Revenue Optimization
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The document discusses the differences between revenue integrity and revenue cycle management, highlighting that revenue integrity is proactive and aims to prevent revenue leakage, while revenue cycle management is predominantly reactive and focuses on addressing issues as they arise. It also covers the role of the National Provider Identifier (NPI) in healthcare transactions, the common outsourcing practices of revenue cycle management among hospitals, and the financial implications of patient care quality indicators. Additionally, the document emphasizes the need for a structured approach to identify and mitigate revenue risks effectively.
Revenue Optimization
- 2. Revenue Integrity vs Revenue Cycle Revenue Integrity … Is meant to prevent recurrence of issues that can cause revenue leakage, revenue degradation and compliance risk. It is proactive, not reactive. It should be structured, informative and affect change. A formal approach w/ goal of better integrated processes. Revenue Cycle … Is usually the focus and cornerstone of finance. It is reactive, not proactive. It cannot uncover all revenue gaps because of workflow siloes and deals w/ issues as they arise.
- 3. Health System Segments - NPI Inpatient Care Acute Care Hospitals – each NPI Long Term Care Centers Specialty Care | Rehab, Psych Emergency Departments Outpatient Specialty Clinics | Ophthalmology Specialty Centers | Dialysis MD Office Outpt | GI Infusion Cntr Testing Centers | Lab, Rad, CT Home Health Care Physician Hospital Owned Physician Groups Hospital Contracted MD Groups Hosp Specialty MD Grps (ED, Rad) Private Practice Groups Clinic Based Physicians The NPI is a unique identification number for covered health care providers. Covered health care providers and all health plans and health care clearinghouses must use the NPIs in the administrative and financial transactions adopted under HIPAA. The NPI is a 10-position, intelligence-free numeric identifier
- 4. RCM Ecosystem - Vendors EHR Integration Practice ManagementSpecialty Services - Vertical
- 5. Typical RCM • Simply fix transaction errors instead of identifying and correcting the root causes of process issues. • 80% of hospitals outsource RCM to external vendors • 69% outsource to multiple vendors • 28% outsource to > 3 vendors Of note: Large vendors such as MTBC and Constellation Healthcare Technologies are leading the charge of consolidation
- 6. Beyond RCM … Dollars at Risk | Care Mgmt other Medical Necessity (InterQual) Avoidable Days (Acute Care) Observation vs Inpatient (IPPS) Accurate Diagnosis (CDI - SOI | OM vs EM | CMI) Discharge Disposition Billing Rules (Infusion Meds) Coding | Sequencing (UHDDS)
- 7. Beyond RCM … Dollars at Risk | Quality Hospital Acquired Conditions (HACs) Patient Safety Indicators (PSIs) Hospital Value Based Purchasing (HVBP) Complications Translate into $$: PSI – HAI: risk of a 1% penalty if in lowest 25% HVBP: risk for up to 2% penalty or bonus (w/ Mortality metrics) Readmissions & Mortality Rates: no payment
- 8. Shift in Perspective Encounter Complexity Paid based on Services Provided MSDRG APRDRG Per Diem Charge Based/Charity _____________________________ PDX (Primary Diagnosis) MCCs (Major CoMorbidities) CCs (Co Morbidities) Patient Complexity Paid based on Risk Scores (Quality) Capitation (MA, Anthem etc) HCC -> RAF -> $pmpm Continuum: MD | OP | Clinic | IP | Rehab | LTC Charge Based/Charity _____________________________ PDX (Primary Diagnosis) HCCs MCCs & CCs (Co Morbidities)
- 9. Strategy & Planning Low Hanging Fruit | Current $ at Risk Prepare for Future | Risk Algorithms