This article is published in sponsorship with Ciox.
By Geoff New, MBA, RHIA, CRCR, CHFP, FHFMA, FAHIMA
The revenue cycle landscape continues to become more complex with each passing year. As we start 2020 and a new decade, gone are the days when the business office was the leading player in the revenue cycle. That’s not to say that health information management (HIM) has not historically played a significant role; it’s just that HIM was not always recognized for its critical contributions and value. Going forward, HIM will play an increased role as part of the clinically integrated revenue cycle (CIRC). However, we must first address historical organizational baggage as well as the revenue cycle challenges that organizations face daily.
Current Revenue Cycle Challenges
The current revenue cycle process is laden with clinical and financial challenges. Specifically, advances in technology related to the patient record, coupled with the industry’s inability to change, are forcing age-old problems to escalate to critical points that have not been seen previously. The revenue cycle is not immune to these problems—in fact, it is more susceptible than ever.
Historically, some organizations may have taken the “out of sight, out of mind” approach. However, this approach is no longer a viable option. A few of the challenges facing the revenue cycle today include:
- Decreased operating income related to declining reimbursement
- Increasing revenue cycle costs
- More complicated, higher-risk compliance issues
- Increased business intelligence to support technology challenges
- Increased denials and revenue leakage
- Migration to value-based reimbursement
- Staffing issues caused by higher-skilled workers who are harder to attract and retain
Introducing the Clinically Integrated Revenue Cycle (CIRC)
Healthcare organizations must keep in mind that at the foundation of everything they do, every record represents a real person. This holistic view of the patient experience requires the integration and involvement of clinical and financial teams to support value-based care models. In a CIRC, when a patient begins their healthcare journey, clinical and financial pathways are interwoven more than ever before; therefore, resources, processes, and technology must be integrated and no longer siloed.
One approach or method will not serve as a long-term strategy for the traditional revenue cycle. The CIRC provides an integrated approach looking at the revenue cycle through a different lens and leveraging internal and external partnerships while utilizing quality documentation and the “True Clinical Picture” of the care provided to our patients. The CIRC provides a foundation for organizations to financially succeed without negatively impacting patient care. A few advantages of a CIRC are:
- Increased quality of patient documentation
- Decreased expenses related to rework and duplicate processes
- Increased operating income
- Reduced compliance issues and associated risk
- Increased integrated technology automation
- Decreased payer denials
- A sustainable path forward
A CIRC-Driven Approach to Denials
With a CIRC, when revenue cycle management (RCM) staff come across an account that requires information from the medical record, they can request those records from HIM systematically, without gaining entry to the complete electronic health record system. When the request is connected to both the primary RCM workflow tool and HIM’s release of information process and system, requests for records tied to a denial can be prioritized above requests that are not as time-sensitive and don’t have the financial repercussions that a denial does. Furthermore, the system could prioritize requests based on the value of the denial—a $50,000 denial will be given higher priority than a $100 denial. This process outlines a step in the proactive direction of addressing denials.
Another benefit of a CIRC approach is visibility. Clinical and financial teams can work more efficiently when they both have visibility into how much time remains for the provider to respond to the denial, how much the denial is worth, whether it is the first or second request for clinical information, and how the information needs to be delivered (e.g., electronically, by fax, or in person). That visibility plus the use of analytics to correct avoidable denials through easy-to-interpret information driven from source data such as 835/837 and remit files—coupled with CMI data, coding data, and a quality lens—are vital to addressing the denials challenge with which all organizations struggle.
Moving Forward with CIRC Implementation
To optimize the revenue cycle, we must bring together clinical and financial pathways to achieve the goals of delivering high-quality patient care and being reimbursed appropriately for the level and quality of care provided. Who would be better than HIM professionals to lead the charge toward the CIRC? HIM professionals have always operated in the middle, between clinical and financial, and are experts in the requirements, rules, and regulations for complete and accurate billing. To successfully drive the transition to the CIRC, HIM professionals can serve as transformational leaders with the expertise to:
- Understand and utilize data to address a multitude of challenges and share that knowledge across the organization
- Assist all contributors in the world of documentation and advocate for complete, concise, and clear documentation
- Drive the shift from denials management to denials prevention
- Guide the integration of clinical and financial processes and data to succeed under a reimbursement system that hinges on the quality of care and outcomes achieved
There’s no way around it; in a value-based world, healthcare providers must make significant changes to their revenue cycle operations. In highly effective organizations, it is imperative to create cultures of change and organizations that are self-sustaining and highly organized. Moving to a CIRC requires formerly separate HIM and RCM departments to come together to ensure their organizations can provide high-quality patient care and are appropriately reimbursed for the level of care delivered. HIM professionals are well-positioned to address technological advances and prepare leaders for the next phases of the digital revenue cycle revolution. They also have the knowledge, skillsets, and the understanding of the connectors that are required to support a CIRC. Leaders must embrace evidence-based documentation and understand how to explore integration in complex systems. For this reason, HIM professionals are the ideal change agents and CIRC champions. Are you ready to lead the way to a CIRC in your organization?
Ciox Health, a leading health technology company, is improving patient health by transforming clinical data into actionable insights. Combined with an unmatched network offering ubiquitous access to healthcare data, Ciox’s expertise, relationships, technology, and scale make a difference for healthcare stakeholders and empower greater health for patients.