Becker's Hospital Review

41 EXECUTIVE BRIEFING EXECUTIVE BRIEFING 2 Clinical care and coding expertise are the keys to financial sustainability Often hospitals let the fear of denials affect how they code patient encounters. "It's understandable that organizations may lean into a conservative mindset when it comes to self-selecting out of risky or high-frequency denials like sepsis or acute respiratory failure, and opting for a 'safer' DRG," Ms. Daszewski said. Representing the true clinical picture of each encounter, however, safeguards revenue long term and impacts quality outcomes for physicians and the hospital. Accurately reflecting the acuity and complexity of patients in documentation is critical for both quality care and reduced revenue leakage. "This is where a strong marriage between domain expertise in clinical care and coding impacts financial performance and quality metrics," Dr. Judeh said. "Documentation integrity is a huge factor. A strong team and thoughtful, judicious selection of technologies and the vendors supporting them is critical. There's too much at stake." The journey to improved financial and patient outcomes: Insights from Prisma Health Specialized support and proper education are essential for hospitals as they navigate complexity, mitigate denials and optimize revenues. This approach is exemplified by Prisma's success, which has resulted in improved financial outcomes and improved quality metrics. In the area of reimbursements, Prisma Health compared its capture rates to cohorts in the area and identified opportunities for improvement. One challenge was ensuring that documentation in the clinical record spoke to the complexity of patients that were receiving treatment. Prisma Health was also seeing more critically ill patients, which created complexity in coding. "We started by analyzing our data using appropriate metrics for comparison," Ms. Robertucci said. "This enabled us to identify opportunities. We also had the help of a strong vendor to take a deeper look at our cases and to identify clinical documentation opportunities." Like many healthcare organizations, Prisma Health's coder population is aging and a strong pipeline doesn't exist to fill positions as employees retire. This, along with multiple coder vacancies is creating a stronger dependency on contract coding. This can create cracks in coding that warrant a strong auditing process. Prisma's partnership with Accuity directly addresses these issues and functions as a safety net, bolstering the work and capabilities of Prisma's CDI team. "Many hospitals and health systems are struggling with vacancies in their CDI teams or they may not have tenured experience," Ms. Robertucci said. "Gaining assistance from a vendor with expertise in this space creates an extension of your team." Ongoing provider, coder and CDI education tailored to the specific needs of these roles was also a game changer for Prisma to drive continuous improvement around codifying the patient record. Using appropriate service line and deeper analytics drove improvement in the clinical documentation and coding space, which is key to focusing time and energy where it matters most for education. A multi-disciplinary review approach that includes CDI, coders and physician assistants ensures that cases depict the true acuity of patients receiving treatment at Prisma Health. Technology assists end users in reviewing the right cases at the right time and ensures that all the relevant clinical information is captured. "Technology also decreases the time spent capturing the codified story by finding all the hidden 'Easter eggs' in the expansive EMR data," Ms. Robertucci said. "The right technology can identify a clinical diagnosis that has not yet been fully documented and prompt for a CDI review." By taking advantage of strong case review technology, Prisma Health has seen vast improvements in its capture rates. This has equated to a strong financial return, as well as indirect impacts to certain quality scores, like observed-to-expected mortality rates. "As of today, we continue to score at top decile performance levels which have been enhanced, in part, due to our focus on ensuring that we are comprehensively capturing both acute and chronic diseases accurately," Ms. Robertucci said. With the continued shortage of seasoned coders and the need to drive down administrative costs, Prisma Health believes that now is the time to redefine the middle revenue cycle. "I think it's critical to re-evaluate the way we do business now and how we can reframe technology in the coding and CDI space," Ms. Robertucci said. "With the speed of AI development, we will be able to re-create this workspace. I'm excited to be a part of a rebirth of an aged and legacy workflow. It's time to think outside the box and gain better results with less cost and effort." Conclusion The silent payer discount underscores the significant financial burden that hospitals face. Denials are one important contributor, but the more significant issue is the lost margin opportunity that often goes unnoticed in healthcare organizations. Accuity has a unique lens into U.S. health systems due to its review of over four million inpatient charts. This work has revealed the impact that the silent payer discount has on hospitals and health systems nationwide. Accuity's mission is to bring this issue to light and to help healthcare organizations compliantly capture this significant revenue that could otherwise slip away unnoticed. "Leaning into a partner that can leverage technology to drive accurate, complete and compliant records, as well as clinically defend against denials, will be the strongest line of defense against the silent payer discount," Ms. Daszewski said. References: Baxi, S., Parikh, S., Peterson, M., & Ray, A. (2023, July 25). Automation, analytics and AI in revenue cycle management | McKinsey. McKinsey & Company. https://www.mckinsey.com/industries/healthcare/our-insights/setting-the-revenue-cycle-up-for-success-in-automation-and-ai Cass, A. (2023, August 17). More than 33% of health system execs plan to automate 2 or more RCM functions in 2024. https://www.beckershospitalreview.com/finance/more-than-33-of-health-system-execs-plan-to-automate-2-or-more-rcm-functions-in-2024.html Eastwood. (2023, May 8). How to Navigate Structured and Unstructured Data as a Healthcare Organization. Technology Solutions That Drive Healthcare. https://healthtechmagazine.net/article/2023/05/structured-vs-unstructured-data-in-healthcare-perfcon Gamble, M. (2023, June 26). Hospital capacity problems will persist as patient acuity rises by 2033. https://www.beckershospitalreview.com/strategy/hospital-capacity-problems-will-persist-as-patient-acuity-rises-by-2033.html Grønsund, T., & Aanestad, M. (2020). Augmenting the algorithm: Emerging human-in-the-loop work configurations. The Journal of Strategic Information Systems, 29(2), 101614. https://doi.org/10.1016/j.jsis.2020.101614 Muhammad, M. (2023, December 13). What will be different in 2026? 65 healthcare executive predictions. Beckers Hospital Review. https://www.beckershospitalreview.com/hospital-management-administration/what-will-be-different-in-2026-65-healthcare-executive-predictions.html Sedlakova, J., Daniore, P., Wintsch, A. H., Wolf, M., Stanikic, M., Haag, C., Sieber, C., Schneider, G., Staub, K., Ettlin, D. A., Grübner, O., Rinaldi, F., Wyl, V. von, & Community, for the U. of Z. D. S. I. (UZH-D. H. (2023). Challenges and best practices for digital unstructured data enrichment in health research: A systematic narrative review. PLOS Digital Health, 2(10), e0000347. https://doi.org/10.1371/journal.pdig.0000347 Wankier, R. 2023. Power Your Revenue Cycle With Automation and AI. American College of Healthcare Executives. Retrieved April 12, 2024, from https://www.ache.org/blog/2023/power-your-revenue-cycle-with-automation-and-ai

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