Category Archives: News

Revenue Integrity & Capture – Who’s Herding the Cats?

Cross functional processes can be difficult to manage in hospitals. One reason pertinent to Revenue Integrity is that typically, the organization structure is a series of vertical disciplines with differently defined focus (HIM, PFS, PATIENT ACCESS, ANCILLARY DEPARTMENTS, MD’s, This structure can be and is very effective in many hospitals. However, revenue integrity management doesn’t always “fit”. It requires that all of these disciplines (a) agree on work definition, (b) have consistent education addressing CDM changes, compliance matters and related topics, (c) have the tools in place to manage their performance (d) are clear on current state and change opportunities that require attention (e) communicate routinely specifically about Revenue Integrity matters.

We all know the obvious – if revenue is not captured, coded and billed correctly we risk HIPAA violation consequences, cash flow, cost associated with denials and duplicate handling of work, patient satisfaction and P&L impact. So in an environment where cross functional processing challenges exist and the expressed risks are critical, “WHO’S HERDING THE CATS” in your organization to ascertain that you are banking every dollar that is coming to you? Who in your organization is charged to remain contemporary on what you can bill for and what you cannot bill for and related implementations as change occurs? Is that responsibility spread among various stakeholders and if so, do all disciplines in the revenue capture continuum agree or is there a need for conflict resolution – who identifies and handles that? Who is the leader?

Some hospitals have a staff position designated to lead the revenue integrity charge. In order to be effective, this role must be defined such that it carries authority that crosses organization lines. Other hospitals have established a committee or team consisting of representation from key stakeholders. The committee or team is usually lead by the CFO, VP Revenue Cycle or COO. Either structure or even some hybrid can be effective.

However, many hospitals have not embraced this field with a well-defined multidisciplinary plan that has a specific function as part of the organization. When we are asked to consult with those hospitals about revenue issues, it is usually because they are experiencing symptoms like inordinate denials, decline in same-store revenue, cash flow issues and sometimes conflict regarding coding policy. Our initial discovery work is designed to identify current state, confirm those “symptoms” and address what has caused them. As a result, we can introduce early wins and sometimes interim leadership but the more strategic solution often requires organization change that establishes Revenue Integrity discipline and accountability. It is rewarding to facilitate and see transformation in Revenue Integrity practices at hospitals that previously focused more on symptoms than development of a strategic approach.

If you are working on charge capture, CDM or another component of Revenue Integrity and have questions or if you have in place relevant best practices you are willing to share, please post to this BLOG so that others can benefit. Our healthcare management consulting experts are always available to answer questions or assist you regardless of where you are on the path leading to Revenue Integrity.

Posted By: nearterm-admin

Revenue Cycle Processing Backlogs Are Not “NORMAL”. It’s time to raise the bar – eliminate BACKLOG TOLERANCE!

I talk every week with Revenue Cycle Leaders from all types of hospitals around the country. When I ask how things are going, there are many common responses that reflect current concerns and challenges they are facing. These include conversion issues, staffing constraints, volume fluctuation, talent acquisition/retention, cooperation among stakeholders, change in payor practices and training, just to name a few. Here are some recent quotes that typify their remarks:

“We are preparing for a conversion. The training and build distractions have resulted in backlogs and performance decline. After the new system is implemented, there will be a learning curve and modifications to make for the new system to do what it is purported to do.”

“Budget constraints require me to do more with less every year. This year, we are struggling to keep up with processing volumes, especially billing and follow-up. We are getting behind. Our aging looks awful.”

“Our Revenue Cycle Team is great but it seems like every day we learn of new HIPAA and other rules imposed on us that require change, training and personnel shifts. For example, we have about 12 days of DNFB and can’t seem to get a handle on it. Chart assembly and completion are also behind. If we can’t get it coded on time, we can’t bill and collect on time. But it’s been that way for some time now so nothing new.”

“Denials are killing us! We have done some analysis to determine root causes and we have a feel for that but we just don’t have the resources to address those causes. We devote our existing FTE’s to working current volumes but the denial backlog is growing and it is a real problem for us. Not only are we not getting paid by insurance and Medicare, but patients complain, citing that we are to blame so until the denials are resolved, they are reluctant to pay patient liabilities like deductibles and coinsurance.”

“We are doing OK. We have backlogs in various areas but we know that we are in a community with a limited talent/labor pool so we are always working hard to balance make or buy decisions. Our days, DNFB and denials are higher than facilities in other communities but we just don’t have the technology or budget to compete with their benchmarks.”

Identify and Eliminate BACKLOG TOLERANCE

You get the picture. We have developed what I call BACKLOG TOLERANCE. We know backlogs exist and can usually identify why, but we just can’t seem to address the root causes effectively. Furthermore, we can’t eliminate the backlogs and sustain current processing designed to prevent recurrence. Instead, we often change the standard.

eliminate backlog

This condition would not be acceptable in other industries and in my opinion; it should not be tolerated in ours. Sure, every business experiences episodic conditions that result in temporary backlogs from time to time – understandable. But when they do, they scramble immediately to meet the problem head-on and take definitive steps to resolve the issue. They implement the technology, invest the human capital and embrace preventive design aimed at making sure the backlog was in fact temporary, and not a permanent “NEW NORMAL.”

Of course, many hospitals have been very progressive and certainly are not tolerant of backlogs. They proactively anticipate influences that might result in processing challenges and they reinvent their organizations well ahead of impact. I always learn from them and have great admiration for their approach, vigilance, creativity and the leadership they have in place that enables their success.

If you can relate to my comments, I would love to hear from you. If you are in a hospital with some degree of BACKLOG TOLERANCE, I would welcome an opportunity to talk with you about solutions you are working on that might help others. If you have “recovered” from “BACKLOG TOLERANCE DISORDER” (Is there a code for that?), please share your plight – I am sure your colleagues would appreciate hearing ideas that might be helpful to them.

Posted By: nearterm-admin

Hospitals Staffing Levels Improve With RCM Solutions

rcm solutions

There’s no doubt that healthcare workers are the backbone of the health service, so it makes sense for a healthcare provider to manage their staffing levels in a strategic manner. Healthcare revenue cycle management consulting services (RCM) help hospitals to meet staffing needs while saving money. This cost-effective approach is gaining momentum as healthcare providers strive to offer excellent care while meeting business needs.

The Market Is Changing

Nowadays healthcare workers enjoy the freedom of being able to work flexibly and at different locations, because they don’t like the idea of being tied down to one place. Also, they like to make the most of the opportunities that arise at any given time, because they understand that this will add to their employment portfolio. This model is also beneficial for healthcare providers, as it makes the process of hiring skilled staff easier, and because contract workers often get paid a little more than in-house staff, they don’t have to offer benefit packages.

According to Global Human Capital Trends 2015 series, more than one-third of all workers in the United States are contract workers. What’s more, just over half of all respondents say that their need for contingent workers will continue to grow over the next three to five years as the market shifts toward a more agile workforce.

Contract Workers on Demand

Many firms rely on contract staff to meet supply and demand, but with hospitals, the need for contingent workers is even greater, because they simply can’t afford to be understaffed. Healthcare providers constantly need to meet their patients’ needs so that they can provide a good level of care.

rcm solutions

Nearterm’s 360 Managed Services can help you meet your staffing needs by meeting with you to discuss your requirements. Project staffing involves meeting with one of our experts to ascertain the type of workers you are looking for. This will include skill set, the scope of work, project details, schedule and other related matters. Once this has been established, we gather the resources you need and arrange for them to be there as and when you need them, both on-site and remote.

Revenue Cycle Management Service

RCM services manage a number of business-related tasks so that you can get on with what you do best: caring for your patients. These RCM services include:

  • Situation Analysis — Objective operations assessment to facilitate planning and decision-making processes.
  • Operations Action Plans — The plan of action process is a proprietary service wherein Nearterm leads your organization through a very structured process aimed at establishing targeted change.
  • Implementation Assistance — We deliver the additional ”horsepower” you need when implementing certain planned activities.
  • Organization Development — Our team of professionals serves as the catalyst your organization needs in the development process.
  • Centralization and Decentralization — We specialize in assisting providers with all aspects of centralization and decentralization, from the earliest consideration through the continuum.

In addition to RCM services, we also:

  • Present customized training programs
  • Develop and document policies and procedures
  • Provide conversion assistance
  • Design reporting packages
  • Tailor our services to meet your organization’s specific needs

RCM services help you to plan better so you can deliver top-quality care in this increasingly competitive market.  Hospital finance departments are often under pressure to crunch the numbers and balance the books. But without careful planning, recruiting staff can be more expensive than it should be. If you want to find out more about what we can do for your organization, please get in touch.

Posted By: nearterm-admin

Should Hospitals Leverage Outsourced Coding or Keep It Internal?

Hospitals have adapted many different coding models. Most are designed around contributing factors that differ from one facility to the next. However, there are three models that arguably prevail. The following is a summary of each;


All coding functions are managed and performed by internal staff/employees. The function is generally housed at the facility. Some remote coders may be used but they are hospital employees. Hospital is responsible for audit, QA, productivity, staff management, technology, employer taxes and employee benefits.


Coding is managed internally. Most coding is done internally by hospital employees but some coding is outsourced to a vendor. Hospital manages both employees and the vendor.


The coding function is outsourced to a vendor.

Each of the above can be successful. That said, many hospitals are rethinking and reinventing their processing environment. The driver is often an awareness of current state and how it has changed. Here are some examples of current state “influencers” gleaned from discussions with several hospitals and HIM professionals;

“ICD 10 coding implementation has resulted in staff increases. I have space constraints so I have no work area to accommodate additional staff. Besides, our leadership team believes the space currently occupied by HIM could be put to use for revenue generating services.”

“We are in a rural community and local coders are hard to find and retain. Turnover and leaves of absence require overtime. We usually get behind when these occur and morale is impacted. When new services are introduced, we are challenged to find coders qualified to code the new services. Billing gets behind, cash flow suffers and physicians are irritated by late query requests.”

“A recent coding audit revealed that coding accuracy among our coders ranged from 79% to 91%. This was a surprise since we had not had an audit done all year. Review of the audit results by coder made it clear that we had both performance issues and training deficits. The CFO had approached us about why the denial rate increased in recent months – now we know.”

“The DNFB standard at our hospital is no more than 3 days revenue. We meet that standard occasionally but typically run at about 7 days. Week-ends, holidays, technical issues, turnover and absences are keeping us from meeting our standard. Overtime is not approved here so performance suffers.”

Coding outsource is not for every facility but it is an option that meets the influencers illustrated above head on. The benefits of outsourcing include:

  • The facility no longer incurs certain costs shifted to the vendor:
    • Employer FICA taxes
    • Workers comp, health benefits, retirement plan
    • PTO & holiday pay
    • Software licensing and maintenance
  • Space occupied by internal coding staff can be used for revenue producing or other services deemed strategic:
    • Desks, office equipment, phones etc. can be re-purposed
  • Staffing problems are eliminated. The outsource vendor maintains expert staff with credentials and experience to accommodate any service type while meeting production standards. Coverage for vacancies, holidays, week-ends and PTO is provided by the vendor.
  • Testing, training, continuing education, meeting attendance, trade association dues, audits and other “soft cost” items are the responsibility of the vendor.

It is important to consider not only influencers but also “inhibitors” related to outsourcing when assessing the processing environment for your coding function. Inhibitors might include the absence of technology to support remote processing, the perception of job loss or merger/acquisition activity that prohibits contracting. Another inhibitor is the unwillingness to partner – the outsource option requires good communication and a “partnering approach” in order to capture the many benefits associated with it.

This article is only a summary of different medical coding options. We hope you find it thought provoking. Whether you are considering outsourcing the entire coding function or you simply need coding support from time to time, or maybe Interim HIM Leadership, we at Nearterm are available to assist you.

Feel free to call or ask the experts if you would like to access our team or offer comments about this topic.

Posted By: nearterm-admin
Managed RCM