Medicare Compliance & Reimbursement

Ethically optimizing reimbursement and lowering compliance risks is every facility’s dream. Reduce expenses and strengthen your bottom line by creating a revenue integrity team (RIT). Whether it is simply a group or is a formal department, take these five steps.

1. Understand the Team’s Purpose

The RIT shouldn’t simply focus on how to reduce the hospital’s expenses. The team’s purpose is to study business processes and analyze the causes of repeat problems. Understanding and improving processes such as workflow, communication, and accountability on both the front and back ends will lead to revenue integrity down the road: increased operational efficiency, lower compliance risk, and optimized reimbursement. Hospital management and members of the RIT should also understand that reimbursement isn’t only about sending claims to insurers as quickly as possible. You want to be sure that all charges are accurate, and that all charges are included on bills the first time.

Advice: “The way I usually indicate the distinction with types of activities is with ‘efficiency’ vs. ‘effectiveness’,” explains Duane Abbey, Ph.D., president of Abbey and Abbey Consultants, Inc., in Ames, Ia. “For instance, efficiency involves getting things done more quickly while effectiveness addresses doing the right thing. In other words, make sure you have the correct process and then make the process more efficient.”

2. Choose the Best Players

Experts agree that building a diversified RIT works best. Members of the core team might work in areas such as:

·         Case management

·         HIM

·         Nursing

·         Patient admissions/registration

·         Patient financial services/billing

·         Chargemaster coordinator

·         Internal audit/compliance

·         Managed care.

3. Expand the Team When Needed

Keeping the RIT to six or seven members can increase its productivity, but sometimes other help might be beneficial. For example, if the team is tackling an issue in the lab, it could be worthwhile to invite a lab employee to temporarily join the group. That employee who understands the daily responsibilities, challenges, and information in the department can be a valuable resource for the RIT.

4. Include Coding Expertise

Coders play a significant role in revenue integrity, particularly because of their expertise regarding diagnosis guidelines, inpatient and outpatient procedures, and modifier usage. The ability to capture all of a patient’s comorbidities helps document the level of patient acuity. That, in turn, is essential to ensuring the hospital receives appropriate reimbursement. Because coders know what is and isn’t working from a reimbursement perspective, they can help identify aspects of documentation and registration that can prove beneficial in the long run.

As more facilities implement revenue cycle teams, coders’ roles could expand into other areas of reimbursement, such as chargemaster coordinator.

5. Set Realistic Expectations

Once a foundation for revenue integrity practices is in place, the RIT can focus on reimbursement. Hospital administrators and stakeholders should know that the typical U.S. hospital can easily experience an initial annual denial rate of 7 percent or higher on its claims, according to information from Karen Bowden, senior vice president at Craneware InSight in Atlanta. Lowering that denial rate is a time- and resource-intensive commitment. She gives these examples of benchmarks a well-performing hospital might set to move toward improvement:

·         Initial denials less than 4 percent of charges rejected on remittance advice, measured monthly.

·         Rejected claims are worked within five days of receipt.

·         Write-offs are less than 0.4 percent of gross revenue.