HIM Performance and Payer Denials Grab Attention at AHIMA 18
The American Health Information Management Association (AHIMA) held its 90th annual convention and exhibit last week in Miami, Florida. Amid humidity, convention center construction and political banter, attendees found common ground on two important revenue cycle issues: operational performance and payer denials.
Keynote presenters Karl Rove and Donna Brazile shared a refreshingly balanced and humorous exchange about today’s political climate as attendees sharpened their knowledge on such important topics as privacy, cybersecurity, information governance, coding and data-driven advances in healthcare.
Underlying all the futuristic conversations and advanced technology sessions, one fact continued to ring true: HIM leaders are perpetually pushed to do more work with fewer resources. This reality pushed operational performance to the forefront of attendees’ focus and convention priority lists.
Mid-cycle revenue performance matters
Health information management (HIM) professionals are responsible for myriad mid-cycle revenue functions in healthcare. From clinical documentation improvement (CDI) to releasing records to payers, HIM team performance makes or breaks revenue cycle success. Two of the convention’s highlights included the release of the industry’s latest coding quality results and an educational presentation by Yale New Haven Health on improving business office staff performance during payer communications.
According to Pena4, sponsor of the 3rd annual nationwide coding contest to measure coding accuracy, inpatient performance dipped slightly lower in 2018 compared to 2017 results. Average accuracy scores for inpatient ICD-10 coding hovered at 57.5 percent while outpatient coding accuracy experienced a slight bump from 41 percent in 2017 to 42.5 percent in 2018.
Eileen Tkacik, vice president, Information Technology at Pena4, said, “HIM professionals working in the trenches of coding, CDI and audits weren’t surprised by the low coder accuracy results. However, other revenue stakeholders don’t see a clear correlation between suboptimal accuracy and reimbursement.” Tkacik suggests that “disconnects in coder accuracy expectations are caused by multiple departments working in silos across the revenue cycle—with blurred lines of responsibility and communication.” Stovepipe systems and separate operations were found to impact another important revenue cycle area—business office.
Yale New Haven Health’s Executive Director of Corporate Health Information Management, Cindy Zak, MS, RHIA, PMP, FAHIMA, presented outcomes of a recent project performed in conjunction with the organization’s protected health information (PHI) disclosure management partner, MRO. As the recipient of AHIMA’s highest honor, the 2018 Grace Award, Yale New Haven Health System worked diligently over the last year to assess information governance, identify areas of revenue cycle inefficiency and centralize processes.
Prior to completing the project, system business office (SBO) staff were spending a significant part of their day mailing medical record attachments to payers. HIM spent time printing the medical records and would deliver the paper records to the SBO daily which resulted in Zak incurring an additional $3,000 per month in paper costs—since many cases contained thousands of pages. Under the new model, MRO provides medical record attachment services and Zak has achieved the following benefits:
- Billers are more efficient and focused on their core functions.
- A dedicated outsourced team prepares and sends all medical record attachments.
- Duplicate work is eliminated.
- Payer requests are analyzed to identify patterns and trends.
- Most information is sent to payers electronically—versus in paper format.
Other revenue cycle staff process concerns shared by AHIMA attendees include:
- Shift to ongoing coder performance assessments versus traditional audits
- Revenue backups due to cases getting stuck in EHR work queues
- Challenges with adjudicating claims across systems and departments
- Missed opportunities for the risk adjustment factor (RAF) to be increased, impacting value-based reimbursement
- Need for evaluation and tune-up of CDI programs—inpatient and outpatient
- Preparing coders for single-visit coding in preparation for value-based models—code once for all coding needs
According to Wendy Coplan-Gould, RHIA, president and CEO of HRS, “Future coding teams will have an important role in reviewing and coding cases across the entire continuum of care, not just single encounters, as organizations move from fee-for-service to value-based reimbursement.” Revenue cycle leaders are already having these discussions, but many coding teams are not. Another critical concern expressed by AHIMA attendees is the dramatic increase in commercial payer denials.
Commercial payer denials on the rise
During prior AHIMA conferences the Medicare RAC program was a hot topic of discussion and concern. However, at this year’s event commercial payers represented a more urgent concern. Moving commercial payers from an organization’s anathema to collaborative stakeholders in healthcare reimbursement is the long-term goal—but attendees at three health systems suggested the journey will be a rough one.
One large New York organization has experienced double the volume of commercial payer denials within the past six months alone. Another large Western U.S. health system went so far as to suggest that any case with a CC or MCC that impacts the DRG is being denied. Finally, at a leading Connecticut health system, approximately 80 percent of denials are now from commercial payers.
Commercial claim denials are also more complicated as there are no consistent rules, guidelines or time frames. This spike in commercial denials is causing significant drain on coders’ time and performance. Further, when denials are managed by various departments versus a centralized team, miscommunication and duplication of work run rampant.
Brian McGraw, CEO of Intersect Healthcare, recommends that revenue cycle teams use proven tactics to combat the rise in commercial denials:
- Include new parameters, time frames and audit limits in payer contracts.
- Educate the entire revenue cycle team—from patient access to denial managers—about contract terms.
- Centralize denials into one department or team to improve communication and reduce rework.
- Ask for the credentials of payer-designated reviewers. Know who is performing the review at the payer location (or the payer’s business associate).
- Review denial patterns and trends to circumvent future denials and educate staff.
- Schedule meetings directly with the commercial payers to discuss correct coding guidelines for commonly denied diagnoses, DRGs and procedures.
Take stock of the current state
AHIMA attendees responsible for revenue cycle management functions were all encouraged to assess, audit and measure the current state—including coding accuracy, business office efficiency and payer denial practices. Technology and data-driven analytics have become the new normal in revenue cycle management—now is the time to put them to work!