Research brief: 8 No-Regrets Investments for Access and Population Health


At the Margins

Our latest insight into health care margin improvement efforts

Dual coding: What we learned from 8,000 claims

by Ellie Stoller January 26, 2015

We’ve seen how 5% revenue reduction risk under pay-for-performance has gotten the industry’s attention. Our own research has also shown that ICD-10 can affect 4.8% of reimbursement revenue—a risk that merits attention as well.

Due to the potential reimbursement impact, hospitals are beginning to dual code patient claims, allowing ICD-10 project leaders to compare DRG assignment of the same claim under ICD-9 and ICD-10 and prepare for the changes.

Barnes Health (pseudonym), a system in the Midwest, began dual coding a year and a half ago and shared its data with us.

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In case you missed it: RAC contracts get renewed—but with new limits

Christopher Kerns January 12, 2015

CMS has said it will revamp its Recovery Audit Contractors (RAC) program in order to increase transparency between the agency and providers and to enhance its oversight of the program.

CMS has renewed RAC contractors for CGI Federal, Connolly, HealthDataInsights, and Performant Recovery, allowing them to audit claims until Dec. 31, 2015. Those auditors will all be subject to the new rules, which limit the patient status claims review period to six months, as long as the provider submits its claim within three months of the service date.

Case study: Generating an annual RAC reserve estimate aids financial planning

The rule change limiting lookback periods is a big assist to providers wishing to re-bill certain denied Part A claims under Part B. Because CMS limits re-billing to one year from the date of service, those providers who submit claims in a timely manner (within three months), will have lookbacks limited to only six months from the date of service. Previously, many providers were often hamstrung in their re-billing efforts with longer lookback periods allowed.

But while the change is an important acknowledgement from CMS that the RAC program is in need of overhaul, it is also a reminder to the industry that the program has been incredibly successful in its goal to reduce overpayments/fraud and slow the growth rate of health care costs. It's also a reminder that the federal government remains committed to continuing these efforts for the long-term.

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Confronting the new era of post-payment audits

Get 16 best practices for reducing your institution's risk exposure to audits and creating a streamlined workflow to implement during an audit.

Read the study

Choosing not to choose—invest in infrastructure without losing price competitiveness

Rick Conlin January 6, 2015

Current health care markets are making two big asks of hospitals and health systems. First, they’re signaling a clear interest in population-health capabilities. Second, they’re placing a premium on the “retail” characteristics of our offerings, including frictionless access, differentiated offerings, and broad geographical coverage.

The major infrastructure spending required to rise to either of these challenges won’t be a simple thing for most of us to manage. One big reason is the persistent pressure on hospitals to deliver low-unit cost—you’re not going to be able to pay for those big capital expenditures by raising prices.

Instead, progressive providers are upping their ambitions for the scale and speed of cost savings they’re going after. They’re continuing to pursue longer term cost-trend control—painstaking work, based on managing demand and utilization to prepare for risk contracting. But they’re also looking for more immediate impact, on a grander scale.

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Point-of-service collections start with you: 4 ways to get your staff on board

Samantha Hauger January 2, 2015

“This isn’t what I signed up for.”

In my work helping organizations improve their front-end collections, I hear this phrase a lot.

I get it. Most employees come to a hospital to help patients. They often feel they didn’t sign up to collect money, and many staff haven’t had adequate training to do so. What’s more, no one wants to upset patients or drive them away.

And yet, I’ve seen the best of the best help their staff do more than just tolerate asking for point-of-service collections. How do they get their teams excited about this effort? Here are four strategies I’ve found that are keys to optimizing your up-front collections:

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Get the most bang for your CDI buck

Christopher Kerns December 18, 2014

Clinical documentation improvement is a marathon, not a sprint.

Getting a CDI program up and running requires significant time and resources. But that’s not the end of it. We’ve found that top-performing CDI programs continually improve and re-evaluate their efforts, in order to sustain the gains they’ve made.

I sat down with Morgan Haines, a partner in our Consulting and Management Services division, to find out how the best-of-the-best programs are maintaining momentum.

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Overcoming the patient pay problem requires patient engagement

by Marcus Hincks December 16, 2014

Health insurance coverage alone is not indicative of patients’ ability to pay their medical bills. As consumers increasingly gravitate towards high-deductible health plans (HDHPs) because of the low premiums, many still cannot afford the high deductibles, thus creating greater amounts of bad debt.

The average American has $1,766 in overdue medical debt

Providers are revisiting collection efforts, hoping to engage patients and alleviate bad debt. We spoke with leaders from Novant Health to discuss a tactic they’ve taken—partnering with interest-free loan providers to help patients with their financial obligations.

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An ounce of prevention pays off: 90% of denials are preventable

Morgan Haines December 11, 2014

Denials management is a perennial topic. Most hospitals have ongoing efforts in this area—but very few can say definitively, “We’ve cracked the code on denials.”

Part of the challenge is that denials management is not just a do-one-thing-and-do-it-well issue. You have to master three core skills—recovery, prevention, and contract negotiation—to truly stomp out denials. But other initiatives have a way of taking priority, causing teams to default to focusing their efforts on revenue recovery.

As you make your list of goals for the coming year, I challenge you to consider this: Preventing denials is always better for your bottom line than recovering them. Only about two-thirds of denials are recoverable, but almost all (90%) of them are preventable. Though prevention is not easy, fixing the root cause of denials has a much larger financial impact than overturning them.

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Leading by teaching: A CFO's perspective on managing a system's finance team

Robin Brand December 9, 2014

Ann Pumpian is the CFO of Sharp HealthCare in San Diego, Calif. This is the second part of our two-part interview with her about her system's decision to leave the Pioneer ACO and how she mentors and educates her team to understand the implications of SharpHealthcare's financial strategy.

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