Clinical data plays a vital role in the financial dealings of healthcare businesses today. The volume of value-based care arrangements continues to rise, and it is more common than ever for health plans to drive prescriptive medical necessity requirements when authorizing benefits and services. Together, these factors mean a growing number of providers are at risk for the costs associated with the delivery of care. Therefore, the quality of care and the need for quality data about that care are inextricably tethered to the financial transactions created each time a patient walks through the door.
While the clinical and financial divisions of labor in the healthcare space have traditionally operated with relative autonomy from one another, the reality is that they exist as two sides of the same coin. When a patient begins their healthcare journey, clinical and financial pathways alike are opened up, and their relationship is far less siloed and far more interwoven than the current operating model reflects.
But, this is not just a clinical care pathway challenge. Every year there are more than $262 billion in claims that are initially denied,3 often related to clinical information gaps. In fact, over $28 billion is directly related to lack of medical documentation.3 Health organizations are gathering a wealth of clinical data but failing to effectively leverage it in ways that benefit revenue cycle operations.
With better technology, partners, and processes in place, healthcare providers have the chance to improve patient experiences and bottom lines by better utilizing clinical and financial information for all involved. In pre-service, more complete clinical data could be better used to drive authorization and medical necessity which represent over 18% of denials—12.4% for authorization and 5.8% for medical necessity.3 While post service, the full clinical record could be used in claims attachment, denials prevention. and appeals workflows. How can providers get to this key clinical information to support the revenue cycle processes given the reality of interoperability with EHRs?
A key first step is further connecting revenue cycle and health information management from a technology and process perspective. Integration between claims processing systems and health information management workflow platforms provides more timely access to clear and legible clinical record without multiple handoffs and manual processes. In addition, this can ensure that all parties involved across the health system, as well as the health plan, have clear visibility to and awareness of the status of medical documentation requests in queue.
No matter what structures are in place across a healthcare organization, the clinical information-minded revenue cycle teams are already doing three things well:
- communicating effectively across siloes,
- collaborating and integrating processes across teams, and
- sharing organizational data, findings and ideas.
In doing so, these organizations are improving patient satisfaction and outcomes, and driving improved health and wellness among patients. Simultaneously, they are improving the flow of clinical data through reimbursement and creating greater operational efficiencies in billing. In today’s rapidly changing environment, the organizations that focus on the relationship between their two siloes are the ones winning the day.
References
- Sullivan, Tom. Healthcare IT News. “Why EHR data interoperability is such a mess in 3 charts.” May 16, 2018. https://www.healthcareitnews.com/news/why-ehr-data-interoperability-such-mess-3-charts
- Leventhal, Rajiv. Healthcare Informatics. “KLAS 2017 Interoperability Report: Some Progress, but Providers Expecting More.” October 19, 2017. https://www.healthcare-informatics.com/article/interoperability/klas-2017-interoperability-report-some-progress-providers-expecting-more
- Healthy Hospital. Change Healthcare. “Change Healthcare Analysis: $262 Billion in Healthcare Claims Initially Denied in 2016.” June 23, 2017. http://healthyhospital.changehealthcare.com/wp-content/uploads/2017/06/change-healthcare-healthy-hospital-denials-index-2017-06-a-2.pdf
Jeff Gartland is Ciox’s President of Clinical Revenue Integrity Solutions. He brings 20 years of leadership experience in healthcare and technology companies spanning clinical connectivity and integration, patient engagement, and revenue cycle performance improvement.
