Revenue integrity technology as a growth catalyst: Six questions to consider...

By: Roberta Peters 

If there’s anything that COVID-19 has taught us, it’s that change is hard.

In the blink of an eye, our worlds were turned upside down. Providers nationwide faced multiple operational and strategic challenges, ranging from the sudden need to ramp up usage of personal protective equipment and telehealth platforms to cessation of elective procedures and the subsequent margin impact they provided. As one particularly impactful challenge, healthcare coding was uniquely disrupted by the pandemic.

Embracing chaos to drive revenue integrity

Every great change is preceded by chaos, but we must be willing to change. In healthcare, transformation is highly contingent upon stakeholder and end user buy-in, especially when it involves any new technology. Change requires challenging the status quo.  It requires letting go of the idea that technology adds operational burden and embracing the possibility that it can be a win-win catalyst for increasing operational results while also improving revenue integrity.

In fact, now may be the perfect time to focus on coding optimization and revenue integrity. Between the current healthcare crisis and the shift toward value-based payments, there’s an opportunity to re-evaluate existing processes and adopt technology that can drive change. It’s about empowering your team to make informed decisions in real time, while also taking advantage of new options like Cloud-based tools and robust automation.

However, not all technology is created equally. Smart investments are those that provide immediate benefits associated with compliant and timely claim submission while also supporting a long-term revenue integrity strategy that ensures sustainable improvements.

Here are six questions organizations should consider as they search for a pre-bill coding optimization solution:

1. How easy is the implementation? How well does it work with existing systems and processes? Anything that takes longer than 60 days to implement, or doesn’t work with your existing EHR, encoder, and billing systems will be a hard sell to your teams. Look for a Cloud-based solution to ensure fast implementation and easy access by staff.

2. How robust is the rules engine? Ideally, you want a partner that has decades of auditing insight and can bring thousands of proprietary rules to the table, with an equal focus on potential under- and overcoding for true revenue integrity. These rules are what enable you to identify and address issues for improved coding accuracy and compliant revenue capture prior to billing. Additionally, the vendor will proactively work with your team to help identify opportunities for custom rule development and ongoing operational improvements.

3. In addition to identifying potential coding issues, does the solution help you monitor quality- and performance-related information? Does it flag potential issues with PSIs, HACs and HAIs? Having insight into these helps you track quality-related criteria that can impact CMS Star Ratings and other variables that contribute to ongoing financial performance.

4. Does the solution provide actionable insights? Does it provide information on coder and auditor performance, including error trends to inform proper coder training? Does it provide feedback on issues originating with documentation, including opportunities for physician queries? A comprehensive optimization strategy includes case-level analysis as well as trends for specific DRGs, service lines, hard-coded elements and more.

5. Does the solution promote coder development? Does it provide coders with narrative advice with detailed corrections in real-time to improve performance? Without this critical information, coders may make the same mistakes over and over again, leading to revenue leakage, overpayments, or both. If a solution isn’t sustainable, it won’t deliver long-term value.

6. Does the solution enhance efficiency? Does it offer automated review of inpatient and outpatient cases—including actionable feedback on potential issues—prior to billing? Does it prioritize cases based on custom thresholds and route the highest impact cases to designated resources for immediate review and correction? Ideally, a coding optimization solution will even offer feedback on its own performance, including impact on total undercoding and overcoding, while also generating summaries of performance and impact summaries of each coder and auditor.  

Leveraging technology improve processes, compliance

Healthcare organizations need technology to drive sustainable revenue integrity improvements and stay ahead of regulatory changes. This isn’t an admission of weakness; it’s actually a commitment to success by empowering your team to ensure accurate coding and documentation. It’s also about giving managers the analytics and flexibility necessary to drive operational and strategic progress. This type of technology is a conduit for positive change as providers evolve their HIM and revenue cycle management processes. To learn more, discover eValuator. 

Roberta Peters, MS, RHIA
Vice President, Solutions Executive, eValuator™
Streamline Health