As our clinical teams have been learning about case management under the Patient Driven Grouping Model (PDGM), the revenue cycle teams have been hard at work breaking processes. This may sound counterintuitive, but I promise, it’s not. We have been testing theories and finding cash bottlenecks and communication. Just imagine the faces when you say to the team you want to break a process. It ends up being a fun (most of the time) experience that also serves as a bonding experience for everyone as it takes the entire team watching for results and reporting findings to come up with a collaborative solution. Having a safe environment as a harbor to keep ideas flowing, to share and solve breakdowns in real time, is key.
Utilizing our innate curiosity, love for setting lofty goals, and just because we may be a glutton for punishment, we began to test theories in Quarter 3 of 2018. By testing theories, I really mean we took a chart or two, changed a way we handled a process without telling anyone, and watched it through the process to see what happened. Did it stop? Did it move faster? Slower? Who caught it? Who was involved? What did we learn?
Revenue cycle refers to the combined efforts of both clinical care and back office support functions that make up the total patient experience. At each touch point of patient care, there is an agency process that triggers a reaction in the cycle. The series of processes, and reactions, make up the workflow that leads to booking the revenue, billing the patient’s insurance and collecting cash for the services rendered.
Key components in the PDGM revenue cycle are:
1. Intake processes working to ensure proper information and care coordination documentation is received
2. Insurance Verification – Not only do we need to verify the plan is active, but if the referral source is an acute or post-acute institution, we need to check their billing status
3. Strong nursing case management expertise – Responsible for making sure all diagnoses and health conditions are addressed and documentation is present for proper diagnosis coding
4. Timely documentation – Completed within 24 hours of care provided
5. Diagnosis coding – Certified coders available for quick turnaround coding
6. Quality Assurance – Reviewing Start of Episode OASIS for proper documentation
7. Visit utilization management – Making sure the patient is addressed as a whole body, and not simply a presenting illness/injury. Reviewing and ensuring that visit frequencies are appropriate
8. LUPA management
9. Revenue Cycle Coordination of all items needed to bill claims are present. If items are missing, the proper department is notified of need to resolve billing hold
10. Contract management for payer diversification strategy
11. Billing, Cash Posting and Accounts Receivable
a. Submitting timely claims
b. Tracking HIPPS changes from Medicare due to institutional claims not yet present for institutional referrals
c. Follow up with institutions holding adjustments
As you can see, all departments make up the revenue cycle and each cause a reaction in the other. It is imperative that each department is represented and collaborates so all teams are working together as a unit and revenue cycle leadership can quickly identify potential issues that may result in a cash bottleneck. Everything begins and ends with the strength and trust of the entire team. Strong and constant communication is a must.
For further information please contact Sara Koenig – Vice President of Revenue Cycle Management – firstname.lastname@example.org