Revenue Integrity and Healthcare: Prevent Revenue Leakage

Chargemaster Management

A health system’s chargemaster (CDM) is the central program from which hospitals prices are applied and managed. The tool essentially contains the supply prices for all procedures clinicians perform, as well as diagnostics, medical devices and medications. A carefully managed chargemaster can make a difference in whether a hospital receives full reimbursement for its procedures, which is one of the primary goals of revenue integrity.

The integrity of your chargemaster depends on having a fully vetted and complete process by which prices are input and managed. Manual review and management of the chargemaster is incredibly labor-intensive and leaves room for plenty of errors and oversight. One of the best ways to manage your chargemaster is by automating your CDM through chargemaster management software and regular maintenance updates.

Revenue and Charge Reconciliation

The charge reconciliation process is an absolute necessity because it ensures accurate charge capture at the point of care. Due to the complexity of care delivery as delivered across multiple departments and systems, charge capture is also a major source of potential revenue leakage. As such, the best practice is to ensure charge reconciliation on a daily basis.

A common challenge for providers is that they lack a comprehensive manner to compile, assess and validate charges at scale. Charge reconciliation is best managed at the department level, but this means staff will often have to take up to several hours per day to generate and review reports for all charges around each patient encounter. Since many organizations simply can’t comply with this requirement on a daily basis, charge inaccuracy is common, and the organization subsequently suffers from substantial revenue leakage.

Missing and Late Charges

Ensuring charge accuracy is a somewhat complex process. There are many variable—direct and indirect— that can influence the accuracy of charges for a given encounter.  Pricing accuracy, as dictated by payer contracts and managed by the chargemaster, is one factor.  Certain prerequisites for when a charge applies, or when it may be bundled with other charges, also must be taken into account. Any combination of factors can lead to missing and delayed charges resulting in revenue loss. One of the most significant contributors to revenue loss is charge discrepancies between clinical and billing. If charges are not being accurately managed at the department level, the hospital will lose money. Building an effective, clinically-based charging system is crucial for any hospital looking to ensure revenue integrity and optimize financial performance.

Compliance Adherence

When Medicare added hierarchical condition categories (HCCs) to assess patient risk as part of the consideration for payment, the need to be precise with coding and charge capture increased. Compliance with state and federal regulations is a must for healthcare systems. It’s critical to keep track of regulations and mandates to support price transparency, maintain compliance, and ensure an efficient, effective revenue cycle.

Discrepancies

Increasingly, patients are becoming responsible for their medical expenses. Yet payers are still contracted with providers for the bulk of payments for care.  The volume of data exchanged around healthcare claims creates complex administrative requirements for the providers, especially with regard to managing payments from the payer, which often include partial payments for a single claim.  Insurance companies deposit money directly into a healthcare organization’s bank account and then will send a record of that deposit to the organization’s medical billing office. The problem is that the deposit doesn’t always match the record, and balancing the discrepancy requires a lot of manual effort from the provider’s staff. This is where a charge capture audit can yield wonders.

Denial Rate

Payer denials of claims can reveal process problems that occur at the coding, charging, or billing level, and can even be traced back to issues with the initial payer contracts. Implementing effective denial management strategies by analyzing claim denial patterns can identify and resolve workflow issues causing submission errors, ultimately leading to increased revenue. Keep an eye on denials percentages, as well as the dollar amounts from denied claims. Standard industry denial rates range from 5% to 10%, with 2% to 3% considered to be successful. A recent report is showing that the average hospital claim denial rate is trending upward.

Annual CPT Updates

Current Procedural Terminology or “CPT” is the code set containing identifiers and descriptors assigned to each medical, surgical, and diagnostic service available to patients. Each year, the American Medical Association updates the code set – this enables accurate reporting, measurement, analysis, and benchmarking of medical services and procedures across the healthcare world. With the continual expansion of CPT, your system’s revenue integrity needs to import new CPT codes into existing claims and billing software. Additionally, you coding staff needs to stay current with these changes to ensure they codes they’re assigning are accurate and compliant with these updates.

Revenue Integrity Automation

Using automated programs, a hospital system’s charges can be analyzed for accuracy and corrected as necessary before billing. This is incredibly helpful, as you want to catch errors before bills are sent out for payment. While automation can remove the daily need for manual aggregation of charges, ensuring their accuracy still relies on an element of human review. As such, most charge optimization solutions use rules-based logic to identify potential issues, then compile and present a list of questionable charges for assessment by a qualified staff member.