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10 Steps to Improved Charge Capture: Why Revenue Integrity is a Team Sport

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Imagine running a service-based business — say, house-painting or plumbing — and simply failing to get paid for the work once every couple of months.

Not very likely, right?

But the equivalent volume of loss has been all but baked-in for many healthcare organizations. From undercharges, to incorrect codes, to documentation misses, to overcharges — getting paid properly for all the work done, and supplies and medication used, is anything but a sure thing. The complexity of most revenue operations and hospital environments makes consistent revenue-capture a constant challenge. With cost-cutting pressure coming from both carriers and third-party payers, hospitals can’t afford to go unpaid for procedures, supplies, and medications.

The sheer breadth of connected factors (such as the multitude of touchpoints between the clinical and billing systems) can make complete charge capture feel a little bit like bailing out a leaky boat. As soon as one cause of loss is discovered and patched, another hole opens up. And even when one chronic problem seems to be solved, they often show up again a year (or even a few months) later.

Modern EMR and dedicated charge capture solutions have led organizations to significant improvements over paper-based processes, but of course, the technology that facilitates a process doesn’t actually do the process. Unfortunately, tech solutions, even those expressly designed for improved charge capture, can lead to a false sense of security: a pervasive notion that “the system” will catch errors.

The notion of “the system” at least begins to hint at the right idea — but experienced advisors in this space suggest that the entirety of the system is much bigger than a single technology solution.

“The best way to address charge capture issues,” says William (Bill) Malm, VP of Client Strategies at Vitalware, “is looking as broadly as possible. You really want to include the whole clinical and business environment in your scope of analysis. Getting revenue integrity right, and keeping it that way, requires that we understand the whole ecosystem. The right technology can do wonderful things, but none of them can obviate the need for good teamwork.”

In the ten steps outlined below, Bill Malm outlines for us the core elements for creating charge capture success, reframed in this broader context as “revenue integrity.”

10 Steps To Improved Charge Capture and Revenue Integrity

#1 Go Public With Your Goals

One of the problems with charge capture is the lingering psychological association of the capture process with auditing, often including the use of third-party personnel to perform the process. A better mental model, Malm offers, is a drive or campaign, motivated by the establishment of common team goals. “The idea is to create a broadly shared sense of excitement, with big, shared goals, measured in terms of efficiencies, real dollars, or both.” Monetary goals needn’t be expressed in defined figures, but the full range of positive results should be expressed as tangibly and specifically as possible. If possible, try to become more specific with goals as the campaign gets underway.

#2 Be Inclusive

“You want to involve everyone who plays a role,” Malm observes. Many hands make for lighter work, but a bigger team also means that clarity of message and specificity of communications become more crucial. The idea is to broadly enroll physicians, nurses, lab and radiology, pharmacy, supply, clinicians, and coders. In general: if they touch the revenue process, make sure the program communication touches them.

#3 Create (and Publicize) Charge Capture Policies

One of the key steps for revenue integrity is making sure your chargemaster file is scrupulously kept up to date — but even a squeaky-clean chargemaster doesn’t guarantee faultless revenue capture. Policy and process play an equally important role.

The key with policy development is for everyone involved to understand the various players and their roles — and to see clearly, through the expression of policy and process, how the whole team is designed to work together. Policies should be expressed in terms of duties, or roles…which leads us to our next entry:

#4 Establish Role Clarity & Job Aids

The need for “role clarity” is implicitly expressed in the creation and sharing of policies delineated above. But the idea of role clarity is so important, it warrants its own entry in this list. Every player on the team needs to know who the team members are that rely on them for their work, and, if at all possible, what they need specifically from them to obtain that outcome. This can be achieved in a role-specific Job Aid with “tips and tricks” for successful management of the concern or task.

“Role clarity is an interesting pursuit,” Malm says, “some tend to think of it as a focusing set of blinders, but the fact of the matter is, the most effective role clarity comes from knowing how one’s effort affects all the others who depend on you. Roles should be expressed in terms of responsibility to other individuals, or the effort of the whole team.” When your policies and roles are clear, “shared responsibility” is actually possible, and it can help improve processes that may periodically require a combined perspective.

#5 Put Workflows to Work

One of the best ways to formalize policies and achieve enduring role clarity is through the use of workflow capabilities. Not all tech solutions for chargemaster management and revenue integrity fully integrate workflow with coding rules, but those that do will give you significant advantages. Flexible workflow capability is one of the most effective ways to ensure compliance, even on the most detailed processes. Workflows also enable you to measure compliance to policies (are people following the policy?) as well as the efficacy of the policy itself (is the policy getting the result it was designed to achieve?). Note that whether or not your workflow is integrated & automated, it’s crucial to have it documented. Revenue integrity solutions that integrate workflow with rules and reports offer the advantage of policies being both documented and measurable. More on this idea, immediately below...

#6 Measure Early and Often

One of the best features of embedded workflows is that they enable easier measurement, and thereby, allow more discrete measurements to be included in your overall process design. Reporting of results is helpful, but the key, Malm says, is measurement that tracks both inputs and outcomes. “To understand whether or not policies are effective," Malm offers "it’s crucial to understand and measure the adherence to those policies.” Reporting on progress to goals is also an essential component of keeping everyone informed, and it can also be used strategically, to foster friendly competitions for improved results.

#7 Keep Communication Lines Open

You want physicians and staff to have an open, positive engagement with the overall revenue integrity effort. One of the most important ways to create that positivity is to listen: which means continually touching base, and responding effectively to input.

Physicians and staff need to have an easily accessible forum, or representative — a willing ear, listening to any concerns or suggestions they may have about information gaps, competing goals, or unanticipated challenges created by newly required processes. You can formalize this input with regular get-togethers for feedback, and further open-up channels by offering direct access to dedicated experts, for staffers who have questions or suggestions. Sharing feedback regularly on progress and results is another key component of keeping engagement invigorated.

The main idea is to keep the sense of teamwork and progress fluid and fresh, and to make sure those who are managing the overall revenue integrity effort are always actively listening.

#8 Seek Out Root Causes

The combination of good communication, broad engagement, focused policy development, and integrated-workflow and coding rules enables teams to get at root causes. Malm further recommends that the involvement of a Six Sigma team for more complex issues touching multiple areas can be of benefit.

The last ingredients required to assure sustained improvement are continuous measurement…and time. Like any finely tuned machine, your overall revenue integrity plan should be designed to be regularly maintained and updated. Coding changes and added complexity are a fact of life in healthcare, but the great advantage of getting your plan in place is that these continuous sources of change can be much more easily assimilated into a system that’s already working. When you have a solid revenue integrity base, you're better positioned to manage complexity, and over time, you can develop a sharpened instinct for knowing where new problems are coming from.

#9 Partner Wisely

The charge capture space is crowded, and there are many providers who can legitimately claim significant revenue successes. That breadth of choices for partners and solutions is both a plus and a minus. It’s great that this discipline attracts so much creative energy and innovation — but it also makes the providers’ job of choosing the right partner more difficult. There are many factors and key questions to think about, but two deserve emphasis:

Is your provider able to share a comprehensive vision for revenue integrity? ...One that pulls your entire team together into the effort cooperatively, with clear swim-lanes, data views, and reports that serve the policies you need to gain success? Do they have values or a mission statement for their team? Do they have service line agreements with other teams to ensure that technology and human capital interface well?

The second question is best seen as a continuation of the first:

Does your provider have a vision for turning over the process to your team, with support available on an as-needed basis? One of the keys for doing this is having a methodology to discover issues at their root, and (of course) for transitioning processes to your staff. It's a good idea to discover as much as you can about how your potential partners approach preparing you for self-sufficiency.

#10 Celebrate The Wins And Stay On The Case

The combined effort of the whole team brings your facility significant and sustained success. To keep everyone engaged, it’s important to celebrate the successes on every level: for the whole team, for specific departments, and for individuals. There are also key maintenance processes required: an annual review of your chargemaster for example. Keeping all of these contributory elements on the same map, and making sure that successes are celebrated, is real work that you’ll need to account for. Staying on the case also means that you’re constantly looping back to step-one, and reframing your goals.

Ideally, sustained improvement establishes the value of the overall effort early, and continuously optimizes over time. Results have a magic all their own.

Ten Steps…Make Them Yours

Our purpose in this article has been to identify the commonalities we’ve seen in the most successful revenue integrity efforts. However, the precise tuning of any such effort requires the input of people on the ground at your healthcare facility. Just as many successful efforts share these common traits, it’s also quite true that every ecosystem and organization is different. Bill Malm suggests this is another point of consideration when you’re considering partners. “The most important skill a partner can bring to you in this space is the ability to listen. It’s like being a good dancer, you don’t get there just by knowing all the steps. You have to know where your partner is at, and where they want to go.”