Turning Financial Crisis Into ‘Opportunity’ Using A Clinically-Integrated Revenue Cycle

Winston Churchill once said, ‘Never let a good crisis go to waste.’ It’s the idea that even in the most challenging of times, there are lessons to learn and perhaps even opportunities to seize. COVID-19 is truly a crisis of monumental proportions. The statistics are shocking: Many healthcare organizations have seen a 40% to 45% decrease in operating revenue since the pandemic began, leading to operational crises such as insufficient adequate staffing and lack of personal protective equipment.

Fortunately, there’s a silver lining: Healthcare organizations can improve operational and financial efficiencies … but only if they act quickly using a thoughtful approach to denials prevention.

Clinically-Integrated Revenue Cycle: Why it makes sense for denials prevention

Turning crisis into opportunity starts with a single step. First, use COVID-19 as the impetus for creating a clinically-integrated revenue cycle (CIRC)—that is, one in which proactive denials prevention and revenue recovery is everyone’s responsibility. We mean everyone. This includes registration and patient access staff, nurses, physicians, coders, clinical documentation improvement specialists, ancillary staff, and others. Embedding a CIRC philosophy into company culture is one of the most effective operational changes an organization can make—particularly if it wants to avoid risk and take advantage of financial opportunities that arise during the pandemic. Some of these opportunities may only be available for a short period of time. Organizations with a CIRC can pinpoint opportunities, disseminate information quickly, and enable nimble operational changes.

Regulatory requirements are evolving with a rapid pace during COVID-19. For example, there are new coverage requirements for COVID-19 vaccines as well as changes to telehealth-related waivers, new ICD-10-CM and CPT codes, and more. These updates require constant oversight. Stakeholders must be able to act quickly to determine whether and how regulatory changes affect daily workflow.

Organizations can’t wait until their next monthly revenue cycle meeting to discuss new regulations. By then, opportunities may be long gone. In some cases, the organization might even be at significant risk for noncompliance.

What are two important financial opportunities to date? Consider the following:

1. Higher payments for COVID-19-related admissions: First, there’s the opportunity to receive 20% higher reimbursement for COVID-19-related admissions. This payment increase, which went into effect for COVID-19-related admissions on or after January 27, 2020, is a code-based payment adjustment. Prior to April 1, the increase was driven by ICD-10-CM code B97.29. However, as of April 1, that code changed to ICD-10-CM code U07.1.
2. As of September 1, organizations that receive the 20% payment increase must have a positive COVID-19 lab test documented in the medical record. This test can be performed either during or within 14 days prior to the hospital admission. It can also be performed outside of the organization (e.g., at a pharmacy chain or independent urgent care clinic).
3. Organizations with a CIRC can help capture this additional reimbursement, when warranted. For example, coders and CDI specialists can work together to ensure that a copy of the COVID-19 test is obtained. The organization should implement a process to ensure test results are included in the record prior to the final claim being released. They can also ensure accurate service dates and admit/discharge dates.
4. Enhanced payments for new COVID-19 treatments: For discharges on or after November 2, 2020, Medicare provides enhanced payments for eligible inpatient cases that involve use of certain new products authorized or approved to treat COVID-19. The enhanced payment will be equal to the lesser of: (1) 65% of the operating outlier threshold for the claim; or (2) 65% of the cost of a COVID-19 stay beyond the operating Medicare payment (including the 20% add-on payment under section 3710 of the CARES Act) for eligible cases.
5. On the outpatient side, CMS has excluded FDA-authorized or approved drugs and biologicals (including blood products) authorized or approved to treat or prevent COVID-19 from being packaged into Comprehensive Ambulatory Payment Classification (C-APC) payment when these treatments are billed on the same claim as a primary C-APC service. Instead, Medicare will pay for these drugs and biologicals separately throughout the course of the public health emergency.
6. A CIRC supports collaboration between all key players so organizations can capture these financial opportunities with ease. For example, coders and CDI specialists can work together to support MS-DRG validation that enables accurate enhanced payments.

Other Areas of Financial Opportunity

For organizations focusing on revenue, there are plenty of other non-COVID-19-related financial opportunities to consider. Here are just a few:

• Alleviating coding backlogs
• Auditing telehealth visits to ensure revenue integrity
• Capturing correct demographic information
• Capturing underlying or pre-existing conditions
• Implementing an outpatient CDI program
• Mastering patient index integrity
• Sequencing codes correctly
• Submitting timely appeals

Devoting time and resources to these efforts can pay dividends in the long-run and help organizations rebuild in the wake of COVID-19. With a CIRC, financial opportunities become much easier to pursue because everyone is on the same page and understands how their work affects the big picture. The time to act is now. Pay attention, collaborate, act quickly, and reap the rewards.