Proactive Healthcare Charge Integrity Captures Missed Revenue

July 07, 2017 - The key to a successful healthcare charge integrity initiative is the ability to trend chargemaster and coding data, stated Harriett Johnson, the Assistant Director of Revenue Integrity at Novant Health. The trending capability allows health systems to identify missing charge patterns and prevent revenue cycle leakage.

Using the ability to trend healthcare charge data, the four-state integrated health network identified about $8.5 million in net revenue cycle improvements in a year and corrected provider workflows to prevent missed revenue capture.

“Being able to trend the data, have a conversation with our clinical teams to understand what their workflow was, work with our IT team to understand what potential opportunities we had within the solution itself, and then move that into production really shows that full circle of how trending information has been extremely helpful for us,” she recently told RevCycleIntelligence.com.

Traditional healthcare charge capture processes involve reviewing claim submissions and flagging potential charging or payer compliance issues, such as inaccurate codes or missing charges for services rendered. 

“We wanted a tool that would allow us to identify opportunities quickly and then translate that back to our clinical teams so they could take action.”

READ MORE: What Is Healthcare Revenue Cycle Management?

Pinpointing potential problems prior to claim submission can help ensure hospitals are appropriately reimbursed for their services and time. But merely flagging charges issues and developing a worklist for follow-up was not enough to improve healthcare charge integrity at Novant Health.

At the integrated health network, eight of Johnson’s revenue integrity team members spent 30 work-hours over three months examining healthcare charge data to find the root causes behind common charge issues. Johnson’s team spent more time analyzing healthcare charge data than training clinical teams on how to avoid common mistakes.

Rather than rely on a reactive healthcare charge integrity strategy, Johnson aimed to shift the health network’s efforts to the front-end. She sought an automated charge integrity tool with data trending capabilities and found a solution in ZirMed’s Charge Integrity solution.

Employing the data trending component, Johnson gained insights into the root causes behind healthcare charge integrity issues.

“We wanted a tool that would allow us to identify opportunities very quickly and then be able to translate that back to our clinical teams so they could take action,” she explained. “The action is really a two-step process. First, can you look at the data to determine if we truly missed a charge and if the answer is yes, work to get that charge entered in the system?”

READ MORE: Is Billing Some Patients at Hospital Chargemaster Rates Legal?

“In addition to getting it entered into the system, we also want to make sure that we look to see if there is a trend where we are consistently seeing that we are missing that type of a charge,” she continued. “If the answer is yes, what is going on? Is there a training or workflow opportunity? Or is it just a human error where it happened every now and again?”

Johnson also divided her revenue integrity team by clinical area to delve deeper into which provider workflows generated healthcare charge integrity challenges.

“Currently, my team is set up to support 14 clinical areas or service lines,” she said. “My team is broken up by clinical areas compared to how some organizations have their teams set up by alpha split. We found that it was beneficial for us to be able to do it by the clinical areas so that we could focus on those specific areas to understand their nuances and be able to provide a more robust type of support to them.”

By coupling data trending and a focus by clinical area, Johnson’s team not only pinpointed revenue cycle leakage before the integrated health system lost money, but they significantly reduced the costs and resources associated with working on healthcare charge integrity.

The revenue integrity team made healthcare charge integrity more efficient by modifying and implementing provider workflows that supported accurate charge capture. The strategy especially improved evaluation and management (E&M) charges.

READ MORE: How to Maximize Revenue with Improved Claims Denials Management

“With the charge integrity solution, for instance, we identified last June an increase in E&M-level charges being missed within one of our clinical areas,” Johnson stated. “We went from having maybe two or three that came in to having hundreds coming in over a week period. That was an immediate ‘what has happened’ moment.”

After identifying the missed charge pattern, Johnson’s team reached out to the clinical staff.

“We asked if they had a recent change in their workflow,” she said. “They said yes and explained that they were doing their scoring on paper. We found immediately that there was potentially an opportunity for them to do that scoring within the Epic solution. We knew the functionality was there and worked on our ambulatory side. We also knew that having the scoring logic built into the system would actually drop the charge.”

She collaborated with the integrated health system’s ambulatory partner and chargemaster assistant director to implement the logic within specific acute provider workflows.

“Working with our IT team, they were able to build that logic within the Epic solution to help clinicians avoid scoring on a piece of paper and then going back and entering the E&M level,” she stated. “They actually could enter the criteria within the system and it would do the calculation. Based off of the score, it would then drop the appropriate charge.”

“Since the logic went into place in October, we may see two to three instances of a missed E&M level charge coming through the ZirMed system where at one point we were seeing hundreds,” she added.

Additionally, the rule-based nature of the healthcare charge integrity solution was critical to reducing false positives. Healthcare charge capture solutions may flag some claims as potential issues because the software does not recognize hospital-specific charging policies. The result is a false positive.

“For example, at Novant Health, if there’s an injection given in the OR [operating room], it’s a part of the OR time,” Johnson explained. “We shouldn’t see a separate injection charge. When we had the previous system, it was difficult for us to build in the Novant charging policy component. As a result of that, it would send us missed charges alerts. Well, it was not that we missed the charges, it was that this charge was a bundle charge because it rolled into the OR time.”

“It was overwhelming for my team, but it was also overwhelming for our clinical teams who are weeding through all of those cases.”

Without the ability to build Novant Health’s charging rules into the charge capture solution, about 70 to 75 percent of issues examined by the revenue integrity team stemmed from false positives.

“It was overwhelming for my team, but it was also overwhelming for our clinical teams who are weeding through all of those cases,” she stated. “Say they had a hundred cases in a worklist, but, out of the total, only five of them truly had a missing charge. For them, it could appear that we are not valuing their time. For our clinical areas, their first priority is providing that remarkable patient experience and providing that remarkable patient care. It’s hard to do that when you have to weed through false positives to get to the instances where we truly may have missed a charge.”

Implementing a healthcare charge integrity solution that contained a Novant Health wiki of charging policies decreased the rate of false positives and allowed clinical teams to manage missing charges in one or two sessions per week.

Adopting a healthcare charge integrity solution that contains data trending and customizable charging rules was important to the integrated health network. But Johnson also pointed to revenue cycle management and clinical staff collaboration as a key to success with healthcare charge integrity.

“One of the ways that we have been successful is partnering with the clinical teams,” she said. “What we found when we initially started to focus on charge integrity was that our clinical teams did not understand their impact on the billing component of the patient experience. In their minds, their relationship with the patient may have ended when the patient was discharged.”

Johnson explained to clinical teams that medical documentation drive charges and the amount that ultimately goes on a patient’s bill.

“Making sure that your documentation is accurate and you are entering all the charges for all the services that were rendered is carrying all the way through that billing process,” she stated to providers. “You actually do have a direct hand in that patient’s experience all the way through to the billing process.”

Johnson facilitated revenue cycle management and clinical collaboration by creating a centralized point-of-contact.

“It allows them to focus their attention on the patient and what is going on within the walls of the hospital.”

“Another thing that we did that has been very instrumental in our success and our clinical teams’ success was having a centralized email,” she remarked. “One of the things that we realized was that when you have facilities that are throughout a region or spanning across states, it is difficult to have team members who might sit at all of those facilities and provide the level of support that may be needed.”

“My team does not sit at the hospital facilities,” she continued. “We actually sit in a billing office. But our mailbox was put in place to allow all of our clinical teams to send us an email with any questions they have.”

Johnson’s revenue integrity team fields any questions that providers and other clinical staff may have about healthcare revenue cycle processes, not just healthcare charge integrity.

“We became the outward-facing liaison not just from the charging or work queue management perspective, but also for acute revenue cycle,” she concluded. “We found that to be extremely beneficial because having to remember one email address versus trying to remember who I should contact about all of these different things makes it so much easier for our clinical teams. It allows them to focus their attention on the patient and what is going on within the walls of the hospital.”