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Navigant Revenue Integrity HFMA Presentation
The document outlines the essential components and best practices for developing a successful revenue integrity program within healthcare organizations. It emphasizes the importance of aligning clinical and billing operations, proactive charge management, and establishing accountability structures that include communication among stakeholders. Additionally, the document presents key performance indicators and case studies demonstrating successful implementations of revenue integrity strategies.
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Navigant Revenue Integrity HFMA Presentation
- 1. / ©2019 NAVIGANTCONSULTING, INC. ALL RIGHTS RESERVED1 Confidential and Proprietary JANUARY 31, 2019 GA HFMA REVENUE INTEGRITY: PREPARING FOR TODAY’S CHALLENGES
- 2. / ©2019 NAVIGANTCONSULTING, INC. ALL RIGHTS RESERVED2 Confidential and Proprietary AGENDA • Key Components and Industry Trends • Organizational Success Factors - Developing a Successful Revenue Integrity Program - Best-Practice Revenue Integrity Structure - Project Timeline and Milestones • Key Performance Indicators • Client Case Study • Questions
- 3. / ©2019 NAVIGANTCONSULTING, INC. ALL RIGHTS RESERVED3 Confidential and Proprietary KEY COMPONENTS AND INDUSTRY TRENDS
- 4. / ©2019 NAVIGANTCONSULTING, INC. ALL RIGHTS RESERVED4 Confidential and Proprietary REVENUE INTEGRITY – DEFINITION Revenue integrity is the source of quality assurance within revenue cycle • Bridges the gap of knowledge between clinical and billing operations • Shifts traditional focus of retrospective auditing to proactive charge management • Increases both gross and net revenue capture, as well as compliance, by viewing the big picture Concept of bringing revenue cycle, managed care, finance, and clinical together to create a global view of gross and net revenue capture
- 5. / ©2019 NAVIGANTCONSULTING, INC. ALL RIGHTS RESERVED5 Confidential and Proprietary REVENUE INTEGRITY – COMPONENTS Integrated group of stakeholders focused on the organization’s ability to properly price, accurately capture and reconcile charges, as well as receive timely and accurate payments for services performed DENIAL PREVENTION • Ensure all charging-related denials are appealed and root causes are identified within the Revenue Integrity team • Track and report recovery efforts and issues with payers, departments, and contracts PAYMENT VARIANCE • Monitor payments and address variances in reimbursement • Review appropriateness of pricing and fee schedules COMPLIANCE • Develop and implement system- wide compliance education • Research regulatory compliance as it relates to charging CDI • Responsible for improving the quality and completeness of clinical documentation • Facilitates and obtains appropriate physician documentation for any conditions or procedures CHARGE CAPTURE • Reviews documentation to ensure timely, accurate, and compliant charge capture • Educates and trains to improve charging processes CDM AND PRICING • Responsible for the updates to department charge codes • Oversees the daily maintenance, regular updates, price impact analysis
- 6. / ©2019 NAVIGANTCONSULTING, INC. ALL RIGHTS RESERVED6 Confidential and Proprietary HOLISTIC GUIDING PRINCIPLES • Provide a central point of communication to system-wide revenue generating and support departments • Focus on creating a collaborative mentality across the system when interacting with clinical stakeholders, finance, managed care, and revenue cycle • Drive standardization and accountability throughout the organization • Ensure compliant, accurate, and timely charging from the clinical side to ensure reduction of denials and accurate reimbursement • Provide education, training, and accountability related to charge capture and revenue reconciliation Revenue Integrity Managed Care Revenue Cycle Clinical Finance
- 7. / ©2019 NAVIGANTCONSULTING, INC. ALL RIGHTS RESERVED7 Confidential and Proprietary BEST PRACTICE REVENUE INTEGRITY STRUCTURE Documentation and Coding CDM and Pricing Denial Mgmt Payment Variance Gross Charge Capture Accuracy Training / Education Claim Edit Review and Revenue Reconciliation CDM / CPT Review and Maintenance Revenue Integrity Revenue Integrity – HB and PB • Acts as a liaison to other revenue cycle and clinic department(s) to monitor revenue flow • Addresses sources of revenue leakage and areas of revenue opportunity • Owns all gross and net revenue related analytics • Ownership of charge capture, revenue reconciliation, and training / education at the department level • Monitors service line pricing variances and develops associated pricing strategies • Organizes payer trends with denials and payment variances Charge-Related Denials and Avoidable Write-Offs
- 8. / ©2019 NAVIGANTCONSULTING, INC. ALL RIGHTS RESERVED8 Confidential and Proprietary IMPORTANCE OF A COMPREHENSIVE REVENUE INTEGRITY PROGRAM Revenue Integrity Program • Centralizes committees and/or task forces and goal setting • Increases transparency of goal setting and achievement • Tasks and primary responsibilities are interrelated • Liaison for gross and net revenue discussions across the system • Decreases risk of missed or inaccurate charge capture • Increases communication across the system highlighting opportunities for additional net revenue realization Lack of Revenue Integrity Program • Siloed efforts between clinical and revenue cycle • Mixed messages on proper processes and education • Complex problems are misunderstood or ignored, and often don’t receive the necessary focus to resolve • Increasing trend of revenue assurance programs results in better margins for competitors – not having an revenue assurance program will ultimately result in mid- to low-tier revenue cycle performance
- 9. / ©2019 NAVIGANTCONSULTING, INC. ALL RIGHTS RESERVED9 Confidential and Proprietary ORGANIZATIONAL SUCCESS FACTORS
- 10. / ©2019 NAVIGANTCONSULTING, INC. ALL RIGHTS RESERVED10 Confidential and Proprietary DEVELOPING A SUCCESSFUL REVENUE INTEGRITY PROGRAM People ProcessTechnology
- 11. / ©2019 NAVIGANTCONSULTING, INC. ALL RIGHTS RESERVED11 Confidential and Proprietary DEVELOPING A SUCCESSFUL REVENUE INTEGRITY PROGRAM People 1) Identify stakeholders impacting gross and net revenue capture • Strategic decision makers • Clinical service providers • Payer / contract experts • Billing and financial specialists 2) Define goals and accountability structure • Individual vs system goals • Individuals responsible for attaining goals at all levels 3) Create communication paths across these key stakeholders • Revenue integrity steering committee • Service line working groups • Revenue integrity reports and dashboard
- 12. / ©2019 NAVIGANTCONSULTING, INC. ALL RIGHTS RESERVED12 Confidential and Proprietary DEVELOPING A SUCCESSFUL REVENUE INTEGRITY PROGRAM Process 1) Identify key processes in gross and net revenue capture • Pricing strategy and fee schedules • Payer strategy • CDM and charge capture • Clinical documentation review and coding • Billing and follow-up 2) Assess current state • Determine whether missing, underdeveloped, or underutilized • Compare against best practice organizations 3) Develop future state plan and implementation schedule • Prioritize focus around areas with biggest impact • Set clear and realistic timelines and resource needs • Assign owners and commit to deadlines 4) Create goals and clear accountability structure • Assign multiple layers of accountability to ensure goals are met • Be consistent
- 13. / ©2019 NAVIGANTCONSULTING, INC. ALL RIGHTS RESERVED13 Confidential and Proprietary DEVELOPING A SUCCESSFUL REVENUE INTEGRITY PROGRAM Technology 1) Identify technology supporting gross and net revenue capture • EHR(s) • Third-party vendors and tools • Reporting and data analytics 2) Assess current technologies and whether they support goals • Complete cost / benefit analyses to determine if replacing or augmenting certain vendors or tools is appropriate • Look for opportunities to automate 3) Create or adjust reporting package and dashboard(s) • Validate and understand data components • Ensure consistency across reports • Help facilitate realization of individual and system goals
- 14. / ©2019 NAVIGANTCONSULTING, INC. ALL RIGHTS RESERVED14 Confidential and Proprietary KEY PERFORMANCE INDICATORS
- 15. / ©2019 NAVIGANTCONSULTING, INC. ALL RIGHTS RESERVED15 Confidential and Proprietary REVENUE INTEGRITY CORE METRICS RI Functional Area Metric Gross Revenue Capture Charge Lag Performance Cost Center Revenue, Volume, and Acuity Trending Professional Pre-AR Hospital DNFB Pending Charges Revenue Reconciliation Performance Identified Missed Charges Net Revenue Improvement Denial Volume Avoidable Write-offs as % of Gross Revenue Avoidable Write-offs as % of Net Revenue Underpayment Recoveries (Internal and External)
- 16. / ©2019 NAVIGANTCONSULTING, INC. ALL RIGHTS RESERVED16 Confidential and Proprietary CLIENT CASE STUDIES
- 17. / ©2019 NAVIGANTCONSULTING, INC. ALL RIGHTS RESERVED17 Confidential and Proprietary REVENUE INTEGRITY PROGRAM DESIGN AND IMPLEMENTATION System Overview • Statistics: • 3 hospitals, 8 outpatient facilities • 1000+ licensed beds • 1,100 employed physicians • Revenue Integrity Program Design • Oversight for hospital and physician RI functions • Partnered with leaders to promote CI with the revenue cycle • Implemented policies and procedures for charge capture, revenue reconciliation, CDM management, denials prevention, and underpayment recovery • Established Denials/AWO Prevention Committee, focused on HB, PB, PAS, and clinical areas and risk mitigation • Implemented a staffing model including gross and net revenue functions • Identified key opportunities through claim edits, charge reconciliation, and denials management • CDM and Charge Capture Audit • Established change control system for CDM mgmt. and audit • Trained clinicians responsible for charge entry and reconciliation • Implementation of Revenue Guardian Solution Implementation Key Accomplishments • Created nine new positions dedicated to RI • Implemented avoidable write-off strategy to increase net revenue in first year by >$10M • Hired system Revenue Integrity Director to lead new department & functions • Leveraged vendor partnership to identify underpayments on $0 accounts($2M benefit) • Created revenue monitor report at cost center level • Improved denial follow up workflow to capture denial root cause issue & owners • Improved communication & visibility around revenue capture at the service line levels: • Started annual CDM & specialty-based charge capture audit • Determined executive Clinical Revenue Champion to support revenue cycle & clinical partnership • Implemented Revenue Guardian checks for anesthesia services, missing surgical supply charges, and ED service levels
- 18. / ©2019 NAVIGANTCONSULTING, INC. ALL RIGHTS RESERVED18 Confidential and Proprietary REVENUE INTEGRITY PROGRAM DESIGN AND IMPLEMENTATION System Overview • 8 hospitals, 90 clinics • 1,500+ licensed beds • 1,200 employed physicians • CDM and Charge Capture Audit - Iterative CDM validation and audit - Charge capture build audit - Year over year charge trend analysis - Improved charging dialogue among service line leaders - Implementation of Revenue Guardian • Revenue Management Program Design - Current state analysis of system processes related to charge capture - Organizational structure re-design - Policies and procedures - Re-education and training - Identification of key opportunities through claim edits, charge reconciliation, and denials management Solution Implementation Key Accomplishments • >4,500 charge codes were identified for consolidation and standardization • Automated alt code assignment • Created six new positions dedicated to Revenue Integrity • Accelerated $17.5M (gross) cash over three months • Achieved over $13M in net revenue benefit related to the reduction of avoidable write- offs • Improved communication and visibility around revenue capture at the cost center and service line levels: - Started Revenue Management Steering Committee - Weekly service line working sessions • Created revenue monitor report at cost center level • Identified >100 charge capture opportunities • Found >3,000 errors in charge code build
- 19. / ©2019 NAVIGANTCONSULTING, INC. ALL RIGHTS RESERVED19 Confidential and Proprietary QUESTIONS?
- 20. / ©2019 NAVIGANTCONSULTING, INC. ALL RIGHTS RESERVED20 Confidential and ProprietaryConfidential and Proprietary ANDREW HANCOCK Managing Director andrew.hancock@navigant.com Phone: 616.322.6457 AMANDA VALLOZZI Associate Director amanda.vallozzi@navigant.com Phone: 571.213.8463 navigant.com CONTACTS