3 Essential Steps for Integrating Revenue Cycle, Clinical Documentation, and Utilization Management

By Megan N. Beasley, RHIA, CPC, CPMA; Colleen O. Hall, CPC, CIRCC, CPMA; and Megan R. Sorensen, CPMA
| 6/13/2018
3 Essential Steps for Integrating Revenue Cycle, Clinical Documentation, and Utilization Management
In the increasingly complex business of healthcare, it is easy to see how departments within an organization can unintentionally drift into their own silos. This segmented approach, however, can have negative results that affect patient care, payer relationships, and the bottom line. With U.S. hospitals losing approximately $262 billion per year due to denied claims from insurers,1 having essential departments all working toward the same goal is critical to operational and financial success.
 
With better integration among departments – particularly the revenue cycle, clinical documentation, and utilization management departments – organizations can begin to break down some of these silos. Better interdepartmental relationships can lead to several benefits, including enhanced productivity and increased revenue due to fewer denied claims and reduced patient length of stay and readmissions.
 
Here are three strategies to integrate and improve communication among departments.

1. Identify a Strategy for Communication
Communication is the cornerstone of any effort to improve working relationships among organizational departments. To start, organizations should establish routine communication among departments. Some examples include daily huddles by staff members to help manage individual patients’ care and monthly cross-departmental meetings.
 
In addition, for departments to be on the same page in daily work and long-term process improvement efforts, they should be able to view the tools and systems the other departments are using. Often, departments are operating and documenting in different IT systems, preventing them from being able to see what is going on elsewhere in the organization. For optimal information sharing, departments should aim to have their individual systems interact with one common system that is readily accessible to all.
 
Each department’s communication with payers is also vital to successful, integrated working relationships. The revenue cycle, clinical documentation, and utilization management departments all should align strategies such as how staff members are communicating with payers during contract negotiations or while mitigating issues related to claims denials. Open communication can promote less duplication of efforts related to payer interactions.
 
Departments must identify and share information about payer deficiencies and opportunities to maximize net revenue. Staff from all three departments should combine efforts to make payer representatives aware of deficiencies and other issues. They also should bring deficiencies to the attention of the organization’s managed care department. Organizations should consider creating a payer log that defines payer opportunities and issues and is available to the revenue cycle, clinical documentation, utilization management, and managed care departments.
 
2. Focus on Clinical Denials – Together
When departments cooperate at all stages of the clinical denials process, they should be able to optimize utilization management and case resolution. By working together interdepartmentally, staff from all three departments can begin to minimize the time spent resolving denials and work proactively to prevent them. Joint reporting of clinical denials data also can help in operational improvement and denials management.
 
To manage clinical denials successfully within the organization, each of the three departments must understand the others’ roles in the process. Visibility into what each department has done or actively is doing to work a denial case is crucial to avoid duplication of work and to maximize staff members’ efforts. Following are three examples of errors that could occur due to lack of shared knowledge:
  • The revenue cycle team prematurely writes off an account without knowing that it is in an active appeal status from a utilization management standpoint.
  • The utilization management team lacks shared knowledge and is not aware of an open denial assigned to their department.
  • The clinical documentation team is actively querying a physician, but the patient bill is sent prior to completion of the query.
3. Make Good Use of Data
An abundance of data analytics is available and accessible within provider organizations. Each department should have insight into the data so they all can see how the organization is performing. Access to data analytics also can help drive identification of opportunities for performance improvement.
 
To promote interdepartmental knowledge sharing further, organizations should establish a robust education and training program that provides targeted education and knowledge sharing among clinical staff and revenue cycle services staff. The organization’s physician adviser — in conjunction with members of the revenue cycle, clinical documentation, and utilization management departments — should facilitate such programs. Training and education should focus on the following topics:
  • Using data analytics
  • Developing focus points for documentation requirements
  • Improving documentation, including creating detailed summaries of care provided to patients
  • Understanding new Centers for Medicare & Medicaid Services policies and guidelines about medical necessity

Consider Additional Help

Implementing these strategies can be a good start to improving communication and workflow within healthcare organizations. Providers also should consider working with a third party or implementing a formal internal process improvement initiative to further break down barriers and open communication among these three areas.

 

 
1 Dave Barkholz, “Insurance Claim Denials Cost Hospitals $262 Billion Annually,” Modern Healthcare, June 27, 2017, http://www.modernhealthcare.com/article/20170627/NEWS/170629905
 

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