Growing reach: Apply revenue integrity to physician clinics

At a growing number of hospitals, revenue integrity directors are seeing the fruits of their labor: strengthened defense against external audits, improved charge capture and chargemaster maintenance, reduced denials, and more clean, compliant claims going out the door. Health systems eager to realize those benefits across the organization are asking revenue integrity to help physician clinics and other non-hospital-based facilities turn over a new leaf. That can be an exciting challenge and a growth opportunity for a revenue integrity director, but the new territory can set a steep learning curve. Although the basic principles of revenue integrity can be applied across facility types, figuring out how to apply them can raise questions that can’t be answered by hospital-based staff.

Be ready to learn and teach to tailor revenue integrity to other settings. The results will be worth the effort—the organization as a whole will benefit, and the revenue integrity department will be able to broaden its scope and strengths.

At first glance

Professional fee reimbursement is an entirely different landscape than hospital reimbursement. The intricacies and peculiarities of professional fee payment models such as the Medicare Physician Fee Schedule can be bewildering to a revenue integrity professional from a hospital background. But it’s not all unknown territory.

“Some of the core tenets of revenue integrity can be applied from a hospital to a physician practice,” says Bruce Preston, CPC, director of revenue integrity at Grady Health System in Atlanta. Common touchpoints for both types of facilities include daily charge reconciliation, completeness of documentation, quality of documentation, and appropriate use of modifiers.

When looking to bring revenue integrity to physician clinics, the first item to check should be the chargemaster, Preston says. Chargemasters are often tricky to manage and can easily become outdated, leading to incorrect charges and even compliance problems. Before going full steam ahead with a physician clinic revenue integrity program, have a thorough chargemaster assessment done to ensure that all charges and CPT®/HCPCS codes are up to date. Next, Preston recommends verifying the relationships between CPT/HCPCS codes and revenue codes. After any issues there are ironed out, move on to pricing. The actual pricing should be above all of the applicable fee schedule rates, he says. Nothing should be priced below the Medicare Ambulatory Payment Classification rates or the fee schedule rates.

Finally, don’t skip building a relationship with the physician clinic charge capture and chargemaster staff. Preston recommends starting with the staff who update the chargemaster and then moving on to the clinical staff who perform charge capture. Go through the chargemaster line by line and ask whether the procedures in the chargemaster are truly indicative of the services the clinical staff perform.

“If yes, then great. If the answer is no, then you need to start the process of adding those missed procedures into that chargemaster,” Preston says. “It could be a case where they’ve been doing a procedure and not billing for it, or they’ve been doing a procedure but have been billing the incorrect procedure.”

Duplicating success

A revenue integrity director who has launched a successful program on the hospital side could be asked to replicate those results for the physician side of the business. Karen Taylor, RN, BSN, MHA, director of revenue integrity at Saint Luke's Health System in Kansas City, Missouri, found herself in just that position after her revenue integrity program made an impact. When she joined St. Luke’s, she pulled together the organization’s disparate pieces of revenue integrity and grew them into a centralized department. Under Taylor’s direction, revenue integrity standardized the chargemaster, consolidated hospital charge capture, and launched a proactive internal audit program.

“Gross revenue increased in many departments. Because of that, leadership said we need to do this on the physician side,” Taylor says.

Saint Luke’s knew that would be a considerable challenge. The physician side was very provider-driven, Taylor says, with providers choosing their codes and chart audits handled by coding compliance coordinators.

As the physician clinic revenue integrity program took shape, a counterpart to Taylor’s role on the physician side was identified and Sheri Bayless, CPC, CPPM, made the leap from director of charging to director of site of service revenue cycle.

Building bridges

Saint Luke’s was already in the midst of an ambitious plan for its physician clinics. Although the system’s hospitals had been on Epic for several years, the physician clinics used their own EHR. Saint Luke’s decided to move those facilities to Epic at the same time as launching the revenue integrity program. Physician-based billing staff were pulled from the clinic offices and moved to a centralized location. Although that offered some process improvements, it put physicians at a remove from revenue cycle processes and reduced communication and feedback.

Saint Luke’s brought in a consultant to help determine how to keep functions centralized while still providing one-on-one feedback and education to physicians. The consultant helped coordinate meetings between Taylor’s revenue integrity staff and Bayless’ new department. At the consultant’s suggestion, Saint Luke’s created a new role, a revenue integrity analyst (RIA), that would act as both a chart auditor and a physician resource.

One of an RIA’s most important functions is to serve as a revenue cycle liaison to the physicians. The RIAs would act as the physicians’ trusted links to the billing office and ensure that none of the physicians’ charges were missed, Bayless says. “We already had some individuals that were providing chart reviews on the providers annually, so we just expanded that existing role and changed the title from the coding compliance coordinator to RIA and added a couple of more positions,” she says.

While the coding compliance coordinator role focused on chart reviews to ensure that documentation supported the level billed, the RIAs also looked at charges and ensured that Saint Luke’s physicians were billing for all services they rendered, Bayless says. Existing coding compliance coordinators were given the option to transition to the new RIA role. Although many were eager to take on the challenge, the new role wasn’t a one-to-one clone of the coding compliance coordinator role.

One of the key duties of an RIA at Saint Luke’s is presenting audit results and education at monthly meetings with physicians, whereas the coding compliance coordinators were accustomed to performing audits but not presenting education and audit results in front of a group—especially not a group of physicians, who can be a tough audience. RIAs need to be comfortable speaking to a group and confident in their own expertise to answer questions and earn the respect of their audience, Bayless says.

Bayless paired her RIAs with specialties that matched their strengths. An RIA assigned to neurosurgery, for example, should have a strong background in neurosurgery coding and billing. Physicians will recognize that the RIA is a seasoned and knowledgeable professional, and thus they will be more likely to listen to and learn from that individual.

“You can’t just go in there and make it up. You’ve got to know how to talk the talk,” Bayless says. “If they get to go to a meeting and show their knowledge, then you can usually get more access to the providers.”

Getting buy-in

Along with chart audits and physician education, RIAs also serve as the primary contact and resource for the clinic physicians. When billing functions were centralized, some physicians raised concerns that a lack of one-on-one communication would mean information would be left off claims, Bayless says. This was a concern for many physicians because their reimbursement is largely based on relative value units (RVU), which are a methodology for comparing the resources required to provide a service. An RVU is a weight value assigned to each encounter, procedure, or service; it represents a measurement of the resources required rather than a real dollar amount. Hospitals and physician groups use RVUs to calculate compensation or bonuses, and payers such as Medicare use RVUs to determine reimbursement. Therefore, missing RVUs can have a huge impact on physician payment.

Each RIA works closely with the assigned specialty group. The RIA runs reports to ensure that the correct RVU data is captured and submitted. That helped reassure the physicians that the RIAs were doing their due diligence and were actively soliciting feedback from the physicians on how they could improve. Being transparent helped ease the physicians’ concerns, Bayless says.

Prior to implementing a revenue integrity program for the physician clinics, some physicians received more attention than others. If a physician was using a new program or something else that might skew chart audit results outside of the normal bell curve, the coding compliance coordinators would meet with that physician multiple times but might meet with another physician less often. Bayless says her goal became ensuring that every employed physician had a meeting with an RIA for an audit review during the program’s first calendar year. She succeeded.

“There was a good opportunity to clean up some EMR templates as well as communicate some of the little additional documentation pieces that would make a difference to what level they were billing,” Bayless says. “So, very positive feedback. The providers would like to have more education, and now it’s more of a resource issue at this point.”

Sharing the rewards

Thanks to the hard work and dedication of everyone involved, Saint Luke’s reaped the benefits of expanding its revenue integrity program. One of the unexpected bonuses was that it knocked down walls between the hospital and the physician clinic sides of the organization.

“From my standpoint, there was a pretty high wall there: They did their thing and we did our thing,” Taylor says. “There wasn’t a whole lot of exchanging of information. Since we started this project and we’ve done some other things together, we do a lot more sharing of information, seeing both factors of this health system being very integral to one another and working together on more projects. To me, that’s been one of the biggest benefits.”

One of the other projects Taylor and Bayless collaborate on is creating a revenue integrity program for Saint Luke’s critical access hospitals (CAH) while getting them set up on Epic. Often, both the professional charge and the facility charge appear on the same claim for a CAH. Although Taylor and her team were used to handling the facility charging for CAHs, they didn’t have experience with professional charging. Taylor was able to bring Bayless in to answer those questions and help them build charges while Bayless crafted an RIA job description tailored to CAHs.

By working together and learning from each other, Taylor and Bayless can build strong programs that serve as mutual resources and continue to expand revenue integrity at their organization. The project was a massive undertaking, but Taylor has nothing but words of encouragement for other revenue integrity professionals in the same situation.

“I would definitely say don’t be territorial,” she says. “Be open to new ideas because we’ve learned a lot from one another just in how to implement change and ask for what we need.”

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