COVID-19 wreaked havoc with the healthcare industry; hospitals and health systems have lost a collective $36.6 billion over the past four months. Recovering from such a major financial hit can seem n insurmountable, however, by optimizing the middle of your revenue cycle, you can identify opportunities and begin to see some immediate revenue lift. By following a few key revenue cycle practices, you can make sure you’re getting the most out of revenue integrity – and maximize reimbursement in the post-COVID “new normal.”
The chargemaster, which serves as the hospital’s starting point for billing patients and payers, is the cornerstone of any revenue integrity program. It’s no surprise that keeping it updated and accurate is imperative for optimal post-COVID revenue cycle management. You’ll need an internal resource or partner with extensive knowledge of both CMS and commercial payer requirements who can keep your chargemaster current on regulatory changes and newly established codes. Equally important is thoroughly educating clinicians and staff about these changes so you can ensure the integrity of COVID-19 clinical documentation. These efforts aren’t anything new or exciting, but they can have a major impact on reimbursement – and will help you avoid denials and appeals by getting everything right the first time you submit a claim.
Because payer contracts are highly complex, revenue integrity has always mandated keen attention to detail. However, COVID-19 has escalated and necessitated an even greater level of knowledge and diligence. To maximize reimbursement, your revenue integrity team should meet regularly to make sure nothing is slipping through the cracks and you are not leaving any revenue on the table. You should specifically focus on identifying action items related to proper coding, telehealth, prior authorization waivers, CMS reimbursement and patient cost share, as payers’ changing reimbursement rules have likely led to to-do’s in these areas. Consider questions such as:
(For a more extensive list of questions, listen to the webinar, Maximizing Post-COVID Reimbursement Revenue).
In addition, work with Managed Care to understand COVID-19 billing and payment nuances. Work with them to understand what patient cost share each have communicated they will cover and the billing requirement for each. Pay attention to details in every area and take the time to understand COVID-related coding and billing nuances. By doing so, these efforts can help galvanize your organization’s post-COVID financial recovery.
The inordinate amount of details in revenue integrity can seem daunting, so develop an action plan based on where you can get the biggest bang for your buck. Review charge capture, coding and underpayments to identify opportunities for additional reimbursement. Determine what changes require the least effort for the greatest return and prioritize accordingly. Should you leverage automation? Create or update workflow rules, prompts and alerts? Will staff or clinicians require training? Often, minor changes such as a coding update, implemented via a new or revised workflow rule, can make a substantial difference with minimal ongoing effort. For instance, look at pre- and post-April 1 coding updates, and whether accounts with ventilation charges have appropriate ICD-10 coding and the correct room and board designation. For underpayments, monitor CMS’ 20% add-on payment for IP COVID-19 cases, and make sure you’re submitting to HRSA to receive reimbursement for uninsured patients.
Long before COVID-19, “doing more with less” has been the status quo for many healthcare organizations. The new normal, however, will be even more taxing for providers since it will require them to quickly ramp up services and find every opportunity to provide revenue for their hospitals and networks. If revenue integrity was important before, it’s doubly so now. Optimizing your revenue integrity program and getting the most out of mid-revenue cycle management can help you achieve immediate results – and get the revenue lift that can help pave your organization’s way to financial recovery.
Andrew Stieve is a Vice President of Revenue Integrity at R1.