Revenue Integrity Getting Started

Let’s Get Started! Evaluate current state Start with an open mind and a conviction that things can be better

What Is Revenue Integrity? Quality Officer – Patient experience, proper requested reimbursement Coding Director – documented. education, support, CDI Compliance Officer – up to date adherence to all laws and regulations Providers – Accurate documentation, timely submission, effective communication with coders Revenue Integrity analyst team CFO – support for resource allocation All of this is on slide 5 RI… is this restatement necessary??

First Steps Identify each function Current positions Staffing/resources involved

Revenue Integrity Who will oversee/what position Who will manage What should the team look like Create organizational chart

Expectations Define the expectations of Revenue Integrity These are not billing Not compliance Not IT This team is billing and reimbursement compliance through responsible maximization of technology

Getting Started Outline Create a definition, expectation, mission statement Outline Short term goals Long term goals Timelines Define roles

RI Manager Program Leader Experience with reviewing coding, documentation, regulatory changes Understands CPT, HCPCS, Modifiers and other claim elements Expert in the relationship between Codes, claim submission, revenue and reimbursement Strength addressing compliance issues, and adhering to regulatory expectations Payor agreements, policies, manuals Experience with contract management – understand that what we bill is not what we get paid How a bill becomes a law Robert Downey Junior image by Mayank.naruto (i Clicked it at comic-con) [GFDL (http://www.gnu.org/copyleft/fdl.html) or CC BY-SA 3.0 (https://creativecommons.org/licenses/by-sa/3.0)], via Wikimedia Commons

The Team – Revenue Integrity Analysts Revenue Integrity Analysts – strong Revenue Cycle skills with strong understanding of billing and reimbursement Government and commercial payors, LCDs (Local Coverage Determinations) Payor Policies and Newsletters Medicare Administrative Contractor (MAC) and probe audits conducted by MAC Skilled in payment methodologies Bundling and packaging – including proper modifier assignment Comprehensive and Composite packaging Skilled in documentation and Documentation Review Nurses CDI

Technology Maximize existing tools or consider adding essential tools Contract management Auditing Front end POS tools The technology should be the adjunct, not the driver NLP documentation should be reviewed and audited Coding tools reviewed and audited CDI Many facilities gain a false sense of security as a result of the latest, greatest technology…

Audit Categories - Departmental Inpatient and Outpatient Charges Charge capture rates Lag days Late charges Pharmacy Inpatient and outpatient Meds returned to stock CDM Maintenance How many charge codes with no CPT or unlisted CPT Multiplier maintenance Supply chain Understanding of revenue code assignment Billable and non billable Markup up Supply policy

Charge Capture Total charge validation processes Reconcile activities vs. accounts Surveys indicate facilities lose, on average, 1% due to charge capture inefficiencies Chart audits Charge capture solutions Tools and technology

Education Develop education based on Audits Edits Patient complaints Payor findings Create training and education expectation for RI team Remain current in regulatory, industry changes Coding, CPT modifier changes Orientation tools Instructional materials Payor website resources Position specific training

Develop Best Practices - Processes Continuous Improvement Follow- up Education Implementation of improvement plan Identification of issues Review

Useful Links https://www.cms.gov/CCIIO/Resources/Presentations/Downloads/hie- risk-adjustment-methodology.pdf