Revenue Cycle Management

Medical Coding

Considered as the backbone of the healthcare revenue cycle, Medical Coding is the principal tool which ensures that patients pay their dues for services rendered by providers. With the onset of a patient encounter, it is absolutely essential for healthcare providers to document the details of the patients visit whilst providing plausible reasons explaining why certain services or items were initiated during the treatment.

In case of a conflict with claim, this all-inclusive documentation is used for justifying reimbursements to payers and patients. If any service or procedure is incorrectly documented in the medical record of a patient, the organization can face a claim denial or be subjected to healthcare fraud.

As the patient is evaluated at a specific healthcare facility, the clinical documentation is studied by our professional medical coders and matched against services with respective billing codes. These billing codes help in translating a patient encounter in languages used for claims submission and reimbursement.

Our AAPC credentialed coders specialize in translating clinical documentation of a patient encounter by connecting relevant services against medical, codes to deduce the scope of billing. Here’s a list of code sets used within the ambit of Revenue Cycle Management

1. CPT and HCPS Procedure Codes

2. ICD-10 Diagnos Codes

3. Charge Capture Codes

4 Professional and Facility Codes

Our medical coders undergo multiple training sessions which in turn enables optimal implementation of the aforementioned codes regardless of the type of your facility. The experience gamered over the years of practicing medical coding equips them with the fruitful skill of creating tailored HCM colutions Whilst recording accurate documentation which eliminates the scope of faulty or insufficient collection of patient’s financial liability towards the provider.

Clinical Documentation Improvement

ATWS understands how an effective Clinical Documentation Improvement (CDI) program creates a positive impact on the functioning of the revenue cycle.

CDI helps in:

1 Ensuring that the events of every patient encounter are recorded diligently

2 Entrancing the quality of data generated within the scope of the electronic health record.

3 Elminating the gaps in reimbursements

With an out-and-out approach, our CDI specialists monitor documentation at every subsequent step. This generates meaningful and accurate clinical
documentation which is then used for estimating the scope of services provided towards the patient.

CDI Improves Patient Care

According to a study conducted by the American Medical Association, a clinician ends up spending two hours on EHR documentation for every hour spent with a patient. This directly cuts into the doctor-patient time thus affecting the overall quality of patient care.
On the other hand, CDI initiatives within the healthcare ecosystem reduce the burden of documentation by a considerable measure. Because of CDI, the clinicians are able to focus better on their patients which leads to improved interactions along with better documentation, later used for settling claims and calculating reimbursements.

Our approach for identifying irregularities in documentation

Our CDI experts have extensive healthcare regulatory experience which allows them to foresee potential areas wherein the scope of error is maximized.
They understand how documentation challenges can displace the focus of healthcare providers from places wherein revenue leakage is more common. For example:-

1. Hierarchical Condition Categories
2. Patient Safety Indicators
3. Severity of Illness
4. Patient density
5. Key Quality Measures

These core areas usually host a bunch of irregularities which are extremely difficult to catch. But with AIWS `CDI solutions, we can guide you in keeping a track of your clinical documentation. We can assist you in realizing bigger financial gains through RCM with every passing year.

Claim Adjudication

Identified as an imperative facet of Revenue Cycle Management Solutions, Claims Adjudication primarily encompasses the three-step process of receiving, verifying, and settling medical claims..

By partnering with AIWS, you can avail the advantage of simplifying healthcare claims which are otherwise a time consuming and strenuous process for your medical team.

Our Claims Adjudication Process comprises of 9 major steps:
1. Procuring Claims Data from your facility
2. Fulfillment of Eligibility criteria
3. Avoidance of Duplicate Claims
4. Benefit Determination Application
5. Analyzing details of your Establishment
6. Coding and Diagnosis Review
7. Edits on the basis of Industry-specific rules
8. Settlement of Claims
9. Disclosure and Presentment

Owing to our experience of serving clients from the healthcare industry, we’re continuously optimizing our processes whilst staying abreast of latest technology and software updates and developments within the industry. This procedural expertise not only produces error-free results but also speeds up the process of adjudicating claims.

Out of our 9 major steps to validate the scope of claims, every step is further broken down into different subsets which enables us to monitor, identify, and rectify errors and discrepancies prevalent within the healthcare regimen.

Claims Processing and Review

Starting with basic errors like Incorrect Patient Names, Missing Diagnosis Code, Incorrect Member IDs, and Patient’s Gender Mismatch, we advance towards an in-depth check of the claims to extract details regarding the Payment Policies of the Payer.

The phase which started by crosschecking basic details of a patient categorically proceeds towards Finding Duplicate Claims, Deliverance of Unnecessary Services, and Invalid Pre-Authorization amongst others.

Authenticity of the Claim

Once the claim passes through the processing stage, our Adjudication experts recheck and in some cases crosscheck claims by asking for relevant documentation and medical records. In a nutshell, our Adjudication team establishes the authenticity of these claims which is extremely important in case of unlisted procedures.

Disbursement of the Claim

As the claim qualifies through the initial rounds of inspection, it finally reaches the disbursement stage. However, our work does not finish here. Whilst submitting the payment to the designated office informed by the payer, we furnish complete details with respect to Reduction in Payment, Claim Adjustment, Claim Denial, Amount Approved and Covered, along with the Remaining Financial Responsibility of the patient.

With such an exhaustive Adjudication Services Module, our track record is considered as a benchmark by healthcare establishments. With AIWS as your RCM partner, you can be assured of the fact that your claims processing is always at the forefront of our business and that our operational and technological efficiency is forever leveraged to produce optimal results for your organization.

QUALITY

Revenue Cycle Management process is like a sophisticated machine consisting of several moving parts. Every aspect of this crucial cycle needs to be constantly monitored and matched against pre-set standards in order to gauge the overall efficacy of this multi-fold process.

We use our set of measures whilst evaluating the Revenue Cycle Management of your healthcare facility. These measures are like performance audits to eliminate even the minutest of errors.

1. Clean Claims Percentage: When a claim is successfully processed on the first submission to the insurance company, it is identified as a clean claim. On average, hospitals in The United States expect between 85% to 97% of clean claims. During our performance audits, If the percentage falls short of this, we bring in our Quality control team to ascertain the reason for this inefficiency.

2. Accounts Receivable Days: When receivables extend to a period of more than 90 days, the number of successful claims drops by a drastic measure. So the number of days it takes you to receive the amount owed by the payer is extremely important In determining if the Accounts Receivable cycle is in place or not.

3. Collection per Patient: Calculated monthly, Collection per Patient plays a pivotal role in determining if your revenue matches against the number of patients you see in a single day. Although this number varies with the type of industry you work in but based on your specialty, we corroborate your revenue per patient encounter against industry benchmarks to ascertain if you need appropriate revisions or not.

4. CERT Audit: Comprehensive Error Rate Testing is a diligent measure put in place to identify if claims complied with billing rules, coding standards, and Medicare Coverage. CERT Monitoring Program is one of the commonly used ways for improving the quality of claim submission. It also ensures that claims are not riddled with unwarranted errors. By and large, coders process claims with an errors rate which does not exceed 2%. Anything above that is quickly rectified by our team.

All these are essentially the Key Performance Indicators that assist in indicating the profitability of your organization. AIWS assures Quality by establishing profitability benchmarks according to the nature of your organization. In addition to that, these benchmarks also help in recognizing loopholes and areas which need special attention.

Care Management

The basic objective of Care Management is to ensure continuity of care between healthcare providers, hospitals, and home. Our team understands the underlying importance of designing mechanisms that empower patients throughout the journey of availing medical assistance.

One of our foremost targets is to facilitate care management services that help patients avoid inconvenience caused by unnecessary visits to the emergency room. We further assist patients by casting stable links between the medical home and hospital. This is incredibly useful if a patient is availing treatment for longer durations. Additionally, the Care Management team at AIWS is sensitive enough to fathom the paramount nature of ensuring a smooth transition between hospital and medical home. Hence, we work round-the-clock to provide medications, services, and equipment for patients so that their focus is solely on improvement rather than managing their treatment.

A. Referrals

Within the purview of the healthcare industry, we’ve seen numerous cases wherein Care Managers fail to identify risk factors associated with a patient’s needs. That’s why we have predetermined guidelines that help us ascertain if the patient should be selected for Care Management or not. Our guidelines also enable us to recognize the timeframe for referring a patient.

Reasons for Care Management Referrals:

  • Non-Compliance with treatment
  • Missed appointments for a prolonged period of time
  • High ED utilization rate
  • Chronic condition that demands integrated care

B. Case Management

Case Management enjoys a unique position that helps exalt the overall functioning of the Revenue Cycle. It is similar to a liaison between payers, patient, and the respective healthcare provider.

It furthers the cause of bridging the chasm between the finance and clinical department of hospitals.

Importance of Case Management services to demonstrate its impact on Revenue Cycle: Care Coordination: To complete this process effectively, Case Manager seeks updates from the physician and the healthcare team of the hospital (establishment) to ascertain if care is appropriate or not. The case manager also keeps a tab on the progression of the treatment plan to record the overall execution of the services. It is the manager’s responsibility to ensure that the patient does not stay in the hospital for longer than necessary. Simultaneously, after a patient is discharged, the manager is required to follow-up and provide healthcare facilities and deliver mandatory medical supplies or equipment.

These follow-ups are beneficial in reducing the number of unnecessary readmissions which help improve the process of RCM.

Utilization Management: According to Utilization Management, the patient or payer has the right to receive timely clinical reviews associated with inpatient care. The reviews help the payer decipher the scope of medical necessity along with financial responsibility for the inpatient stay. The role of a case manager comes up if whenever there is a disagreement about medical necessity. In such cases, Case Management regulations dictate that the manager arranges for a discussion between the payers’ family and the concerned physician.

Discharge Planning: As the name suggests; this step is about planning the day for discharging the patient from the healthcare facility. If the patient ends up spending extra (which can’t be justified) time in the facility, it can later amount to ‘denial of care’ and initiate a lengthy and unsuccessful process of filing appeals. This hindrance can severely affect the accounts receivables which in turn can impair the Revenue Cycle.