Q&A: Charge reconciliation

Thursday, June 4, 2020

Editor's note: This Q&A is included in NAHRI's 2020 State of the Revenue Integrity Industry Report. Click here to read the full report and participate in 2020 Revenue Integrity Week activities. 

The following is a question and answer session with Lisa Kanivetsky, BA, CPC, CHRI, operations director at Guidehouse, on charge reconciliation practices as reported in NAHRI’s 2020 State of the Revenue Integrity Industry Survey. Kanivetsky is a NAHRI Advisory Board member.


Q. Most respondents (35%) stated that operational departments are responsible for reconciling their own charges with regular support from revenue integrity. What recommendations do you have for revenue integrity team members and operational departments involved in the charge reconciliation process?

A. I think 35% is a great start; however, I would encourage all revenue integrity teams to work directly with the operational leaders to design and support charge reconciliation at the cost center or department level for 100% of revenue-producing departments.


Q. Approximately 60% of respondents have a turnaround time of 1–3 days for reconciling charges. What should revenue integrity look for during this time frame?

A. I would suggest looking at gross charges and comparing those to budgeted gross charges and doing a “gut” test. For example, if you have a budget of $100,000 of daily gross charges and you show $500,000 on your revenue and usage report, you need to figure out why—regardless of whether your volumes were way up for the day—there is such a large discrepancy. Conversely, if only $5,000 shows up on your revenue and usage—with a gross budget of $100,000—then you’re on another hunt for charges. But if your gross and actual charges are within a comfortable range as defined by your revenue integrity and operations leaders, then it’s a match.


Q. CMS tasks facilities to have a policy for "carving out" procedures that include active monitoring so that observation hours are not reported for the same time frame. Approximately 27% of respondents say revenue integrity is responsible for this process. What recommendations do you have for carve-outs?

A. Wow! If I’m reading this correctly, 27% of respondents are performing manual carve-outs. This percentage is extremely high, and this method is time consuming and prone to errors. I would recommend coming up with a standard—CMS has provided a couple of options—and working with IT to automate the carve-out time.


Q. Nearly half (45%) of respondents use automation or technology to monitor charge reconciliation practices for consistency and appropriateness. What should revenue integrity look for when using technology for this purpose?

A. I love the idea of using technology for charge reconciliation. However, I would caution that it can only be used at a high level (e.g., general check of $100,000 projected, $101,000 generated, volumes are within projected standard). When one needs to troubleshoot—what I like to call the fun part—it is always driven by an individual expert. You must understand volumes, schedules, clinical services provided, chargemaster and charging rules, and EHR configuration.


Found in Categories: 
Billing and Claims, Revenue Integrity

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