Breaking Silos in Healthcare: A Team Approach to Revenue Integrity

In the past, healthcare departments have typically worked in silos, focusing on their specific roles and responsibilities within an organization. However, this approach has negatively affected business operations and clinical teams.

This separation of function is evident in increased denial rates, length of stay, and back-end expenses incurred to correct work. Moreover, a siloed system can decrease efficiency, duplicate efforts, and undo the hard work of one team by another team without coordinated efforts.

Enhancing revenue cycle integrity processes and adopting a team-based approach to managing hospital functions, from patient identification to reimbursement, is essential to achieving financial stability and role satisfaction. Clinical care departments support each other in the delivery of the highest quality of care for patients and traditionally work within a single silo, using multidisciplinary rounds (MDR) or an interdisciplinary team (IDT) to coordinate efforts. Conversely, business operations teams are not as dependent on each other daily and have not optimized actions within a single silo. Therefore, business operations departments must fully understand their impact on other business operations and clinical departments.

Health information professionals need to know the effects of silos on the revenue cycle integrity  and the throughput of patients, and know the negative impacts of suboptimization or silos on utilization review (UR), case management (CM), clinical documentation integrity (CDI), patient access, insurance verification, and denial management teams. Recognizing the siloed approach of healthcare systems, payers exploit this practice to their advantage, encouraging one hospital department to work against another to achieve the payer’s specific goals.

It's time to optimize and align siloed thinking and find ways to unite departments to meet the changing rules of the game.

Taking a Team Approach to Remove Silos

To break down the silos in healthcare, adopting a team approach to managing hospital functions from patient identification through reimbursement is fundamental. The following are some of the ways that departments can work together to ensure efficient and effective patient care:

• Patient Access - The patient access team should identify the accurate, current payer source.
• Insurance Verification - The insurance verification team should validate accurate payer sources and payer contact information regarding admission for all patients before approving scheduled admissions.
• Utilization Review - The UR team should review documentation for medical necessity supported by nationally accepted criteria, payer-specific criteria, or the Centers for Medicare and Medicaid Services (CMS) Two-Midnight Rule communicated with payers to obtain authorization currently, provide medical necessity status to case management/care coordination (CM/CC) for MDR/IDT discussion, and coordinate with CDI for documentation integrity to support medical necessity and alignment with diagnosis-related groups (DRGs).
• Case Management/Care Coordination – The CM/CC team should assess and coordinate patient care across the continuum of care, including hospitalization and post-acute services based on geometric length of stay (GLOS) and medical necessity; provide MDR/IDT information to UR for payer communication.
• Clinical Documentation Integrity – The CDI team should review documentation for accuracy and completeness to capture appropriate diagnoses to assist coding in the completion of the coding process, identity working DRG and GLOS and provide to CM/CC for MDR/IDT discussion, and coordinate with UR for documentation integrity to support medical necessity and alignment with DRG.
• Coding – The coding team should review documentation for coding accuracy to drive billing and review CDI information.
• Billing – Validation of billing accuracy based on coding, contractual guidelines, and compliance with regulatory agency requirements.
• Denial Management – Review denials to identify appropriate “buckets” of accountability, facilitate the interdisciplinary team’s discussion of denials, and develop mitigation strategies.

Effective Communication is Essential for High-Quality Outcomes

Ensuring team alignment is critical to process improvement within the multi-dimensional revenue cycle process. Effective communication is necessary to achieve high-quality outcomes, such as reimbursement for patient care. Departments must coordinate their efforts and share information to ensure alignment and support each other.

CM, UR, and CDI must work together in a coordinated manner to ensure efficient concurrent alignment. A robust physician advisor (PA) program is crucial in facilitating this coordination. The PA works actively with all three teams to address misalignment and ensure documentation and provider engagement.

Shared information and coordination of efforts are important, and the PA plays a vital role in this concurrent process. The emphasis should be on supporting all teams working together to ensure alignment, with no department working alone.

Revenue cycle teams collaborate from the point of entry through reimbursement. Teams must work together to ensure the efficient and effective operation of the entire revenue cycle process.

Healthcare organizations are under increasing pressure to improve the quality of care while simultaneously monitoring and containing costs. To achieve the best possible outcomes, it is essential for all teams to work together. Promoting team alignment and open communication helps to improve revenue cycle processes, ensure accurate reimbursement, and provide high-quality patient care.

By adopting a team approach to managing hospital functions, healthcare organizations can break down silos, optimize processes, and better meet the evolving challenges in the healthcare landscape. It is time to unite critical departments into a cohesive team to adapt to the changing rules of the game.

Shari L. Garceau, MSN, RN, CMAC, CCM, ACM-RN, TCM, CLSSBG, is a managing consultant for Guidehouse, a global consulting firm.