One of the first critical steps in the revenue cycle is proper charging. Charging is the process of codifying a visit and turning that code into a claim to send to the insurance. Charges can come in many forms, each requiring a different level of review, which impacts the potential for error:
Because of this variation, the charge process is an area of the revenue cycle that is ripe with optimization opportunity. With evolving regulations, stricter standards, and changing workflows across systems and staff, now is the right time to automate some of the costly manual review required to get the right information out the door to payors.
When an organization moves to electronic charge capture, they often review all charges coming through to ensure the charges are correct and accurate. Through our revenue cycle implementation and optimization work with customers, we often see customers who are unable or unwilling to scale down the 100% review process. Without reducing the review time, they are not seeing the gains of reduced charge lag with electronic charge capture. For more on how to make the leap to electronic charge capture successful, take a peek at our previous blog on 4 Steps for Effective Charge Capture.
In a recent engagement, Prominence worked with a customer who had been reviewing 100% of their professional charges since their EHR go-live in 2012. It obviously wasn’t their goal to maintain this level of review, but they needed the confidence to stop and trust the system automation. During this engagement, we focused on three keys to success
1. Rule Automation
Since the manual review of all charges had been going on for many years, the first hurdle was to understand what the coders were doing with each charge session. We wanted to take the action of the coders and turn them into automatic system activities or better edits, so that only the charges or encounters that required their attention were where stopped for review.
Codifying human behavior is a huge trend in Business Intelligence and Analytics and is the buzz behind AI and NLP. While we are waiting for vendors and models to improve technology and provide models, we took the low-tech but effective approach of surveying and shadowing the coders. We then used our system, industry and customer-domain knowledge to create rules to apply modifiers, edit charges, and flag sessions for additional review.
2. Actionable Edits
Creating appropriate and actionable edits is an art. Anyone can create a rule to review all EKG charges with a great pop-up text of “EKG charges require review”. But how helpful is that? How does it help the coder act on the review? The art of rule creation comes down to being specific and action oriented. What if the edit instead said, “EKG performed on the same day as a scheduled surgery are bundled with the pre- or post-operation assessment and should not have a modifier 59 (per CMS Packaging for Claims Resulting in APC Payments – page 22/248).” Now the coder knows where to look to review the modifier associated with the charge.
When building edits, you must also keep in mind the 80/20 rule. This means that you should focus on the 20% of charges that are taking up 80% of review time. Think about what is requiring the bulk of the review and create detailed and action-oriented alerts for these charges. Coding rules change on a regular basis, and it can be a person’s full-time job to update and create rules, so prioritize their time appropriately to make the biggest impact at your organization.
3. Workflow Review
Habits can be extremely powerful. Think about one of your own habits, like going to get a Starbucks coffee on the way to work every morning. It isn’t the most cost-effective thing to do, but it has become a part of our daily routine and we do it without thinking about the time and money it is adding up to. It is easy to get into bad habits, which applies to more than just caffeine addictions. You see a lot of habits related to registering a patient, attaching referrals, capturing MSPQ documentation and assigning an overseeing providing for Nurse Practitioners that don’t really impact the clinic until the point of charging. As part of every charge automation optimization, you must look at the workflow generating the charge data. Make sure to educate and reinforce the proper procedures to get optimal results. A word to the wise, it doesn’t hurt to provide Starbuck gift card incentives to clinics that are the most compliant!
At the end of our client engagement, these charge automation efforts culminated in some very promising results! The customer moved off a 100% review of charges and are now filing 33% of the charges directly to the account. This saves the coders time, giving them more time to reduce their charge lag and speed up the revenue cycle. The biggest change came in the acceptance and promotion of the idea of continuous improvement. You don’t have to wait for an annual event or system upgrade to continue to automate work. One change a week can make a big impact.
Interested in automating your charging? Reach out to us!