There are often big misconceptions when it comes to revenue cycle activities. One is that the revenue cycle is almost exclusively a back-end process. The reality is that the revenue cycle begins well before the patient ever crosses the threshold of the health care facility, continues throughout the “clinical” experience, claim submission and beyond. There are many technical reasons that healthcare claims can be denied, ranging from errors in the registration process, all the way to missing billing deadlines. In between, there are a whole host of clinical interactions that are also ripe for claim denials.
Pre-Access
The referring provider is often responsible for initiating the prior-authorization process. It is vital that the referring provider uses the most appropriate diagnosis and procedural codes to ensure the correct service is submitted for authorization consideration under the most appropriate clinical circumstances. Who is assisting the provider in ensuring the payer’s clinical coverage criteria are met?
During Treatment
There is an intricate dance that takes place between the treating provider(s) and the revenue cycle team. Was the patient admitted to the hospital in the most appropriate status? Is the patient progressing through the care delivery phase in the most efficient, clinically appropriate manner? At discharge, has the patient received the most clinically appropriate services for the stated reason for admission? Has timely, appropriate communication transpired between the facility and the insurance company? Who facilitates this communication and addresses issues that arise between the payer and the facility?
Post-Discharge
Ideally, there is a relatively short period of time between the end of clinical care delivery and claim submission. During this window of time, it is imperative that the clinical components of the claim are properly documented, which in turn, assists with ensuring accuracy in completing the technical aspects of claim submission (e.g. appropriate authorization numbers are on the claim; the most appropriate clinical diagnosis is on the claim to support the medical necessity of the delivered service(s), etc.).
Conclusion
Certified coders, Registered Nurses, and more increasingly, physicians all play a vital role in helping the facility ensure that all the required clinical components are present so that the facility can reasonably expect reimbursement for the services it delivers. These clinicians play a vital role in claim denial resolution as well as denial prevention. Who better to appeal a denied claim than a clinician who can speak to the medical side of things? Who is better to engage with front-line physicians to provide education about the best “status” for any range of clinical diagnoses? The clinical professional is ideally suited to identify what should have happened and to provide feedback in an understandable manner.
The revenue cycle is an increasingly complex endeavor for any healthcare provider. There are many technical points in the process that must marry seamlessly with the clinical rationale for treatment in order for the provider to receive payment for the services it renders and facilitates. The clinical team member plays a vital role within the overall revenue cycle. They can facilitate important clinical interpretation to the technical team as well as communicate technical information to front-line clinicians. Revenue cycle teams that reliably utilize clinical resources at various points in the revenue cycle are best poised to enhance the overall revenue cycle process and ensure better outcomes.
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Author: Darren Anderson, MSN, RN | Director, Revenue Cycle Operations , Healthrise.
