California revenue integrity department hones in on missed reimbursement, clean claims

With healthcare billing growing in complexity each year, healthcare organizations must take extra steps to maximize reimbursement and maintain compliance. To meet these needs, Glendale Adventist Medical Center (soon to be Adventist Health Glendale) in Glendale, California, created a revenue integrity team to coordinate and oversee a consistent and standardized revenue integrity approach across the organization.

“As part of the revenue integrity team, I see our goals as two things: one to get that claim out the door clean the first time so that we’re paid quickly and to make sure we’re maximizing reimbursements,” says Kay Larsen, revenue integrity specialist at Glendale Adventist Medical Center in California and a National Association of Healthcare Revenue Integrity (NAHRI) advisory board member.

Since its initiation, the revenue integrity department at Glendale has saved money by examining various charges, including pharmacy charges. Frequently, miscellaneous charges are placed on outpatients when they are given pharmacy prescriptions that are not built into the pharmacy formulary. They are then billed with miscellaneous codes, which may negatively impact billing. For example, if a healthcare organization should receive a $5,000 reimbursement for billing a chemotherapy drug with a specific drug code but instead bills with the miscellaneous J-code carrying a $100 reimbursement, then the medical center misses out on revenue, says Larsen.

They also look for missed revenue in physician-run clinics by examining the resources used. When Glendale’s revenue integrity department examined the billing unit for a knee pain medication, Larsen found that the quantity posted was one for the syringe used, which translated to a billing unit of 1 mg. However, one syringe contained 48 mg.

“That difference between billing one syringe (1 mg) and billing 48 mg was over $500 in reimbursement from Medicare,” she says.

Larsen downloads charges daily and uses a spreadsheet to look for errors. Once or twice a week, she finds errors related to quantity, such as entering the billing units instead of the quantity or adding an extra zero to the quantity. In one instance, the medical center posted a charge for a 1,000 mg capsule but entered the quantity as 1,000 instead of one capsule. 

Another crucial aspect of revenue integrity is staying up to date on CMS changes that impact department workflow. For example, on January 1, CMS released Transmittal R3538CP, which introduced modifier -JW and required all facilities to identify the amount given and the amount discarded for any single dose of vial of drugs. This requirement means that if 800 mg of a 1,000 mg vial are used, one charge is posted with 800 mg for the amount administered and a second line with modifier -JW for the 200 mg wasted. 

“That was a challenge in how do we identify the drug within our system and how do we make it automated,” Larsen says. At Glendale, health information management reviews the reports and charges to keep track of wasted drugs. 

The revenue integrity department also focuses on ensuring the accuracy of claims before they are submitted. “Getting those claims out the door and correct the first time saves us so much money,” Larsen says. Look for patterns when reviewing errors. If a claim error is common, it may indicate that staff need more information on that claim type. 

When claims are sent back as incorrect, it can take up valuable resources. For example, it means billers must cancel claims, departments must repost charges, coders must rework the account, and then billers must drop a new claim. “If you can get it correct out the door the first time, you save on the resources plus you get your payment back a lot faster,” Larsen says.

In addition to focusing on clean claims and accurate charges, facilities must focus on the organizational structure of the revenue integrity department and departments with which it collaborates. According to Larsen, Glendale’s first challenge was separating the roles of each member. “We had people in different departments, and we were overlapping duties, which sometimes came up with wasted time on both our parts. That was a hard lesson—to find a good balance,” she says.

Currently, Glendale’s revenue integrity department has five staff members: a manager, who also is the team’s chart auditor, a charge description master coordinator, two charge auditors, and Larsen as the revenue integrity specialist. Both charge auditors focus on emergency and labor and delivery departments.

Larsen advises cross-training staff so they feel like part of a team. “If everybody has an important part to play, it makes it so much easier. And they feel like they are truly making an impact on the hospital,” she says.

Associate Director’s note: NAHRI is interested in learning more about training and education challenges in revenue integrity departments. Please take a moment to complete our Revenue Integrity Training and Education Needs survey. Results will be shared in an upcoming issue of Revenue Integrity Insider to help you understand the training concerns and priorities of others.