ROI realized from pre-bill review of documentation and coding

Photo: Helen King/Getty Images

Involving physicians in the mid-revenue cycle process can increase hospital ROI by 700%, according to Enjoin CEO Dr. James Fee.

Hospitals and health systems can improve revenue through a pre-bill review prior to claims submission, according to Fee. Enjoin does this work as a revenue cycle consulting business focused on documentation and coding. 

One of the first things Enjoin physicians check is that the care of the patient has been properly recorded. 

"We're never taught how to communicate with those who record our work, so it can be captured in the coding system," said Fee, who continues to practice as a physician in Baton Rouge, Louisiana.

Secondly, hospitals need to check the accuracy of the representation of that patient. 

"You want to make sure the severity of the patient is justified to get appropriately reimbursed," Fee said.

WHY THIS MATTERS

Documentation and coding falls in the middle of the revenue cycle. Through a pre-bill review of the estimated 30-50% of cases that are chosen for review at this stage because of their complexity, organizations can ensure the documentation supports coding compliance, MS-DRG accuracy, quality performance data and other measures.

Results have shown an impressive 700% percent ROI on average and in some cases, 1,000%, according to Fee. On average, the process shows that providers are17 times less likely to get a denied claim after a pre-bill review. 

Hospitals already have clinical staff in the rev cycle. Physicians add a layer of review. 

"We have practicing physicians who understand the disease process," Fee said. "We look at a case to make sure the diagnosis is correct. What was the focus of care for that hospital stay? That takes a level of clinical interpretation."

Enjoin, which has been around for about 30 years, does not offer a software product, but uses an analytics platform. It partners with clients as consultants in a technically agnostic way.  

Fee will speak on the topic "Mid-Revenue Cycle Drives Financial Stability During COVID19: How One Academic Medical Center Prospered," in-person during the Healthcare Financial Management Association annual conference, Monday, November 8, in Minneapolis. 

AUTOMATION

As revenue cycle directors look to automate, this is more easily done on the front and back ends of the revenue cycle rather than the mid-cycle process, according to Fee. This is one area that will have to wait until AI makes it possible to interpret the data seen by physicians and other clinicians, he said.

"Automation is easy to say as one-stop shopping for an easy solution, but you need to understand what you're automating," he said.

There can be an automation component to the prioritization of reviews, something Enjoin plans to bring to market soon.

"Automation will continue to rapidly grow," Fee said, "but there will always be that people component."

THE LARGER TREND

As in other areas of healthcare, COVID-19 brought a level of uncertainty about the proper testing and diagnosis recorded in the revenue cycle.

During the most recent wave of COVID-19, many hospital ICU beds were again full, and health systems once again were canceling elective surgeries, with a resulting loss of revenue. 

Higher expenses for labor, drugs and supplies, as well as a continuation of delayed care, are projected to cost hospitals an estimated $54 billion in net income over the course of this year, according to Kaufman Hall analysis released last month by the American Hospital Association.

"The biggest impact for reimbursement was the loss of patient care," Fee said. "We were in a fee-for-service model and margins were driven by elective surgeries."

COVID-19 also shifted the commercial dominance of margins to lower-paying government reimbursement as employees lost their jobs, according to Fee.

During the first COVID-19 wave in 2020, CFOs were asking he said, "How do I adapt to that?" Many looked to prevent financial leakage in employing resources they already had. 

"That's where CDI (Clinical Documentation Improvement) is helpful," Fee said. 

Twitter: @SusanJMorse
Email the writer: susan.morse@himssmedia.com