Becker's Hospital Review

40 EXECUTIVE BRIEFING EXECUTIVE BRIEFING 1 T he "silent payer discount" can be defined as a margin of revenue opportunity (between 3% and 5% of the hospital's annual net revenue 1 ) that is lost due to the complexity of documenting and coding complex inpatient cases. At a mid-size health system, this could equate to $22 million to $38 million in lost revenue, according to research conducted by Accuity, a provider of physician-led clinical documentation review services. Even in organizations with top- performing clinical documentation improvement (CDI) programs, this margin often goes uncaptured, resulting in significant losses for health systems that are providing critical patient care. To learn more, Becker's Healthcare recently spoke with three leaders with experience reducing the silent payer discount. The panelists were: • Hani Judeh, MD, Chief Medical Officer, Accuity • Candice Daszewski, Chief Client Officer, Accuity • Anne Robertucci, Vice President, Clinical Revenue Cycle, Prisma Health (Greenville, S.C.) To reduce the silent payer discount, leaders must understand current market conditions Although the negative margins experienced by hospitals in 2022 and 2023 are in the rear-view, gross revenue at hospitals is rising faster than net revenue. Two contributors to this trend are payer mix challenges and revenue growth that is driven primarily from the outpatient setting. Patients with multiple comorbidities and procedures require complex care, complex documentation and complex claim submission to ensure 100% revenue integrity. The most complex cases also cost hospitals the most money in terms of clinicians' time. "With high-acuity and increasingly complex patients, the demand for hospital services is predicted to rise," Dr. Judeh said. "These patients are resource-intensive, with longer lengths of stay, resulting in a higher cost of care. This population has increased morbidity and mortality, as well." Missed revenue has widespread impacts and contributes to hospital consolidations. The result is reduced access to maternity care, specialists and emergency departments. The impact is particularly acute in rural areas. In some cases, hospitals end up closing their doors. Reimbursement for complex cases is challenging for a number of reasons. Staffing shortages are widespread for experienced clinical revenue cycle teams like multi-disciplinary physicians, coders and CDI specialists. Hospitals often don't have the systems and resources necessary to capture all the details of complex cases consistently. On the payer side, guidelines are constantly changing, clinical denials are on the rise and documentation criteria vary from payer to payer and from state to state. For example, a 2021 survey found that the healthcare industry saw a 20% increase in claim denial rates over the prior five years. Clinical validation denials commonly result from discrepancies between documented diagnoses and the payer's clinical criteria. Proposed rules, such as CMS's requirement for insurers to streamline prior authorization processes, are one step toward addressing these complexities. "Having a strong clinical mid-revenue cycle program to stop revenue leakage and to accurately reflect the acuity and complexity of patients is critical when managing the challenges that a hospital faces in providing quality care," Dr. Judeh said. Internal education is necessary to ensure accurate complex case documentation Complex patient cases are associated with higher reimbursement because more complex care is necessary for these patients. In many instances, patients engage with multiple specialties during their clinical encounters. Navigating the documentation for these cases requires multi-specialty clinical experience. Hospitals, while having general CDI and coding staff support, may not have the specialist expertise to navigate complex clinical scenarios. To navigate the clinical nuances and ensure that documentation is accurate, experts are needed. Proper documentation and adherence to clinical criteria are key to mitigating denials and ensuring appropriate reimbursement. Education is also essential to address the root causes of denials, whether they stem from insufficient documentation, coding errors or process failures. Clinical programming and ongoing education for healthcare providers, CDI teams and coding personnel are crucial for improving the accuracy of documentation and reducing denials. To minimize denials and optimize revenue cycle management, hospitals must understand payer contracting, including payer-specific criteria. With this knowledge, healthcare organizations are in a stronger position to negotiate more favorable contract terms. Automation reduces the burden associated with documentation and the revenue cycle Technology can augment the detailed and often tedious work of documenting complex cases. Automation streamlines and standardizes processes, reducing errors and costs. Both front- and back-end revenue cycle processes lend themselves well to automation. "These processes are more standardized, involve structured data and have a linear workflow," Dr. Judeh said. "Registration and coverage verification, as well as claims processing and payment submission, are examples where automation may work well." The middle stage of the revenue cycle, however, is a different animal. The data is unstructured and determinations demand critical thinking and clinical expertise. Augmented reviews and a human in the loop are needed to validate findings. "The middle revenue cycle space is quite different and it's so dependent on critical thinking," Ms. Robertucci said. "Technology in this space should serve as a support or assistive device to those involved to ensure that claims are coded appropriately and comprehensively." In the mid-revenue cycle, technology can still assist with clinical and coding accuracy. Most providers utilize some sort of technology solution that pinpoints areas of the chart for potential leakage and prioritizes the workforce for those opportunities. "Those tools do bridge some of the gaps," Ms. Daszewski said. "But given the complexity of each diagnosis and varying payer requirements, providers still face a material increase in denials. Our clients are focused on how they can move any learnings upstream, as well as mitigate the denial from happening through the use of technology and/or analytics." One of the advantages of technology-enabled chart reviews is that the approach used for every case is uniform in terms of documentation findings. Each chart accurately represents the complexity of the clinical state of the patient, as well as the care delivered to support the patient encounter. Reducing the 'silent payer discount' — Tips from Prisma Health + Accuity 1 Based on Accuity's 4+ million chart reviews since 2016 for hundreds of hospitals across the U.S.

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