Scope of HIM In Revenue Integrity

Bonnie S. Cassidy, MPA, RHIA, FAHIMA, FHIMSS

REVENUE INTEGRITY

Where does HIM fit?

AGENDA• What is Revenue Integrity?

• Understanding Revenue Cycle Management• HIM, Coding and CDI aka ‘The Middle’ form the foundation for

Revenue Integrity across the Continuum• How do you define your own Success?

• Embrace Teamwork & Governance• Become familiar with the 7 Habits of Efficient People• Keep a pulse on the industry:

• Rules and Regulations• Technology

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Is it the latest buzz? YES, it is!

Many may think that "revenue integrity" is new! Do you?

It is HOT in healthcare revenue cycle, audit and compliance.

"I WANT IT! . . . . But what is it?“

Results of a national healthcare industry survey revealed that 60 percent of hospital executives believe revenue integrity is essential to their organization’s financial health.

Defining Revenue Integrity

• Revenue Integrity can be a stand-alone department, initiative, program or organizational structure.

• The basis of Revenue Integrity is to prevent recurrence of issues that can cause revenue leakage and/or compliance risk.

• Activities under Revenue Integrity are expected to focus more on process improvement.

• A successful revenue integrity program will provide for a holistic view of the revenue cycle, with support from leadership and technology.

REVENUE INTEGRITY

The revenue integrity approach ensures that providers can clearly identify, track, and realize the profit margins for the care they deliver. Through a series of integrated systems and processes, providers can detect and eliminate many of the pitfalls in traditional revenue cycle processes that are quickly becoming liabilities.

REVENUE INTEGRITY

As a holistic concept, integrity is characterized by consistency of actions, values, methods, measures, principles, expectations, and outcomes. Applied to the healthcare industry, revenue integrity is the achievement of operational efficiency, compliance, and legitimate reimbursement. Revenue integrity can be achieved only with the proper processes, tools, and related expertise aimed at effectively pricing, charging, and coding for services and supplies related to patient care.

• Process efficiency – people and technology• Compliance – following rules of engagement• Correct payment – proper pricing, charging, coding, and

documentation

REVENUE INTEGRITY.

What revenue integrity IS NOTis having someone work the same issues every day or analyzing and benchmarking issues without a direction to improve. This is not a time to be reactive, but proactive.

Revenue Integrity

These intricacies commonly show up when dealing with complex payer contract reimbursement requirements, or when working with patient populations that lack awareness of their health coverage and payment responsibilities. PREVENTING: End result is an undetected underpayment, a claim with missing charges, or an unnecessary write-off of a patient-owed balance.

REVENUE INTEGRITY.Suzanne Lestina, revenue cycle technical director for the Healthcare Financial Management Association (HFMA), takes it a step further.

“Revenue integrity means right revenue, right delivery, and right protocols to ensure right [accurate] reimbursement and compliance. Revenue integrity doesn’t begin with a charge.”

REVENUE INTEGRITY.

To understand and be a Champion for Revenue Integrity, You must understand Revenue Leakage.

Healthcare providers have long relied on conventional revenue cycle management practices to drive and ensure financial performance, yet most are NOT collecting all the revenue to which they are entitled. This disparity – the gap between the amount of revenue providers are entitled to and the amount of reimbursement eventually received – is called revenue leakage, and it’s a significant problem.

REVENUE INTEGRITY.With up to 40,000 or more line items in a hospital’s chargemaster, the potential for costly errors is high, and likely to result in lost revenue, rework, fines, and penalties. A hospital with annual revenue of $300 million can easily lose $3 million to chargemaster and charge capture errors per year. Identifying the source and extent of leakage is essential to achieving revenue integrity.

REVENUE INTEGRITY.

54 percent of hospital executives added additional staff to address revenue integrity issues, while 25 percent went so far as to establish an entire revenue integrity department.

http://www.healthcarefinancenews.com/news/revenue-integrity-tops-list-concerns-hospital-executives

The critical role of the Middle Revenue Cycle

VALUE of HIM

We must be able to articulate the Value of HIM, Clinical Documentation and CodingIn patient care organizations, proper and accurate clinical documentation has always been important, but in today’s shifting healthcare landscape, it has become even more of a strategic imperative than perhaps ever before. Documentation is critical for: patient care, not only because it validates the care that was provided it shares key data with subsequent caregivers and optimizes claims processing and reimbursement

HIM Best Practices address “Documentation Integrity”

• Information Governance• Patient identity Management• Authorship validation• Amendments and • Record corrections • Auditing the record for documentation validity when submitting reimbursement claims. EHRs have customizable documentation applications that allow the use of templates and smart phrases to assist with documentation. Unless these tools are used appropriately, however, the integrity of the data may be questioned and the information deemed inaccurate—or possibly even perceived as fraudulent activity. Established policies and procedures such as audit functions must be in place to ensure compliant billing and REVENUE INTEGRITY!

HIM, Coding & CDI: VALUE Propositions

Both documentation and coding accuracy ensure correct provider profiles and a true reflection of patient severity.

This includes documentation and coding of chronic conditions included in Hierarchical Condition Categories (HCCs). Specific secondary diagnosis codes equate to HCCs and impact the Risk Adjustment Factor for Medicare Advantage beneficiaries as well as some commercial payer beneficiaries.

Scope of HIM in RCM

Identity Mgt

CDICDI

Denial Mgt

ROI

Prebill Review

Coding

Compliance

Information Governance

The Impact of ICD10 Coding Compliance• Documentation practices have been considered by many to be the top

driver for ICD-10 success, given that clinical documentation must meet the level of coding specificity and granularity required to achieve:

• REVENUE INTEGRITY achieve optimal reimbursement; • COMPLIANCE: meet all regulatory and reporting requirements; and • DENIALS AVOIDANCE accurately reflect the level of care provided.

• A good CDI program and good clinical documentation is a fundamental critical step to achieving a successful ICD-10 Coding Compliance.

HIM, Coding & CDI Best Practices are essential for achieving Revenue Integrity• Revenue integrity is the achievement of operational efficiency,

compliance, and legitimate reimbursement.• Revenue integrity can be achieved only with the proper

processes, tools, and related expertise aimed at effectively pricing, charging, and coding for services and supplies related to patient care.

Revenue Integrity: We must have Documentation IntegrityThere are CDI-specific operational analytics, in addition to traditional metrics like case mix index with appropriate, comparative benchmarks. Clinical documentation integrity impacts all other performance measures, including quality and safety.You need to be collecting, validating, disseminating and trending CDI metrics, as you do with other management information.

Clinical Documentation Integrity• Documentation integrity involves the accuracy of the complete

health record.• Coded data is then translated into quality reporting, physician

report cards, reimbursement, public health data, and disease tracking and trending.

• The convergence of clinical documentation and coding processes is vital to a healthy revenue cycle, and more important, to a healthy patient.

Revenue Integrity

Can you achieve Revenue Integrity without Clinical Documentation Integrity?

Teamwork is Essential for Revenue Integrity

Teamwork is essential to achieve Revenue Integrity

Revenue Integrity TeamworkEngaging physicians to improve their clinical documentation is critical to the success of the entire healthcare organization.Yet getting physician buy-in for this strategy remains difficult.We see this problem occurring everyday!

Physician EngagementCannot be bottom up!

Must be top down!

Executive leadership and Physician leadership are a must on your team!

The organization must embrace all aspects of good clinical documentation and support the CDI and Coding team.

Revenue Integrity: Include HCCs in Your Program

• Both documentation and coding accuracy ensure correct provider profiles and a true reflection of patient severity.

HCCs are also found within Advanced APMs and are important in capturing the acuity, severity, and chronicity of patient conditions.

Revenue Integrity: Include HCCs in Your Program

Reimbursement is linked to how sick the member is and adjusts risk based on specific diagnoses. Documentation of these chronic conditions should be included at each patient encounter and should include the specific evaluation or treatment for each condition coded.

Both Coding and CDI professionals will play a critical role in quality reporting for all providers across the continuum of care.

Risk Adjustment and Revenue Integrity• Where do you Fit?

Making strategic and effective decisions regarding the organization’s information assets. This includes:

• Defining roles for HIM, Coding, Clinical Documentation Integrity

• Team work: Contracts/CDI/Coding• Defining roles and responsibilities for data.• Establishing data quality policies.• Creating metadata management practices.• Arbitrating shared data questions.• Release of information Best Practices

Physician Education on Clinical DocumentationThe Importance of Better DocumentingPhysicians might not be quite in tune as to the impact poor documentation can have on the bottom line.

Remember: CDI is critical in the physician office, too!

Revenue Integrity

• MUST address COMPLIANCE• Keeping track of constant changes to CMS regulations.• Ensuring an adequate internal audit trail to defend revenues

received, is an ongoing challenge for healthcare organizations.

Impact of Clinical Documentation Integrity on Financial Performance• Understand Risk Adjustment (RA) and RA in my own

organization• Clinical Documentation-enabled Quality Measures Performance• Quality Measures Performance very real and evolving tie to

optimal reimbursement

Revenue Integrity Across the Continuum of Care

Coding & CDI Across the Continuum

We cannot be ‘acute care focused’ without thinking about Coding and CDI across the continuum of care.• Now is the time to review the initiatives associated with Health

Care Reform Initiatives and consider the necessity of education and training for both providers and staff.

• It will be important to review current documentation and coding practices and identify the potential benefits of CDI programs in the physician practice setting.

How to define your own success

Front End DesignDenials and Repayment• How do you migrate from a less efficient “find and fix” approach that you

know and trust to a more effective approach? • A sensible solution requires a fundamental shift from quantifying return on

investment (ROI) based on errors found downstream, to a process that ensures industry best practices are followed from early in the revenue cycle all the way through to the measurement of real-time transaction accuracy.

THINK WITH THE END IN MIND!

Let’s think about bringing this altogether!

Role of HIM in Revenue Integrity

Must have Enterprise-wide Information Governance which is a collaborative effort that empowers and supports improved patient care, financial integrity, clinical documentation integrity and coding compliance.

Moving to a Comprehensive Revenue Integrity Program• Best practice revenue integrity processes essentially take traditional RCM

to the next level by using predictive analytics to drive smart workflows that integrate functions, such as coverage identification, charge capture, billing, denial management, and payment, in order to optimize revenues.

• Data extracted from various stages of the revenue cycle powers automation that proactively identifies potential issues before they become problematic.

• The best response is to incorporate lessons learned from Analytics into workflows to better educate and communicate with patients, securing more patient-responsible balances as a result.

https://www.healthmgttech.com/revenue-integrity-better-reimbursement-strategy

Five questions to consider when planning for future clinical documentation needs

• How can more accurate documentation improve quality of care and patient outcomes?

• What are the justifiable and action-oriented outcomes that could result from taking a more in-depth look at our current clinical documentation effort?

• How can Coding professionals collaborate more effectively to design and sustain a more productive work plan?

• How can HIM and Coding professionals aspire to become advanced CDI professionals and claim roles that will add value to clinical documentation outcomes?

• What other roles, responsibilities, and education will advance our clinical documentation program and contribute to value-based care?

Stay Relevant: Keep Pace with Industry

CMS Rules & Regulations

• Most hospitals lack an effective means of monitoring ever-changing CMS regulations to ensure both ongoing compliance and proper reimbursement

What do you see?

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HIM Leadership

From this point forward…we in HIM, Coding and CDI must accept one another as equal shareholders of a

partnership called “The Future State of Revenue

Integrity”

Thank You!

Questions?

References• CDI Expanding Beyond the Hospital Walls Through Standards, HIM Body

of Knowledge, http://bok.ahima.org/doc?oid=61572#.Wny8AainHIU• HIM’s Role in Supporting CDI Across the Continuum , AHIMA Advantage,

April 2017, Volume 22, No. 2• HIM’s Role in Value Based Reimbursement

http://bok.ahima.org/doc?oid=301941#.Wny6QqinHIU• Informatics Toolkit for HIM and HI Professionals. AHIMA Body of

Knowledge • Information Governance Toolkit, 3.0, AHIMA Body of Knowledge,

http://bok.ahima.org/PdfView?oid=302242

References• Integrity of the Healthcare Record http://library.ahima.org/doc?oid=300257• Revenue Integrity: A Better Reimbursement Strategy

https://www.healthmgttech.com/revenue-integrity-better-reimbursement-strategy

• Revenue Integrity and Coding Compliance: The Sharp Experience ,AHIMA Body of Knowledge, http://bok.ahima.org/doc?oid=61572#.Wny8AainHIU

• Revenue Integrity in Healthcare https://public.craneware.com/resources/white-papers/revenue-integrity-in-healthcare

References• Revenue Integrity Tops List of Concerns for Healthcare Executives,

http://www.healthcarefinancenews.com/news/revenue-integrity-tops-list-concerns-hospital-executives

• What is Revenue Integrity and How can Your Organization Best Achieve it? https://www.streamlinehealth.net/HIM-blog/revenue-integrity-can-organization-best-achieve/