Navigating Revenue Cycle Operations in a Time of Uncertainty

August 28, 2020 | Article

By Janice Swan and Rachel Pugliano

The effects of the COVID-19 pandemic have changed the way many organizations operate. For healthcare entities specifically, it’s taken a toll. With workers on the front line and cancelled surgeries adding to the pressure, healthcare organizations must continue to try and navigate through a time of uncertainty.

One key area healthcare organizations need to review is the operational impact on revenue cycle. The revenue cycle has long been recognized as the backbone of a healthcare organization. Patient Access is the first touchpoint through which patients enter to receive services. Coding provides validation of the care the patients receive, and billing and reimbursement are dedicated to recouping payment for the services rendered.

Let’s look at the revenue cycle processes by breaking it down into its key components.

The Impact of COVID-19 on healthcare entities is far-reaching. Here’s what you need to know.

Patient Access
Patient Access is often where patients have their first experience as they enter healthcare organizations, either by phone or upon arrival. Patient Access can set the stage for the next "first impression" at the end of visits as they assist with scheduling follow-up appointments and referrals. Each point of contact sets the stage for a patient's perception. This is one of the many reasons that organizations have found value in using their Patient Access department for both customer service and to begin introducing the patient to value-based care. 

Accurate Insurance Data
COVID-19 has changed the ways patients access care, and front-line staff are more important than ever during this change. It is imperative that staff ensure that financial insurance data gathering is accurate. As the number of layoffs increases, many will be without commercial insurance coverage.

The revenue cycle leaders of organizations need to communicate to front-line staff the importance of being diligent in capturing the correct insurance and demographic information. This likely will require organizations to re-educate staff on how to ask for updated insurance, rather than just pulling forward the prior insurance data. The pulling forward of information tends to be a common practice, but it’s not necessarily a leading practice; it is the “least resistant” way to obtain someone’s personal information and not feel like you are prying.

One suggestion is to change the employment status scripting to assist the registration team. Work with staff, the revenue cycle steering committee, compliance department and executive leadership to create the right scripting for your organization.

Insurance verification and eligibility will be more important now to complete and interpret the responses. With payers providing waivers to copays for testing, connecting with your insurance eligibility vendor to see how their system is handling benefit changes under the waivers in the TCS 270/271 (Eligibility Inquiry/Response) will be critical.

To stay up to date, create a grid of your top payers for staff to be knowledgeable on what copays are waived at this time and if it only applies to specific tests/procedures.

Key Performance Indicators
Now, more than ever, proper key performance indicator tracking will be important. Do you monitor the percentage of patients that have a completed insurance verification check as a KPI? Do you monitor up-front collections? This may be an opportune time to also incorporate new KPIs for your staff.

Consider how to improve patient and staff safety in the collection of demographic details, insurance information and cash collections prior to arrival. Does your current patient accounting vendor offer technology options to send patients links via email or text so they can complete these processes and self-register/pay prior to arriving? If not, are there options you could employ?

Financial Counseling
Organizations must be ready to address the additional burden of private pay and patient responsibility. This will affect more than those who are laid off, it will also impact their dependents and the senior population. If seniors have not secured Medigap coverage or supplemental insurance, they will have more out-of-pocket expenses.

Items to review include:

  • Your organization’s charity care policy and procedures.
  • How your organization handles Medicaid Eligibility.
    • Do you contract with an outside vendor to process these applications? If so, do they have the resources to keep up with the influx of patients who may now qualify?
  • Your payer mix, which will give you insights on how your community is changing and adapting.

Uninsured Population
The Government has created a COVID-19 Uninsured Program Portal and claims reimbursement center to help monitor the impact of the uninsured on healthcare entities. Other ways to monitor uninsured trends are to set up internal codes in the patient accounting system to differentiate and track the various patients related to COVID-19.

It’s important to update your charity care and self-pay discount policies. With this influx of uninsured during these unprecedented times, the last thing an organization would want is to be called out in the media for perceived aggressive collection policies and processes. Determine other tools such as partnering with a healthcare credit card vendor or local bank to assist with payment. Picking up the patient’s COBRA premium may be beneficial for the organization if revenue can be obtained.

Now is the time to ensure the charity care and self-pay policies clearly state eligibility criteria for charity care vs. self-pay and are clear on how they are administered. Be proactive and educate your front-line staff so they can speak on the options and help ease patients’ minds.

Coding and Claims Processing
Many organizations are turning to remote work during this time. Coders, billers and others are working from home, and many have not done so before. The unique challenges of COVID-19 should be taken into consideration when monitoring productivity, but the mindset should be that productivity standards are still important and goals still remain in place—even during a pandemic. Have open discussions with staff to set realistic productivity expectations so the workload can still be accomplished during this time.

Some organizations have had to furlough coding and billing staff due to the decreased volume of claims to code and process. As more services are offered, keep in mind that when coding and billing staff are furloughed, the claims will not be coded and processed as quickly. Turnaround times for these areas may have to be adjusted while the furlough is in place.

CMS has issued numerous temporary waivers and guidance as it relates to telehealth, code assignments and billing. New diagnosis and CPT codes for COVID testing were adopted in record time. Systems enabled for order entry, lab test processing, charge capture and billing will need to be updated to accommodate for these new codes. The chargemaster maintenance or compliance committee and the chargemaster coordinator, at a minimum, should be involved in these conversations, along with lab, ordering providers, IT and vendors to ensure all systems utilized can process these key pieces.

The COVID-19 pandemic has created an environment where some services are being rendered and allowed when they were not allowed in the past. Claim edits may be triggering services that are now temporarily allowed. In addition, payer’s system edits may likewise be creating issues and slowing payment. Therefore, the claims editing processes need to be monitored closely, as does the payment turnaround time from payers.

The following key performance indicators (KPIs) should be monitored daily or weekly to ensure claims are running through smoothly.

  • Clean claim rate
  • Untransmitted claims
  • 277 response rate
  • Medicare Claim Error Rate
  • Medicare claims processing system (FISS) backlogs
  • Payer negative responses on 835s (Remittances)
  • Claim turnaround time

One thing to keep in mind is that it’s likely claims were processed prior to and throughout CMS providing guidance. Commercial payers are providing their own guidance as it pertains to sending corrected claims. In order to be sure that you receive the full payment due to your facility, you should go back and resubmit those claims with the correct codes, modifiers, condition codes, etc. as instructed by the payers.

Here’s what you need to know about COVID-19 and medical procedure codes.

Accounts Receivable Management
Managing a remote workforce is a learning curve. Plus, the remote workforce deployment may not have been developed systematically and with the security to ensure HIPAA compliance, such as printing from home. Productivity has more than likely deteriorated and staff communication will need to be heightened. As time goes on and things seem to settle into place, consider the following:

  • Communicate expectations to those impacted
  • Track your claims processing time as payers may have slowed down
  • Connect with your third-party vendors
  • Think through scenario planning and how you’ll continue to work with limited staff

Key Performance Indicators to Consider
It’s important that you keep your leaders informed of the KPIs. Start projecting your cash and monitor the changing payer mix, monitor the following KPIs weekly and keep them clearly visible to leadership:

  • Gross AR Days (Clinics vs Hospital)
  • AR Days Discharged Not Billed
  • Slowdowns in DNFB Throughput:
    • Discharge to Code time
    • Discharge to Bill time
    • Coding / Medical Records backlogs (AR Days Discharged not Coded)
  • Backlogs in claims and follow-up work queues
  • Slowdown in payer “bill to pay” tracked by financial class
  • Percentage of AR by Payer Class
  • Percentage of AR by Age and Payer Class
  • Self-Pay collection percent
  • Payment and adjustment posting backlogs
  • Payer denials from 835s
  • Denial write-offs as a % of revenue

Outsource Vendor Usage
Your patient accounts staff (Billing and/or Follow-up) may be pulled to help Patient Access areas as resources become strained and payers may develop issues slowing their processing time. To help answer the need for additional resources, consider outsourcing. Being connected to an outsource vendor allows you to deploy immediate attention to aged accounts receivable and avoid inflation of your AR, which will deteriorate your cash.

Selecting the right vendor requires due diligence to ensure the integrity, experience and compliance with billing rules and regulations you expect. Research and connect with an outsourced vendor to understand their capacity to increase their volume of work. Carefully review each vendor, rate them against your required criteria and provide insights and recommendations to ensure you will be capturing the full value for services rendered. 

Need a trusted outsourced vendor to help?

Opening Up for Business With states and counties opening up for businesses again, organizations will need to think through what it will look like bringing employees back in-house:

  • How will the departments maintain social distancing to protect their staff?
  • What will the procedures be if someone is identified as having COVID-19 symptoms?
  • Will you send all staff home for 14 days to self-quarantine if they had potential contact?
  • What cleaning measures will be conducted? 

There are several things to consider and procedures to put in place when it comes to reopening.

Understanding the Importance of Revenue Cycle Management
It’s important to document the system and process changes you have implemented so they can eventually be reversed and/or revised.

Communication with all applicable areas and quality data intake is critical during these times; 60% of the insurance claim sent to payers is captured during the patient access processes. Changing and developing coding and billing guidance is difficult to manage, especially if the workforce isn’t at full capacity. Cash flow is necessary and can be more challenging if staff are pulled into other roles. The right procedures need to be in place to ensure employees have a safe work environment, but they also need to be documented and communicated.

The impact of COVID-19 is far reaching, from your staff to coding to billing and securing financial payment.

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