3 Strategies to Improve Your Mid Revenue Cycle and Protect Your Bottom Line

The mid-revenue cycle was a buzzword among finance executives around 2015 as reported by the Advisory Board. Now it’s making a comeback with providers facing mid-cycle losses and an evolving value-based healthcare landscape.

The revenue cycle is traditionally divided into the front-end (patient access) and back-end (business office). But a lot of important things happen in between that are linked to financial performance; comprising the mid-revenue cycle: clinical documentation improvement (CDI), coding, case management, and compliance. 

A Markets and Markets report revealed that the mid-revenue cycle management/clinical documentation improvement market is projected to reach $4.5 billion by 2023 from $3.1 billion in 2018, at a CAGR of 7.9%.

In a pay-for-performance and value-based healthcare landscape, the mid-revenue cycle is going to play a crucial role. This includes reducing loss of revenue due to medical billing and coding errors, resolving issues with declining reimbursement rates, managing ever-increasing amounts of unstructured data, and maintaining regulatory compliance.

Here are 3 strategies to consider:

Improve Data Accuracy in Clinical Documentation and Coding

In the past, many executives didn't consider documentation to be a financial function. With pay-for-performance, the reality today is the increasing relationship between quality and finance. Depending on your organization’s size, a 1 percent accuracy change may be worth millions of dollars; but from a compliance perspective, you also don't want to under code and lose revenue.

For example, ASC’s may lose 2 percent of Medicare reimbursements in 2019 if they have not been serious about participating in the ASC Quality Reporting Program (ASCQR) and failed to report certain data in 2018.

Quality is measured based on what is written in patient's charts and if that's not accurate, then quality-based payments will suffer. Codes are data, and that data is used in ways that will directly impact your revenue like quality reporting (MIPS), physician report cards, and more. High-quality coding is essential to profitability and is dependent on the quality of your physicians’ documentation.

Procedure documentation is quite challenging in the ASC space with complex procedures especially in specialty surgeries. Poor charting can make good care look bad as it’s going to be very difficult to explain what happened if the record isn’t accurate or well-documented.

Here are some suggestions:

• Perform quality checks
• Integrate new technologies like intelligent documentation platforms
• Upgrade tools and templates used in documentation
• Train physicians to document better and staff to code better

Effective Clinical Documentation Improvement (CDI) Program

One of the top barriers to effectively implementing a CDI strategy is a lack of understanding among physicians about the importance of strong documentation practices according to two-thirds of CDI specialists participating in a 2015 AHA survey.

In addition to its impact on patient care, the quality of data generated within the electronic health record and elsewhere in the organization is increasingly tied to cost efficiency under value-based reimbursement models.

Healthcare organizations are turning to CDI programs and staff to increase understanding of the importance of good documentation and help maximize revenue.

Here are some suggestions with some pointers from Shearwater Health:

• Set-up query tracking and analyze performance
• Categorize common documentation gaps (queries)
• Build a physician education plan focused on specific gaps for the service line.

Shorten the Claims Reimbursement Cycle by Preventing Denials

Imagine this: just 1 percent of net patient revenue can equate to $2 - $3 million annually for an average 300-bed facility. Yet an estimated 30 percent of claims are denied or ignored on first submission.

There are many providers that have become so conditioned to working the back-end denials management process; resulting in write-offs, partial payments, and time and money spent on appealing denials; that little attention is focused on preventing those denials in the first place.

To avoid back-end problems, preventing denials can be resolved in the front-end and mid-revenue cycle. And quite often, the cause of denials can be resolved through surprisingly simple process improvements.

In clinical documentation, you write a physician “query” when something about the physician’s documentation is confusing you. A query is a routine communication and education tool used to advocate complete and compliant documentation. It ensures that appropriate documentation appears in the health record.

Here are some suggestions for preventing denials at the mid-revenue cycle (documentation) from Eye Care Leaders:

• Set-up a strong query process to catch errors retrospectively in addition to physician education to prevent errors in the first place
• Implement query tracking to help you discern patterns that will help you build your CDI program (e.g. track common reasons for query, query rate per provider, provider response turnaround time, and recurring query themes).
• Work with the physician who is queried least often (CDI champion) to help work together with doctors for better documentation.

The goal is to have fewer queries in the first place. That’s why education and training is very important. Things like annual code updates, covered and non-covered services, and modifiers will help doctors and staff to be on the same page in streamlining the claims reimbursement cycle. 

David Hamilton is the CEO of Mnet Health Services, a Business Process as a Service (BPAAS) and Financial Technology (FinTech) firm with a specialized focus on End-to-End Revenue Cycle Management, Care Coordination, and Quality Assurance in the healthcare industry.