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

Policy & Regulation News

How Business Intelligence, CDI Focus Sharpens Revenue Cycle

By Jacqueline DiChiara

- Celebrating success is generally much more fun than learning from failure. But the latter is sometimes more necessary.

revenue cycle management ICD-10 claims denials

Eighty percent of nearly 300 healthcare providers surveyed last month said ICD-10 implementation was an overall success, according to KPMG’s online webcast survey. Twenty-eight percent of respondents said the transition was smooth. Fifty-one percent noted general success, albeit “a few technical issues.”

On the flipside, 11 percent described their overall ICD-10 experience as a “failure.” This 11 percent “bears watching,” and is “cause for caution,” wrote earlier this month.

The most common ICD-10 challenges for healthcare providers, said KPMG, included rejected medical claims, clinical documentation and physician education, lower revenue because of coding delay, and information technology glitches.

In light of this 11 percent seeing "failure," perhaps it is too soon to celebrate. Commented Joshua Berman, Director of ICD-10 at RelayHealth Financial, to, “I don't want people to get lax. I want people to celebrate the successes, for sure, but we're not done yet.”

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Healthcare providers need to “dedicate more attention to the quality and specificity of clinical documentation to reduce rejected medical insurance claims,” stated Catherine O’Leary, KPMG’s Managing Director.

“Organizations are beginning to see dips in cash flow due to payers delaying the processing of ICD-10 claims while they ensure their ability to appropriately adjudicate these claims, while others are seeing an increase in claim denials over pre-ICD-10 levels,” asserted Craig S. Greenberg, CMPE, Director, Advisory at KPMG.

Greenberg (pictured above) chatted with to further explain the greater implications of KPMG’s survey results. What did the 11 percent not do that the rest did well?

Craig S. Greenberg: The 11 percent may not have mediated their systems to the extent they needed to for claim submission or done testing with payers. They may not have provided in-depth training for their providers around improving their clinical documentation capabilities. The approach we take with clients is to train providers to be excellent documenters rather than coders.

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CG: It's especially important with ICD-10 to evaluate IT systems, processes, workflows, and staffing models. In particular, from a revenue management perspective it is important to ensure IT systems are optimized for operational efficiency and performance.

[Regarding business intelligence (BI) reporting,] many organizations do not receive management and clinical reports in a timely manner. Reporting capabilities must be secured to ensure that organizational leadership has the ability to proactively review key performance metrics and take action as required. What are your strategies for doing this?

CG: We did this through the utilization of a BI tool that can aggregate data easily and provide daily high-level reports for leadership through the provision of daily dashboard reports.

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A lot of organizations have dashboards but they don't necessarily have drilldown capabilities to conduct a root cause analysis for metrics moving in the wrong direction.

Benchmarking is also a key component to an effective ongoing revenue cycle management strategy. It’s important to have targets so you know what you're measuring against, both internally against your past performance and externally against industry standards.

You can’t hit a target you can't see. Bridging that gap is important in terms of looking at root cause problems and being proactive. How important is the BI tool in relation to revenue cycle?

CG: When you step outside of revenue cycle and pure cash flow and talk about compliance, it’s important to identify any out of the ordinary behavior from a billing, coding, or documentation perspective, so you can be proactive.

BI tools can help determine that. [You] want to take action before someone else external to your organization is informing you of the problem(s).

But that creates a whole host of other issues. The BI tool is important from the standpoint of revenue cycle driving cash, but it’s also important to look at your edits, documentation tendencies, and trends. What is most important from a Clinical Documentation Improvement (CDI) standpoint?

CG: Establishing a program. A lot of organizations have it on their radar and are implementing or modifying existing programs.

An effective CDI program begins with buy-in and support. There has to be buy-in from the top down, from administrative and clinical leadership and throughout the organization. What is the CDI / revenue cycle connection?

CG: You want to make sure you're billing in a compliant manner.

There are three things about billing. You want to get every dollar you're entitled to. You want to receive payment as fast as possible. And, you want to make sure you're doing it in a legal manner. That’s the core of a revenue cycle.

The CDI program along with an optimized revenue cycle process and a revenue cycle management team is extremely important for organizations to make sure they're getting everything they're entitled to and doing it in a compliant manner.

A lot of organizations we work with were rolling out and implementing ICD-10 at the same time as trying implement a CDI program. It was a challenge but, those organizations at least have a head start. And they have policies and procedures now they may not have had a year ago. Therefore, they are certainly on the right road to building a sustainable CDI program.


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