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Orlando’s revenue integrity initiative was structured to rely upon both human expertise and technology. In one major step, Clinical Liaisons were added to the Revenue Integrity department for each service line to uncover lost charges and correct CDM line items to meet regulatory requirements. Next, a combination of MedAssets technology and services were selected to support the Revenue Integrity team to identify charge issues before claims submission and achieve net revenue improvement.
Orlando Health implemented CDM Master® to support its objective to build an accurate and compliant chargemaster. The solution is designed to scrub the chargemaster and report inefficiencies or discrepancies. It flags incorrect procedure and device codes, and helps to maintain Medicare regulatory standards by reconciling and validating those regulations at the end of every month.
Orlando spent one year in cleaning up its chargemaster and building institutional knowledge on the relationship of the items in the file. The following year, the Revenue Integrity team tackled those service areas across its eight hospitals presenting greater regulatory compliance opportunities and the most challenging in CDM builds and pricing strategies – cardiac rehabilitation, pulmonary wellness, reference laboratories and orthopedics hip packages.
A Web-based coding and compliance reference tool, KnowledgeSource®, also came into the mix to provide a single source for regulatory and coding compliance information related to pricing and reimbursements.
“We now have one charge master maintaining the same price for all campuses in one file,” says Loomis. “It really helps keep us straight. CDM Master gave us the binoculars to see descriptions and CPT codes that didn’t match and find pricing discrepancies.”
A clearer, cleaner CDM set the stage for Orlando to develop pricing for the most price-sensitive and greatest revenue and compliance opportunities. The holistic charge file enabled the revenue team to see where pricing didn’t make sense or where items bore no relationship. “ACT scan costs more than an X-ray, but we needed to understand the cost relationship,” notes Loomis. “We knew if we could understand our costs, we could create our own pricing methodology, apply it and then assess financial improvement.”
An initial step was to identify the cost of supplies. Orlando turned to the MedAssets solution, CrossWalk®, to build out a pricing relationship to its supply costs as one basis to form its pricing methodology. CrossWalk is designed to help healthcare organizations link supply chain and revenue cycle information. CrossWalk provides complete, side-by-side visibility into supply charges and cost data. It offers the industry’s most complete and accurate master item file and chargemaster to highlight compliance issues and revenue opportunities. With CrossWalk, Orlando was able to utilize multiple data sources to link current supply cost to the CDM price for validation.
Orlando Health next initiated MedAssets Defensible Price Modeling Services and used both internal and external data comparisonsto improve pricing consistency and validate defensibility. The services include applying internal pricing methodology to their CDM and then analyzing pricing sensitivities with their payor mix. APC and Fee Schedule review was also included in the analysis used to ultimately achieve a gross increase goal set by the executives.
Orlando created a multi-tier strategy for cost mark-ups on imaging services. Cost mark-up tiers for supplies were fine tuned. Other cost areas either fit into cost-based constraint groups defined by Orlando, or into a “catch-all” group receiving an across-the board increase to achieve the gross target. Achieving the target was done consistently across all service lines keeping within regulatory standards and being mindful of defensibility and community responsibility. In a later phase, Charge Capture Audit (CCA®) was implemented to help identify problem areas within the billing cycle. With more than 1,700 standard billing rules, as well as capability to build additional rules customized for organizational needs, CCA electronically audits all inpatient and outpatient itemized bills and flags potential missed charges so that errors can be corrected before bills are sent. “We want to work every rule for each service line for which we do charge management,” says Mary Corr, Operations Manager, Revenue Integrity. “Using CCA more aggressively is enabling us to work the rules, identify and correct the root causes prior to submission, educate our staff and decrease the error rate across ourcharge management team,” she reports.
The charge management team used CCA to audit and analyze charts to identify exceptions. CCA also supported defining workflows where incomplete or incorrect documentation might prevent a charge opportunity. As Corr recounts, “One project involving critical care CPT codes identified that hundreds of thousands of dollars were being lost because additional increments of time for critical care couldn’t be charged without charging the initial time spent. Consequently, the Emergency Department process was changed and an interface was built to recognize and automatically capture the initial increment of critical care time to “start the clock.”
Other care scenarios were flagged where documentation failed to produce a charge, including strep tests for pediatric patients, infant hearing screenings, morphine injections and lumbar punctures. CCA also led to discovery that while patients in the observation unit were properly charged, observation patients admitted in other units were not. New processes were implemented that allowed identification and assignment of proper charges for observation patients in all areas of all facilities.
Orlando’s work to strengthen the revenue cycle continues to accrue benefits. Each year, the health system reviews its net growth and looks at its service line pricing strategy. The “forever plan” described by Teresa Loomis is ongoing, and what once seemed daunting now inspires confidence for the future.
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