The Revenue Cycle (RCA) professionals have been challenged over the years with new regulatory implementation including the Affordable Care Act, the implementation of ICD10, Value Based Purchasing, adoption of the EMR, and MACRA. It is imperative that hospital leadership invest in a robust revenue cycle team.

RCA faces many challenges today:

  • Lack of skilled resources: many organizations have struggled to find the right personnel with the skill set to accurately code ICD 10 specifications, project management, clinical documentation improvement, denials, and other revenue cycle functions.

  • Escalating Costs and Narrowing MarginsDecline in Medicare, Medicaid, and commercial reimbursements are forcing executive leadership to review processes to increase efficiencies and automation to curb expenses

  • Value Based Purchasing: " The Hospital Value-Based Purchasing (VBP) Program adjusts what Medicare pays hospitals under the Inpatient Prospective Payment System (IPPS) based on the quality of inpatient care the hospitals provide to patients. For fiscal year (FY) 2019, the law requires that CMS reduce a portion of the base operating Diagnosis-Related Group (DRG) payment amounts otherwise applicable to a participating hospital for each discharge by two percent (2.0%), and that the estimated sum total of these reductions be the amount redistributed to participating hospitals based on their performance on a previously-announced set of quality and cost measures. We estimate that the total amount available for value-based incentive payments in FY 2019 will be approximately $1.9 billion." (CMS, 2019,para 1)

  • Total Performance Score (TPS): equal weights of 25%

    • Safety​

    • Clinical Care

    • Person/Community Engagement

    • Efficiency & Costs Reduction

  • Concurrent Quality /Safety Programs: many organizations still employ a retrospective approach to quality and safety reviews. It is important to restructure the quality/safety departments so they employ concurrent processes and address errors/problems through root cause analysis.

  • System integration: implement software that houses revenue cycle, Clinical documentation and quality under the same umbrella to prevent further losses in reimbursements

  • Implement a robust Clinical Documentation Program(CDI): Restructure the CDI program that incorporates HCCs, meaningful use, second level quality reviews that target PSIs (Sepsis, Heart Failure, etc.) Hospital Acquired Conditions, Mortality Reviews, and Readmissions. Expand your CDI program into the Outpatient arena to ensure appropriate reimbursements.

  • Billing and Claims Management: It is imperative that leadership address denials and rejected claims. Provide training to your staff or employ outside expertise in denial management, point-of-service collections and decreasing the days in patient billing resulting in improved revenue cycle reimbursements and productivity.

What are the next steps? HQM Consulting can provide an audit and assessment your revenue cycle processes to assess


  • Educational & Training Opportunities

  • Policies & Procedures

  • Workflow Processes

  • Software

  • Outsourcing as an alternative

Audit & Assess CDI & QA for:

  • Educational & Training Opportunities

  • Policies & Procedures

  • Workflow Processes

  • Software

Example of processes to implement:

  • Bill hold on all HACs to be reviewed by CDI/QA & Provider

  • Bill hold on all 'Deaths' to be reviewed by CDI/QA & Provider

The goal is to ensure the assignment of the HAC is without an exclusion or POA status. All mortality reviews should assess if it was an expected outcome, and if not " what happened?"​

HQM Consulting will collaborate with executive leadership to design a targeted plan that will include front/back end billing, claims management to dash board reporting. There is tremendous opportunity to explore how best your RCA team can improve the organization's bottom line.


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