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  • Writer's pictureEffy Healthcare

Raise Your Hospital KPIs with a Focus on Cause and Effect Relationships

Healthcare organizations depend on monthly reporting of key performance indicators (KPIs) to measure financial performance and operational efficiency. As a result of the pandemic, almost all health executives expect a decline in revenue, so keeping a finger on the pulse KPIs may be more critical than ever before.

Analytic dashboards are commonly used to track performance between monthly KPI reporting – but like monthly reporting, the activity analyzed has already happened, and the opportunity to avoid situations that adversely affect KPIs, such as denials, has passed.

The key to keeping KPIs strong and cash flowing is to avoid situations that inflate days in A/R, denials, write-offs, and decrease net collections. Unfortunately, even after substantial time and effort have been invested in identifying the root cause of situations that result in KPI disruptions, often the solutions are not permanent, and the same issues crop up time and again. The answer to maintaining healthy KPIs is pinpointing and lastingly correcting the situational causes that later affect RCM outcomes – the question almost all facilities face is how?

Identify root causes

A combination of experience, historical reporting, and automated analytic technology can get to the heart of operational deficiencies that cause negative financial performance. There can be many reasons for weak KPIs, but some of the most common causes include:

Days in A/R KPI factors

  • Slow claims submissions

  • High denial rates

  • Delayed payment posting

Claims denial KPI factors

  • Unsolved technology issues

  • Inaccurate or incomplete eligibility and insurance verification

  • Outdated rules engines

Write-off KPI factors

  • Fatal denials

  • Incorrectly applied adjustments

  • Timely issues

Net collections KPI factors

  • Outdated fee schedules

  • Failure to collect patient payments

  • Under or over coding

All situations leading to poor performance begin with data points that are eventually brought together on claims. Some circumstances that cause claims problems can be solved using existing technology; for example, most EHR systems will not let staff book an appointment until all relevant information (data) is recorded. Therefore, if birth dates are consistently missing from patient records, the platform can be set to lock until a birthdate is set. However, persistent RCM issues usually have an element that is much harder to control, for example, authorization denials because of an existing technology glitch or under coding due to inadequate documentation. These problems often need solutions that reach across departments and platforms. Up until now, a lack of communication between systems and siloed information has made permanent solutions impossible.

Reach across your enterprise to correct root causes at the source

Fortunately, there is a solution that can reach across disparate systems and facilities and alert staff when there is a data point that could later lead to operational or performance issues – healthcare business assurance.

Healthcare Business Assurance technology is a proactive solution that provides a permanent fix to RCM issues – wherever they originate. It is layered on top of existing technology and triggers an alarm to alert staff to problematic data. Since alerts happen in real-time, corrections can be made immediately before a claim is generated.

The problem: Decreasing net collections

For example, a large hospital system was continually hearing complaints from providers about under-compensation and saw a worrying trend towards declining revenue. After investigation, the group recognized two leading root causes of inaccurate coding leading to low RVUs and subsequent revenue leakage:

  • Problematic documentation from providers resulting in under coding and low RVUs

  • Failure to prove medical necessity

The solution: Proactive correction of root causes

Like many RCM issues, the solution needed a multi-pronged approach to reach across systems and departments. Hospital staff quickly realized BA technology was ideal for providing oversight of operations and providing lasting corrections. The team placed strategic alarms to instantly flag problematic data, allowing staff to correct issues before claim generation.

Solved: Inadequate documentation and inaccurate coding

One primary source of revenue leakage involved transcatheter aortic valve implementation (TAVI) coding. The solution involved multi-tiered alarms placed on the EHR and coding applications that virtually eliminated the circumstances ultimately leading to low net collections. Alerts allowed staff to be aware of and correct scenarios before claims were generated – accelerating overall collections and providing the information needed for accurate coding. Scenarios that triggered alarms included:

  • Missing fields in provider notes

  • Lack of terminology in notes to prove medical necessity and align with NCDs and LCDs

  • Lack of detail in notes to justify accurate procedure coding

  • Coding anomalies involving coding conventions such as NCCI edits, MEUs, and add-on codes

After correcting documentation and coding, RVUs reflected work done and raised net collections. (In many cases, the top 15 - 40 codes can drive up to 90% of revenue.) Then, alerts were placed on the RCM analytics platform to indicate when a provider deviated from expected RVUs as determined by historical data and compared with other providers performing the same procedures. In a noticeably short amount of time, providers had confidence in their compensation or (through education triggered by alerts) understood the documentation changes needed to ensure they captured the information necessary for accurate coding.

A permanent solution

Continual, automated monitoring and reporting ensure inefficiencies are permanently corrected. In the event an alert is triggered, a customized, integrated case-management workflow tool ensures timely follow-up that protects RCM outcomes. Flexible business rules engines can accommodate an unlimited number of triggers, alarms and automated case-management workflows, allowing organizations to build upon improvements and create lasting change.

Boost your hospital KPIs and increase overall provider and patient satisfaction

Organizations that concentrate on permanent solutions to circumstances that adversely impact KPIs will regain control of financial performance, ensure a steady stream of revenue, and benefit from a smoother revenue cycle experience that raises both staff and patient satisfaction.

Interested in learning how Effy Healthcare can help you eliminate the root causes of underperforming KPIs? Contact us today.


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