AGS Health experts share weekly blog posts focusing on innovative approaches for healthcare organizations to adapt to various regulatory changes that may impact revenue cycles. They also provide insights on how to manage those revenue cycles by leveraging technology and services to streamline and optimize revenue cycle management. Here are 10 popular blog posts that have been recently published.
The U.S. Department of Health and Human Services (HHS) created a risk adjustment model similar to the one created by the Affordable Care Act (ACA) in that it is based on the Hierarchical Condition Category (HCC) classification system. But there are key differences. Primarily used for commercial ACA payers and not restricted to older patients, HHS-HCC was developed using commercial claims data and refined HCCs to reflect those conditions expected within the commercial risk adjustment population. It also calculates risk scores concurrently, which means it uses diagnoses from a period to predict costs in that same period.
Proper documentation and coding are all that stand between a healthcare organization and the potential loss of millions of dollars when the Office of the Inspector General (OIG) comes calling. ICD-10-CM Coding Guidelines state that all documented conditions coexisting at the time of an encounter that require or affect patient care treatment or management must be coded as a diagnosis. As such, physicians must clearly and precisely document each diagnosis based on clinical medical record documentation from a face-to-face encounter – which means that diagnoses cannot be completely determined from test results and a patient’s past medical history.
Patient access operations – financial clearance activities in particular – play a critical role in laying the foundation for a high-performance revenue cycle. The challenge for many provider organizations is that they lack the staffing, technology, and operational processes needed to capture the full scope of critical information, eligibility, and authorizations in advance of a patient’s visit, resulting in denials. However, correctly designed and implemented Integrated Financial Clearance processes can create a seamless and cohesive approach to all facets of the long journey between scheduling to authorization to payment.
To establish an effective outpatient clinical documentation improvement (CDI) program, healthcare organizations can build upon existing inpatient CDI processes and develop robust chart review and communication query processes. When doing so, it is important to evaluate Medicare Advantage contracts to ensure alignment with the payer contracts and specific requirements, define program scope, and use analytics to prioritize areas for improvement. Metrics should be carefully chosen to demonstrate ROI and align with key objectives, such as RAF scoring improvements.
The emergence of autonomous coding is the most recent transformation of the medical coding landscape. Consisting of AI-driven systems capable of automatically assigning medical codes to patient charts without the need for human intervention, autonomous coding technologies have the potential to streamline coding processes, reduce costs, and improve accuracy. However, while the potential benefits of autonomous coding are considerable, there are also limitations to consider, and organizations must carefully evaluate how this technology will fit into their existing coding processes and how it will affect the accuracy and efficiency of their coding results.
Advances in AI and the highly transactional nature of revenue cycle management (RCM) have set the stage for AI to address many of RCM’s biggest pain points, while increasing revenue capture and helping achieve revenue integrity. Whether it’s automating manual and redundant tasks within patient access or billing or applying AI to real-time analytics, prior authorization, workflow prioritization/optimization, and denial mitigation, the potential for AI in RCM is already being realized by early adopters. However, when it comes to deploying any AI strategy, selecting the right technology vendor can make or break the entire project.
The chronic coding and RCM staffing shortage that has healthcare organizations looking for new ways to keep revenue flowing with too few qualified professionals to handle critical processes, including moving staffing to the top of priority lists for many finance and HIM leaders who are already dealing with the extreme financial pressure as well as greater regulatory uncertainty and audit scrutiny. Many are also realizing that the smart strategy to address these woes is one that focuses on optimizing the productivity of existing teams by adopting a hybrid approach that augments internal teams with outsourced coders and a substantial focus on automation wherever possible.
As healthcare organizations progress in navigating the roadmap toward RCM maturity, the effective use of analytics is a key driver of success in the journey to improve operational excellence, achieve greater efficiency, and maximize financial performance. Analytics can provide valuable insights and actionable intelligence for that journey – intelligence that can transform a revenue cycle from a basic, retrospective reporting system to a strategic decision-making powerhouse. Effective analytics enable organizations to assess their performance in real time, answering critical questions about the health of their operations, financial metrics, and collections. By leveraging analytics, organizations gain a comprehensive view of their revenue cycle, helping them benchmark performance against peers and world-class organizations to identify areas for improvement. This understanding is crucial in driving decision-making and optimizing operations.
When Tidewater Physicians Multispecialty Group (TPMG) began its transition into value-based care, it soon found its revenue cycle was being bogged down by a unique problem, the need to manually write off penny charges assigned as placeholders on claims submitted to payers who could not accept claims with zero-dollar quality codes. AGS Health provided a unique solution – Robotic Process Automation (RPA) – that quickly resolved a backlog of more than 100,000 outstanding penny write-offs. Today, 98% of TMPG’s penny adjustment process is automated with RPA with an accuracy rate of 99% and is expected to generate an estimated savings of more than $200,000 over a five-year period.
Healthcare organizations are grappling with the issue of underpayments – a silent revenue killer that often goes unnoticed but can represent millions of dollars in unrecognized net revenue. One major reason for underpayments is the lack of attention to uncollected revenue that is hidden in zero balance accounts (ZBAs) that have faded from view, leading to missed opportunities to identify and recover underpayments. There is a seven-step framework to quantify the issue of underpayments as well as best practices for managing underpayments.
Looking Forward
AGS Health experts will continue sharing their insights, resources, and recommendations for navigating the complex and evolving RCM landscape with a fresh slate of blogs publishing through 2024. Find the topics that impact your organization.
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