Summary: Profitability can be achieved through addressing the denials portion of the revenue cycle.
Are you struggling with profitability? Have you reviewed your revenue cycle? Do you know why your claims are being denied? Have you analyzed your processes both human and technology?
Below are 10 steps to boosting profitability through the revenue cycle:
1. Audit Claims.
In order to boost revenue through the revenue cycle, a thorough review should be conducted of denied claims over the past at least 3 months, preferably the last year.
2. Root cause analysis.
Why are these claims being denied? Perform a root cause analysis to determine why claims are being denied. Are they missing required authorization? Were inappropriate billing codes used? Was a particular field missing? Were they filed late? Was it a system error with the billing system?
3. Review the claim submission process.
A review of the claim submission process from start to finish might point to areas of inefficiency which could be slowing down the process. This analysis should involve input from the front-line staff demonstrating the process rather than upper management’s perception of the process. This also promotes greater buy-in from the staff knowing that their input matters.
4. Fix any system issues.
Any issues such as incorrect CPT codes need to be addressed immediately to mitigate the denied claims.
5. Educate the staff.
Once the root cause analysis is complete, it is critical to share the uncovered information with the staff in a constructive not punitive manner. If this step isn’t completed, the claims will continue to be denied and the organization will continue to lose profits through the revenue cycle.
6. Resubmit claims.
Can these denied claims be resubmitted? Are they still within the timeframe to do so? Can you recoup some of your profits lost through denials.
7. Review, review, review – and then review again.
Going forward, processes need to be put in place to make sure all claims are reviewed and audited prior to submission. Submitting clean claims reduces the time, effort, and cost involved with looking at claims a second time, fixing any errors, and going through the resubmission process.
8. Set goals.
Once everyone has been educated and processes are in place to review claims prior to submission, goals should be set and shared with all staff.
9. Monitor and document progress.
Make sure a mechanism is in place to monitor progress toward achieving goals. Where are we now? How far have we come? This should occur at least on a quarterly basis.
10. Celebrate milestones and successes.
Achieving goals and celebrating those successes with the staff round out the process toward increasing profitability. The process should be a fluid and continuous, always striving to increase efficiency and profitability, always asking how things can be done better.
One of the easiest ways to increase profitability is through managing the claims process. Auditing, reviewing, documenting, and monitoring will begin to turn your profits around.
The post was written by Linda Ringquist, a Marketing Consultant for BHM Healthcare Solutions. BHM is a healthcare management consulting firm whose specialty is optimizing profitability while improving care in a variety of health care settings. BHM has worked both nationally and internationally with managed care organizations, providers, hospitals, and insurers. In addition to this BHM offers a wide breadth of services including healthcare transformation assistance, strategic planning and organizational analysis, accreditation consulting, healthcare financial analysis, physician advisor/peer review, and organizational development.
Phil C. Solomon is a healthcare finance and revenue cycle BPO strategist with experience spanning three decades. He is a sales, business development and marketing professional who provides business solutions for hospitals, health systems, large physician groups and channel partners. Phil has deep domain knowledge and expertise in revenue cycle optimization, clinical documentation improvement, healthcare technology integration and BPO outsourcing He is the publisher of Revenue Cycle News, a healthcare revenue cycle blog and is a featured speaker at many HFMA, NAHAM and AAHAM healthcare educational conferences.