Creating a Hospital Quality Management Cycle

According to Susan DeVore, president and CEO of Premier, Inc., a healthcare improvement company, today’s healthcare providers are being judged on more than the amount of payment for a procedure and the effectiveness of their billing and collection process. They’re also being increasingly evaluated based on their quality, creating a need for “total quality management.”

In a new op-ed published in the Wall Street Journal, Devore notes that, in today’s health-care industry, “the quality of care is just as important to a hospital’s revenue as making sure claims are paid properly.” Additionally, federal programs requiring hospitals to publicly report their outcomes, as well as rewards or penalties as a result of these outcomes, put pressure on hospitals to perform well. As a result, understanding how to measure performance is essential to a hospital’s success. 

“Much like the revenue cycle process, hospitals need to be able to keep track of and manage the quality cycle of care to determine the most important areas of focus and consistently meet high-performance measures,” she writes. “If we take some of the best practices from the revenue cycle, we can implement a quality cycle management process that aligns and focuses firmly on the specific elements of performance that produce continuous quality improvement, and in turn, a healthier balance sheet.”

In the article, Devore notes that these “best practices” include “a clear cadence, metrics with targets, a firm culture of accountability and… deep executive engagement to generate change.”

“Yesterday’s revenue cycle management is today’s quality cycle management,” she says.

Nearterm sees RCM quality metrics as a subset of the overall mission that hospitals embrace which is to deliver quality care in a sustainable way. Quality cycle, in our opinion, is as much among the objectives of RCM as it is also among the objectives of Nursing Services, Supply, and other operational areas of care.

AMA President Urges Physicians to Prepare Billing Cycles for ICD-10 Implementation

In response to a letter to the Centers for Medicare & Medicaid Services (CMS), which expressed concern regarding the potential for an accumulation of millions of dollars in unpaid Medicare claims following the ICD-10 implementation, American Medical Association (AMA) President Robert M. Wah is urging physicians to prepare their billing cycles for the transition.

The letter, which was a joint effort from a hundred physician groups, including the AMA, expressed concern that contingency plans have not been established to prevent critical billing disruptions caused by the implementation of ICD-10, which goes in to effect October 1.

“By CMS’ own analysis, one of the most significant risks to moving to ICD-10 is the likelihood for claims processing and cash flow interruptions,” the letter states.

AMA President Wah told RevCycleIntelligence.com that the biggest concern regarding the transition to ICD-10 was demonstrated in CMS’s end-to-end testing, which found a decline in claims acceptance, from 97 percent to 81 percent, among the relatively small sample size tested.

“When this is expanded to all physicians and all claims, the results may be disastrous,” Wah said.

Wah also pointed to issues with previous HIPPA implementations, including NPI and Version 5010, which left some physicians unable to be paid by Medicare for several months.

“Some practices were at the point of being unable to make payroll for staff and needing to temporarily close the practice, or obtain lines of credit with financial institutions until processing was complete,” Wah states. “We are extremely concerned that physicians will face similar issues as a result of the switchover to ICD-10.”

To prepare for the transition, Wah is urging physicians to prepare for the federal mandate.

“Physicians will need to closely track various metrics for their claims including pending claims, rejected claims, days in accounts receivable and payments,” says Wah. “Any issues will need to be addressed and reworked as early as possible to prevent a backlog of unprocessed claims and lack of reimbursement.”

Nearterm can help you get your RCM in top shape in preparation for the ICD-10 compliance date of October 1. We offer coders, claims specialists, and billers to work onsite or remotely. 

Read the entire article on RevCycleIntelligence.com

How Outsourcing RCM Supports Company Growth: A Client’s Perspective

Several years ago, Capital Women’s Care (CWC), an obstetrics and gynecology group in the Maryland, Virginia and Washington, D.C. areas, was facing a challenge with regards to their revenue cycle. According to Debbie Redd, CWC’s President and CEO, the practice’s revenue cycle was “not functioning to its full potential,” hindering the company's ability to grow.

In a recently-published article from Healthcare Finance News, Redd details how the practice overhauled their revenue cycle management system by streamlining the internal front-end financial processes and outsourcing back-end billing efforts.

According to Redd, the choice to outsource was a “practical alternative to keeping things in-house,” as it allowed the practice to “rely on an expert whose sole business is revenue cycle management” while freeing up time for the practice to “focus on expanding… and supporting providers in high-quality clinical care for patients.”

Overall, Redd concludes that outsourcing back-end processes both stabilized CWC’s financial operations and built a foundation of support for the company’s expansion. 

"Before we began outsourcing our backend processes, our days in A/R were over 100," writes Redd. "Now we consistently see rates of less than 20. We also have about a 99 percent collection rate."

Additionally, Redd notes that the strong changes made to the front- and back-end of the revenue cycle make the organization “more attractive to new providers and potential partners.”

“Providers come to us seeking membership because they see how we effectively manage both the clinical and business sides of the practice. This has allowed us to expand our business and prepare for the coming changes in healthcare.”

Read the entire article on Healthcare Finance News.

Nearterm provides healthcare revenue cycle management (RCM) services for hospitals, medical clinics, and physician practices. Our RCM services are designed to provide clients with practical solutions and assist them toward strengthened financial positions.