Solve revenue integrity pain points with interdepartmental shadowing

Wednesday, September 18, 2019

It’s a familiar story: revenue integrity uncovers an issue, tracks it back to a root cause, and provides education and recommendations to address it. Yet during the next round of audits, the same issue is uncovered. For revenue integrity departments chasing an elusive solution, it may seem as if success is always just out of reach. But sometimes reaching the goal is as simple as a change of scenery.

Shadowing staff in other key departments, such as clinical departments, billing, or coding, can help put success in reach, says Lisa Banker, MD, FACP, CCS, CCDS, chief medical advisor, value analysis and revenue integrity, at CarolinaEast Health System in New Bern, North Carolina. For a busy revenue integrity professional, it can be tempting to stick to familiar territory, but solutions developed in the office might not address problems that are apparent in the field.

“Sometimes you’re sitting in a financial meeting and people are complaining about the fact that clinical staff maybe don’t capture these certain diagnoses for tests or the registration folks are finding it hard to get orders from the outside offices. You maybe need to go see those workflows,” Banker says. “You may need to go shadow the ED doctors to understand what sort of pace is going on and how hard it is for them to think about certain things, to understand that maybe you’ve got to build better processes or tools to take that remembering part out of it for them.”

Banker has made interdepartmental shadowing a staple of her revenue integrity work—and discovered simple solutions to stubborn problems. Recently, her organization’s appeals work hit a roadblock. Payers were sending responses that they had submitted remittance advices that included instructions on further appeal steps. However, Banker didn’t see any additional instructions included with the remittance advices. On a hunch, she took a trip to the mailroom where the Electronic Remittance Advices (ERA) were received and processed.

When Banker first asked staff to pull up the ERAs on their computers, she didn’t notice anything unusual—she also didn’t see any additional instructions from the payer. Then she pointed out an icon she didn’t recognize.

“I said ‘What’s this icon?’ They said they didn’t know; they’d never clicked it. So, they clicked that icon and it was just a different piece of the program that had a more complete version,” Banker explains. “Sure enough, there it was, the piece of the remittance advice that we’d been looking for and assuming that we just weren’t getting. We wouldn’t have known that if we hadn’t taken the field trip.”

Process, policies, and solutions can work perfectly in theory, but if they aren’t adapted to real life conditions and existing workflows, they won’t be effective. Missing charges are a common revenue integrity pain point, but a solution is less common. In some cases, that may be because charge capture policies and tools weren’t developed with clinical staff in mind, according to Banker.

“Sometimes you have to take a field trip and shadow behind the nurse and actually see how she’s capturing charges for the meds she’s administering, how she enters into a computer the start and stop times for hydration therapy,” she says. “You may see that’s really difficult to do. Maybe we’ve got to reconfigure our computer system to make it easier. You can give people a lot of instructions but sometimes you’ve got to sit down right next to them and see how they do their work to appreciate the workflow, to see what their computer looks like versus what your computer looks like.”