Hayes Management Consulting helps healthcare organizations succeed by streamlining operations, improving revenue and enhancing technology. Mission is to enable healthcare organizations to manage mission-critical operational challenges. The Hayes' blog covers a range of strategic, clinical and financial issues affecting healthcare organizations.
Quality Management is a familiar concept in healthcare, especially when it comes to organizational excellence and patient safety. Minimizing risks and ensuring safe outcomes for those under your care are critical goals in every healthcare setting.
But patient care isn’t the only area where quality management matters. An effective quality management system is an essential element of a revenue integrity program. In order to provide the best healthcare to your patients, you must build a strong revenue integrity foundation that ensures a financially viable organization. To reach that goal, you need a quality management approach that incorporates auditing and corrective action to optimize every aspect of your business and revenue cycle operations.
Healthcare organizations take pride in building and maintaining an effective internal auditing team. A robust internal audit program is crucial to avoid the perils of penalties and overpayments that can sabotage both top and bottom lines. Yet despite their best intentions, healthcare organizations that rely exclusively on internal monitoring and auditing functions – regardless of how effective they may be – can face significant pitfalls.
To ensure that the organization's financial operations are performing to the required standards, it is essential that billing compliance programs go through periodic reviews from an independent, external entity.
"The more things change, the more they remain the same." This French proverb is more relevant than ever when it comes to the proposed CMS changes for E&M documentation. Despite the exuberant celebration that greeted the announcement from CMS earlier this year that promised to reduce "documentation overload" for physicians, the reality is that the E&M documentation rules that have been around for over 20 years aren’t changing anytime soon.
One of the common definitions of insanity is "doing the same thing over and over and expecting a different result."
That definition came to mind after attending the National Association of Healthcare Revenue Integrity Symposium in Phoenix a few weeks ago. The event was well run, with expert speakers covering many critical revenue integrity issues, such as IPPS and OPPS annual updates, chargemaster maintenance, patient status, denials management, appeals and Medicare Fair Hearings, payer audits, value-based purchasing, utilization review (UR), and revenue cycle management strategies.
It’s been an exciting ride over the past 15 years, watching our company evolve and adapt to the ever-changing healthcare landscape. Anyone who has been reading our blogs over the past several years can attest to the knowledge we’ve gained by working alongside healthcare professionals to tackle a variety of modern healthcare business challenges: helping department leaders staff teams with qualified professionals; partnering with IT departments to evaluate their systems and implementation strategies; and working with revenue cycle departments to help identify untapped sources of revenue. It has been a tremendous learning process.
Healthcare providers are focused on delivering the most effective care for their patients. In recent years, however, it has become increasingly challenging for them to carry out that mission due to the growing regulatory demands and accompanying documentation requirements. Failure to adhere to these requirements can result in painful consequences, such as lost revenue, heavy financial penalties, or significant reimbursements due to poor claims documentation.
Compliance leaders bear the responsibility for ensuring their organizations avoid these adverse consequences by making sure their providers are complying with the mountain of regulatory directives. To carry out their charge, compliance professionals audit the providers to identify areas of risk and remediate any potential non-compliance issues. In many cases this puts physicians and compliance teams at odds, as we've noted in other recent blog posts.
The tools compliance teams use can also create strained relations between these two groups; by focusing attention on claims and coding errors, they can create a negative feedback loop in which auditors circle back to providers to hold them accountable for errors that may have occurred. Frustration between the two groups can grow from there.
This is the fourth and final post in our series of blogs discussing how a revenue integrity program can help clinical, compliance and revenue cycle teams join forces to address the increasing challenges of compliance. In our first post, we discussed how a revenue integrity program can be a unifying force in the organization. In the second, we explored the impact to physician practices as regulatory demands have grown. In the third post, we showed how the increasing rules and regulatory burden have strained the relationships of the three key stakeholder groups.
In this final installment, we lay out a plan that shows how to break down silos and bring the three groups together under the umbrella of a strong revenue integrity program. Following these steps will not only enhance morale, but will dramatically improve the financial health of your organization.
The provider community has been begging for documentation reform for over 20 years, and there is no question that simplifying the complex requirements of clinical documentation is necessary. Unfortunately, the recent release of the proposed changes from CMS surrounding evaluation and management (E/M) is not the answer. The benefits of the modest reduction in documentation requirements are more than offset by the devastating impact the changes will have operationally, clinically, and financially.
This is the third in a series of four posts discussing how a revenue integrity program can help clinical, compliance and revenue cycle teams join forces to address the increasing challenges of compliance. In our first post, we discussed how a revenue integrity program can be a unifying force in the organization and in the second we explored the growing complexity of physician practices as regulatory demands grow.
In our previous post we discussed the increasing regulatory burden on the healthcare industry, and how it spurred the creation of large physician groups who could afford to staff their organizations with compliance teams and revenue cycle departments. Today we’ll look at how these regulatory demands sometimes put these groups at odds, and how a strong revenue integrity program can help bring them together in a new spirit of cooperation.
Gentlemen, take your corners
The growing oversight by government payers and insurance companies caused a splintering inside healthcare organizations into three groups, each with seemingly different goals and responsibilities:
Physicians. Practicing clinicians were forced to balance the desire to spend quality time with their patients with the need to fulfill documentation demands.
Compliance teams. In an effort to avoid the penalties and reimbursement costs associated with compliance violations, compliance professionals became the "watch dogs" – responsible for monitoring clinicians to make sure they were adhering to the new requirements.
Revenue cycle departments. As clinicians began to “play it safe” and under-code the services they were providing in order to avoid compliance penalties, the revenue streams of their organizations began to suffer. This required establishing another team – the revenue cycle department – to monitor payments to ensure the organization was being properly reimbursed.
Increasing pressures cause tension
As each group diligently attempted to carry out its mandate, it was inevitable that relationships between them would become strained. For example, when Medicare changed the DRG reporting requirements in 2008, another new group was created – Clinical Documentation Improvement (CDI) – to “support” physicians to tell them how to document their services according to the new requirements. However, many clinicians interpreted this as payers dictating to them how to practice medicine in order to be compliant, causing further frustration. At the same time, revenue cycle teams, who were trying to collect for the services provided, would often become irritated when claims were rejected because of improper coding or insufficient documentation.
The shift from fee-for-service to value-based care increased the pressure on all three groups. Because of the additional risks posed by the new requirements, which could result in inadequate reimbursement for services delivered if they didn’t meet certain quality standards, compliance teams now also had to audit clinicians to make sure they were complying with new requirements. They also had to protect the organization from additional penalties for not complying with new mandates.
Increasing cost burden
The costs associated with the additional resources needed to monitor compliance and protect revenue streams - plus the reduction in the time that physicians could spend with patients - all contributed to a hit on both the top and bottom lines, creating a fiscal nightmare for many healthcare organizations. Over the years the mountain of regulations has taken its toll: suppressing revenue; imposing new controls on clinicians and how they practice medicine; inducing fear of financial penalties for non-compliance; and causing conflict across all three groups instead of bringing them together as collaborators.
It doesn’t have to be that way. Focusing the resources and experience of all three groups to provide quality care, to help make the organization profitable, and to remain in compliance can be much more effective approach. In the fourth and final post of the series, we will outline how you can set up a revenue integrity program that will break down silos and get clinicians, compliance groups and revenue cycle teams to work together to reach those common goals.
This is the second in a series of four posts discussing how a revenue integrity program can help clinical, compliance and revenue cycle teams join forces to address the increasing challenges of compliance. In our first post, we discussed how a revenue integrity program can be a unifying force in the organization.
When it comes to medicine, many like to wax poetic over the simpler times of the 1990s. Although we have improved dramatically when it comes to medical advances and quality of care over the past several decades, clinicians sometimes long for a return to certain aspects of those “good old days” when practicing medicine was a much simpler pursuit.
Looking back at the evolution of the physician practice over the past quarter century, you can certainly understand that point of view. One thing is clear: the dramatic changes affecting the health care profession since the 1990s have contributed to a growing regulatory monster, which has negatively impacted the relationship between clinicians, compliance and revenue cycle teams.