Five Steps to Capture Lost Revenue for Hospital Outreach and Outpatient Services

This blog post is part one of a five part series. View Part Two, View Part Three, View Part Four, View Part Five.

Health systems and hospital groups are looking to outreach, outpatient, and ancillary services to boost topline and bottom-line results and bolster overall quality of care. Yet many of these departments are confined to using EHR systems designed for inpatient services. Too often, this leads to coding discrepancies, cumbersome appeals with insufficient documentation, excessive write-offs, and potential compliance risks. A lack of advanced analytics further compounds the problem, preventing needed data transparency and impairing critical decision-making.

According to a recent report from the Deloitte Center for Health Solutions:

• Outpatient services grew from 28 percent of total hospital revenue in 1994 to 48% in 2018.
• Between 2011–18, hospital outpatient revenue grew at a 9% compounded annual rate, compared to 6% for inpatient revenue.

This dramatic shift further heightens the negative impact of using inpatient billing systems for revenue cycle management (RCM) in outpatient services. By employing five key strategies for managing claims within this framework, you can minimize the number of unsuccessful claims and avoid substantial lost revenues.

Step 1. Automate Front-End Processes:

Revenue Cycle Management success is heavily reliant on the accuracy of data provided by ordering physicians. Errors and missing data, in part caused by a lack of patient interaction, lead to downstream complications and delays. By design, standard EHR setups do not wait for a manual scrubbing of medical necessity, eligibility, and demographic inputs. These bad claims are simply routed on and ultimately denied by payors.

XiFin data show that it costs $25 or more each time a person intercedes to resolve an outpatient claim. Because of the relatively low dollar amount for many outpatient and outreach services, policies dictate that these claims simply be written off. In effect, there is a growing built-in claim failure rate for outpatient and outreach service billings in EHR systems.

The cumulative impact of these systemic defects is often substantial, unnecessary, and preventable. How can these issues be avoided?

Front-end automation capabilities that assist with this process include:

• Patient data discovery: Integrated within patient and client correspondence workflows, identifies and fixes inaccurate patient data and improves client and patient experiences.
• Automated eligibility checks: E.g., confirms patient insurance information corresponds to indicated date-of-service.
• User-friendly client and patient portals with real time connectivity.
• Payor edit automation: Published payor edits are automatically updated to ensure claims meet current payor requirements prior to submission.
• Automated consolidation rules with compliance logic and prompts: Simplifies payor billing rules to comply with health care policies and requirements; ensures the appropriate number of service units are billed for a specific date of service based on payor MUEs; bundled services are billed with the correct procedure code(s) and modified or appended as needed based on NCCI edits and AMA codes.
• Pricing based on contracts.
• Configurable outpatient-specific workflow logic to address relevant claims requirements (E.g., “72-hour rule”).
• Patient responsibility estimator provides up-front visibility to pricing.

Interested in reading the rest of this series? Subscribe to our blog. View Part 2, “Enhance Your Denial Management Process.“

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