Healthcare Consulting as alternative career path for RHIA/RHIT Siobhan Byrne, MHA, RHIA 27 June 2014
Agenda • EY – Building a better working world • Healthcare industry challenges • Importance of Health Information Management expertise in healthcare consulting
Advisory - Accelerating business performance Advisory = consulting Japan 800 people EMEIA 13,800 people Americas 11,200 people Asia-Pacific 4,200 people 30k people $5.3b revenue
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Healthcare industry challenges Presentation title
The healthcare environment is constantly changing Are you able to move quickly and carefully? Is your reputation authentic and managed? Are your plans aggressive and risk-adjusted? The healthcare environment is being constantly challenged by a number of current forces of the business world and the ground continues to shift under the feet of today’s executives. Some examples of these forces include: • Innovation and competition require changes in how providers and payers define, drive and prove value • Social media enable closer interaction with consumers • Complex regulatory requirements challenge long-term decision making • Organizations must share and analyze unprecedented amounts of data more quickly • Rapidly evolving business product launches can unsettle business processes and models • Providers and payers must accelerate the rate at which their technology matures and the rate at which they implement technology • Population health outcomes dictate product performance and influence consumer behaviors • These forces are making healthcare firms think about and organize their business performance efforts in more proactive and structured ways. • We help clients find ways to respond to these forces in innovative ways that will help them assess and protect their businesses, grow revenues, and optimize processes.
Healthcare organizations need to find new ways to innovate — and do it quickly Grow How do organizations react to these ever-present forces and transform their businesses to succeed in spite or because of them? • Is our growth strategy patient-centric? • Where do we invest to improve competitive position in the evolving healthcare market? • Which emerging markets present the best opportunities for our competencies? • How do we respond and act on the volumes of data? • Are we nimble enough to adapt new business models and technologies as they evolve? Optimize • Do we have the information we need to evaluate the effectiveness and efficiency of our company activities? • How can we more effectively capture and share data with patients and providers to improve care? • Are we positioned to deliver and manage care in an efficient and cost-effective way? • How will new technologies influence the industry, and how can we stay at the front of those movements? Protect • How do we influence regulatory reform to protect our business? • How do we balance the cost of compliance with the demand of regulatory needs? • How do we maintain or improve compliance as the regulatory environment becomes more complex? • How can we affect behavioral change with member - patients and caregivers? • How can we plan for outcome-based service delivery and payment models?
Healthcare Advisory delivers services that address key healthcare industry issues Our services, competencies and depth in the healthcare industry addresses each of these issues from organization, people, technology, process and metrics standpoint. Transforming Through Payer/ Provider Integration Thriving Through Changing Regulation Improving Operations Attacking Healthcare Costs
Mid-revenue cycle is comprised of care delivery, documentation and coding HIM/coding, CDI Utilization review/ case mgmt. Claims editing submission Documen-tation charge capture Third-party collections Financial counseling Payment posting Copayment collection Denials mgmt. Registration Appeals Scheduling Pre- registration Contract mgmt.
Why we’re hired for mid-revenue cycle work • Charge capture • “Are we charging appropriately for the care being delivered?” • “What happened to our revenue post implementation?” • CDM standardization • “Patient statements should look the same for the same service across our system.” • “We need to be able to manage our hospitals as a system.” • Pricing studies • “How can we defend our prices, while also meeting budgetary needs?” • Vendor selection assistance • “All the vendor presentations are impressive, but how do we decide?” • Compliance reviews • “Are we prepared for RAC audits?” • Assessments • “Are we ready for ICD-10?” • “Are we getting the most value out of our EMR (e.g., meaningful use)?” • “Are we leaving money on the table anywhere across our revenue cycle?”
Mid-revenue cycle challenges • Many changes in the healthcare terrain have increased the pressure on mid-revenue cycle improvement. • Commercial insurers transitioning to reimbursement structures based on Medicare • Changes focus from chargeable to reimbursable • Fixed payments (e.g., DRGs, APCs, per diems) reduce financial benefit of price increases • Shifting of more financial responsibility to patients requires more transparency • High deductibles and co-insurance increase visibility of charges • May lead to a more consumer-driven industry • Transition from fee for service to value-based models will completely change role • Approaches being tested (e.g., ACOs, population health management and bundled payments) • Charge capture, pricing and CDMs need to be revisited under new lens • New care delivery models are challenging the status quo • Stand-alone imaging centers, surgical hospitals and independent labs • Many services can now be bought piecemeal at rates hospitals cannot compete against • Increased/changing regulatory requirements • Meaningful Use • ICD-10 • Pricing transparency regulations (e.g., CDM disclosure, price publication, reference prices)
Documen-tation charge capture Example of common charge capture issues/solutions
Documen-tation charge capture Charge capture market developments/challenges • Changes in the healthcare industry could potentially impact charge capture services significantly. • Large IT implementations increase opportunities, risks and budgets. • Implementing a new EMR is expensive, time-consuming and risky. • Entire revenue streams can dry up instantly if implementation and training are not handled appropriately. • Shift away from fee-for-service reimbursement models will limit value. • Population health management and ACO incentivize, reducing charge volume • Fixed payments do not increase for new charges, but may increase for higher acuity service • Market share is currently low due to high competition. • Labor intensive projects drive up hours/cost • Projects require specific competencies • Larger systems often have revenue integrity teams focused on charge capture
Documen-tation charge capture Example of common CDM/pricing issues/solutions
Documen-tation charge capture CDM/pricing market developments/challenges • The public profile of the CDM and hospital prices has never been higher. • Time Magazine’s “Bitter Pill: Why Medical Bills Are Killing Us” article (4 March 2013) • Provided a national platform for an issue that has existed for years, but had not gained traction previously on a large scale • Resulted in public releases of Medicare data, creation of national transparency task forces and summits and forced providers to reassess their approach to pricing • May actually lead to provider price decreases • Shift away from fee-for-service reimbursement models will change role of CDM • Revenue generation may not be the primary purpose, but billing regulations will require its continued use • Data generated will still be useful for productivity, cost allocation and utilization review • Health plan designs putting more patients into consumer role in selecting care • High deductibles require all patients to pay cash for initial care • Narrow networks may still limit choices for patients • Price sensitivity may drive volume out of the hospital setting
Utilization review/ case mgmt. Example of common utilization review and case management issues/solutions
Utilization review/ case mgmt. Utilization review and case management market developments/challenges • Changes in the healthcare industry could potentially impact utilization review and case management services. • 2 Midnight rule • CMS attempted to minimize the impact of “observation” status on beneficiaries with the new guideline. While it clarifies the patient status assignment approach for seniors with multiple chronic conditions, it raises operational and reimbursement questions regarding other patients requiring inpatient care for a short period of time (e.g., deliveries, surgical cases). • Population health management/ACOs • CM/UM focus has typically been on inpatient care and the transition to the next level of care. New delivery models will be dependent upon management of case, regardless of the care setting. • RAC audits • Compliance with standard criteria helps hospitals minimize, but not eliminate, the risk of negative audit findings. Assisting organizations communicate across various disciplines to understand high risk areas and implement appropriate, consistent practices is necessary to remain compliant in an ever-changing regulatory environment.
HIM/coding, CDI Example of common HIM/coding issues/solutions
HIM/coding, CDI HIM/coding market developments/challenges • Coding is getting a lot of press coverage related to implementation of ICD-10 scheduled for October 1, 2015. • Coding assessments are typically a subset of a larger revenue cycle engagement. • With the exception of ICD-10 assessments and implementations, coding is usually just one piece of a larger charge capture revenue cycle assessment. • Incorrect and/or inaccurate coding is one possible way that a client may be leaving money on the table. • Large scale coding assessments are frequently conducted for compliance purposes by EY’s Fraud Investigation and Dispute Services (FIDS). • Transaction Advisory Services (TAS) sometimes requires a coding assessment as part of its due diligence program for clients considering purchasing a healthcare provider. • Compliance is always an aspect of a coding assessment. • Clients that are aware of non-compliant billing practices that result in overpayments may be required to self report, if federally funded programs such as Medicare are involved. • Coding assessments are frequently performed under attorney-client privilege for this reason. • Clients appreciate inclusion of a certified coder on revenue cycle engagement teams. • Due to the link between coding and reimbursement, most provider clients appreciate having access to the specialized skills of a medical coder on these engagements.
HIM/coding, CDI Example of common CDI issues/solutions