Recovering from Covid-19: Mid-revenue cycle management

by Adriane Martin DO, FACOS, CCDS

Martin Luther King Jr. Day took place January 20 this year. What else makes January 20, 2020, significant? It was the day the CDC confirmed the first case of COVID-19 in the United States. In the following days, weeks, and months, profound changes impacting every facet of our lives were made to slow the spread of the disease and to properly care for those who contracted COVID-19.

The changes worked. New cases of COVID-19 declined nationally, and there were fewer deaths. However, success did not come without a steep price. The negative economic impact wrought by COVID-19 will likely resonate for years to come.

Healthcare has been hit particularly hard. For instance, cancellation of elective procedures and admissions coupled with increased spending has left many hospitals facing significant revenue loss, compounding the preexisting problem of thin operating margins.

Where does recovery for healthcare start? With efforts to improve revenue so that hospital and physician office doors stay open and the lights stay on.

Improved revenue begins with mid-revenue cycle management. For immediate revenue lift, look toward a pre-bill MS-DRG review process. Optimization of inpatient revenue through an MS-DRG pre-bill process is critical. In this process, the medical record is reviewed to ensure complete and accurate clinical documentation and coding prior to final billing. While many regulatory waivers have been issued to allow for flexibility in responding to the public health emergency, they did not excuse inaccurate or incomplete documentation from being a target for review and denial by payers. By uncovering missed documentation, coding, and query opportunities, the pre-bill process drives revenue integrity, mitigates financial risk, and secures future revenue. Clinical documentation integrity (CDI) efforts should be assessed and aligned to support the goal of revenue lift. In the face of staffing limitations and changes in payer mix, a shift in the usual practice of inpatient CDI departments may be needed.

Mid-revenue cycle management must also be considered in the ambulatory setting to ensure accurate reimbursement under accountable care organizations and managed care organizations. Complete hierarchical condition category capture can be accomplished with a pre-visit planning process designed to alert providers to open, missed, or suspected conditions.

Complete economic recovery from COVID-19 will require many different solutions. The strategies listed above for mid-revenue cycle management provide avenues to impact the immediate short-term need of revenue lift and start healthcare on the road to recovery.

Editor’s note: Martin is the vice president of physician services at Enjoin. She also serves on the NAHRI Networking Committee.