Translating revenue integrity principles to a small organization

Wednesday, March 7, 2018

Revenue integrity at a smaller organization looks much different than revenue integrity at a multi-hospital system. Fewer resources mean it’s an all-hands-on-deck operation with everyone taking on multiple roles.

“I’m in a rather unique position,” says Sondra Hess, CCS, CRC, documentation specialist at the Levy-Kime Clinic, Los Angeles Jewish Home in Reseda, California.

Hess’ facility is small but diverse—the Los Angeles Jewish Home operates 14 lines of business ranging from residential care to hospice, short-term and long-term rehab, assisted living, skilled nursing, and participates in CMS’ Program of All-Inclusive Care for the Elderly. The average age of the clinic’s patients is 93, Hess says, and most have long-term chronic conditions. With so many high-risk patients, it’s imperative that financial and administrative functions are handled as efficiently and correctly as possible.

To meet her organization’s needs, Hess wears many hats—a concept familiar to most smaller organizations. She’s the coder, CDI specialist, and medical records auditor. She works closely with the providers and clinic staff and the facility’s biller. Other revenue cycle and financial staff at Hess’ facility are always willing to share their expertise and assistance. Revenue integrity at larger organizations is sometimes more contained, but at a smaller organization everyone will likely be called on to bring their expertise to the table and share some part of the work.

When Hess stepped into the role two years ago, she knew there was a significant amount of work ahead of her. Much of her previous experience was at large health systems such as Kaiser Permanente in Oakland, California, and the University of California San Diego Medical Center. The Los Angeles Jewish Home offered a fresh set of challenges—and rewards.

One of the biggest challenges at a smaller organization is, of course, resources. Hess is a department of one—that made it difficult to find the right focus and prioritize tasks at first. At many smaller organizations such as clinics and physician practices, the providers are also the coders. When Hess first joined the Los Angeles Jewish Home, she took on coding responsibilities from the providers. However, that arrangement, in which Hess reviewed charts and coded them, quickly became too time-consuming. She shifted gears to a more purely auditing function, conducting prospective, concurrent, and retrospective audits, and was able to review a more significant percentage of charts. Initially, she reviewed 100% of clinic providers’ charge slips and provider notes. That gave her the opportunity to see the big picture and analyze common issues with documentation and coding.

“I found that there was sometimes a mismatch,” Hess says. “They would write a diagnosis on the billing slip, but the documentation supported something more specific. Or, they would write in a code that was not supported by the documentation.”

Deeper audits allowed her to target education for the providers, who, in turn, were highly receptive and open to change. Over time, she was able to increase the specificity of the providers’ documentation and reduce the audits she conducted. After several months, Hess saw few mismatches between the superbill and the documentation. Any reconciliation that needs to be done goes back to the provider to handle, she says.

Hess also used her audit findings to educate the clinic’s providers at bi-monthly staff meetings. Hess had experience educating providers as a CDI specialist and knew that it could be a challenge. At larger facilities, it can sometimes be difficult to make a meaningful impact on providers—there’s often little opportunity to develop a positive relationship with them. Communication is largely electronic and staff such as internal auditors and CDI specialists may work in offices that are not on the main campus. That can translate into low provider engagement and high resistance to change.

“That’s one of the changes I’ve found here,” Hess says. “The physician engagement at a personal level, at a point of care, face-to-face level becomes more real, and it sticks with them. The providers here are just as likely to bring an opportunity to me.”

That’s notable, Hess adds, because providers are already busy and are typically reluctant to take steps that they feel will add to their workloads. However, the providers at the Los Angeles Jewish Home take a different approach: they don’t object to doing a little extra work if it means doing it right. That level of engagement and commitment from the providers is a hallmark of success.

That means Hess doesn’t have to repeatedly remind providers of the same documentation errors, leaving more time to tackle the next set of challenges. Establishing sound processes and honest communication helps everyone make the most efficient use of resources—no matter the size of the organization.