Now More Than Ever, Providers Need Pre-Bill Coding Optimization
April 19, 2022 •Streamline Health
By: Guest Author
Revenue Cycle/Compliance Expert
Despite investments in both technology and people, clean claim submission and optimized revenue capture still pose a distinct challenge for healthcare organizations. Given the indefinite impact from the COVID-19 pandemic on providers’ financial performance via increased labor costs and revenue disruption, the need to ensure full, proper reimbursement is greater than ever.
Various forms of coding optimization technology such as claims scrubbers and CAC have been in existence for more than a decade but have proven unable to resolve the issue of timely coding optimization that results in prompt payments, reduced compliance exposure, and minimized revenue leakage.
During the critical stage of coding an inpatient DRG, the process of ensuring the coded data accurately reflects the acuity of care delivered should occur after a patient is discharged but before the final claim is submitted for payment. According to HMFA, coding represents 30% of total billing expenses. which represents a 10% increase during the past 15 years. Yet initial coding accuracy for most providers remains below the 95% threshold recommended by CMS. The AHA estimates that hospitals received payment of only 84 cents for every dollar spent by hospitals caring for Medicare patients in 2020.
In addition to this revenue leakage, the ongoing third-party scrutiny led by federal and state plans adds to the challenge and poses a risk of substantial penalties for non-compliance that also affect the bottom line. For example, in February of 2021, the U.S Department of Health and Human Services (HHS) Office of Inspector General (OIG) raised concerns about the "trend toward more expensive inpatient hospital stays in Medicare” The trend emerged before COVID-19 and “warrants further scrutiny.
Learn how automated pre-bill coding analysis can protect revenue integrity and improve financial performance.
Current claim auditing methodologies are either prospective, retrospective, or a combination of the two. While many providers focus primarily on retrospective audits, the additional effort required to recoup lost revenue or address compliance exposure limits the potential impact and ROI from this approach.
To achieve substantial, scalable improvements, healthcare organizations are moving from reactive to proactive strategies as they lay the proper foundation for ensuring compliance with the latest regulatory guidance and capturing all appropriate reimbursement opportunities. Achieving a sustainable level of financial health requires the adoption of technology-enabled processes to transition to a prospective model that delivers immediate and sustainable improvements.
“The AHA estimates that hospitals received payment of only 84 cents for every dollar spent by hospitals caring for Medicare patients in 2020.”
Technology can amplify prospective claim auditing scope and deliver sustainable improvements in terms of auditor efficiency, as well as dramatically increasing the impact of the overall program. And this can be implemented with minimal disruption to existing processes or the need for additional staff resources, enabling a ‘work smarter, not harder’ principle for improved results.
By utilizing an intelligent prospective technology platform, organizations realize the following operational and financial revenue integrity improvements:
- Pre-bill coding/charge review process improvement
- Increased coder and auditor productivity
- Coder and auditor development via real-time feedback
- Centralized, timely communication to HIM/RCM stakeholders
- Patient revenue optimization due to accurate charge capture
- A single database that promotes detailed analytics and reporting to drive operational and financial improvements
- Accurate reporting on quality key performance indexes
- Reduced compliance exposure for greater revenue integrity
“Shifting to a technology-enabled pre-bill strategy to ensure coding accuracy will help turn reactive measures into proactive management that ensures optimized compliant revenue— and subsequent financial performance.”
Technology and process automation have improved many revenue cycle pillars. Unfortunately, reliance on retrospective coding review methods continues to inhibit progress in terms of optimized revenue integrity and overall financial performance.
Prevention is a term widely used in medicine, and it serves as a vehicle to identify health conditions that, if untreated, can be difficult and expensive to reverse or cure. Applying the same approach to coding optimization will help reinforce the financial health of healthcare organizations. Shifting to a technology-enabled pre-bill strategy to ensure coding accuracy will help turn reactive measures into proactive management that ensures optimized compliant revenue— and subsequent financial performance —that’s aligned with the acuity of the care delivered.
About the Author:
Vasilios Nassiopoulos is a healthcare executive with more than 25 years of experience in revenue cycle operations. After starting his career in revenue cycle and compliance management with several large health systems, Vasilios moved into healthcare information technology where he leveraged this experience in supporting innovation and process improvement. He also provides consultative services to providers and is a published author and speaker on RCM challenges and optimization strategies.
See for Yourself
As more providers are discovering, pre-bill technology is the key to optimizing revenue integrity and financial performance across all service lines. As the leader in solutions to optimize coding accuracy prior to billing, Streamline Health is helping providers establish a new normal that improves their bottom line despite these challenging times. To discover how we can improve coding accuracy and financial performance for your organization,
contact Streamline Health today.