Cycle of Revenue

7/31/2019 Cycle of Revenue

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Purpose of this Case Study

An assessment was performed to identify opportunitiesfor improvement in the Revenue Cycle, focusing oncase management.

Findings and recommendations address areas ofimprovement that could impact revenue capture,compliance, and reduce RAC denials.


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What is Revenue Cycle?

FINANCIALCOUNSELING

INSURANCEVERIFICATION

PRE-REG &PRE-CERT

SCHEDULING

REGISTRATION& POS CASH

COLLECTIONS

CHARGECAPTURE& ENTRY

MEDICAL

MANAGEMENT

MEDICALRECORD &

CODINGCLAIMS

SUBMISSION

THIRD PARTYFOLLOW-UP

PAYMENTPOSTING

REJECTIONPROCESSING

DENIAL &APPEAL

MANAGEMENTCONTRACTMANAGEMENT

EDI-capability

FOCUS AREA

RegulatoryCompliance

Metrics & KPIsCDM


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Assessment

Conducted over 4 to 6 days, consisting of:

Interviews

What have you inherited that may not belong in your

department? Observations

Chart review

Data Analysis


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RegistrationFindings

Staff require orders prior to procedures

Staff do not always ask to see insurance cards and identification

Inefficient communication between patient access and utilization

Recommendations Implement a quality audit for registration and insurance verification

Involve patient access in the weekly case management meetings toaddress authorization issues

Patient access and utilization review staff need to consistently utilizework lists provided by the system to ensure information is sharedbetween departments


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Denial Management

Findings Medicaid denials are appealed by an LPN in case management

All other denials are reviewed in the business office by non-clinical staff

Recommendations

All denials reviewed by same area, reporting to patient access

All clinical denials reviewed by a nurse

Enhance denial tracking by using a common work list with alldenials in process and capturing denial reasons to uncover trends


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Utilization Review

Findings UR staff each have their own daily work flow; however, the

process is similar enough to allow staff to cover for each other

Process is paper driven and requires a number of manual steps

UR staff do not use the provided system for work lists

Recommendations

Define work flow and processes

Evaluate staffing plan to promote teamwork with CM

Provide feedback on denial trends to UR staff


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Case Management

Findings Documentation process is inconsistent for case management, and

forms are ineffective

Documentation does not always stay with the patients chart

There is no defined or consistent work flow process

Staff lack tools required for their jobs: text pagers/cell phones,printers, fax machines

The Important Message from Medicare and Choice letters are not

provided to patients on a consistent basis


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Case Management

Findings (continued) No formal discharge rounds or long-stay patient meetings

currently being conducted

Tasks are assigned by discipline (SW versus RN), which creates

confusion for patients, hospital staff, and amongst themselves No physician advisor/champion to support the department in

difficult physician situations or to appeal denials

Nursing home referral process is disjointed, involving various

departments


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Case Managers

Findings Case Managers lack a consistent daily work flow

Most try to see Observation patients first

Reactive versus proactive

Case Manager carrying 30-50 patients a day

Limited direct communication with physicians

Limited insight into financial impact of case management


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Social Workers

Findings Social workers receive unnecessary referrals as a result of limited

patient screening performed by nursing staff

Confusion regarding which tasks require a social worker and

which belong to case managers Social workers spend a significant amount of their time on

nursing home placements


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Case Management ModelsRoles: People

3:3 Model 2:1 Model 3:1 Model

1. Social Workers (SW) Discharge Planners Psychosocial Needs

2. Utilization Management (UM) RN

Insurance Management Other

3. Case Managers (CM) Nurses

Models within

CM assignment varies Unit Physician Payer

Disease Management

Two versions1. UM/CM (2) with SW on own2. CM/SW (2) with UM on own

CM assignment varied as in 3:3

Unit Physician

Payer

Disease Management

CM/UM/SW roles in oneperson

Assignments

Unit Physician

Payer

Disease Management


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Model ComparisonModel Advantages Disadvantages

3:3 Individual Expertise

Easiest to implement

3 people in chart

Poor productivity

Confusing to customers

Confusing to patientsDifficult case sharing

Hand-off mishaps

More staff to manage

2:1 Works well in certain hospitals

Expertise driven

Promotes teamwork

Good transition to 3:1

2 people in chart

Confusing to customers

Difficult case sharing

Hand-off mishaps

3:1 1 person in chart

Clear assignment for customersComplete start to finish care

Fewer staff to manage

Comprehensive understanding of all aspects has

positive revenue implications

Only for high-functioning hospitals

Requires more training than others


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Choosing the Right Model

FTEs will depend on hospital services

Denial resolution falls with front or back end regardless ofmodel utilized

Caseloads

3:3 40-50s

3:1 22-25

Hospital culture

Compliant and revenue-conscience


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Recommendations

New staffing model

Caseloads 22-25 based on floor assignment

2-in-1 model

Nursing home placement coordinator

Gatekeeper 24/7

Cross training is key to success

New orientation plan


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Case Manager/Social WorkRecommendations

Move entire Case Management department to the CFO

Weekly revenue cycle meetings

Registration/Patient Access Supervisor

Registration/BO Director

CM Director

HIM Director

Coding Supervisor

Charge Master leader

Director Revenue Cycle

Representative negotiating managed care contracts

CFO


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Recommendations

Implement weekly long stay/high dollar meeting Goal: review patients with LOS>5 days; charges higher than $50,000; and

all self-pay patients

Attendees

Case Managers/Social Workers/Utilization Review staff Patient Access

HIM/ coding

Physicianhospitalist group

Physician advisor or CMO

Nursing

Financial counselor


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Meeting Process

Distribute list 24 hours ahead of meeting

Schedule for each Case Manager (e.g., 3-3:10 Mary)

Script expectations

Basic clinical, Days authorized, Days left for Medicare,

Discharge plan, Problems Physician issues

Compliments to be shared

Follow-up on compliments


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Sample Patient Report

Patient Jon Doe admitted 7 days ago for sudden onset confusion

My discharge plan is

I faxed clinicals yesterday and have 3 more days authorized

Report for tracking: Supervisor works it that AM and knows whois behind

Dr. Smith seems to be dragging out the stay

No family support

Id like to thank the PT that saw him yesterday, she was very

patient (specifics)


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Tools Implemented

Defined work flow and updated policies and procedures

Improved documentation with customized forms to assess riskand plan for placement

Defined which case management documents become apermanent part of the chart and are scanned promptly

Provided tools like cell phones and laptops with wireless access

Trained staff to use Interqual criteria to document medical

necessity


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InterQual

InterQual (IQ) criteria is a trademarked tool provided byMcKesson Health Solutions

IQ is the preferred tool used by the Centers for Medicare andMedicaid Services and most RAC audits

CMS requires hospitals to monitor and document medicalnecessity to assure compliance

Methods

IQ books

Software purchased from McKesson Case Management software that includes IQ within its product


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Level of Care DefinitionsCategory or setting based on the clinical picture when patient is admitted to the

hospital and/or when patient reaches clinical stability at one level.

1. Observation: onset last 24 hours, reasonable expectation that duration ofassessment is 6-24 hours, assessment/medications unresponsive for at least 4 hoursER treatment, psychiatric crisis intervention

2. Acute: onset within one week, medications requiring monitoring q4-8 hours, IVmedications, post critical care, post vent wean

3. Intermediate: onset within last 24 hours, medications requiring monitoring at least2-4 hours, hemodynamically stable, telemetry, neuro assessment, post-op trauma

4. Critical: reasonable expectation for patient to stabilize with high-tech critical care,hemodynamically unstable, medication monitoring q1-2 hours, acute intubation, etc

5. Levels continue with LTAC, Acute rehab, sub-acute rehab, SNF, Home Care, home


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Definitions Severity of Illness (SI) criteria consists of objective, clinical

indicators of illness including chronic illness or co-morbidities,which focus on an individual patients clinical presentation rather

than the diagnosis

Intensity of Service (IS) criteria consists of monitoring and

therapeutic services, singularly or in combination, that can only beadministered at a specific level of care

Discharge Screens (DS) are organized by the levels of care subsetsand provide objective, clinical indicators to determine if the

patient has reached the level of clinical stability appropriate for asafe transfer to a different level of care


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Review Process

1. Pre-admission review (Acute)

2. Admission review (Acute or Observation)

3. Continued stay review (Acute or Observation)

Cannot go backwards (e.g., acute back to observation)4. Discharge review

Gatekeeper or case manager to perform IQ reviews

Always start with acute care section to see if criteria is met Observation status should be used if case does not meet acute

criteria


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Observation Process

Findings Observation versus Inpatient status determined by physician

recommendation upon admissionUM review for clinical support oftheir decision

Presence of the order is checked after discharge unless CM happens to

be reviewing the chart

If the order is unclear or missing, CM calls the physician for aclarification order

Continued stay reviews are completed but not retained in the patient

record

Poorly understood process by all involved


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Observation Process

Recommendations

Implement 24/7 gatekeeper role to recommend status on allpatients entering the hospital at all access points

Order present Charges entered

Case managed

Change billing to hourly


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Gatekeeper Role: Overview

Responsible for patients needing a bed: inpatient, observation,ED, L&D, etc.

Ensures that a status order is in all records

First to know of requests for beds to allow for immediate

assessment of status, then calls House Supervisor Logistics

Two or more FTEs to cover at least 12 hours a day, 7 days a week

RNs preferred, with previous Utilization Review Experience

Laptop needed for mobility around hospital


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Observation Responsibilities

Entering OBS hours with appropriate start and stop times

Run OBS list twice a day

Visit floor to assess OBS patient progress toward

discharge Perform usual CM tasks to manage these patients,

including discharge planning

Upon discharge or conversion to inpatient, enter order

and enter exact observation hours into system


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Results

Improved compliance, with an appropriate level of careassigned within 24 hours of admission and with acorresponding order present in the chart

Improved revenue capture due to proper procedures in

place at beginning of patient stay Reduced LOS with proactive planning for discharge and

interdepartmental meetings on long stay/high dollar cases

Reduced RAC denials


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Impact on RAC Audit

Using InterQual criteria to determined the correct level of carewill establish medical necessity and ensure that an appropriateorder is in the chart within 24 hours of admission.

Assigning an appropriate patient status prevents one day

inpatient stays, which have been targeted for RAC. Continued stay reviews ensure that a patient meets the Intensity

of Service requirement and are performed every three days toprevent an unnecessarily extended length of stay.

If there is no documentation in the chart to support the level ofcare chosen by the physician, these continued stay reviews mayprompt improved clinical documentation.

Documents

Cycle of Revenue