If you work in Hospital Revenue Cycle Management (HRCM), you get three chances to get the invoice right.
This makes sense when you think about the front, mid, and back sections of the revenue cycle. However, all three edit points occur prior to the claim getting out to the payor. Within the three core sections of HRCM, there are these three ‘Edit Points’ that can be identified to ensure the claim processes as clean as possible without defects, holds, errors, or rejections.
ONE: Front-End Edits - Patient Access Edits
ADT/Host system and Registration Edits
Cannot process patient visit due to errors
TWO: Mid-Stream Edits - HIM/Coding Edits
ADT/Host Platform Edits and Coder Edits
Cannot final code accounts due to errors
THREE: Back-End Edits - Billing Edits
Billing Editor Edits
Cannot final bill account due to errors
Up until the point the bill is sent (either electronically or hardcopy) to the payor, all actions can be categorized in general as "Preventative Actions". These are the actions that are taken to ensure the claim is paid in full (PIF) without errors or resubmissions the first time it is sent/submitted to the payor.
We should call out that each edit point within the revenue cycle is a compounding summary of the previous edit points. This is easier to understand with an example.
Example: Account is registered in the Emergency Department (ED), it is a quick registration on a trauma patient. The patient then goes into trauma surgery and they are in the facility a few days as an inpatient recovering.
First we need to scope out what could go wrong. The ED Triage team may have to register the patient under a generic name or number if the patient is unconscious and/or unable to respond. The ED registration team likely will be unable to obtain any demographic or insurance information until after the patient is stabilized, or even days later in an inpatient setting recovering.
ONE: Front-End Edits - Patient Access Edits
The registration team is going to need to locate the patient and visit them while inpatient to obtain from them or a family member their insurance and the rest of their demographics. This will be a few edits/holds in the registration system.
The registration is going to have errors/edits to reconcile the patient name/Medical Record Number (MRN). Think a facility Trauma protocol. This may be separate processes and reporting. Hopefully, the registration team can get enough information for the new or established patient to allow this reconciliation to occur.
Did they spell the patient's name right?
Did the patient's address get entered correctly, and is it valid?
Is the insurance valid for the coverage on the service dates?
Some of the most common registration errors come from incorrect spelling or full verification of a patient's name, or input of their insurance. These are more common in emergency departments, but often occur on all patient types.
TWO: Mid-Stream Edits - Health information management (HIM)/Coding Edits
While the front end edits are occurring, the HIM team is working to get this patient reconciled. Let's say this was an established patient. Well, that means they already had an MRN. So HIM has to get any and all documentation from the generic trauma account back into the patient's main account.
Coding is also jumping in here, they may be missing documentation they need the providers to complete.
Are the units correct on all the services? ex: Medically Unlikely Edits (MUEs)
Have the correct Healthcare Common procedure Coding System (HCPCS) codes been selected?
Have the correct modifiers been applied to the Current Procedural Terminology (CPT) codes?
Are there CPTs/care that are unbillable, or should be bundled?
Are the diagnosis codes in the correct positions based on the patient's presenting problem?
While coding/mid-stream edits can occur while the registration edits are being cleared, it all comes to a halt when we get into the final edit space. This is where the paper CMS-1500 or the electronic UB-04 claim forms merge the first two edit stops. On these forms, the patient demographics and insurance, now cleared of front-end edits, are processed with those mid-stream documentation-produced HCPSCs, CPTs, modifiers, units, and diagnosis codes.
THREE: Back-End Edits - Billing Edits
Do we have the correct Point of Service (POS) code?
Do we have a valid NPI linked to the payor, or group, or location?
Does the patient have coverage for the date of service (DOS)?
Were there any pre-authorizations required for the patient's care?
While the claim form and its fields are standard, when you add in variations of service lines, payor, states, and billing entities, the level of complexity increases dramatically. There are some pretty standard industry billing edits that may get spit out of a claim scrubber, or even a clearinghouse rejection. These are nothing new, they also point upstream to the two earlier edit points. Each edit point is looking for any remaining edit issues, but they are also looking for ones missed upstream. Yes, even when the claim is about to be submitted, we still may not have the patient's name correct, or their policy number may be from the prior year's insurance. This is our last chance to get it right the first time.
Here is the tipping point where we move from Denials Prevention into Denials Management. Once that claim is out the door and at the payor, we now can only manage denials. Whereas, we had three core points upstream to prevent future denials. Now, the same can be applied to the denials space. Any denials we receive can turn into more robust upstream edits. It is critical that trends found in denials are fed back upstream so denials prevention can actually occur in the revenue cycle.
Here is where I would recommend you start:
Denials Prevention:
Determine what your top 3 edits/errors/holds are for each of the three edit points?
Determine if People, Process, or Technology.
Determine if short-term, or longer-term fixes are needed.
Denials Management:
Determine what your top 3-10 denials are by combinations of payor, CARC, and HCPCS/CPTs.
Determine if they are upstream issues from the three edit points.
Determine if People, Process, or Technology.
Determine if short-term, or longer-term fixes are needed.
By consistently looking down and up stream, you will have a process for both Denials Prevention and Management. As you clear/resolve your top edits/issues, you will have a new top three; therein, building out more robust claims submission edits.