Updated: Oct 18, 2021
In the Professional Billing (PROFEE) space of healthcare, there is a special type of person who I am magnetized to...The Provider Education Champion.
This person is someone who cares about the innerworkings of the entire system in healthcare, they see the downstream impacts, and want to assist with increasing the throughput. These are our best friends on the RCM side. Why? I am sure if you have been in healthcare for any number of years you may have heard is the most difficult thing is to change provider behavior. Well, I’d like to challenge that outdated notion. The issue is not that people, especially providers, do not want to change and make a process better. The underlying roadblock is this: we are not speaking the same language with the same context.
Here is the best part, these few special providers are a catalyst for change. They know, and/or are willing to learn, the downstream impacts of provider processes and documentation.
Did you catch that? They want to learn more. Being someone on the RCM side who always has to research the clinical application of any topic, I find this to be a relationship worth fighting for.
Step 1: Find Your Champion
This person may be a key leader of the practice, or someone who has had substantial involvement with the RCM reporting and understands the general ebb and flow of the practice. Best place is to start with the practice owners, and/or key leaders for the group. And just ask!
"Who would be the best person for me to work with to provide trends and opportunities for providers to impact the downstream RCM coding and billing?"
Step 2: Know Your Data
This is a two-sided relationship, a provider cannot be a champion if they are not provided with helpful, timely, actionable feedback by their RCM counterparts. So what are these things? How do we make the vast array of RCM data meaningful to a provider's day-to-day actions? There is surely a lot of opportunity when we look at clinical data sets; however, those do not always impact the direct day-to-day flow of RCM coding and billing.
I would like to give you three areas that you can start working on today, if you have not already.
Missing and Suspended (M&S) Records - This is the space between a fully documented medical record, and a fully coded record. Coding's request for missing information, additional clarifications, or records that seem to be lagging for timely completion. This occurs on both the facility and provider side. You should have a report that shows the "reason" why the account could not be coded on first pass. If you do not have standard reason categories, make them. Start tracking and make the data sets meaningful.
Lost Charge/Downcodes - These are the misses; traditionally education-only datasets that are lost opportunities. Yes, we want to catch as much as possible in the M&S space, but in the RCM world, we cannot wait forever. There is a timely filing clock the moment that patient is treated. Get with your coding teams, get this data set. Watch the trends, is it ROS, PE, HPI, PMFSH, is it EKGs, or Rhythm strips? What is it, what is the documentation standard you are not setting as a best practice requirement for your providers?
Merit-based Incentive Payment System (MIPS) - With each new year comes a new set of MIPS requirements, thresholds, and measures. If you work in Professional Billing and do not have someone keeping a pulse on MIPS, find that person as soon as possible. This is where clinical and RCM datasets collide. Documentation and treatment that are converted into G-codes that can impact your Medicare reimbursement 2 years later. I will not go into detail here, just know, MIPS can be your greatest hurdle, or you greatest opportunity for using data to merge the worlds for clinical and RCM healthcare.
I am hopeful with just these two steps and a few conversations you can greatly change the course of 2021 and get ahead for 2022. Better documentation, better coding and billing throughput, better reimbursement.