A recent study of data from the Centers for Medicare & Medicaid Services (CMS) by the Center for Medicare Advocacy (CMA) has shown a disconnect between the results of CMS infection control surveys and outbreaks of COVID-19 within skilled nursing facilities.
Infection control citations
In mid-March, CMS announced that inspections would focus on infection control programs – in addition to cases of immediate resident danger – to help suppress the spread of COVID-19 within SNFs. A review of CMS inspection data by CMA showed that a very small portion of infection control surveys resulted in citations. Out of 5,724 infection control surveys performed from the March announcement through June 24, only 99 resulted in citations.1
Of the citations, 93 were marked as having minimal harm or potential for minimal harm, and three were marked as having a potential for minimal harm. The remaining three were marked as putting residents’ health and safety in immediate jeopardy. Thirty-five of the citations resulted in fines.
The disconnect between citations and infections
The concern raised by CMA has been raised by officials in many states, as well as by families of afflicted nursing home residents: With the high rate of COVID-19 cases in nursing homes, the low amount of citations – which translates to 2.4 percent of surveys – seems “implausible,” according to CMA officials. Through the end of June, more than 40 percent of COVID-19 deaths in the United States were related to skilled nursing facilities.2
The CMA’s review showed that several of the CMS infection control surveys that did not result in citations took place even as SNFs were in the middle of COVID-19 outbreaks. Three days after a passing survey at one California facility, there were 68 diagnosed COVID-19 cases documented. The staff refused to return to work over concerns for their safety, and members of the California National Guard were deployed to care for residents.3
Those eyeing the survey results give different causes for the disconnect between passing surveys and COVID-19 infections. Some say SNFs lacked access to the personal protective equipment needed to keep staff and residents safe. Others called out a lack of regular testing among residents and staff. One CMS administrator said the disparity between survey results and infection rates likely shows that SNF staff demonstrated compliance during surveys but failed to follow protocols when they were not under scrutiny.
Maintaining infection control programs
Amidst the COVID-19 pandemic, maintaining infection control protocol has become more important than ever in keeping residents and staff safe. The number of SNF deaths due to the pandemic and the results of the CMA’s data review could lead to further scrutiny of infection control programs or more stringent infection control program requirements.
SNFs can stay on top of regulations, infection control protocol and patient data with ABILITY INFECTIONWATCH. The application allows for easy tracking of McGeer criteria, infection reports and infection control measures. SNFs can tighten their vigilance against infections by customizing infection thresholds; when those thresholds are reached, an alert appears on the ABILITY INFECTIONWATCH dashboard so staff won’t miss the signs of an outbreak.
1. “Special Report Additional Infection Control Surveys at Nursing Facilities Show Same Results: Few Deficiencies, Most Called ‘No Harm’; Poor Ratings on Nursing Home Compare,” Miriam Edelman, July 9, 2020, https://medicareadvocacy.org/wp-content/uploads/2020/07/Report-Coronavirus-Infection-Controls-Second-Batch-.pdf?emci=0f6236c7-f5c1-ea11-9b05-00155d03bda0&emdi=526f3f5a-0dc2-ea11-9b05-00155d03bda0&ceid=7801066.
2 “More than 40 Percent of U.S. Coronavirus Deaths are to Nursing Homes,” The New York Times, July 23, 2020, https://www.nytimes.com/interactive/2020/us/coronavirus-nursing-homes.html.
3 “As Coronavirus Raged Through Nursing Homes, Inspectors Found Nothing Wrong,” Jack Dolan & Brittny Mejia, June 28, 2020, https://www.latimes.com/california/story/2020-06-28/coronavirus-nursing-homes-state-inspector-covid-19.
ABILITY and design® and ABILITY® and ABILITY INFECTIONWATCH® are trademarks of ABILITY Network, Inc.
The Centers for Medicare & Medicaid Services (CMS) has imposed more than $15 million in penalties on 3,400 skilled nursing facilities for failure to comply with infection control regulations in the midst of the COVID-19 pandemic. The announcement of the penalties comes with a warning to SNFs to stay vigilant in monitoring their infection control programs.
“Now more than ever, nursing homes must be vigilant in adhering to federal guidelines related to infection control to prevent the spread of infection disease, including COVID-19,” said CMS Administrator Seema Verma. “We will continue to hold nursing homes accountable and work with state and local leaders to protect the vulnerable population residing in America’s nursing homes.”1
Avoid CMS penalties
ABILITY INFECTIONWATCH can help your facility avoid costly CMS penalties with better infection control monitoring. This valuable application makes it easier for your facility to meet all CMS Requirements of Participation, and it allows you to quickly pull reports to meet the requests of surveyors. Using built-in national infection criteria, infection control administrators align facility data with reporting requirements consistently and efficiently.
Accurately track symptoms and infections
As COVID-19 continues to spread throughout the U.S., ABILITY INFECTIONWATCH helps you to protect against outbreaks utilizing your facility’s data. Monitor symptoms, track and report infections, oversee facility visitors and identify the sources of infections through the application. The convenient dashboard allows you to customize alerts so you are notified when your preset data points are reached.
Protect your facility
COVID-19 poses a real danger to SNF residents and staff. And never before have facilities been placed under such scrutiny. ABILITY INFECTIONWATCH provides the tools you need to protect your facility from a coronavirus outbreak. It also allows you to track, access and report the data required by CMS to reduce the risk of survey deficiencies and costly penalties.
Protect your facility from a potential outbreak – and potential financial penalties. Learn more about ABILITY INFECTIONWATCH now.
1. “Trump Administration Has Issued More Than $15 Million in Fines to Nursing Homes During COVID-19 Pandemic,” Centers for Medicare & Medicaid Services, August 14, 2020, https://www.cms.gov/newsroom/press-releases/trump-administration-has-issued-more-15-million-fines-nursing-homes-during-covid-19-pandemic
ABILITY and design®, ABILITY® and ABILITY INFECTIONWATCH® are trademarks of ABILITY Network, Inc.
|Healthcare workers across the U.S. – many who thought the worst of the COVID-19 pandemic was behind them – have been hit with a blast of harsh reality.
Hospitals in California, Texas, Florida and elsewhere are reporting shortages in equipment, drugs, beds and staff as the pandemic has spiked in some areas. Concerns abound that more waves could land in the fall, right as the annual flu season starts.
Healthcare workers on the front line, despite being more cautious and better equipped than the average citizen, are at high risk for contracting the virus. In fact, according to the Centers for Disease Control (CDC), healthcare professionals account for 106,180 cases and 552 deaths. And those numbers don’t paint the full picture because, of the data collected, healthcare personnel status was only available for 21.6% of the subjects.
The CDC warns that healthcare organizations must be prepared for staffing shortages due to exposure to COVID-19, actual illness or to care for loved ones who become ill with the virus.
In healthcare, where staffing shortages already make shift management and adequate staff-to-patient ratios a challenge, more surges are bound to leave hospitals reeling.
To help healthcare organizations, the CDC has released Strategies to Mitigate Healthcare Personnel Staffing Shortages on its website. We highly recommend you read the full article, but here are some highlights.
Understand how many employees you must have
Know the minimum number of staff you need to provide high-quality care and a safe work environment. That is the benchmark for establishing your schedule for all doctors, nurses, paramedics and support staff, including custodians and administrators.
With that as your baseline, you can then set up contingency plans in the event of a surge in your facility, for example, by:
The goal here is to not wait until you are up against a shortage, but instead, prepare for a worst-case scenario. That starts by understanding your most basic staffing needs and having steps in place before a shortage occurs.
How do busy healthcare leaders track it all?
A previous post examined how the pandemic is complicating credential tracking, as states waive requirements and help comes from retirees, students, volunteers, ex-healthcare staff whose licenses have expired and out-of-state professionals.
COVID-19 is creating the same challenges for staffing.
Think about it: What if three ICU nurses called off sick one hour before a shift? What if several hospital custodians went on strike because they weren’t receiving adequate PPE? What if the on-call ER physician is a no-show? Or half of your ER registrars had to quarantine?
Do the managers who oversee those employees have the information they need to find replacements quickly and efficiently?
For many organizations, that is a “No.” Healthcare leaders and managers don’t have the broad visibility or context to make quick staffing decisions on a “normal” day – much less during a crisis. They can spend hours poring over spreadsheets and making calls to find replacements.
Add in an influx of on-call volunteers or new hires and the complexity grows. And if your organization has no other choice but to allow employees with suspected or confirmed COVID-19 to work, scheduling that person so that they can treat patients that meet the CDC’s criteria is a logistical nightmare. That’s a detail that you would need to consider and track as you create the schedule and fill open shifts.
ABILITY SMARTFORCE Scheduler enables you to act fast
With the deep visibility and intelligence you gain from ABILITY SMARTFORCE Scheduler, you can better meet the needs of your patients and staff now and long after you’ve recovered from the pandemic:
Plus, check out the rest of ABILITY’s suite of mobile applications that take the work out of workforce management:
All our applications are affordable and easy to deploy and use. Upgrade how you manage your workforce by contacting our sales team at 888-552-4049.
ABILITY and design®, ABILITY®, ABILITY SMARTFORCE® and Credentialer® are trademarks of ABILITY Network, Inc.
|It seems like eons since the first case of COVID appeared in the U.S. – even though it was only January. Since, we’ve been on a bit of roller coaster ride, as states have experienced peaks in cases, hospitalizations and deaths. While some locations are experiencing downward trends, or at least remaining steady in all three areas, others are seeing a second surge, and many states are tightening restrictions and facing further shutdowns.
To help manage the public health threat, states loosened mandates on nurse credentialing and licensing. Response has varied by state, including waiving state requirements and regulations for RNs, LPNs and NPs so those who held unrestricted licenses within a specific time frame could temporarily reactivate their licenses without taking any test or paying fees. Additionally, healthcare professionals have been permitted to work in a state without being required to obtain a license in that state.
For some organizations, volunteers from other states, students, retirees or others who left the profession are working again, alongside existing staff, They all have different licensing and credential requirements and expiration dates.
Realities of licensing testing also complicate matters
Adding to the challenge is that many healthcare licensing testing sites are temporarily closed, and of those that are open, many are operating at half the capacity. Others have switched to an electronic format. For many employees, especially those in areas with limited testing sites or for those who don’t have easy access to the internet or a PC, scheduling a certification or recertification can be difficult, if not impossible.
Tracking licenses and credentials has become more complicated than ever
Regulations and licensing testing challenges are part of the problem. The other is simply prioritization. Many organizations have been in survival mode, doing whatever it takes to care for patients. It’s easy to forget about your CPR recertification, for example, when you are fighting to save people’s lives.
For organizational leaders and managers, it’s a troublesome situation. Because while some requirements in your state may be waived now and for the short term, at some point, those mandates will tighten again and you’ll need the visibility and intelligence to ensure everyone is up to date as quickly as possible – or face costly penalties.
Reduce compliance concerns with ABILITY SMARTFORCE Credentialer
With ABILITY SMARTFORCE Credentialer, a cloud-based application that you can access from any device, you and your staff can organize licenses, certifications and in-services in one secure, intuitive dashboard.
Plus, both you and staff members will receive alerts when a certification is up for renewal, so you dramatically decrease the number of lapsed credentials in your organization.
With ABILITY SMARTFORCE Credentialer, you can easily track these vital certifications:
If you want to prevent lapsed credentials, we can help. Don’t wait until the mandates tighten to find that you aren’t in compliance. Gain the visibility and intelligence you need now to keep staffing credentials current. Learn more about the highly affordable ABILITY SMARTFORCE Credentialer or see it for yourself by signing up for a free demo.
ABILITY and design®, ABILITY® and Credentialer® are trademarks of ABILITY Network, Inc.
In a memorandum released on June 25, CMS announced the end of the COVID-19 emergency waiver for staffing data submissions.
Back in March, CMS had granted a series of blanket waivers to lessen administrative burden and allow nursing homes to focus on responding to the COVID-19 threat. Facilities now must resume submission of their staffing data through the payroll-based journal (PBJ) system as required by regulation.
Why it matters
A recent study published in the Journal of the American Geriatrics Society found that facilities with lower nurse staffing levels and lower scores on the Five-Star Quality Rating System before the pandemic had higher rates of COVID-19 infections and deaths. In fact, higher nurse staffing ratios were strongly correlated with fewer cases and deaths.
The authors of the study recommended that nursing home inspections should target facilities with lower RN staffing levels and quality ratings in addition to those located in areas with high infection rates.
On the heels of these findings, CMS made the announcement that nursing homes must recommence submission of their staffing data, stating that “we continue to emphasize the importance of staffing based on its relationship to quality.”
What this means for your facility
Here’s what you need to know about PBJ data submissions for 2020:
- Staffing data for April-June is due by the usual deadline of August 14
- You are not required to submit your staffing data for January-March
- Nursing Home Compare is displaying the staffing star rating based on your October-December 2019 data
- New Five-Star staffing ratings, based on your April-June data, will post at the end of October 2020
- Facilities that received an automatic staffing downgrade to one star for the fourth quarter of 2019 will have their measures and rating temporarily suppressed and that one-star staffing rating downgrade removed
How ABILITY can help
While CMS is giving long-term care providers the opportunity to correct and improve their star rating, the agency plans to restart inspections “as soon as possible.” To protect your star ratings and ensure compliance with the PBJ reporting requirements, it is crucial to act soon. This is where ABILITY can help.
ABILITY CAREWATCH PBJ puts the right tools at your fingertips so you can efficiently collect, classify, validate and submit your facility’s direct care staffing data accurately and on-time.
To see firsthand how easy PBJ reporting can be, request a demo today.
ABILITY and design®, ABILITY® and CAREWATCH® are trademarks of ABILITY Network, Inc.
Uncompensated care is a growing concern for hospitals, health clinics and skilled nursing facilities.
In 2016 and 2017, community hospitals provided $38.4 billion in uncompensated care—a $2.3 billion increase from 2015.1 Between 2012 and 2017, bad debt resulting from Medicare patients not paying deductibles and coinsurance increased by 17%.
How can healthcare organizations actively combat write-offs and payment delays while maintaining high patient satisfaction? One way to do so is through proactive financial clearance.
What is financial clearance?
Financial clearance is a process that determines a patient’s ability and likelihood to pay. Using that information, providers can design intake and collection processes tailored to the unique needs of different patient populations, including eligibility for financial programs, patient counseling and payment plans.
In short, financial clearance improves the patient experience and the productivity of your staff.
A rising need for payment flexibility
With high-deductible health plans on the rise, more patients are opting to self-pay for medical care—but it’s an uphill battle for the average American. Forty-four percent of adults don’t have the savings to cover an emergency expense of $400 or more,2 yet the average outpatient hospital visit costs almost $500.3
For those who do use insurance to cover medical expenses, the costs are also going up. The average patient balance after insurance (PBAI) rose from 8% of the total bill in 2012 to 12.2% of the total bill in 2017.4 The average family spent $7,726 on premiums and cost-sharing in 2018, an 18% increase over the $6,571 spent in 2013.5
The growing financial burden on patients makes it tougher for healthcare organizations to collect. Not only that, but it can lead to feelings of frustration and confusion, which hinder the patient experience.
Tackling financial conversations head-on with proactive financial clearance gives providers a clearly defined path toward the most likely payment method while helping patients feel confident about the options they have to pay for care.
How does financial clearance work?
Financial clearance combines two complementary components: patient identity verification and propensity-to-pay scoring.
Credit and non-credit data sources are used to verify identity and address data during admission or intake, which cuts down on patient information errors. Incorrect patient information is one of the leading reasons for claims denials and past due accounts, which cost time and slow down the revenue cycle.
Next, the patient (or financial guarantor) is assessed a propensity-to-pay score, which indicates the individual’s ability and likelihood to pay. The score is linked to a set of custom messages designed to help segment patients into various population groups. For example, a score within one range might prompt the user to collect a co-pay on the spot, while a score within a different range might recommend an installment plan.
In this way, healthcare organizations can capture payment more confidently knowing they’ve offered the most suitable option for the individual. In turn, staff spends less time acting as a bill collector and patients leave with a sense of empowerment over the cost of their care.
Boost payments with ABILITY COMPLETE Financial Clearance
Whether you’re a hospital, ambulatory care center or skilled nursing facility, ABILITY can help you analyze where and when you’re most likely to collect. Strengthen your financial performance, improve your staff’s productivity and most importantly, better serve your patients. Request a complimentary demo of ABILITY COMPLETE Financial Clearance today.
1 “American Hospital Association Uncompensated Hospital Care Cost Fact Sheet,” January 2019, https://www.aha.org/system/files/2019-01/uncompensated-care-fact-sheet-jan-2019.pdf
2 “Federal Reserve Report on the Economic Well-Being of U.S. Households in 2017,” May 2018, https://www.federalreserve.gov/publications/files/2017-report-economic-well-being-us-households-201805.pdf
3 “Study: Average hospital outpatient visit cost approaching $500,” Tauren Dyson, United Press International, December 13, 2018, https://www.upi.com/Health_News/2018/12/13/Study-Average-hospital-outpatient-visit-cost-approaching-500/6121544734917/
4 “Patient Balances After Insurance Continue to Increase in 2018, Driving Bad Debt and Uncompensated Care,” TransUnion, June 26, 2018, https://www.globenewswire.com/news-release/2018/06/26/1529420/0/en/Patient-Balances-After-Insurance-Continue-to-Increase-in-2018-Driving-Bad-Debt-and-Uncompensated-Care.html
5 “Tracking the rise in premium contributions and cost-sharing for families with large employer coverage,” Matthew Rae, Rebecca Copeland and Cynthia Clark, HealthSystemTracker.org, August 14, 2019, https://www.healthsystemtracker.org/brief/tracking-the-rise-in-premium-contributions-and-cost-sharing-for-families-with-large-employer-coverage/
ABILITY and design®, ABILITY® and ABILITY COMPLETE® are trademarks of ABILITY Network, Inc.
While healthcare profit margins continue to dwindle, the aging population increases. According to the U.S. Census Bureau, by 2030, adults aged 65 and older will outnumber children under the age of 18 for the first time in history!1 That makes it imperative that home health, hospitals, physicians’ offices, and other healthcare organizations find ways to do more with less. Finding home health billing solutions that streamline the scheduling of physicians and nurses and shortening the turnaround time for Medicare payments is crucial. Learn how home health billing works to navigate the best practices for success.
Step 1: Getting approval for patient services
The first step in home health billing is to connect with the patient and the physician to identify the services needed. The next step is to determine financial responsibility for that care (e.g., any combination of Medicare/Medicaid, supplemental insurance and private pay). Medicare will generally only pay for home health services that involve nursing care, physical therapy, occupational therapy or speech therapy. Home or personal care assistance are generally not covered by Medicare or supplemental insurance plans. Patients also must be homebound and meet a variety of other requirements for 100% reimbursement. With an all-payer eligibility management system, you can manage multiple payers, tasks and activities as well as assign and prioritize patients to keep the billing process moving smoothly.
Step 2: Checking Medicare/Medicaid eligibility
Once you determine the services and timing required, and have assigned the correct billing codes, the next step is checking the patient’s eligibility with Medicare/Medicaid. Having access to Medicare’s HETS database will make checking eligibility much easier as it gives your staff real-time, detailed eligibility and benefits information at the onset of a patient’s stay.
Step 3: Submitting the claims
Once care is provided, you will need to submit the claims to Medicare/Medicaid and to any supplemental insurance companies for payment. With all of the potential for human error in the billing process, automating your Medicare claims submissions can save you time and money. This efficiency can improve your cash flow and maximize your revenue. Automation helps eliminate ongoing follow-ups, reduces multiple contacts with payers and helps ensure the claims are processed without errors.
Step 4: Resolve denials
Because you are working with a variety of physician services, coding numbers, payers, and rules and regulations, there are bound to be times when claims are denied by either Medicare/Medicaid or private insurance. With powerful software solutions like ABILITY EASE All-Payer, you can automate the claims denial process and the correction of complex, multi-step claims. From a single dashboard, you can track appeals and communicate securely to resolve denials and improve cash flow. Automation can also free up your physicians and nurses so they can focus on seeing and treating more patients.
Step 5: Collect balance due from patient
An often overlooked, but important process in home health billing is to collect the balance due through patient payments. It’s important for patients to understand the bill, the itemized charges and the portion of the bill that was paid by insurance. Since only 50% of patients who experience billing difficulties pay their bill in full,2 it’s imperative to make patient payments as easy and convenient as possible.
Simplify your home health billing with ABILITY Network
Home health agencies have plenty to manage without having to worry about billing processes that can easily be upgraded from manual tasks to automated workflows. Whether it’s physician or nurse scheduling or researching denied claims, the powerful automated technology offered by ABILITY can help you. Give us a call today at 888.895.2649 and find out which software systems will work best for your needs. Or, request a no-obligation quote online. We’ll show you how we can increase your revenue cycle management and increase your cash flow!
1 “Older People Projected to Outnumber Children for First Time in U.S. History,” U.S. Census Bureau, March 13, 2018, https://www.census.gov/newsroom/press-releases/2018/cb18-41-population-projections.html
2 “How Patient Experience in Billing Offices Impacts Patient Payments,” Sara Heath, Xtelligent Healthcare Media, October 15, 2018, https://patientengagementhit.com/news/how-patient-experience-in-billing-offices-impacts-patient-payments
ABILITY and design®, ABILITY® and ABILITY EASE® are trademarks of ABILITY Network, Inc.
Regardless of the business you’re in, the capability to efficiently capture, manage and collect revenue is critical to success. Many healthcare organizations are turning to revenue cycle management (RCM) vendors and their high-tech software applications to help them achieve consistent profits. The demand from home health, physician offices and hospitals has resulted in a consistent stream of new RCM companies providing these services. But how do you decide on the RCM platform that’s right for your healthcare operation? Here are the top five things to look for in a revenue cycle management provider.
1. Comprehensive, customizable applications
One of the first things you should look for in a revenue cycle management provider is a full range of RCM components. Depending on your organization’s size, your current staffing and your top priorities, you may need a customized application that is just right for you. A company that offers an “all-or-nothing” approach won’t have the flexibility to meet your specific needs. In addition to all-payer claims and remittance processes, you may need physician scheduling or Medicare eligibility verification at some point. Ideally, you want to choose an RCM vendor who can help you identify your needs and then be equally happy to partner, to consult, to co-manage or to fully outsource their revenue cycle management. Plus, if you start small, you want a provider who can easily add-on the services you need as you grow.
2. Technology and security
Rapid technology changes are common in healthcare. You’ll want to make sure you hire a revenue cycle management provider who offers the most productive and efficient technology, including cloud-based software that’s reliable, easy to use and connects to your existing software. You’ll also want a vendor who stays ahead of changes in technology, modifying their products to bring the best to their customers.
3. Trust and transparency
Your revenue cycle management provider will be critical to your organization’s overall success. That’s why both trust and transparency are so important. Do your homework and read reviews, look at customer testimonials and business case studies. Investigate the company — how long have they been operating? Who are their owners? How involved are they in the industry? What is their financial health?
With regard to revenue cycle management software, will you have full access to manage claims and pull reports? You should have transparency when it comes to knowing and understanding the work that is being performed.
4. Effective software processes
When choosing a revenue cycle management provider, you want to make sure the automated processes implemented by the software are effective and easily customizable to your specific needs. That means your RCM platform needs to support rapid turnaround time for claims, as well as a low percentage of denied claims and a process for resubmitting those claims. Find out what the provider’s denial management strategy is — what percentage of claims are denied in the first place and how many will be resubmitted? You want your RCM vendor to take an active approach to quickly submitting claims and have the processes in place to appeal denials.
5. Personalized customer service — training and reporting
Get to know your potential providers and know the person who will be directly responsible for ensuring the success of your revenue cycle management program. Will that person run, analyze and review reports with you on a regular basis? Are they or other customer service personnel available 24/7? What is their level of expertise in working with healthcare systems like yours?
Part of great customer service includes proper onboarding of the new system with current employees. Make sure your RCM vendor provides onsite training to help you transition to their services.
Discover the difference at ABILITY Network
When searching for the best revenue cycle management provider for your physician practice, hospital or health system, consider ABILITY Network. You’ll find we score at the top of every important criterion you need for a high-quality RCM process. We understand your goal is to maximize revenue and we have the processes and technology to help you do just that. Streamline your workflows, avoiding coding errors and reducing denials means you get paid faster. And when you expedite your cash flow, you’ll have more money in the bank. Improving efficiencies enables your organization to do what you do best — take care of patients. Call 888.895.2649 and let us throw our hat in the ring as your revenue cycle management software provider!
ABILITY and design® and ABILITY® are trademarks of ABILITY Network, Inc.
Revenue cycle management (RCM) in healthcare is the fiscal process that guides the identification, management and collection of payments for patient services. The process begins with patient pre-registration, is followed by claims submission, and concludes with remittance processing. We understand hospitals, physician practices and other healthcare operations want to prioritize their limited funds to improve facilities for patients and retain caring, skilled staff. Revenue cycle management in healthcare can help you do just that by streamlining and automating the process of receiving timely payments. The objective of RCM is to generate a system that helps you get paid the full amount for the care provided as quickly as possible. Successful implementation of your revenue cycle management is what pays the bills. Learn more about the healthcare revenue cycle and the seven basic steps your RCM process should focus on.
Step 1: Patient pre-registration
Your revenue cycle management process starts when the patient makes his or her appointment. To successfully collect patient payments, healthcare organizations must engage the patient throughout the process. The best way to start is during the first contact with your patient. You’ll establish the patient’s account and collect as much information as possible during this step, including payer information (insurance or other payers such as Medicare/Medicaid), and the medical history you’ll need later in the cycle. Next, you’ll distribute information to the appropriate doctors, nurses and administrative personnel to enable the best possible care.
Step 2: Pre-authorization
In the next step, staff will schedule visits and verify insurance eligibility. Confirming that the service is medically necessary according to the plan’s agreement (assuming it is not a medical emergency) will confirm benefits and help determine payment options. This process can be trying and time-consuming for healthcare staff. Often, organizations employ software that assists in checking patient eligibility electronically, which can expedite the process.
Step 3: Submitting claims
A claim is used by healthcare providers to submit and receive funds from insurance companies or other payers. A “clean claim” that gets reviewed and paid by a payer upon initial receipt expedites reimbursement and improves your cash flow. It’s very important that the physician records information accurately. Without accurately documenting the clinical service provided and attaching the correct code(s), the claim could be denied, or you could receive an incorrect reimbursement. Good software can submit claims electronically, helping to avoid human error. It’s best if a charge capture system can interface with the electronic medical record (EMR) to optimize identification and capture of charges for more complete billing. You may also want to consider centralized charge standards across all departments to improve consistency. ABILITY Network has several RCM applications to help you streamline your claims management and billing and ensure compliance with CMS guidelines.
Step 4: Posting of the payment
Once you receive the insurance payment and it is posted to the account, you can submit the balance to the patient for payment. Once you have developed a relationship with the patient and gathered contact information, you should be able to use automation tools to send billing statements via mail and/or secure electronic data interchanges (EDI). You could also implement text message reminders. The easier you make it for patients to pay during this step, the faster you will receive payment.
Step 5: Managing and re-submitting denied claims
Tracking your denied claims is an important part of revenue cycle management in healthcare. Claims can be denied for various reasons, such as improper coding, missing items in the patient chart or incomplete patient accounts. Having a process to manage denials can help you recover revenue that might otherwise have remained overlooked because of insurance being filed incorrectly. Properly executed denial management will boost earnings if cash flow has been slow because of problematic claims. You might uncover denial patterns or trends, whether from human error or billing problems for certain types of procedures or members of your patient population. For anything that is not covered by insurance, healthcare organizations must notify and collect payments from the patient. It’s essential that providers help patients understand what they owe and why, identify primary or secondary insurance, consolidate bills, and be able to set up payment plans.
Step 6: Processing payments
Accounts receivable staff should verify all claims payments and process them as quickly as possible. The goal should always be to collect the maximum revenue in the shortest amount of time. You may need account specialists to help identify problem claims and to work with patients on collecting balances due.
Step 7: Financial reports
No automated RCM process is complete without the capability and processes needed to prepare valuable financial reports. Using custom software to develop the financial and management reports you need is key, along with reports on key performance indicators (KPIs) to track whether or not your team is meeting their defined goals.
Let ABILITY simplify your healthcare revenue cycle management
No doubt many medical practices, hospitals and other healthcare providers want to focus more on treating patients than ensuring the financial viability of their company. However, your revenue cycle management process is crucial to running your organization successfully. Without this key financial process, providers cannot keep their doors open to treat patients. That’s where ABILITY can help. We put systems in place to streamline claims management and billing, increase the flow of income, improve the care of your patients and reduce provider costs. Find out how we can help by reaching out via phone at 888.858.0506 or requesting an online quote. We look forward to helping you simplify and optimize your RCM process.
With so much attention on data – from strategies and ownership to data centralization, integration, mining and ethics – it can be easy to overlook the power of simple data sets. Staffing decisions have significant financial implications, and because overtime is one of the more visible drains on healthcare budgets, it tends to get the most attention.
However, for most healthcare managers, preventing overtime is a massive challenge. If overtime data is sitting in a report somewhere, managers don’t have real-time access to that data when they need to make a quick decision.
Even if you are doing an outstanding job of collecting and maintaining staff data, it may not be enough to reduce overtime and the associated costs. Healthcare managers must have easy access to meaningful data – at the moment they are making staffing decisions.
Solving the overtime conundrum
Overtime occurs because of two reasons: the decision maker didn’t know the person would go into overtime or the decision maker knew about the overtime and made the decision anyway.
While setting policies on overtime use and approval processes can help reduce overtime, a better solution is to make readily available the tools and data necessary for informed staffing decisions.
Something as simple as displaying an alert that an employee is or will be in overtime prompts decision makers to look for other options. Assessing those options can be quicker and more efficient with an Avoidable Overtime function, like the one that is integrated into ABILITY SMARTFORCE Scheduler. The feature displays other qualified staff members who aren’t at risk of going into overtime, so the manager can make a quick, informed decision.
Consider the difference:
John is a manager in the ICU, and he is looking at the staffing for the next shift. He has had two admissions and the unit is busy. He has his hands full and the evening shift is short one RN.
- Scenario 1: John asks one of the nurses from the day shift to stay over. Expensive, but efficient.
- Scenario 2: John opens his iPad and instantly sees staffing for his unit showing that he is down an RN. With one tap, he gets a view of staffing in the other ICUs and sees that none of them have extra staff to offer. He taps back to his shift and receives a list of available nurses. Two of the three have an indicator letting him know that they would be in overtime if selected. He taps on the third and instantly sends a text offering her the shift.
In the second scenario, John had easy access to the data he needed to make a cost effective decision, including:
- Visibility into other units that are staffed with the same skill type he needed
- Who was available
- Who was in overtime
- Who last called off
Plus, he could contact a nurse to fill the open shift, all in a matter of seconds. That data enables John to manage overtime costs, while also allowing him to be fair and in compliance with the seniority policy. He also minimizes risk by avoiding having a fatigued nurse giving care.
With the availability and affordability of staffing applications on the market, you simply can’t justify staffing practices that are not supported by data. So, if you are still using paper-based scheduling, spreadsheets or outdated staffing technologies, contact us today to learn more about ABILITY SMARTFORCE Scheduler, a cloud-based application that streamlines staffing and provides you with instant access to the data you need to make the right decision fast.
To see it in action, request a demo now.
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