COVID-19 has been the impetus to new federal and state regulatory requirements, causing hospitals, healthcare organizations and providers to struggle with properly executing medical billing claims for it while questioning the kind of healthcare data analysis they should employ to help secure appropriate reimbursement.
In the nThrive webinar, “Securing Revenue for Hospitals and Providers in a COVID-19 Environment,” nThrive Senior Vice President Rebecca Marsh and Senior Director of Revenue Integrity at Central Maine Healthcare Jason Cunningham, share tactics, measures and real examples of how to assure successful revenue cycle outcomes in the face of COVID-19 and beyond.
Marsh focused on the information, tactics, and next steps to help hospitals, healthcare organizations and providers obtain revenue through detailed plans and data analysis. Cunningham shared real life examples of Marsh’s recommendations, including tactics for workflow documentation, practical account analysis, payor communication negotiation and vendor analysis.
Throughout the webinar, Marsh provided thorough lists of referenceable, critical information, all of which can be accessed here. Marsh and Cunningham identified the key analysis elements to help your hospital or healthcare organization thrive during the current pandemic and into the future.
What is included in a data analysis?
General data analysis
- Patient volume
- Patient revenue
- Payer analysis
- DRG analysis
Proactive account analysis – general billing
- Aged AR analysis
- DNFB/timely filing deadlines associated with each payer
- Appeal deadlines by payer
- Analysis of claims on hold
- Like balance analysis, including low balance review
Proactive account analysis – Self-pay; assumes upon registration that providers have:
- Checked eligibility for healthcare coverage to validate no coverage
- Accepted defined program reimbursement as payment in full
- Agreed not to balance bill the patient
- Agreed to T’s and C’s, may be subject to post-reimbursement audit review
- Ensured all claims submitted are complete/final with DOS on/after 2/4/2020
Retro account analysis
- Denials received with root cause analysis
- Eligibility for COVID-19/non-COVID-19 patients
- Billing form denials for claims released prior to policy completion or payers not ready to process claims based on CMS guidelines
- Requested documentation on COVID-19 accounts or related diagnoses
- Diagnostic testing effective dates
- Potential recoup due to retroactive coverage termination
- Payer communication and negotiation
- Contract management and modeling
- Proactive communication
- Stop-loss, outlier, and lessor-of provisions
- Vendor analysis to quantify ROI
- Establish baseline metrics and lead indicators
- Monthly KPI performance
Workflow, policy and procedure documentation
It is critical from a reporting standpoint to document any denials or adjustments you have made pertinent to coded claims, especially if there is a need to prepare for a second wave of the COVID-19 pandemic. Identify and ensure that the patient responsibility adjustments are made appropriately and accurately to ensure patient satisfaction throughout your hospital or healthcare organization. Documenting workflow processes is critical now as staff changes.
Cunningham shared that, at Central Maine Healthcare, an important workflow process implemented was with the regulatory compliance team – they now have a tracking mechanism to ensure that the start date of each particular project is documented, the colleague working on the project and the project owner, and whether it’s in the implementation or monitoring phase.
A quick recap of guidance on documentation of new workflows, policies and procedures can be summed up as create, document, draft, document, develop. Create COVID-19-specific denials write-off codes when adjustments are made to patient responsibility. Document new workflow process, review with colleagues, communicate and monitor. Draft procedures with follow-up instruction for patients with coverage-related denials. Document workflow process to prevent balances rolling to patient post insurance payment. And finally, develop a well-defined response and workflow for responding to patients who cannot pay previous balances unrelated to COVID-19, especially if due to COVID-19 related job loss.
What are sound next steps to follow on the return to normalcy, or the new normal? Implement good processes around impactful patient solution options, such as Telehealth, “I believe that if the payment will suffice and hold true, then we’ll see more Telehealth visits potentially occur future state post COVID-19, as well,” commented Marsh. Make sure that you have a good analysis system to measure productivity, especially for colleagues still working from home or if you are considering a stay-at-home model for cost savings. Think about how to measure the productivity and more importantly, provide colleagues with the education, training, tools, and technology necessary to succeed. Develop a Medicaid authorization for retrospective review process with the necessary steps in place. With the high population of unemployment be sure to employ a recurring check process to go back and validate each patient who may be recurring and confirm if they are eligible for service. A good cost savings measure is to look for opportunities to streamline processes with automation deployment. nThrive Patient Access technology and bots are leveraged by clients across the country and are an effective way to streamline and save cost on manual processes that may be consuming a full-time colleague’s hours or even multiple FTEs. Implement an analytics platform that provides insight into your organization’s data on a daily basis – a critical must – to identify the patterns, trends, gaps and opportunities that may exist to quickly identify a system-related issue before too much time passes. We all know revenue integrity drives revenue in the hospital. A comprehensive CDM compliance review will help make sure that you have the accurate and complete CPT/HCPCS codes assigned and routed to the appropriate payor code. Leverage the power of chart audits to look at documentation tracking all the way through to claim submission to validate units of service, medical necessity and coding that is coming, not only from the CDM, but from HIM as well, including modifier assignment, diagnoses, and all of the necessary elements that drive reimbursement. And finally, price modeling. Make sure that you can defend the CDM structure you have, that there is transparency into how your prices have been developed and the discounted prices you are offering to self-pay patients within the next six months. Define your pricing strategy and document it in writing. Whether or not there is a repeat wave of COVID-19, we all know how important it is to prepare for any disruption to your healthcare organization and revenue cycle.