#GetToThePoint: Outpatient Revenue Integrity

In the latest episode of our podcast, our HIM expert and VP of Revenue Cycle Services, Keith Olenik, brings 30 plus years of experience on this topic.

Let’s get to the point!

They need to first look at the claim and edit process. When you bill for a service under an insurance plan, there are certain coverage requirements, and every payer is different. The diagnosis that covers one blood test is not necessarily going to cover another depending on who the payer is, so there are notifications called claim edits built into the software that pop up on the screen. There is a whole process for this, but the first thing is to manage your claim edits and make sure you understand them.

In a professional facility, the codes change every year. Once you figure out what the code is for a procedure, it could change next year. Technology allows us to automatically update those, but having an annual update of the code is important. Providers need to make sure they are aware of the change and are inputting them into their systems.

Medical necessity is also a factor related to revenue integrity. This allows the provider to get paid for their service, or the patient to make sure they can have that service done because of a medical condition and that their insurance company will pay for it. The process of medical necessity gets convoluted when it is dependent on the provider and usually requires the physician to provide adequate information at the time the care is requested instead of chasing it on the back end, which oftentimes is what’s done.

When the medical necessity isn’t met, you get a denial from the payer and it’s not covered. Organizations with low dollar amounts and large volume on the outpatient side, are tempted to just write it off. There are potential fraud issues with inducements for giving patients free care, but it’s tempting when you have large volumes that do not get covered to write them off. If you have a medical necessity process in place that obtains a valid diagnosis to cover the service you avoid the denial and the need to do a write off on the back end.

Lastly, what they can do to control this area is be aware of the shift to value based payments. There are specific focuses on wellness prevention that happened on the outpatient side. Make sure chronic conditions are documented appropriately by the provider. Providers need to understand the payer rules and make sure the codes are assigned appropriately so when they submit the claim, it will get paid.

It all comes down to people, process and technology. With outpatient revenue integrity, you’ve got to have the right people — the right number of people and they have to be educated on process. If your process does not work, you are not going to get anything done and technology feeds into the process, but there’s a lot of technology options out there beyond what you buy from your base EHR.

Here are the top five takeaways:

  1. Have a multidisciplinary team.
    This is critical. Cover all the bases and all the areas of expertise.
  2. Invest in the right technology and optimize workflows.
    Technology can be your friend, but it can also do you a lot of harm. Make sure you have the right technology and the right workflows and look at that process to make sure you are not just accelerating bad processes.
  3. Continue ongoing training and education.
    After you’ve done all this work, it does not do you any good if nobody knows how to use it. Also, turnover is inevitable. Education and training need to be core and ongoing.
  4. Establish medical necessity upfront.
    To avoid issues with denials, this requires physician engagement, which goes back to training and education, so they know how to get that information upfront.
  5. Communicate about the denial and appeal process.
    You can have the best process, the best people but you are still going to get denials. Make sure you can address denials to be able to capture the money that you can or solve the problem when you continue to see patterns.

Hear Keith’s top five quick strategies to ensure outpatient revenue integrity in the latest episode of “Get to the Point.”

Listen Now