Healthcare Revenue Cycle Management, ICD-10, Claims Reimbursement, Medicare, Medicaid

Policy & Regulation News

Cost Management Effectively Optimizes Revenue Cycle Activity

By Jacqueline DiChiara

- Effective means for managing revenue cycle activity and optimization continue to evolve amidst the upcoming effects of ICD-10 implementation, the urgent push for mainstream mobile data processing, and a vigorous demand for bundled and capitated payments.

Karen England, MBA, CPC, Revenue Cycle Consultant at Ingenious Med, spoke with this week about how developing a concrete grasp of ICD-10 coding and documentation and an active push for technological prowess will help providers best identify upcoming revenue cycle patterns and outliers, thus, maximizing revenue cycle activity.

The effective monitoring of trend and cost analysis will lead to organized performance. Erroneous data could result in inaccurate decisions and decrease quality of care. According to England, the key elements of successful revenue cycle management involve tracking data. Revenue cycle leaders must be on the lookout for outliers or trends that indicate shifts in payment or denial patterns,” she claims.

A smooth aftermath of ICD-10 implementation is likely based on timeliness to reduce complications. England confirms an effective, aggressive management of revenue cycle activities will alleviate medical professionals facing arduous times.

“Everyone is expecting some lost productivity among all players of the healthcare industry,” England maintains. “However, the ability to identify activity which negatively impacts the revenue cycle is critical, considering no one is quite sure what that lost productivity will actually look like.”

An increasing focus on accuracy and quality as the shift to value-based payments materializes is necessary following ICD-10 reimbursement. Denials and payments can quickly become cumbersome to monitor.

“I believe there will be some ups and downs for several months post transition,” England reveals. “As the industry becomes comfortable with submitting and processing claims in the ICD-10 code-set, I believe payers will become smarter and more aggressive in pending claims for documentation in order to support medical necessity.”

A new focus on outcomes and costs as fee-for-service payments will dissipate as physicians are encouraged to focus their energies and efforts on patient care and cleanly executed documentation.

“As reimbursement models continue to move toward bundled or capitated payments, providers must then fully utilize the concepts of specificity and improved documentation in order to receive appropriate payment for the care provided,” England explains. “At that time, providers with a solid grasp on ICD-10 coding and documentation will be able to optimize reimbursement for the services they perform.”

Accuracy for coding will only improve with adequate training and education. More precise, fair reimbursement with fewer claims rejected is possible. Revenue for healthcare professionals can be optimized.

Healthcare providers will continue to struggle with increased performance and limited resources, and must strive for efficient and effective workflows,” England states. “Having immediate access to data and being able to respond to opportunities as they arise is a big help as opportunities arise.”

ICD-10 implementation will affect medical professionals financially, as redundantly processed claims waste revenue and time. Managing expense as reimbursement rates decrease is a top way to optimize result, England maintains. Although a slowdown in claims processing will happen, England believes this effects will be better than initially anticipated.

“Healthcare providers will see the patient financial services teams doing additional work in order to get a clean claim out the door and appropriate payment received,” England continues. “Providers may see an increase in non-revenue generating activities such as confirming diagnoses required in scheduling ancillary services or in obtaining prior authorization for procedures or medication. Times will be hard for many providers.”

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