Help Wanted: Healthcare Struggles with Revenue Cycle Management

Once upon a time, we lived in a fee-for-service world where healthcare providers would send in a bill and payers would simply pay it. Today, hospitals and other healthcare facilities face a much more complex revenue cycle, particularly the mid-revenue cycle, that period between when the patient first comes through doors of the office or hospital and the payment of the bill.

Healthcare organizations must act strategically to stop the loss of revenue due to documentation gaps and errors in medical coding and billing that lead to payer denials, inaccurate reimbursements, and even penalties for overbilling. Today, organizations must comply with a host of complex compliance requirements that entail accurate coding, along with developing effective information management for case management and utilization review.

How Good is Your Coding?

Since 2015, all HIPAA-covered entities have upgraded to ICD-10. The question is, how good is the quality of documentation, coding, and information management infrastructure at these healthcare organizations? Are they keeping up with the constant regulatory and technology changes, along with all the new code sets? Is the quality of documentation and coding accurate enough to capture the revenue they’re owed, maintain accurate cancer and trauma registries, and support case management, utilization review, and clinical documentation improvement? How good are their healthcare coding education programs for nurses, physicians, and other clinicians?

Many healthcare organizations may be unsure of the answers. And consolidation in the healthcare industry creates a new array of challenges, often related to the centralization of coding and health information management at the newly consolidated and much larger organization.

Coding and information management challenges differ from hospital to hospital, clinic to clinic, and health system to health system. Mandates and requirements may be the same, but responses can be very different. If healthcare leaders and managers begin to question the quality and accuracy of their coding and information management, they may require an expert partner who can customize solutions ranging from bringing in a few expert coders backed up by quality assurance or a complete turnkey operation.

Expert Help May Be Needed

When the healthcare industry was ramping up for ICD-10, most healthcare organizations assumed that coding and information management had to be internal capabilities. With compliance deadlines behind us now, all organizations have some infrastructure in place. However, with a shortage of skilled coders and managers, many find that quality, not just productivity, is their problem today.

Quality is the problem when revenue is lost due or billing is improper due to undercoding or overcoding errors. The answer is quality assurance through education, pre-bill audits, continual assessment training of coders and managers, platform upgrades, retrospective reviews, record analyzing through artificial intelligence and machine learning, and other services and procedures.

If a healthcare facility or system does not have this capacity, or the resources to scale up its coding and health information management to solve current and future challenges, it may need to seek an expert partner for help. The loss of revenue, threat of penalties, demands for regulatory compliance, and technology needs of value-based care are too critical to leave at risk.