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

Revenue Cycle Management Interviews

Bringing Back House Calls to Cut Spending on High-Risk Patients

by Jacqueline LaPointe

Before the early 1960s, the majority of healthcare visits were performed in patient homes. But as healthcare evolved, providers could no longer fit their tools in a transportable medical bag and the proportion of visits made by house calls ...“The reason for doing house calls is to really focus on these patients who have to call 911 and they land in the emergency room,” the system’s Director of Geriatrics said. “The program is there to really prevent 911 ...

How Palomar Health Created a High-Value Post-Acute Care Network

by Jacqueline LaPointe

Ensuring patients receive high-value care delivery during their hospital stay or office visit is a top priority for healthcare providers. But value-based purchasing models are pressuring doctors to extend that same cost-efficient, high-qual...The California-based system started by identifying high-value skilled nursing facilities to serve communities in their 850-square mile healthcare district. “We’ve formulated a skilled nursing facility pilot program with six diff...“About a year and a half before we actually put the performance network together, we invited our skilled nursing facilities in to just have dialogues on what the barriers were that they were facing and the barriers that the hospital w...

Private Sector to Drive Bundled Payments After CMS Cancellations

by Jacqueline LaPointe

CMS recently announced its intention to modify its bundled payments strategy by proposing to eliminate forthcoming mandatory cardiac models and decreasing the scope of the Comprehensive Care for Joint Replacement (CJR) program. The pull awa...“The rationale provided makes it clear that such models are considered to have value in encouraging care redesign to improve quality and lower cost,” Abrams commented. “The pullback is framed as a move to moderate change d...

Real-Time Data for Denials Management Aids Practice’s Lagging A/R

by Jacqueline LaPointe

Without transparency throughout the claim denials management process, healthcare organizations are leaving a significant portion of potential revenue on the table. Limited access to timely claim denial and reimbursement data can prevent pro...“The biggest problem was transparency,” John Kulin, DO, FACEP, Urgent Care Now’s President and CEO, recently explained to RevCycleIntelligence.com. “By that I mean, it was getting a report. Understanding our dat...

Physician Expert, Clinical Documentation Key to MIPS Success

by Jacqueline LaPointe

Since the Obama administration signed MACRA into law in 2015, healthcare providers have been attempting to understand the Quality Payment Program and its Merit-Based Incentive Payment System (MIPS). But regular updates and tweaks to MACRA h...Understanding the changes while keeping track of performance periods for the Quality Payment Program’s value-based reimbursement tracks have proved to be an obstacle for providers, Rebecca Altman, Managing Director at Berkeley Re...Altman recommended that practices across the size spectrum identify one to two physicians to become experts in MACRA implementation and Quality Payment Program requirements. “It is hard to get physicians to take time out of seeing the...While the additional time may help practices of all sizes implement the resources necessary for quality measurement and reporting, Altman argued that it may not be enough to truly help small practices prepare. “They have bumped the or...Hardwiring quality measure checklists that align with MIPS is key to maximizing performance scores and earning a value-based incentive payment rather than a penalty. “Folks need to really optimize and utilize their EHR to hardwire som...

NYC Health’s ERP System to Bring Business Ops to Digital Age

by Jacqueline LaPointe

From payroll and workload management to orders and purchasing, health systems manage a myriad of back-end business operations, using a combination of automated systems as well as manual processes associated with each function. The web of di...ERP implementation is the next step in NYC Health + Hospital’s digital transformation project that will transition business operations and revenue cycle management as well as patient care to the digital era, the health system’s ...“Most of our procurements were done by paper with manual approvals,” he elaborated. “This system actually streamlines that process electronically. Our payroll and time capture system is done on paper timesheets right now, ...To implement the new system, NYC Health + Hospitals plans to gradually install the ERP tool across its hospitals, starting with two facilities in July 2017. “We started deploying in NYC Health + Hospitals/Queens and NYC Health + Hospi...“The Epic revenue cycle project just got approved in May and was approved by the health system’s board of directors,” Guido said. “Right now, we are going through what I’ll call our discovery phase, as well as ...

Accountable Care Organizations Grow, But Face New Challenges

by Jacqueline LaPointe

Since the Affordable Care Act paved the way for accountable care organizations (ACOs) in 2010, healthcare providers have increasingly turned to the alternative payment model as a way to engage in value-based care across patient populations....David Muhlestein, PhD, JD, Chief Research Officer at Leavitt Partners and co-author of the Health Affairs blogpost, explained that the ACO’s maturity as an alternative payment model is the primary driver for its recent growth. “...Without provider buy-in, ACO success may be in jeopardy, a 2016 American Journal of Managed Care study indicated. The early experience of a non-risk bearing Medicare Shared Savings Program ACO revealed that limited provider engagement acted...The shift to value-based reimbursement is also more of a journey than an overnight achievement, which may cause providers to pause before backing care transformations in favor of just the new model. “Fee-for-service has been really go...He also stated that ACOs may be risk-adverse or still experimenting with financial risk because they have not been in operation long enough to confidently put ACO revenue on the line in the face of shaky population health management strateg...Incorporating health IT use in provider workflows has helped mature ACOs get the right data to the right people at the right time. “They have figured out things that work for their own organization to get the data that their providers...“One thing that they can do is try to align their contracts to the point that they are not just administratively being swamped,” he explained. “A big part of this is quality metrics.” For example, assessing A1C level...

Breaking Down the Top 5 Healthcare Revenue Cycle KPIs

by Jacqueline LaPointe

With value-based reimbursement and healthcare consumerism taking hold of the industry, provider organizations are under pressure to ensure their healthcare revenue cycle is operating at maximum efficiency. To effectively track healthcare re...The former healthcare consultant and community hospital CFO recently explained to RevCycleIntelligence.com that starting with top KPIs and expanding to other metrics should provide hospital and practice leaders with a strategic view of how ...The information needed to calculate net days in A/R stems from an organization’s balance sheet and income statement. The industry group clarified that net A/R is the net patient receivable on the balance sheet and it comprises the net...Providers organizations should not include non-patient A/R, 340B Drug Purchasing Program revenue, capitation or premium revenue from value-based contracts, and A/R related to non-patient-specific third-party settlements (eg, payments from M...The total collected service cash is the monthly revenue from patient service payments posted to patient accounts, including undistributed payments, bad debt recoveries, Medicare DSH reimbursement, and IME payments. The value is net refunds,...For the number of claims denied, organizations should find the total number of processed claims in a month and identify the actionable denials, or denials that could be corrected within the organization to boost reimbursement. This includes...HFMA elaborated that the value for net dollars written off as denials in a month includes denied RAC revenue from failed appeals or neglecting to appeal as well as dollars stated at net. The average monthly net patient service revenue ...Finding operational performance with a cost to collect KPI To find healthcare revenue cycle efficiency and productivity, provider organizations should create a cost to collect KPI. Leaders can find the rate by dividing the total revenue cyc...“The following revenue cycle costs should be reported with their respective functional area’s costs as applicable: salaries and fringe benefits, subscription fees, outsourced arrangements, purchased services, software maintenanc...

Geisinger Lowers Turnover for Healthcare Revenue Cycle Success

by Jacqueline LaPointe

A MAP Award for High Performance in Revenue Cycle from the Healthcare Financial Management Association (HFMA) indicates that a health system achieved outstanding healthcare revenue cycle performance on metrics such as net days in accounts r...“It’s more the cohesiveness of the team that brings Geisinger the good performance,” she recently shared with RevCycleIntelligence.com. “We have a very engaged executive senior executive team here with CFOs and our S...In light of healthcare employment challenges, Geisinger Health System targeted rising turnover rates to achieve excellent healthcare revenue cycle performance. The most recent HFMA recognition represented the system’s success with low...“Even when I have employees at different hospitals and they’re in different teams, there is centralized management so that we have standardization in our processes,” Tapscott pointed out. “We work very closely with o...However, if the patient reports a negative experience, he can request a refund. “Simply, they didn’t feel that the encounter was as valuable as it should have been,” Tapscott elaborated. “That ProvenExperience progra...

Bundled Payments Rely on Robust Networks, Healthcare Markets

by Jacqueline LaPointe

Healthcare providers are finding that it takes a village to succeed in bundled payment models. From primary care to specialists and post-acute care, providers need an integrated network of provider types and to play to their healthcare mark...Without the provider power behind the large integrated healthcare system, Bark explained that Scripps Health would not have been as successful with implementing a variety of bundled payment models with payers in the county. “When you ...“In our medical foundation, we have a lot of control who we hire and who we bring into the tent, if you will,” he elaborated. “We know we have the best of the best in that environment. But, employers, if they are local in ...Scripps Health partnered with the bundled payment platform Carrum Health to identify Diagnosis-Related Groups (DRGs) that presented an opportunity for travel-based bundled payment models. “There has to be a certain amount of cost...

Proactive Healthcare Charge Integrity Captures Missed Revenue

by Jacqueline LaPointe

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 healt...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 improv...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...“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 faci...

Payer Collaboration Key to Value-Based Reimbursement Strategy

by Jacqueline LaPointe

Value-based reimbursement arrangements come in a myriad of shapes and sizes much like provider organizations. But successful value-based contracts will align provider and payer goals for care quality and healthcare utilization as well as es...“There are two major portions to aligning incentives and one probably gets more focus than the other,” explained panelist Chip Howard, Humana’s Vice President of Payment Innovation. “First, there’s the arrangem...A lack of shared financial risk between payers and providers may exacerbate payer and provider misalignments, especially regarding value-based care goals, stated Linda Ellis, MD, MJ, MA. “We can align incentives based on HEDIS measure...Howard recommended starting with the payer that dominates an organization’s payer mix. Understand every nuance of the arrangement because those provisions may drive value-based reimbursement implementation for the dominant part of an ...Collaborating with payers is especially important for managing financial risk under value-based contracts, Howard added. “In order for value-based care to be successful, and in order to successfully transition away from a fee-for-serv...Most payers can also share predictive analytics capabilities with providers to show stakeholders which patients are at risk for hospital readmissions or other adverse health outcomes. “That’s something that is generally availabl...

Implementing Value-Based Healthcare Revenue Cycle Management

by Jacqueline LaPointe

To align healthcare revenue cycle with value-based reimbursement, healthcare organizations should start by breaking down clinical and financial siloes established by fee-for-service payment models, agreed presenters at Xtelligent Media&rsqu...“It is really getting everybody to pull together and breaking down siloes,” Roberts told attendees of the healthcare revenue cycle management workshop. “People are not used to having to work together. They are used to bein...However, the value cycle overlaps clinical, operational, and financial functions. At the foundation of the value cycle is the superbill, Roberts explained.“The superbill, or our chargemaster data, is where you’re translating every service you are providing,” she explained. “That’s where it’s translating everything that you are doing to your payment.” ...The Medicare bundled payment program “changes the thought pattern of orthopedic surgeons,” he said. “They were really focused on the surgical part and the post-acute cost was not in their mindset unless the patient had a b...However, the post-acute care costs were dramatically lower under a managed total joint replacement surgery. “When we looked at the claims data, a lot of the costs were post-acute costs because certain cost you cannot make many adjustm...

Exploring Quality Measures Under Value-Based Purchasing Models

by Jacqueline LaPointe

CHICAGO – Jason Goldwater, MPA, MA, Senior Director of the National Quality Forum, recently likened the value-based purchasing transition to the evolution of music at Xtelligent Media’s Value-Based Care Summit in Chicago. Music ...In a similar fashion, value-based purchasing has put massive amounts of healthcare data into the hands of providers, patients, and payers. However, the increased access to healthcare data has presented several challenges for quality measure...Additionally, focusing on clinical outcomes under value-based purchasing models allows healthcare organizations to understand and analyze the patient experience. “It has grown in a way that patient-reported outcomes have more importan...The global accountable care organization offers the greatest opportunity for care coordination and physician alignment, but organizations can implement a range of alternative payment models depending on their investment plans. Organizations...

Care Standardization Key to Healthcare Revenue Cycle Excellence

by Jacqueline LaPointe

To be named a top health system by Truven Health Analytics and IBM Watson Health, it takes a range of clinical quality improvements and healthcare revenue cycle efficiencies. But for St. Luke’s Health System, one of 15 top health syst...“When you standardize your processes and you perform consistently, we have seen fewer of those occurrences that ultimately add extra cost without value, such as readmissions, longer lengths of stay, and more complications,” Hill...“By standardizing it, you reduce the variation in care and you can track and measure lengths of stay, readmissions, complications, and all the things that contribute to excessive and non-value-adding costs,” he said. Using a dat...To implement value-adding quality improvement projects across several hospitals, St. Luke’s Health System engaged their clinicians and staff members to put their revenue cycle management and care quality goals literally at the center ...Engaging C-suite level leaders in the quality improvement push also ensured that providers had the resources they needed to achieve clinical and revenue cycle management excellence. “The leadership is very active in supporting us to b...

Optimizing RCM During Value-Based Reimbursement Transition

by Jacqueline LaPointe

Value-based reimbursement revolutionized how providers get paid for care delivery. However, the slow push away from fee-for-service payments has challenged providers looking to optimize healthcare revenue cycle management. To advance health...“Do they have the technology, the teams, and the processes to operate either in a fee-for-service model, in terms of revenue, and from a value-based care perspective,” he recently told RevCycleIntelligence.com. “Are they g...Consequently, the group’s technological services appeared as a patchwork of different solutions. “Our technology is almost a reflection of our physicians,” Hollander explained. “It’s a stretch analogy, but we h...The clinical pathway method generated significant healthcare cost savings and utilization reductions. Drugs costs declined between 5 and 37 percent and the provider organizations saw 6 to 40 percent less emergency department visits as well ...Clinicians who may not be part of physician groups with that many patients can still earn favorable MIPS performance scores by engaging with an alternative payment model. “I do not think we will meet the threshold number to be exclude...

Payment Plans Tackle Hospital Patient Collection Challenges

by Jacqueline LaPointe

The growing popularity of high-deductible health plans has wedged many healthcare organizations between a rock and a hard place. Healthcare organizations are struggling to implement patient collection strategies that acquire all of a patien...“We don’t want our patients to have to choose between paying for food or rent and healthcare,” Nanette Houck, the hospital’s interim CEO, recently told RevCycleIntelligence.com. “We also want them to have the b...Providers and other hospital staff connected with patients who incurred significant patient financial responsibility to give them the option to pay via a payment plan. For example, rather than require the patient to pay $2,000 upfront, the ...While the hospital is fairly new to the patient collection plan strategy, Houck noted that hospital staff and provider education has been crucial to successfully implementing the program. “The key to it is educating as many people as ...

Commitment Key to Successful Value-Based Reimbursement Adoption

by Jacqueline LaPointe

It is time for healthcare providers to move past understanding the concept and start the value-based reimbursement adoption process. Otherwise, they may face profitability decreases from operating both fee-for-service and alternative paymen...“Value-based payment is a situation where you either will be fully committed towards it or be a latent doctor because what you don't want to do is do just a little bit,” he recently told RevCycleIntelligence.com. Value-based...Healthcare executives are also behind the industry-wide push away from fee-for-service. A recent survey showed that 55 percent of healthcare executives believe that the majority of their organization’s healthcare payments will be link...Only 11 percent of healthcare professionals stated that their organization’s physicians view value-based reimbursement adoption as a positive move. Gans explained that most physicians may be skeptical about value-based reimbursement b...From clinical documentation, CPT codes and diagnosis identification, to appropriate reporting, most physicians worked on implementing health IT systems that catered to a fee-for-service system. Replacing or customizing the systems to integr...The modest adoption rate within a practice caused many providers to lose money with the endeavor because they were trying to operate both fee-for-service and the alternative payment model, Gans stated. “The practices that had the leas...About 42 percent of MSSP ACOs that started the program in 2012 produced savings beyond their financial thresholds, whereas only 37 percent of 2013 starters, 22 percent of 2014 starters, and 21 percent of 2015 starters achieved savings above...

Surviving Solo with Independent Practice Association Support

by Jacqueline LaPointe

Healthcare reform and market forces are driving more independent practice leaders to consolidate with larger hospitals or health systems. But an independent practice association, like Vermont’s HealthFirst, can help solo providers lev...“Sometimes independent physicians are so independent that it's a detriment to their own survival,” Paul Reiss, MD, HealthFirst’s Chief Medical Officer, recently told RevCycleIntelligence.com. “Whereas joinin...Reiss explained that Vermont’s small and independent provider organizations are especially struggling to remain independent with the healthcare consolidation trend. “Practices are at a disadvantage with hospitals consolidating a...The financial benefits coupled with the advocacy component make independent practice associations an attractive option for solo providers. However, many independent doctors are staunchly opposed to sacrificing their independence. But the be...

How Clinicians Add Value to Healthcare Supply Chain Management

by Jacqueline LaPointe

Engaging clinical staff is key to adding value to healthcare supply chain management, according to three supply chain leaders at MaineHealth, a recent ECRI Institute Healthcare Supply Chain Achievement award recipient. The healthcare networ...To support MaineHealth’s journey to healthcare supply chain management efficiency, the health system placed five full-time nurses on a value analysis team. “We also have a Director of Value Analysis who is a nurse as well,&rdquo...Incorporating the clinician’s voice allows the healthcare network to create a value-based healthcare supply chain based on patient and cost outcomes. “We strongly emphasize the value equation, which is value equals quality plus ...“Across the country, as hospitals have moved to EHRs, it’s become complex in terms of developing capital quotes and tying in all these software-driven systems and equipment, so we integrate with the EHR,” Soto explained. &...

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