Whose Territory Is It Anyway?

Whose Territory Is It Anyway?

By John Zelem, MD, FACS

Hospitals and health systems need to update their current revenue cycle processes, becoming more efficient in that arena. Revenue cycle must eliminate inefficient processes in order to drive revenue preservation that translates into optimal net patient revenue. These changes need to be sustainable, consistent, with standardization and accountability. Profit margins have declined over the last several years and COVID-19 has added another layer of complexity that must be dealt with requiring a heightened focus upon revenue preservation as a key component of revenue optimization. There is no room for failure, although many hospitals have had to close with today’s challenges. The question arises as to how can this be done in today’s territorial environment?

When looking at revenue cycle from an end to end perspective, from the start of a patient’s hospital stay to the discharge and final bill submitted, there are five major components involved. They are:

  • Utilization Review
  • Case/Care Management
  • Clinical Documentation Integrity
  • Physician Advisor
  • Coding/Compliance

These components tend to be siloed, even to the point of protecting their territory. The only component that really is not in a silo is the physician advisor as they interact with several of these components daily. The interesting fact, or “cement” to this as I call it, is that all of these “territories” are looking at the same documentation, the same chart, just through different lenses.

Each component listed above needs to be considered in a holistic manner, a process where each part affects the whole. Processes must work towards the greater good, not silo protection, because they are all seated at the same table. Collaboration is needed along with the standardization and accountability that is required for success and sustainability. Without that, you may fail.

Here are some questions that one must ask when it comes to accountability and breaking down these silos. There MUST be communication between all parties.

  • Does leadership really understand what their component does?
    • It may even be necessary for a leader to shadow some of their reports, not just the managers, to actually learn what they do
  • Does each component have the right tools and staff to achieve outcomes?
    • Are standardized outcomes defined
  • Is there some type of education across the enterprise to have an overarching understanding of each component?
  • Is physician education consistent across all specialties and components?
  • Are there reward for outcomes, not tasks, KPI’s?

Marcela Sapone,  an American entrepreneur and CEO of New York-based startup Hello Alfred, has said: “Ticking off tasks on our to-do list might make us feel productive. But to truly be productive, we must clearly visualize the outcomes we want and design everything we do around getting them.” Clinical Documentation Integrity (CDI) is the prime example of this concept. Instead of focusing upon such a narrowly scoped component of documentation, capture of CC/MCCs, we need to immediately address the root cause of all nontechnical denials, poor documentation. When 80 percent of all improper payments for 2019 under the CERT program are attributable to medical necessity and insufficient documentation, they must move away from the tasks, the KPI’s, of how many CC’s and MCC’s can they secure, to accuracy and completeness of documentation by taking a preemptive proactive denials avoidance approach to documentation and retain net patient revenue.

Where does this solution start? It starts with the “cement,” the commonality, the documentation. Clinical documentation is at the core of every patient encounter and it must be accurate, timely, and reflect the scope of the services provided. It must tell the patient story. Medical Necessity must be established to facilitate the accurate representation of a patient’s clinical status that will eventually translate into coded data for revenue preservation. Without accurate documentation to support the medical necessity of an inpatient level of care, CDI is not needed. Simply put CDI Is Immaterial and Irrelevant.

This coded data then gets translated into quality reporting, physician report cards (if utilized), reimbursement, public health data, and disease tracking and trending. This process, this documentation, is vital to a healthy revenue cycle, and, most important, to a healthy patient. CDI can materially have a direct impact on patient care by providing information to all members of the care team.

Some of the results that can be achieved as “boots on the ground” are the following:

  • The integration of workflows and/or thought processes that promote best practices in the continuum of care, and documentation capture that is critical in improving quality and patient experience by ensuring care is delivered appropriately to every patient and that the hospital is reimbursed for that care
  • All members support Coding accuracy to accurately depict the patient encounter
  • Collaborative platform that validates the level of care
  • Focus on specificity of documentation with clinical validation for improved accuracy and clarification
  • Streamlining of messages from multiple sources
  • Education of each department to the other

There is no doubt that today’s healthcare crisis has affected all of us in every industry. Hospitals have not been immune to this consequence, but hospitals must remain as a hallmark of our healthcare. They are critical to the well-being of every one of us. Hospitals deserve to get paid for the services they provide, PERIOD!  Processes must be improved and streamlined. We owe it to our patients and the fiscal health of our healthcare facilities.

Hopefully, this analogy will make you think! There is a story about a farmer sitting in a rocking chair on his front porch and his dog lying next to his side. Every once in a while the dog would raise his head and howl, then lay his head back down. Later on, that day a salesman came by and started talking to the farmer. During the about 15 minutes of conversation, the dog did that about 3 times.

The salesman asked: “What’s the matter with your dog?”

The farmer replied, “Oh, he’s just laying on a nail.”

The salesman retorted, “Why doesn’t he move?”

“I guess it doesn’t hurt him enough!” the farmer stated with a smile.

What kind of pain needs to be experienced to get one to move off their nail?