PART 1: REVENUEINTEGRITY PROGRAMDESIGN, PROCESS ANDIMPLEMENTATIONCAROLINE RADER ZNANIECOWNER/FOUNDERLUNA HEALTHCARE ADVISORS

AHIA 33rd Annual Conference – September 21-24, 2014 – Austin, Texas

www.ahia.org

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Today’s Presenter2

Caroline Rader Znaniec is the founder and owner of LunaHealthcare Advisors LLC, headquartered in Maryland. Her focus isproviding high quality healthcare provider integrity consultingservices to the nation's top health systems, hospitals and physiciangroups, and freestanding providers.

Caroline has close to 20 years of healthcare experience within theprivate industry and as a consulting professional. Prior to starting her own company,Caroline was the Revenue Integrity Services National Lead for Grant Thornton,Associate Director of Charge Integrity Services at Navigant Consulting, CorporateCompliance Officer of a large Maryland integrated health system, as well as otherpositions within the revenue integrity profession.

This is her 3rd year speaking for AHIA. She also speaks for other organizationsincluding HFMA, HCCA, AHIMA and ACDIS.

caroline@lunahealthcareadvisors.com

Learning Objectives

Determine your organization's revenueintegrity needs and how to incorporateinto an annual work plan

Recite key principles in the performanceof a revenue integrity review

Assess revenue integrity key performance indicatorsand benchmarks

List the stakeholders and processes behind thesuccess of key performance indicators

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Today‘s Session

This session will provide for an introduction to aformal revenue integrity process, including: program design staffing key strategies key performance indicators stakeholder involvement

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Takeaways

Live Participant handouts: sample program and committee charters job descriptions sample work plan

Post conference online copies can be accessed atthe following link:

www.lunahealthcareadvisors.com/ahia2014Password: Austin

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Assess your Program oryour Expectations . . .

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Question 1

1. Where does the Revenue Integrity Program reside?A. Patient Financial ServicesB. ComplianceC. Health Information Management

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Question 28

2. Within Revenue Integrity, most of the staffs’ time isspent performing the following:

A. Entering chargesB. Auditing and monitoringC. Reviewing and correcting accounts

Question 39

3. What word best describes the daily operations ofthe Revenue Integrity Program?

A. ReactiveB. ProactiveC. Random

Question 410

4. What defines the overall goals and objectives of theRevenue Integrity Program?

A. Volume of accounts not billedB. A formal work planC. The “fire” of the moment

Question 511

5. The Revenue Integrity Program measureseffectiveness utilizing the following:

A. Volume of unbilled accounts; monthlyB. Measured improvement against benchmarksand goalsC. Reductions in requests for assistance fromclinical departments

Tally Time!

Mostly A’s Not Effective. Your program is in a more reactive state.

Programs that operate reactively cannot break thecycle. The root cause of the breakdown compounds theissue and prevents other risks from being identified oraddressed.

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Tally Time!

Mostly B’s Potentially Effective. Your program has the infrastructure

to identify risks, audit and monitor those risks. However,the healthcare environment is ever-changing and thefrequency, content and methodologies utilized toadminister the program may require substantial effortsto sustain positive momentum.

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Tally Time!

Mostly C’s Not Effective. Your program is not only reactive, but

disorganized. Programs that are not formally structuredwith clear goals, objectives and direction will not affectchange in the process and breakdowns will continue.

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Defining Revenue Integrity15

Revenue Integrity can be a stand-alonedepartment, initiative, program or organizationalstructure.

The basis of Revenue Integrity is to preventrecurrence of issues that can cause revenue leakageand/or compliance risk.

Activities under Revenue Integrity are expected tofocus more on process improvement.

A successful revenue integrity program will providefor a holistic view of the revenue cycle, with supportfrom leadership and technology.

Defining Revenue Integrity (CONT)16

Revenue integrity depends on compliance withproper revenue-cycle processes from the pointwhere the patient is referred to the organization tothe payment of the claim.

These processes function sequentially to producethe desired patient outcome and to generate thebill for services related to that outcome.

If any of these processes are not functioningproperly mistakes may become compounded alongthe way leading to denial of the claim.

Objectives17

Identification and correction to the processes andsystems that lead to lost revenue opportunitiesthrough the creation and oversight of processes toensure the accurate capture and reporting of data,translation of data into useful information and useof data to support strategic initiatives;

Assurance that every chargeable procedure, item orservice is coded, documented, captured, billed andpaid according to the terms of governmentguidelines and payer contracts;

Objectives (CONT)18

Assistance in bringing on new service lines and/orofferings, including clinical trials, and

Provide for a resource for other staff members onquestions or issues related to documentation, coding,charge capture and billing to create, or betterfoster, an organization-wide understanding of theimportance of revenue integrity.

Key Strategies19

Create staff awareness at all levels on theindividual and provider organization’sresponsibilities through inclusion of responsibilities injob descriptions, on-boarding activities and annualeducation;

Provide tools and/or guidance to the providerorganization specific to those processes of therevenue cycle that are specific to front, middle andback-end revenue cycle processes;

Key Strategies (CONT)20

Design and implement a monitoring program forhigh risk areas identified to include thedevelopment of review tools, analysis of results toidentify root causes and develop corrective actionplans, track corrective action plan implementationand verify improvement, and

Create and maintain a means for oversight andreporting to leadership.

Structure21

Models can vary based on several factors of theprovider organization: Type Size Clinical Services Infrastructure Culture External Forces

Examples for discussion provided on followingslide

Structure – Example 122

Type of Provider Large Health System (6) Academic and Community Urban through Rural Settings

Size of Provider 163,000 Annual Inpatients 2 million Annual Outpatient Visits 2,000 Physicians

Clinical Services Freestanding Radiology Services Physician Offices & Billing Office Durable Medical Equipment Company Clinical Trials Home Care and Home Infusion

Services

Infrastructure Corporate Function and Oversight Separate Finance, Reimbursement/

CDM, Compliance and Internal Audit

Culture Clinically Advanced (overall) High Financial Performance Complicated Communication Channels Reactive

External Forces Single Hospital Under OIG Scrutiny

Structure – Example 223

Type of Provider Integrated Health System Community Provider

Size of Provider 300 Inpatient Acute Hospital Beds 50,000 Annual ED visits 5 Radiology Sites 10 Employed Hospitalists 50 Employed Community Physicians

Clinical Services Freestanding Radiology Services Physician Offices & Billing Office Inpatient Chemical & Drug

Rehabilitation Clinical Trials Home Infusion Services

Infrastructure CDM/Compliance Auditors Revenue Integrity Committee Corporate Compliance Officer Corporate Compliance Committee Finance and Audit Committee Hospital Board Oversight

Culture Clinically and Technologically

Advanced High Financial Performance Collaboration Amongst Key

Stakeholders Open Communication Proactive

External Forces Post Satisfaction of OIG Corporate

Integrity Agreement

Structure – Example 324

Type of Provider Small Community Health System

Size of Provider 100 Inpatient Acute Hospital Beds 35,000 Annual ED visits 2 Free-Standing Radiology Sites 3 Employed Hospitalists 15 Employed Community Physicians

Clinical Services Increasing Outpatient Services Freestanding Radiology Services Physician Offices & Billing Office

Infrastructure CDM/Charge Capture Manager, also

functioning as Educator Corporate Compliance Officer

Culture Looking to Advance Clinically and

with Addition of Technology Low Financial Performance "Many Hats" Reactive

External Forces Looking for Academic Health System

Affiliation

Structure – Considerations25

Define Scope Identify Key Stakeholders Understand Current Initiatives (internal and external)

Staffing26

Better practice has provided for staffing levels thatcan administer an effective program through the useof dedicated independent staff.

Key stakeholders must understand the objectives ofRevenue Integrity and what factors are fundamentalto its success.

Organizations with the greatest success engage keystakeholders through the use of a Revenue IntegrityCommittee.

Work Plan27

The two objectives behind the development of anannual work plan are:

1. Correct the processes and systems that lead to lostrevenue opportunities, and

2. Ensure every chargeable procedure, item or service iscoded, documented, captured, billed and paidaccording to the terms of government guidelines andpayer contracts.

Work Plan (CONT)28

To meet the work plan objectives, providerorganizations should review for policiesprocedures, practices and/or processes whichinclude, but are not limited to, the following: Maintenance of the Charge Description Master Use of Tools or Technology to Document, Capture

Charges, Code and Bill

Responsibilities and Required Knowledge of Registrationthrough to Billing Staff

Work Plan (CONT)29

The work plan should allow for flexibility. The work plan should allow for revision to

accommodate additional items. The work plan should be realistic and achievable. Work plans should identify why the review is

necessary. For each work plan item, the scope of the review

should be determined and specifically outlined.

Performing a Review30

In reviewing departments or services, a holisticapproach is best: Charge Description Master Review

Clinical Subsystem Linkage and Usage Review

Administrative and Financial Subsystem Linkage and Usage Review

Charge Capture Tools Review

Documentation Tools or Template Review

Baseline Coding and Documentation Assessment

Coding, Documentation and Charge Capture Policies and Procedures

Analysis and Review of Payer Remittance

Concurrent Review of Processes

Interviews of Key Stakeholders

Performing a Review (CONT)31

The deliverables for each work plan item shouldbe individually defined.

A time period for the initiation and completion ofthe work plan item should be defined. Each taskdelegated should have a separate and distinctdate for completion.

Audit activities should remain independent. Theresponsible stakeholder should not be designatedas the reviewer.

EXAMPLE Performance Indicators32

Eligibility Verification Benchmark Monitoring

Scheduled Services 98% verified prior to service System generated report

ED Services 90% verified prior todischarge

System generated report

Insurance Verification Benchmark Monitoring

OP Scheduled Services 95% verified prior to service System generated report

Inpatient Services 100% of patients verified System generated report

Financial Counseling Benchmark Monitoring

Inpatients(uninsured/underinsured)

>95% cleared prior todischarge

System generated report

Inpatient Services 100% of patients verified System generated report

Registration Benchmark Monitoring

Registration errors <3% error rate System generated report

FRONT

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EXAMPLE Performance Indicators33

MIDDLE

Interface Reporting Benchmark Monitoring

Error Reports/Ques <10% of encounters System Generated Report

Coding Backlog Benchmark Monitoring

Transcription Turnaround <24 hours H&P, OP<2 days Discharge Summary

System Generated Report

Coder Productivity Inpatient 24/dayOutpatient/Amb Surg 40/dayEmergency 120/dayAncillaries 240/day

System Generated Report

Late Charges Benchmark Monitoring

Late Charge Report < = 2% of total gross charges System Generated Report

Documentation Quality Benchmark Monitoring

Coding Queries 30% concurrent10% retrospective

System Generated Report

Query Response Rate 86 – 90% System Generated Report

EXAMPLE Performance Indicators34

Claim Editing Benchmark Monitoring

Electronic claim scrubbing > 95% clean claim submission Daily claims edit report

Claims requiring editing Worked within 24 hours Daily claims edit report

Follow-up Benchmark Monitoring

Large balance unit Account inventory <1000Productivity > 50 accts per day

System generated worklists

Small balance unit Account inventory <3000Productivity > 90 accounts perday

System generated worklists

Discharged Not FinalBilled

Benchmark Monitoring

Outpatient 6 hold days System generated report

Inpatient 4 hold days System generated report

BACK

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Ready for the Next Step?

Tomorrow . . .Part 2: Troubleshooting Revenue Integrity Issues for Today and Tomorrow

Regular review of integral revenue cycle processes within a healthcareprovider's operations is critical to overall revenue integrity. The monitoring ofrevenue integrity benchmarks such as DNFB can identify potential issues, butthen what? Identifying there is an issue is only half the battle.This session will review "hot topic" revenue integrity benchmarks, provide fortips on troubleshooting and will include the review of actual case studies tolead discussion on how to not only identify, but correct the issue(s).Considerations for organizational culture and industry change will also beaddressed. This may include the adoption of an EMR, acquisition andregulatory changes such as ICD-10.Participants will be provided with handouts including detail for the case studiesdiscussed, benchmark matrix, and a revenue integrity checklist for ICD-10preparation.

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Save the DateAugust 30 - September 2, 2015

34th Annual ConferencePortland, Oregon