Becker's Hospital Review

Executive Briefing: Leading Alignment Through Data Improvement face considerable risks, and not just market share and public relations risks arising from misunderstanding of hospitals' published charge data. Charge compliance penalties and consequences are already very serious, and they continue to ramp up. The Medicare Recovery Auditor program began in October 2009. Since then, $4.5 billion has been recouped from hospitals and providers in Medicare overpayments, according to the newest RAC figures from CMS through April 2013. Without a reliable charge capture and verification process, poor coding and missed charges continue to cost organizations a fortune, not only in compliance risk and lost reimbursement, but also in the major administrative expense of reworking claims, managing denials and audits, and communicating with payors about data issues and errors. Being prepared for external audits encompasses ensuring that the strategy, process and team are in place for peak revenue integrity performance. Leading an effective revenue integrity initiative will mitigate compliance risk while delivering greater operational efficiency and optimal appropriate reimbursement. Revenue integrity — Turning data challenges into opportunities In today's healthcare landscape, in order to manage the challenges presented by historic industry change while providing quality care and improving financial performance, it is vital that healthcare organizations implement a well-developed revenue integrity process. This process engages teamwork across hospital departments, and its physician groups, in order to ensure accurate data management and effective documentation. Now is the time to ensure that the crossfunctional team, strategic process and tools needed for effective data management are in position for ensuring revenue integrity. Don't sink, get in sync. How? First, determine the right questions to ask and the insights needed from your data. 37 The more thorough the data and workflow analysis, the greater the value that can be uncovered while providing a clearer picture of what's working, what's not or what needs to be addressed before it turns into a problem for the organization. From clean data with current, informed, localized context, business insights can be readily derived to support better decisions and apply resources more efficiently. Organizing a data and revenue integrity team The drive for data and revenue integrity requires a cross-functional team with a broad range of knowledge. Because of different roles and expertise, a member from each department should be included in the workflow analysis. Engaging diverse staff members in the process and communicating executive leadership's support behind the team's initiative are vital for success. Consider including representatives from the clinical departments, materials management, patient access, pharmacy, revenue cycle, compliance and insurance/payment specialists who can work together as a multidisciplinary team. The publishing of hospitals' charge data served to fan the flames of controversy. This unprecedented action intensifies the urgency that healthcare organizations ensure their data is ready for prime-time examination. To improve performance, you need to define the data reports needed, obtain a prioritized list of action items and engage a multidisciplinary team with clear processes and accountability supported by reference, workflow and automated data normalization tools. Examples of key tools needed are software programs that enable healthcare provider organizations to score their health data progress and software that produces reports that can be used to show physicians and clinicians how they can improve their documentation for compliance with evolving rules and regulations. Effective use of such data reports enables the building of greater alignment among clinicians and physicians, which enhances an organization's agility for successfully adapting to a rapidly changing payment environment. Missed charges are a primary source of revenue leakage. The lack of accountability and understanding of the compliance impact of these errors are key roadblocks to ensuring all legitimate reimbursement is captured and accurately converted into charges. Successful organization-wide process improvements for charge capture not only uncover data that enables physicians and clinicians to clearly see the impact of their actions and how to improve their clinical documentation that is required to defend revenue in an audit, but it also improves communication and accountability organization-wide to achieve revenue integrity excellence. Data analysis using workflow To help ensure the most effective data analysis possible, there are industry best practices that can be followed: Approach the analysis from a goal-achieving perspective, using established goals at the outset, each one with a specific measure of success. Data analysis can help identify where breakdowns are occurring. When initial goals are reached, analysis can help determine ways to reach greater goals. Support your team with an effective automated workflow. Workflow helps ensure that correct data are being collected and that the person collecting and verifying set of data is the appropriate person. Ensure each participants are accountable for their role and that they have access to current reference information and tools for their particular task. Check data flow. An important aspect of workflow analysis is ensuring that data are being moved to the right people at the right time, using the right process. It is important to verify that this transfer of data is taking place. Especially with today's electronic health records, the validation of data for accuracy and charge compliance using software is critical. Without an automated review and validation, for example, how would anyone find a typographical error in a dispensing cabinet, or a lab machine with data capture problems? Both of these issues result in data not making their way into the patient record. Without a reconciliation and verification process

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