By Jennifer Lavoie, RN, CPC, Zynx Health
In many hospitals, there are inadvertent disconnects between the clinical and revenue integrity operations. These two groups are separated by the software they use, the language they speak, and their operational goals within the organization that contribute to the overall mission. The disconnect can be physical, as these groups usually occupy separate work areas or may even work remotely or in separate facilities.
Clinical and revenue integrity staff quite literally speak different languages. Traditional medical terminology is Latin-based. It is abstract, complex, and multisyllabic to the non-medical ear. Further, physicians speak in terms of the patient care they deliver–the tests, procedures, and medications–while the revenue integrity groups are focused on translating patient care into the codes for the Charge Description Master (CDM), billing, and reimbursement. Finance groups tend to speak in layman’s terms, or they use terminology found in the code sets that are necessary for charging and billing.
Perhaps most importantly, the two groups are often further divided by their IT systems. They may use different platforms and systems altogether or, at a minimum, may work in different modules of the same system.
IT Systems As A Connector
The IT systems that are part of the disconnect can contribute to the translation of languages for the clinical and financial sectors of an organization. Software such as computerized physician order entry and decision support tools, coupled with accounts receivable (AR) systems and data analytics, can speak both clinical and financial languages. Technology can assess the actual care provided and convert it to charges. Software also can evaluate whether the care provided is accurately reflected in the CDM and on patient claims along with identify charge capture opportunities that could financially impact a health system.
Many hospitals struggle to make the operational connections, but a software platform that is designed to create the associations could be the answer. By setting evidence-based, standardized order sets and protocols, then simplifying the process for clinicians and monitoring that the care provided is accurately reflected on the claim, health systems could bridge the gap. This is also another way technology can help organizations achieve both clinical and financial goals. Evidence- and experience-based clinical decision support appeals to physicians who want to provide the best care to their patients. It also appeals to finance professionals who want to ensure that the care provided is accurately reflected in the CDM, which provides many of the codes and the charges billed on a patient’s claim.
Clinical decision support helps healthcare organizations see the complete picture of evidence-based practices from both the clinical and financial perspective. The multi-faceted view and approach will help to alleviate the disconnect between these two sides of the house–each of which is critical to healthcare organizations at an operational level. This type of operational connection will contribute to the clinical and financial sustainability of the organization.
While it is important to monitor and measure when clinicians are following evidence-based practices, it is also important to track when those best practices are not being followed. This is another way technology can be utilized to bridge the clinical-financial gap. That is, it can help organizations shine a light on when–and even why–clinicians are not adhering to standards so they can prioritize making organizational changes as necessary to drive clinical and financial benefits.
Bridging Clinical And Financial Gaps Brings Value
Even if we don’t always like to talk about it in healthcare, the bottom-line matters. We’ve seen the disturbing trend toward hospitals, especially community and rural providers, filing for bankruptcy or shutting their doors. When a patient experiences a serious, sudden, or trauma-type condition–such as a heart attack, stroke, or accident–access to a local hospital seven minutes away versus a facility 45 minutes distant can mean the difference between a poor or good outcome, or between life and death. Proper billing and coding for the care provided can help many facilities maintain their financial viability and continue delivering care for their communities.
In some cases, it’s a matter of a simple fix. It may take an IT staffer one to two hours to create and turn on the automatic charge functionality in the electronic health record. It might also take an additional hour to add the chargeable care if it’s not built into the CDM. Consider the return on investment from taking those steps. Keep in mind that when a correction to the CDM and charge capture is made, year after year an organization can capture dollars for care, supplies, pharmaceuticals, diagnostics, etc., already being provided by clinical staff but had been missing from the claim.
It is important that the care provided to each patient is accurately reflected in the CDM and on the patient claim. The claim contains standardized codes that represent the condition and care, as well as the billing information. Care that is not charged can accumulate into millions of dollars of lost revenue depending on the volume, pricing, payor contracts, and other variables. For a hospital, the historical charges and claimed care form the basis for commercial payor contracts, accountable care organization (ACO) contracts, the Medicare cost report, and internal organizational metrics and budgeting. The accuracy ripple effect can have positive and negative results, so validity is imperative. IT platforms can be an integral part of the solution.
Time To Stop The Disconnect
Healthcare can no longer afford to indulge disconnects between clinical and financial systems and staff. Each side must be willing to listen to and learn what the other side needs, then work collaboratively to achieve objectives. The collaborative work may need to include training, process improvement, IT solutions, group projects, and developing an understanding of how they interconnect.
The right health IT technologies can help organizations bridge their financial and clinical disconnects and uncover new opportunities to increase revenue, reduce costs, and improve the quality of patient care.
About The Author
Jennifer Lavoie, RN, CPC, is director of information architecture and taxonomy at Zynx Health, part of the Hearst Health Network. Throughout her career she has specialized in providing the best quality care to patients while also ensuring that hospitals and physician practices are charging for the care they deliver.