Why Health Systems Should Adopt a Clinically Driven Revenue Cycle

Revenue cycle has always been a clinically driven function. Without clinical care, healthcare organizations would not have claims to bill. Relying on clinical documentation to create and complete a compliant claim has the opportunity to create three key advantages:

1. Increased likelihood that clean claims are submitted the first time

2. Back-office, exception-based workflows versus touching every claim

3. Claims that consistently match the medical record

All these advantages are designed to help lead to presumably faster, more accurate, and increased reimbursement and limit instances of financial loss from time-intensive, payer third-party audits in the world of value-based payment models.

A transformation, not an implementation

Embracing that adopting a clinically driven revenue cycle is a transformation – not an IT implementation – can be the crucial difference in an organization’s level of success. Transforming how the business operates can be difficult and it doesn’t happen overnight. People, process, and technology play equal roles and are all essential to success.

People

Organizations must provide their staff with the resources needed to do their jobs. They need to understand the importance of adoption and advancing their knowledge so the organization knows what to do and why they are doing it. Leadership must provide structure to hold employees accountable and acknowledge when they go above and beyond.

Process

When changing current processes or building new ones, taking the “right work, right person, right time” approach is essential to an organization’s transformation to a clinically driven revenue cycle.

Technology

Intentionally putting systems in place that support the vision and goals of the organization is necessary to deliver on an organization’s shift to a clinically driven revenue cycle.

Advancing the concept

The Healthcare Financial Management Association (HFMA) has taken the concept of people, process, and technology a step further and added a focus on culture, metrics, and communication.

Culture

This adoption is not an IT project. It is a transformation of the way an organization runs its business. Teams must feel empowered to make decisions now and in the future, instead of continuing with the way things have always been done.

Metrics

Long-term operational metrics are critical to financial viability and other key functions. In addition to standard key performance indicators, organizations should also consider which metrics might impact their transformation to a clinically driven revenue cycle. Those metrics may include:

• Reduced loss and eventually reduced interest from third-party auditors

• Improved clean claim rate

• Increase in revenue capture and decrease in revenue leakage

• Shifting away from measuring denial management to measuring denial prevention

Communication

It is important to understand the difference between governance and communication. Organizations should have a systematic plan and assess:

• Who needs the information

• How they best receive information

• What information needs to be disseminated and to whom

• Who is accountable for communicating and meeting the objectives

Communication is key to operational success, regardless of where the organization is in its transformation journey. Elements of communication can include data and reports, policy and process changes, and metrics.

Shifting work upstream

At the center of it all is patient care. Near real-time documentation creates enhanced exposure of information to clinicians and others who need it – when they need it.

As an example, automating patient status throughout the organization in near real-time based on the physician’s order is designed to help improve clinical documentation and perform case management reviews earlier in the revenue cycle. By using the physician order for observation and documentation to identify observation carve-outs, healthcare organizations can charge consistently for Medicare rules, helping to limit the potential of double billing. A charge auditor who does not have to calculate and manipulate charges manually can spend time on tasks with a higher impact.

A clinically driven revenue cycle is also focused on helping facilitate consistency, thus, helping to reduce “needle in a haystack” audits or unnecessary, time-consuming reviews of patient visits that have the potential to cause claim delays.

Capturing the charge

A clinically driven revenue cycle is designed to help support organizations by translating clinical documentation into billable charges with unique requirements for compliance and financial reporting in near real-time. This near real-time transaction management is designed to help accurate revenue reporting and accountability of the budget owner. Near-real-time transaction management also helps to facilitate tracking the volume of care being provided. Nobody knows the volume of work their staff provides and what it takes to cover that work better than the clinical leader.

With near real-time access to charges and total revenue, the clinical leader is empowered to represent their departments and help identify growth areas and needs within their department. With separate clinical and revenue cycle systems, clinical department leaders may not have been directly connected to the charges associated with the care they’ve provided. With a clinically driven revenue cycle, nurses, therapists, technicians, and others are responsible and accountable for capturing consistent, accurate charges. The intent is not to add work but to add value to the work being done.

Orders to scheduling

Orders to scheduling require a physician champion in the physician’s office and within other ambulatory venues. This champion is aimed at helping organizations follow a single process across the enterprise. In addition, this champion helps retain or improve patient satisfaction levels and resource efficiencies. There are controls in the process to help provide standardization without taking away from physician decision-making in the clinical care process.

In a clinically driven revenue cycle model, the physician order is designed to help drive the decision-making process. Schedulers may no longer need to translate nonstandard appointment requests through phone calls or handwritten orders by fax. A task to the scheduler is delivered as a byproduct of the provider placing the order. Medical necessity can be considered at the time of the order or at scheduling, helping educate the patient prior to the day of care.

Payers may also require authorization for the service being performed prior to care being received. A decade ago, if the service differed from what the authorization granted, an organization could appeal to the insurance company, and with proof, the insurance would pay for the service. This process forced organizations to place focus on denial management rather than denial avoidance. In today’s world, there are few appeal departments within insurance companies. Providers have essentially one chance to get it right. The source of truth for scheduling, authorizing, and performing services must be the clinical documentation. The reduction of human intervention and interpretation is aimed at helping advance the movement to denial avoidance.

Patient accounting work queues

Communication within the solutions has the potential to be the keystone of success in a clinically driven revenue cycle. How many organizations use email to request medical records or condition code updates on claims? Standard messaging and other communications tools help enable non-automated items that need an extra set of expert eyes to be directed at the right time and to the right person.

When adopted throughout the organization, a clinically driven revenue cycle is designed to help provide advanced integration between clinical and financial information and support improvements in coding and billing accuracy. It is also aimed at helping enhance productivity through integrated communication across clinical departments, revenue cycle, and payers. Additionally, a clinically driven revenue cycle can foster accurate reimbursement through enhanced coding and clinical documentation processes.

Instead of checking the box, a clinically driven revenue cycle is aimed at helping empower organizations to drive results, like limiting denials, increasing clean claim rates, minimizing re-work, and lessening the chance for delayed or missed reimbursement opportunities.

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About Cerner

Cerner’s health technologies connect people and information systems at thousands of contracted provider facilities worldwide dedicated to creating smarter and better care for individuals and communities. Recognized globally for innovation, Cerner assists clinicians in making care decisions and assists organizations in managing the health of their populations. The company also offers an integrated clinical and financial system to help manage day-to-day revenue functions, as well as a wide range of services to support clinical, financial and operational needs, focused on people. For more information, visit Cerner.com, The Cerner Blog or connect on Facebook, Instagram, LinkedIn, Twitter or The Cerner Podcast. Nasdaq: CERN. Healthcare is too important to stay the same.

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