5 Opportunities for Incremental Revenue Capture for Hospitals

Identify and Recover Revenue Sources Through Revenue Cycle Capture Audits

In today's healthcare environment, capturing every cent of revenue due to a hospital is a challenge. There are many reasons, which inhibit recovery, such as satisfying payer documentation and complying with coding requirements. The elements for billing and collecting revenue are difficult to administer. Intricacies in the billing process and subsequent financial documentation create opportunities for breakdowns in the revenue cycle, which often result in lost revenue.

In addition to the typical challenges of collecting revenue, the upcoming conversion to ICD-10 and the advent of new legislation creating healthcare reform offers more challenges for revenue cycle executives to overcome.

There are many proactive operational strategies available to providers to help improve financial results. Process improvements can come from human capital adjustments or employing innovative revenue cycle technologies. Unfortunately, regardless of the method (s) chosen to help improve revenue capture, leakage and lost revenue opportunities are bound to occur.

The Need for Revenue Capture Audits

A large source of revenue leakage emanates from highly complex and labor intensive tasks where human error is the causation. The required information needed to make certain determinations come from several departments within the hospital. A shortage of qualified staff, inadequate technology solutions plus full-time equivalent (FTE) turnover are contributing factors leading to errors in processing complex and time-consuming claims and supplying supportive documentation to comply with governmental reimbursement requirements.

Revenue capture audits can identify and capture revenue, which often leaks through the revenue cycle and the same audit can provide valuable information helping to find the root causes of breakdowns in workflow.

Providers are challenged to allocate enough full-time personnel to review and correct many billing issues before they result in potential forfeited revenue. The following five key areas offer opportunities for uncovering incremental revenue through performing revenue capture audits:

– Pinpointing missed reimbursable bad debt opportunities
– Identifying and resubmitting unseen claims for Medicare Reimbursement DRG (TDRG)
– Uncovering valid Medicaid eligibility coverage
– Discovering hidden Medicaid disproportionate share (DSH) payments
– Ensuring that proper shadow billing requirements are met

Identifying and rebilling for lost revenue opportunities requires cogent knowledge of the significant changes to Medicare and Medicaid, a close working relationship with all the individual fiscal intermediaries, direct access to Medicare and Medicaid EDI feeds and access to data analysis engines to make faster and more informed recovery determinations.

Due to the complexity and skill required to capture all sources of revenue, many hospitals turn to revenue audit experts who offer outsourcing services or specialized technology vendors who offer niche technology solutions for internal staff to perform audits internally.

What to Look For When Selecting a Revenue Capture Outsourcing or Technology Audit Vendor

Choosing the right vendor is of paramount importance. Not all vendors are equal in quality and ability. Furthermore, not every vendor will be an appropriate fit for your hospital or health system. Most importantly, it is critical to select the right vendor that you feel you can comfortably and effectively collaborate.

An important consideration when selecting a revenue audit vendor is to choose a firm who can demonstrate a history of successful performance and skill. Consideration should also be given to vendors who have competencies in all five areas of revenue capture and who offer a choice of an internally driven technology solution that a hospital's staff can administer or an externally outsourced service solution.

By offering two models for performing revenue audits, revenue cycle executives have the option to choose a solution, which fits the hospital or health system's corporate culture and financial objectives.

Currently very few companies can perform as a sole-source provider to address all five key areas of incremental revenue capture. Even fewer companies can offer an option of installing a leading edge software platform for the hospital's staff to use that addresses all five revenue capture areas. Recently, select few companies have broken the basic standard of service typically seen in the marketplace and now offer an array of solutions, not available in the recent past.

In today's healthcare vendor marketplace, there are audit companies that provide an excellent work product and offer the technology that can meet the criteria listed above. Choose your method of performing revenue capture audits carefully and select the right vendor for your organization, and your hospital will minimize revenue leakage and reap the benefits of capturing every cent of revenue available.