenue Cycle • Metrics/Benchmarking • Future

3. What is the Revenue Cycle • "All administrative and clinical functions that contribute to the capture, management, and collection of patient service revenue."  - HFMA

4. The Revenue Cycle • Successfully managing the revenue cycle is the blood line of an organization • The are a number of Revenue Cycle stakeholders throughout the cycle…

5. It Takes A Village…..

6. Process heavy…..

7. Governance • 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

8. Revenue Leakage • 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,

9. The Role of HIM in the Revenue Cycle • Business owner of the legal record • Discharged Not Final Billed (DNFB) • Documentation management/improvement • Coding • Revenue Integrity • Denial Management • Regulatory compliance

10. Discharged Not Final Billed • Traditionally an HIM function Only • Record completion • Stratify priorities • Coding complete • Best practice measure: < 2 days from bill hold

11. Coding • Timely and accurate coding • Identifying missing documentation • Trending and analyzing case mix • Post discharge queries • Auditing • Education • Impacts: • Core measures • Quality • Reimbursement • Denials

12. Documentation Improvement • 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

13. Revenue Integrity • 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

15. Denial Management • 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

16. HIM and Denial Management • 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

17. Monitoring Metrics 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

19. Revenue Cycle Performance Measures

20. Revenue Performance Measures

21. What does the Future Hold? • 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

23. Thank you!