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Improving ROI and reducing denials with mid-revenue cycle review

December 03, 2021
Health IT
Dr. James Fee
From the January/February 2022 issue of HealthCare Business News magazine

By James Fee

The healthcare industry has had significant impacts from COVID-19. During the most recent wave, hospital ICU beds were one again full and many health systems were canceling elective surgeries. Revenue is down for many health systems and staff is stretched thin.

According to a new Kaufman Hall analysis released by the American Hospital Association, hospitals are projected to lose $54 billion in net income this year. With the added challenge of reimbursements declining and denials increasing, a hospital revenue recovery plan is now more important than ever.

Yet as hospitals and health systems have continued to confront unprecedented financial challenges during COVID-19, it has become imperative for their Clinical Documentation Improvement (CDI) programs to evolve to ensure they continue to have a maximum impact on patient care and revenue.

Now more than ever, hospital executives see the need to increase revenue accuracy and mitigate risk by aligning CDI with organizational goals. Organizations that have not strategically reshaped their approach to CDI in the face of these challenges may find their programs unsustainable. One such method is utilizing a pre-bill review process to examine documentation and coding before claims submission.

Benefits of prebill review
A strong CDI program and prebill review process is the best place to begin when recovering revenue. By incorporating proactive, pre-bill reviews into existing CDI workflows, an organization more effectively engages clinicians and expedites correct quality reporting for CMS programs. In addition, organizations ensure physician documentation supports coding compliance, MS-DRG accuracy and quality performance data.

There is power in the pre-bill review. For example, one academic medical center realized an average ROI for 2020 of 800% and a total revenue lift of 3.4% exceeding $8 million by incorporating a pre-bill review.

More specifically, pre-bill reviews accomplish the following seven goals:

1. Uncover missed documentation, coding, and query opportunities
2. Promote coding accuracy to drive revenue integrity and mitigate financial risk
3. Ensure accurate coding and reporting of quality measure cohorts and risk adjustment
4. Reflect accurate clinical complexity of patients, especially for at-risk populations
5. Pinpoint educational opportunities for coders, CDI specialists, and physicians
6. Strengthen physician advisor programs by generating actionable data

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