The Mid Revenue Cycle: Key to Reducing Claim Denials

By Kevin Smith, VP, Product Management | Posted: 02/12/2018

Are you experiencing documentation and coding errors?  Do you suspect you may be under or over charging?   If so, your denied claims rate may be robbing your organization of cash. Incorrect or incomplete documentation and coding in the middle of the revenue cycle result in more denials and deplete your revenue. 

Claims denials are a huge drain on health organizations; out of $3 trillion total claims submitted, $262 billion were denied, and 65% of claims denials were never resubmitted. Millions of dollars could be slipping away simply by failing to ensure that physicians are documenting correctly to allow for optimal coding.   Also missed is the confirmation that all items for care services or supplies are accurately captured and charged.

Beyond cash optimization, the necessity for accurate coding and charge captures becomes greater when you factor in:

  • Quarterly regulatory updates
  • Increased patient demand for charge information as patients become responsible for larger deductibles
  • Patient satisfaction levels

What can you do now to measure the health of your mid rev cycle?

  1. Double check documentation to ensure it is complete
  2. Implement a training program for physicians and colleagues that assures documentation accuracy
  3. Implement a sound coding audit practice that measures coding accuracy and productivity
  4. Institute corrective actions to documentation and coding processes
  5. Optimize inpatient/outpatient charge master and coding data
  6. Use an automated charge master tool
  7. Implement charge capture audits to assure that all items for care services or supplies are accurately captured and charged

Documentation

Incomplete or poor documentation leads directly to lost revenue. Implementing solutions that assure appropriate documentation eliminates claims rejections due to unclear documentation.

Training

Errors can occur the minute the physician begins documenting the patient’s care and condition. It serves to build the medical record and is referenced by many others in the health organization, including coders.  ICD-10 presents opportunities for error in coding, too. A thorough, evergreen training program that continually educates physicians and HIM colleagues is a strong start to accurate claims.

Coding audits

Auditing coding practices for accuracy and productivity eliminates over or improper payments, insufficient patient details, wrong diagnosis, service and procedure codes and lack of medical documentation. 

Documentation and coding corrective actions

Integrating corrective actions into documentation and coding processes can result in elimination of recurring problems that compromise clean claims.

Chargemaster and coding data

Formalizing CDM process structures, improving related procedural documentation and training clinical managers on CDM are key to realizing measurable benefits, including shorter turnaround times.

Automate

Reputable chargemaster tools update charge data regularly, a significant reduction in time compared to the manual process. They provide daily alerts on new coding changes, including interpretation and suggested action for compliance.

Charge capture audits

Audit your charge process to identify business process or system improvement opportunities to improve compliance and greater revenue. Be sure to benchmark your progress against other health organizations for a thorough quality assurance system.

Improve the middle to improve your claims

Improving key elements in the mid revenue cycle requires a skilled team of seasoned HIM professionals. As the profound effects of a weak HIM system have been identified as root causes of denied claims, improvement of each process requires time, experience, skills.  Health care organizations that are successfully growing their revenue attribute at least part of their success to the decision to engage HIM providers that offer services and technology. Partnering with a dedicated vendor assures thorough documentation, accurate coding and complete billing, identifies charge issues throughout the revenue cycle, fixes issues pre-bill, prevents costly billing rework and late charges, and reviews your charge master for accuracy and completeness. 

nThrive helps health organizations examine and enhance the mid revenue cycle to improve the quality of claims and reduce the chance of denials before they occur. To learn more about how we can help, visit us here.

Want to capture every dollar to which you are entitled? Contact us for more information.     

Kevin Smith, Vice President of Product Management & Strategy

In this role, Smith leads the Patient Access Product Suite, including the industry-leading CarePricer and Charge Integrity product suite, and is responsible for the full product life-cycle management of these solutions. 

Smith joined nThrive in 2012, bringing 20 years of experience in product management, strategy, and technology to his role, having held positions at Intel, Dell, and most recently Fiserv before joining nThrive. 

Smith is a graduate of Kelley School of Business at Indiana University with an MBA and bachelor’s degree in Finance. He is also a certified HFMA Revenue Cycle Representative.