Many others are taking on the burden themselves and utilizing their inhouse team of Regulatory, Finance, and IT staff.

For you, KHC can help in the following areas:

• Answering questions regarding the rules and their specific application.
• Performing a review of your results – as a quality check.
• Help you handle certain portions of the updates needed – you define and you control.
• Training staff on ways to facilitate the data burdens and the Hospital Price Transparency rules.

If these or other areas of assistance are needed, please contact Sara Rivenburgh (srivenburgh@kohlerhc.com) or Linker Mills (lmills@kohlerhc.com).

In an environment of diminishing payments, a troubled economy and ever increasing regulations the consultants at Kohler HealthCare Consulting, Inc. (KHC) understand the importance of an effective and efficient revenue cycle process with specific concerns regarding getting paid the right amounts.

Approach to Improvements

Like peeling the layers of an onion, KHC uncovers the fiscal and organizational strengths and weaknesses of revenue generation and how it impacts your Practice’s bottom line. This is done by understanding the functional details of each step of the process, and devising specific tools and approaches to minimize the deficits. To adequately determine a hospital-owned or independent medical practice’s fiscal health and efficiency we start by assessing, establishing and implementing fine tuned protocols in a variety of areas—operational, staffing, coding, billing and compliance. Through this framework along with tools, education and continuous updating of the skills and knowledge required for optimal performance, KHC works collaboratively to bring the components together for success.

Improvement in Revenue Cycle is supported by assuring physician productivity and models are based on how physicians and non-physician providers actually provide care. We establish an approach that goes beyond the blind application of RVU methodology.

From a compliance standpoint, we also provide expertise and guidance on documentation, coding and billing, and medical necessity to ensure you are paid for the work you do, and the reporting of services is correct.

This approach can only be done by those with a mix of backgrounds and experience. Our consultants are experts in medical practice, clinical, compliance, coding, billing, finance and regulatory issues. We find those who understand the conflicts existing within departments can best provide the solutions and tools to remedy the situation.

The Revenue Cycle is a people and software driven process with many changes and responsive parts. Kohler HealthCare Consulting’s Revenue Cycle Services are designed around your needs. We want to partner with you in traversing the effects of this uncertain economy by offering the following services:

Front End Services

Today’s economy is providing some extraordinary challenges for healthcare providers. Not only are hospitals and physicians dealing with a wide range of issues that impact patient care, but they are dealing with broad revenue cycle processes which can tie up cash for capital spending and stall revenue growth.

Effective and successful management of the revenue cycle has never been more important. With a Centralized Business Office (CBO) the combined experience of both the hospital and the physician network will enable reallocation of business office staff to priority projects, streamline workflows, eliminate redundancy, reduce defects and increase cash collections. Many organizations have typically seen an increase of net cash of 3-5% and a reduction in bad debt of 1% within the first year.

Approach to Improvements

KHC’s team of diverse and talented professionals, experienced in revenue cycle redesign, will work with your staff to develop an integrated, effective solution to improve cash collections through reduced denials, reduction in A/R days and write-offs, Lean Six Sigma process and workflow improvements, reduced underpayments, and improved contract management administration—all with complete oversight to help ensure regulatory compliance.

The CBO model can touch almost every facet of your business—from clinical applications to the revenue cycle. We understand the complexity of the revenue cycle and use a team approach to form a detailed planning and collaboration effort with physicians, practice managers, hospital managers, executives and information technology personnel.

We use our expertise to help bridge the gap between registration, billing, collections and accounts receivable functions to address standards in key areas such as staffing, job descriptions, policy and procedures, workflows, training, software systems, charge master reviews, days in A/R by specialty, gross and adjusted (net) collection rates, electronic billing, error rate for claim filing, A/R over 90 days, denial rates, compliance programs, financial assistance, bad debt and other key performance standards.

Revenue cycle management is as complex as it is vital to the success of healthcare providers. A properly integrated CBO can help maximize efficiency and increase cash flow to create financial stability for the long term.

Even without the concern of the Recovery Audit Contractors (RAC), it is time to recognize that the attention to improving inpatient reimbursement has not been extended to outpatient. Outpatient in many cases may be 50% of the Hospital’s revenue.

Programs to improve documentation touch on it, but Outpatient Services are so different than inpatient – many episodes of care by many departments. Much of it is highly dependent on the people in the individual departments “getting it right” every time.

The questions remain—Have we set up the tools so these people in every department can succeed? Do we know the “what” and “why” of how revenue is lost so it can be captured? Do our Department Managers understand how the little pieces fit together—and that no one is really checking on the accuracy unless there is an audit?

Barriers to Improving Outpatient Results

Over the years, the Department Managers have continued to manage their expense budget. At times we place the update of the charge master and encounter forms on them with little ongoing education. We tend to limit the education to “training” on the mechanical part of the process. The Patient Financial and HIM Departments work within their own framework, Finance within theirs and the clinical staff within theirs. There are different languages and at times, divergent goals. Adding the physician’s component causes additional stresses. By knowing the language of all – KHC bridges the gap.

Approach to Improvements

By evaluating and updating all the tools – charge master, medical records, forms, policies and procedures – as well as creating an understanding of why the CPT/HCPCS codes work the way they do, what is required by Medicare and other payers, how the physician reimbursement system is different than the hospital, and how others have been able to improve results. We add to this mix the realization that meeting the goals also means we need to listen for and minimize the issues and the daily hurdles.

Charge capture and charge reconciliation are vital processes for revenue management. Many successful organizations have put charge capture teams in place to monitor the process of charge capture and reconciliation. These teams provide the revenue producing departments with feedback and training to enhance an atmosphere of organization-wide accountability. High performing hospitals develop clear policies and procedures for all staff and provide training to ensure that the charge capture team understands their role in the revenue cycle. They do this by providing timely and meaningful feedback and making staff at all levels accountable for performance. Common reasons for charge capture problems:

• Lack of sufficient training – Do all team members understand and follow the policy?
• System Limitations – Are all orders up to date? Do charge capture tools support timely entry and reconciliation?
• Computerized Physician Order Entry – Who is responsible?
• Unmonitored Daily Department Revenue Reports – Is there a daily dashboard that monitors revenue by department? Is there clear accountability?

Since every charge is potential cash, organizations need to understand the common factors resulting in lost charges. The CDM should be reviewed for:

• Consistent / Accurate / Optimal Pricing
• Inactive / Obsolete Charge Codes
• Use of Miscellaneous Charges – Pricing Overrides?
• Revenue Codes / HCPCS-CPT4 codes – Up to date and compatible?

Your organization needs to prepare now for diminishing revenue streams. Well-functioning charge capture processes and disciplined accountability will help your organization weather the storm.

Hospitals are being subjected to increasing audits and reviews by Medicare and contractors, as well as other payers and regulatory agencies. The advantage those reviewers have is the power of data analytics, or ‘data mining’, which translates into inconsistencies, the ability to use a hospital’s claims data to identify potential vulnerabilities and compliance problems.

By using claims data analysis these reviews identify errors, trends, and other issues readily identified, thereby allowing for prospective resolution before any significant repayments or even identifying trends of concern. Most hospitals and other health care providers don’t have the tools or dedicated resources to do comparable analysis and get ahead of the Government and other auditors. As a result, the errors are only identified once the audits are done and repayments made. As the hospital focuses on fixing those issues, the auditors have moved onto others.

In addition, the inability to conduct data analysis can cause lost revenue when billing opportunities are missed and money is left on the table. With the challenging regulations and intense audit environment, health care providers absolutely need to create a level playing field and know their own data.

The Solution

Kohler Healthcare Consulting utilizes a data analytics tool that can identify regulatory risks lurking in your claims data, and can also identify potential lost revenue. This tool, referred to as the Balanced Analytic Revenue and Compliance Reporter (BARCR), allows us to analyze the risks for lost income and compliance concerns present in your 837 claims files. This tool, combines with edits from all MACs, RACs, CCI, clinical indicators and OIG focus issues, and MEDPAR data to analyze individual data fields and the claims in total (services and diagnoses). It includes comparison of your data to the data of peer organizations to identify outliers and trends. It helps point to the direction of actions needed in a time of limited resources.