HQM Consulting

Healthcare Quality Metrics

The value-based care models are assigning accountability to providers for the services they provide to patients. These same models are also designed to shift financial accountability away from payers to healthcare organizations. This leaves many hospitals and providers seeking guidance in how to align their revenue cycle management strategies with value-based reimbursement arrangements.

The first area to explore is whether your physicians and nurses are following evidence-based practices across the organization. Implementing standardized care, which is supported by data metrics that can identify outliers and what the cost is to treat. Those outliers are the ones that will drain your resources.

Next is ensuring the medical record accurately reflects the patient’s acuity and in turn will justify medical necessity that leads to decrease in denials. This can best be accomplished through accurate documentation. It would advantageous to invest in a rigorous Clinical Documentation Improvement (CDI) program. There are several ways to approach to building a successful CDI program; first step is to have HQM consulting perform an audit and assessment of the CDI opportunity at your facility.

2015, CMS reported that $24 Billion was not paid out to hospitals across the country due to HACs. Through our consulting practice we believe that one third of the HACS could be reversed. That is $7 Billion back to healthcare’s bottom line. There is an exclusion algorithm that is associated with every HAC; the HQM’s team is very knowledgeable and can (provide a roadmap) establish a HAC review committee  for your healthcare organization and  implementing) concurrent HAC reviews.  

Revenue cycle systems are often stand-alone department, and this can easily lead to lost revenue opportunities. Healthcare organizations may need to invest in updated software that combines patient accounting, billing, collections, and the electronic medical record.

Invest in your staff to have the capabilities in the denial management processes, improving point-of-service collections and decrease delays in patient billing can all be very effective in improving revenue cycle productivity.

The CFO needs accurate acuity data to argue that the patient population is more acute and require more hospital resources than previously reported. This is especially relevant with commercial payers and Medicaid.  

An effective revenue cycle includes the following characteristics:

  • Well trained dedicated staff to support professional pro-fee billing
  • A vigorous well coordinated practice management system
  • Accountability between front and back end staff.
  • Consistent policies and procedures that are well documented and communicated throughout the department with clear performance metrics and expectations.

HQM Consulting will team with your organization to find solutions so you can reach your long term revenue cycle goals. Initially an audit and assessment will need to be performed by HQM consulting team to uncover system failures in a given department. This will provide the data required to develop a short term action plan, and start generating additional revenue in the short term to fund a more comprehensive long term plan that will be self funding and generate sustainable gains.  

THe Alchemy of Reimbursements

Robust CDI

HAC Review

HQM Consulting for Healthcare Quality Metrics

Contract negotiations

Revenue cycle

The HQM Challenge:

the Healthcare Quality Matrix


How to Increase Reimbursements

and Drive DOWN Denials & HACs