Elevating Billing Compliance and Revenue Integrity amid the Pandemic

While the introduction of new COVID-19 reimbursement rules and regulations have brought on their share of confusion, there is one certainty healthcare organizations can bank on: oversight of incentive dollars will be a regulatory priority. In fact, federal watchdogs are not wasting any time, as reports suggest monitoring of billing and claims data is already underway to ensure that hospitals are not upcoding to take advantage of higher COVID-19 reimbursement rates.

Amid notable revenue shortfalls, clinical and financial leaders face an imperative to get ahead of potential revenue and billing compliance risks. The reality is that many health systems face serious bottom-line impacts – to the tune of millions of dollars – related to the halting of elective procedures and significant declines in emergency-room visits as fear and stay-at-home orders kept patients from venturing out. Even with the 20-percent Medicare payment increase, one report from Strata Decision Technology estimates that 97 percent of health systems will lose an average of $1,200 per COVID-19 case, with some losses reaching as high as $8,000.

Consequently, the role of sound revenue integrity practices is critical to optimize reimbursement within a fluid and evolving crisis. Ongoing oversight and readiness will require proper allocation of resources, supported by the right technology-enabled processes. Manual efforts to stay abreast of additions and changes to procedure and billing codes – along with evolving treatment regulations and reimbursement policies – will leave many organizations simply reacting to reimbursement issues.

An Untested Reimbursement Landscape
Accuracy of claim submission amid the introduction of new rules and codes is one part of the equation. Understanding how payors will interpret new guidance is another story. With COVID-19, the market is simply untested. As best practices emerge, healthcare organizations need to be in a state of continuous analysis.

The past few months have brought many changes, from new telehealth rules, modifiers, procedure codes for testing, and ICD-10 codes to a place-of-service code to support payment for these services provided to beneficiaries in any healthcare facilities, and even in their home. Prior to the introduction of new parameters, the industry lacked a specific way to identify COVID-19 cases. This will add to confusion as coding departments likely documented with generic codes related to pneumonia or exposure to a virus.

It’s a tall order for billing and compliance teams to master all these changes and enact new systems to support optimal reimbursement in a timely manner. Consequently, healthcare organizations should expect an initial increase in denials.

Getting Your Revenue Integrity House in Order
Progressive revenue integrity models built on strong partnerships between revenue integrity, revenue cycle, and billing compliance teams are key to getting ahead of the COVID-19 reimbursement challenge. Healthcare organizations that embrace a shared approach to monitoring and auditing between these functions will be best-positioned to optimize revenue capture as the pandemic continues to evolve. Three important steps to achieve readiness include:

  • Increase bandwidth within the revenue cycle continuum.

Coding departments will need additional staff to address COVID-19. One way to expand this resource allocation is to reassign staff from areas where services have not yet returned to normal volume – such as outpatient services or elective procedures – and place them in the key areas of coding and auditing. Also, reallocating staff on the back end can help address needed resources during any second or third wave of COVID-19 cases. This could include patient financial services, where the day-to-day scope of activity may have decreased, such as billing or prior authorization departments.

  • Conduct continuous auditing of COVID-19 claims for compliance.

Revenue integrity teams need systems in place to stay abreast of evolving guidance related to COVID-19. Technology can be a critical enabler of the streamlined processes needed to monitor updates and reimbursement policies across both government and private payors.

Telehealth monitoring should be an important part of this equation due to the uptick in demand for these services and the fact that reimbursement protocols are new. The guiding principle for providers should be to “document everything” that occurs during the patient’s telehealth visit – the purpose of the visit, assessment, and any virtual examination or evaluation. Most importantly, documentation should reflect the thought process regarding monitored symptoms and conditions: what a clinician is ruling out and what requires follow-up.

  • Monitor delayed or denied claims immediately to inform process improvement.

Even as healthcare organizations are feeling pressure from multiple angles during the pandemic, addressing payment delays and denials must remain a priority. Best practices support setting up mechanisms to monitor delayed adjudication to identify the root cause quickly. Then, an optimal corrective action strategy can be put into play to ensure that future claims are submitted with all the correct codes and documentation.

Forward-thinking healthcare leaders will not only put proactive measures in place to address COVID-19 reimbursement, but they will also capitalize on this challenge to elevate revenue integrity strategies. By eliminating existing silos along the revenue cycle continuum through improved communication and collaboration, organizations can better position themselves for revenue optimization and future sustainability.

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