Revenue Assurance: “The Elephant in the Room… Mid-Revenue Cycle Leakage” Daniel Hereid VP Revenue Assurance Revint Solutions RESULTS | EXPERIENCE | VALUE
Learning Objectives Identify challenges of integrating hospital and physician revenue cycles Appreciate the financial impact of mid-revenue cycle leakage and it's effect on profit margins Align a revenue optimization strategy consistent with revenue management strategic objectives
Changes in Healthcare Healthcare reform has had a lasting impact on… Margin compression • Three successive years of negative hospital margin growth • Declining professional service reimbursement, uncertainty over additional reform Physician acquisition and alignment • >42% of physicians now employed by hospitals • 14% projected increase in physician employment between 2014 – 202 Shifts in care delivery models • Proliferation of consumer access points-of-care • Balance shifting from inpatient to outpatient
Advantages of health system/provider alignment Physician alignment can promote… Higher continuity of care • Promotes better patient outcomes • Effective for patients with chronic conditions Readiness for new payment models • Acountable care organizations • Value based payment, need to know total cost of care Mutual benefits • More stable referral base • Allows providers to focus on practicing medicine
Integration of Revenue Cycles - Benefits • Reduce cost to collect • Combining resources, management, overhead, vendors, IT platforms, business intelligence. • Often collecting patient responsibility from same patient • Improved Patient Experience • Eliminates a degree of duplication and confusion • Apperance of integrated system • Patient Flow Improvement • Schedulers can consider all of the patient services being perfmored • Ensure patient end up and the right care locations • More flexible workforce • Education and cross-training allow more staffing flexibility • Increased Efficiency • Coordinated strategic goals • Coordinaton of financial and non-financial units • Marketing a truly integrated health system • Performance Consistency • Coordinated management structure and information sharing • Identify performance trends and improvement opportunities
Productivity Demand • Siloed physician and hospital billing functions • Complexity screams for automation and scalability • Workload and staffing standards vs. quality and/or accuracy • Payer Audits • Insurance companies are increasing their audit capabilities • Focus is on over-coded and therefore overpaid claims rather than under-coded or underpaid claims Integration of Revenue Cycles - Challenges • Charge Integrity and Under-Coding • Complex, varied and fragmented charge capture processes result in 3 – 5% mid-revenue cycle leakage • Pressure from internal and external audits force coders to be more conservative instead of assigning the most accurate and comprehensive DRG • Billing is Fundamentally Different • Billing forms, codes, and skillsets are completely different • PB Billing is based on a relationship • HB billing is based on encounter • Resource Strain • Internal audits focus on expensive procedures, high risk DRGs or long lengths of stay, but cannot achieve 100% review with manual resources • HB Resources not comfortable with physician volumes • Loss of Revenue • Race Against the Clock • Interest in getting bills out the door quickly and not hold claims up due to lack of coding or documentation • Forces staff to work quickly and shoot for maximum efficiency, but not always quality
Charge Capture Leakage Charge capture processes. The complex nature of accurately capturing charges presents multiple opportunities for process breakdowns. Just as the stakeholders are an interdisciplinary group, the process breakdown areas typically are varied and interdisciplinary. Solving these breakdowns requires detailed root-cause analyses to develop a plan of action to improve performance and mitigate future revenue loss. Process breakdowns can involve: Technology (EMR conversions, upgrades, integrations, etc.) Missing or incomplete documentation Documentation that does not meet payer guidelines Clinical or department staff who do not record the appropriate charge for the service provided Untimely or incomplete updates to the CDM Inconsistent or unknown organizational charging policies Inconsistent charge reconciliation processes to serve as a check-and-balance
EMR Leakage Source: Mid Revenue Cycle Epic Leading Practice Strategies”, PWC March 16, 2017.
Charge Capture Leakage Source: Mid Revenue Cycle Epic Leading Practice Strategies”, PWC March 16, 2017.
Why Revenue Assurance? Death by a thousand paper cuts… • $MM in revenue leakage annually • Margin compression • Screams for automation HFMA estimates that 3-5% of all reimbursable charges are never posted The elephant in your midRevenue Cycle… • Low/no visibility (measure→manage) • Spot auditing/erodes productivity • Lacks scalability and actionability • Thwarts process improvements Take off the blindfolds… • Silo’d HB and PB • Targeted cross training • Growth for the unicorns
Focus of Revenue Assurance Revenue Assurance is a Revenue Mid-Cycle charge integrity function that identifies missed, misplaced and miscoded charges that have leaked out of the RCM work stream. Our singular focus is to recognize how, when and where leakage occurs and return charges to the top of the RCM funnel. TECHNOLOGY ANALYTICS Predictive analytics and rules-based algorithms applied against coding, billing and payment information to detect probable missed charges. Revenue leakage specific Business Intelligence to help identify, quantify and trace the root causes of missed charges. SERVICE COLLABORATION Value-as-a-Service delivery and revenue model drives shared accountability for optimizing revenues. A value-add service to filter out false positive findings and offer expert coding advice to refine the predicted missed charges.
Insights Strategic Differentiators Revint’s Revenue Assurance Program provides the industry’s only single business office (SBO) solution for charge integrity delivering proprietary rules logic that compares HB and PB data sets to identify missing and miscoded charges that would otherwise go undetected. Our “Value-as-a-Service” (VaaS) delivery and revenue model provides greater precision and accuracy to our predictions (which translates to heightened productivity for our clients) enabling customers to only pay for the value of the service delivered. 1 2 3 HB and PB Matching Value-Add Service VaaS Revenue Model Only solution that offers HB/PB Matching Rules leveraging multiple data sets to triangulate the true episode of care. The RevReview™ service complements our RevBuilder™ technology resulting in improved accuracy, productivity and usability. Revint’s Revenue Assurance Program operates under a VaaS revenue model that aligns all parties to a common goal - Revenue Optimization.
Traditional Siloed Billing Operations Hospital Billing PB - Employed Physicians PB - Affiliated Physician Group
Network Effect Model Specialty Hospital Community Hospital Post Acute HB – Academic Medical Center Ambulatory Surgical Centers Outpatient Centers Triangulated Patient Episode Data Synergy: 30 – 40% more predictions! PB - Affiliated School of Medicine PB – Medical Foundation
360°Enterprise Revenue Assurance Physicians Inpatient Care Outpatient Care
Service Effectiveness Technology-Only vs. Combined Technology & Service Delivery Model 25% 85% 15% 75% Non-Productive time wasted DIYing 60% Productivity variance, 240% improvement over technology-only offerings. *Last Mile Tool-Only Tool + Service * Last Mile includes rules tuning/smoothing, experimentation, new/changed data elements, tribal knowledge transfer, etc.
Value-as-a-Service… The New Frontier Pay for the certain, undeniable results attained ‘Pay-as-you’ go for capacity or utilization Financial burden spread via lease payments over a defined term VaaS IaaS, PaaS, SaaS Upfront purchase, uncertain costs, adoption and ROI Subscription On-Premise Risk VaaS Customer payments predicated on ACTUAL (NOT PROJECTED) value received which is the only revenue model consistent with healthcare’s transition from volume to value-based care. Results
Hospital & Physician Charge Capture REPRESENTATIVE CASE STUDY CHALLENGES REVINT RESULTS Large Midwestern-based hospital system with over 4,000 beds and 3,000 employed physicians 01 Over $9M of revenue lift in first two years and at least twice that amount in total economic benefit. Significant # of RVU’s recaptured as well. • Significant gaps in charge capture reconciliation processes and opportunities for clinical documentation improvement • Ongoing demands for improved financial performance 02 Provided linkage between their professional billing (PB) and hospital billing (HB) functions APPROACH Initiative designed to increase revenue stream was launched 03 Revenue leakage analytics lead to systemic process improvements, identified technology gaps, and complemented EMR conversion roll-out • Implemented technology and automated processes to consistently and accurately capture this revenue
Revenue Recovery vs. Total Economic Benefit “We have always examined our processes to find places to streamline efficiency but recently, we turned the equation around to look at it from a different perspective: What if instead of just focusing on cost reductions, we also focused on ways to avoid lost revenues?” “In about two years, we’ve measured over $9M of lift, a substantial amount of revenue we would not have received without AcuStream. We’ve realized total economic benefit double that amount or more.” “RevReview™ confirms there is clinical documentation to support missing charges identified through their RevBuilder™ technology. Other vendors expected us to filter out the false positive findings, which would be a drain on our productivity.” – Senior Director, Revenue Cycle Strategic Initiatives
Why Revenue Assurance? • Unique value proposition • Outpatient, inpatient and physician leakage • HB, PB and matching rules • Hospital and physician alignment (SBO) • “Smart Investment” • Incremental revenue, net income, cash flow • Predictable 12:1 ROI • Insights into leakage • Recapture of RVU’s • Short time-to-value • Data onboarding in < 60 days • Operational within weeks thereafter • Low-risk • Low barrier to entry • 90-day termination w/o cause • Cash flow positive with first invoice post go-live
Contact Dan Hereid VP, Revenue Assurance email@example.com 303.579.5419