Total Revenue

Patient Access Solutions

Scheduling, Pre-Registration Services, and Pre-Authorization/Referral

Ensuring that patient information is collected and validated is critical to billing clean claims timely and prompt payment. To do this requires a methodical approach that ensure all necessary data is collected and validated. Pre-access services is one of the most important components of revenue cycle because it is the first point of contact that connects the patient to the organization. Gathering correct and complete information during the pre-access processes, assuring insurance is verified and prior authorization and other plan requirements are met helps ensure reimbursement of services and prevents denials. Our team helps establish policies, workflows and training to support a successful pre-access program.

Revenue Integrity Solutions

Revenue Integrity programs serve to bridge gaps between clinical, coding and revenue cycle functions. The best Revenue Integrity programs are proactive, with the goal of improving workflows and creating a knowledge base inside an organization to help revenue cycle professionals operate more effectively.

An effective Revenue Integrity program includes the following elements:

• Multi-disciplinary resources to facilitate, strengthen and improve the collaboration between clinical and revenue cycle areas
• Strategies to leverage technology and process improvement to reduce revenue leakage across the revenue cycle (patient access, charge capture, clinical documentation and billing)
• Proactive and corrective education and training programs
• Proactive audits/reviews to identify risks associated with payer and/or regulatory changes
• Action plans for improvement and performance measures
• Monitors frequently denied codes, especially codes under $500, to fight automated denials that are often missed through normal denial surveillance activities." Enterprise-wide communication strategies and mechanisms to disseminate information regarding accountability, process improvement and regulatory changes across revenue cycle and clinical departments

Our Revenue Integrity Improvement Services focus on the identification of opportunities to improve existing programs and/or implement new initiatives that drive revenue and margins.

Discharge Not Final Billed (DNFB) & Accounts Receivable (AR) Solutions

Discharge Not Final Billed

Following a patient’s discharge from inpatient care, claims are held for a pre-determined time period known as the “bill hold” to allow providers and staff to complete charge entry and documentation. The inability to complete these activities during the bill hold timeframe result in DNFB risks and billing delays.

Delays may occur due to a variety of reasons:

• Missing and/or incomplete clinical documentation
• Delays in responding to coding queries
• Missing authorization, technical and charge edits

Our team of experts can help you identify DNFB root causes and implement solutions to support timely billing. We will partner with your Providers, coding/HIM, clinical departments and revenue cycle staff to identify root causes impacting DNFB. We work with your teams to develop and implement collaborative solutions to reduce coding and billing delay, improve collaboration and revenue.

Accounts Receivable Solutions

Improving the management of unbilled and billed receivables takes a coordinated effort to make the many facets of revenue cycle work together to address root causes, improve workflows, increase knowledge and skills and assure technology is being used as effectively as possible.

Improving management receivables may include:

• Reducing unbilled A/R by improving completion of medical records, optimizing responses to coding/CDI queries and coding processes
• Improving pre-access and registration data quality through enhanced training and optimizing system edits
• Developing reporting and analytical tools to monitor initial denials and rejections received by payers to drive root-cause analysis
• Building efficient and balanced work queues to assure DNFB and A/R are properly prioritized, and resources are appropriately allocated
• Creating and providing strong training programs across the revenue cycle to increase staff’s understanding of the billing and adjudication processes
• Coordinating with the organization’s payer contracting and legal teams to establish and leverage an aggressive payer management and escalation process

Registration

The registration process is a critical opportunity to collect and update information. It is also when providers capture necessary signatures, obtain any other forms required such as consents, ABNs, waivers, etc. and collect payments Our experts can help redesign the registration process and ensure that the policies, training, and tools are in place to ensure that registrations are quick, prioritize critical tasks and support an outstanding patient experience. 

Financial Counseling and Price Transparency

Bad debt and charity expenses can have a significant impact on financial performance, especially with the increase in patient out-of-pocket costs. Having processes to provide patient estimates, collect out-of-pocket costs, screen for Medicaid, financial assistance, and even marketplace insurance is crucial. Our experts can assist in improving the workflows, standardizing point-of-service collections, formalizing financial assistance programs and identify other sources of coverage, creating screening tools, and help evaluate technology and outsourcing options.

Point Of Service Collections

Collecting patient copays and coinsurance at the point of service is an integral part of the registration process. If not properly calculated and quantified, patient liability payments are often delayed and can result in increased write-offs downstream. Kaufman Hall evaluates staffing levels and training in addition to the processes related to point of service collections to calculate payments based on patient insurance information and services provided.

Vendor Management

Effective vendor management in the healthcare revenue cycle is crucial for financial and operational efficiency. Successful utilization of vendors’ tools and services is critical to realize the expected ROI and to assure optimization of overall revenue cycle performance. Key considerations for revenue cycle leadership include selecting vendors with a proven track record, establishing clear, measurable KPIs, and seamless integration with existing systems. Clear contract terms, robust risk management, and collaborative partnerships based on trust and communication are essential for continuous improvement and optimal financial and patient care outcomes.

Over time, a hands-off approach to managing vendors tends to result in worse than expected results, reduced ROI, and frustration. To maximize the effectiveness and performance of revenue cycle vendors, it is crucial that the vendors are proactively managed. By establishing a vendor management program that monitors vendor performance, financial results, quality, and compliance, providers have confidence in the vendor and maintain the ability to assure expectations are met. Our vendor management improvement services help providers:

• Assess and select vendors and negotiate contracts
• Transition to new vendor services and adopt new technology tools
• Establish performance standards and reporting capabilities
• Create processes to assure reconciliation and verification of services, results, and fees
• Formalize escalation policies and procedures
• Develop standing client/vendor meetings to address issues, concerns and improve results

Kaufman Hall’s comprehensive Managed Care Contracting solution includes a tailored approach that can include: establishing payer strategies, supporting the contracting and negotiations process, implementing and monitoring contracts, and establishing payer escalation pathways.

Payer strategies consist of performing a comprehensive review of payer contracts and portfolio, including Commercial, Medicare Advantage (MA), and Managed Medicaid, providing a fair market rate assessment and competitive price benchmarking, identifying distinctive leverage points and value propositions to support the negotiation strategy, and developing a selective payer partner strategy.

Negotiations and contracting include payer negotiation support for rates and language, alternative language recommendations, contract modeling, and securing reciprocity in terms and conditions that level the playing field. This process can include hospital, physician, and Integrated Delivery Network (IDN) contracts.

Implementation and monitoring of contracts include developing payer scorecards for comparative performance against internal standards and external benchmarks, reviewing and disseminating material payer policy changes, contract implementation education and guidance, and periodic reporting of Alternative Payment Model (APM) performance.

Payer escalation pathways include developing criteria to raise heightened awareness of sub-par contract performance and developing intervention strategies to address contract performance issues at the department level. They also include establishing expectations and performance standards with payer partners, providing tools, and empowering managed care leaders to resolve root causes of contractual, administrative, and compliance issues.

Denials management refers to the process of identifying, investigating and resolving pre and post claim denials to ensure reimbursement for services rendered. Strategic denials prevention requires a proactive approach to address root causes that commonly contribute to denials. resulting in less denials. Our team of denial experts establishes the infrastructure necessary to support organizational goals with a hands-on approach of advising and implementing industry leading denial prevention strategies ultimately improving the organization’s bottom line.

Our team of revenue cycle and clinical experts understand the importance of cross departmental collaboration when addressing denials to ensure appropriate information and documentation is captured when fighting payer denials. In partnership with our clients our team will work to implement our leading practice multi-disciplinary approach designed to incorporate key stakeholder representation from revenue cycle (patient access, coding and patient financial services), case management/UR, training, IT and physician leadership. This collaborative, integrative, enterprise-wide denials approach allows us to focus on identifying trends, pain point and areas of focus for implementation of denial mitigation strategies through process improvement efforts, ensuring buy-in and accountability system wide.

By leveraging our denials software, our team applies leading edge, data-driven analysis to identify specific denial trends within our client's data sets and determine the level of intricacy of denials. Different denial types call for different action steps - ranging from soft denial, temporary denial requiring provider action; hard denial, requiring appeal and in-depth payer discussion; and clinical denials, resulting from medical necessity and/or patient level of care. Our team is able to help clients accurately and efficiently bucket, prioritize, and focus on the top denials most likely to result in reimbursement for the organization through integration of our unique software tools, medical necessity outreach (MNO), enhanced physician advisor program and resources.

Placing a patient in the appropriate level of care is integral to caring for patients. It ensures the patient is cared for with the right level of services and the hospital is reimbursed appropriately for services rendered. However, many hospitals are challenged by the status determination process, and often overutilize the observation level of care. There are considerable financial implications related to inappropriate status assignment, which often results in missed revenue. Hospitals and health systems should consider implementing status determination process improvements to enhance net patient revenue while prioritizing patient outcomes. Our team has the clinical and operational expertise to navigate the challenges related to observation management and utilization of service to ensure hospitals are accurately placing patients and maximizing revenue.

Patient Status Determination

The determination of whether a patient is inpatient, requires outpatient observation, or outpatient services is a critical decision point that is often undervalued. Our team of clinicians can help the physician advisor navigate the distinctions of a status determination, ensure compliance with CMS conditions of participation and managed care contracts. We provide at-the-elbow clinical review support to ensure the appropriate status assignment, and the documentation contains the critical components to support medical necessity and the assigned level of care. With this knowledge the physician advisor is better able to work with the medical staff in conjunction with the utilization review/case management team to conduct timely follow up on case prioritization, reviewing cases to ensure medical necessity is met with the desired quality outcomes. This in turn decreases denials related to status.

Length of Stay and Medical Necessity

Few things erode margin like over-utilization of resources and longer than necessary lengths of stay. With reimbursement generally fixed based on a patient’s condition, the key is to use necessary resources as quickly as possible improve the patient’s condition at a cost at or below the reimbursement rate. Physician advisors are pivotal in this space, advising on treatment decisions not adequately supported by documentation and partnering with medical and professional staff to promote organizational stewardship of healthcare resources. Our team of experienced clinicians coaches physician advisors on how to interact with their physician peers about appropriateness of services without being accusatory while progressing care to meet length of stay goals. We help physician advisors understand the finances of a stay and average length of stay benchmarks by participating in case reviews of complex admissions, resource utilization and avoidable delays.

Physician Advisor

Physician Advisors will play a key role ensuring clinical documentation accurately reflects the high-quality clinical care patients receive; such a role can help an organization stem significant revenue losses associated with avoidable payer denials. The physician advisors will focus on the mid-revenue cycle, which is when providers translate bedside care for accurate payment, justify services rendered and measure quality. As a liaison between clinical services, finance, and payers, they have a pivotal role in helping to review these clinical denials and engaging with the payor to conduct pre-bill peer-to- peer discussions and overturning denials from the payors. On the post-bill side, physician advisors can lend their clinical expertise to support the clinical argument in the formal written appeal. Our experienced clinicians can help physician advisors speak not only the clinical language but also financial so that the operational and clinical knowledge are shared in a way that all can understand what is being discussed and the potential impacts. We provide case studies to test their denial challenges and build supportive arguments and reference guides to ease the understanding of Medicare regulations and keep the organization away from a targeted audit.

Length of stay reduction is a function of efficient patient throughput, reduced clinical variation, and an effective approach to care management. There are financial and quality impacts associated with reducing length of stay. For payors that pay on a DRG schedule, the payment amount is reflective of the level of resources required to treat the acuity of that patient. Therefore, it is beneficial to meet length of stay expectations. Moreover, reduced length of stay is beneficial to the patient receiving care. In fact, the member of the care team for whom throughput matters the most is the patient themselves. Research shows that the longer a patient stays in the hospital, the more susceptible they are to hospital acquired conditions and other complications. These are negative quality indicators for the hospital as well. Efficient patient care coupled with clear communication, are paramount to not only driving throughput, but also enhancing the overall patient experience. For providers to be productive and ensure patients are seen in a timely manner, throughput and length of stay are major components. Claro Healthcare helps our clients reduce length of stay by driving efficient processes and operational support throughout the entirety of a patient’s stay.

• Patient Throughput: Efficient throughput helps to create capacity; ultimately allowing the hospital to continue to provide care to other patients in the community. Throughput is the backbone for hospital length of stay. It is critical to have system wide, multidisciplinary buy-in to throughput with all care team members focused on treating the patient and transitioning them to the next level of care. In today’s healthcare environment, a hospital’s ability to get patients in and out of the facility is critical to hospital operations. Without efficient processes and operational support to help drive throughput, hospitals will experience significant constraints. There are five leading practices that efficient hospitals have in place daily, to progress throughput. These are, house operations huddle, unit-based patient progression rounds, afternoon unit touch base, real-time demand capacity planning meeting, and collaborative night shift hand-off.
• Clinical Variation: Standardized patient care aligned with evidence-based practice to ensure safety and high-quality outcomes is a critical component of the mission of all providers. We help our clients reduce variation in their care delivery by working with our client physicians, clinicians, and other allied health professionals to standardize the delivery of care and establishing defined and standardized clinical practices. Guideline Directed Medical Therapies, Clinical Pathways and order sets are all helpful tools in reducing excess days and expediting care.
• Care Management: Care Management's role in length of stay is vital in today's healthcare environment. This role includes care coordination, utilization management, patient progression, discharge planning and social work. We understand the importance of collaboration, efficiency and effectiveness in this area. It is imperative that roles and responsibilities within the Care Management team are aligned with patient needs and hospital goals. We help our clients successfully implement observation huddles, proactive discharge planning, an escalation process, early intervention of palliative services, rounds for complex, long length of stay patients, and procedures focused on discharge support and financial assistance.
• Leading Practices: When it comes to impacting throughput and reducing length of stay, Claro Healthcare utilizes many complimentary solutions to address the various barriers that commonly arise throughout a patient’s hospital journey.

Foremost is the assurance that the patient is receiving the right care. Patients in the wrong status may experience delays in treatment due to the requirements associated with their payors, or the fact that a particular diagnostic is prioritized for a different status than the one the patient is in. Confirming that the patient is in the right status at the right time allows for the appropriate treatment to begin at the right moment. Additionally, assuring the patient is in the right status from the point of entry helps to avoid confusion over co-pays, deductibles, and out-of-pocket expenses once the patient leaves the hospital, regardless of the setting.

Efficient throughput requires participation from the care team, operations, finance, and transport; throughput is everyone’s business. There are five leading practices that top performing hospitals have in place daily to expedite throughput. These are, house operations huddle, unit-based patient progression rounds, afternoon unit touch base, real-time demand capacity planning meeting, and collaborative night shift hand-off. Claro Healthcare has the experience to guide your organization through the implementation or enhancement of these processes and more, to help you attain and sustain your length of stay goals. 

New 340B Program Development

Our team of 340B consultants supports covered entities interested in enrolling in the 340B Program to assess potential opportunity and develop an implementation strategy to maximize benefit. Our approach aligns the program strategically across an organization with shared responsibility across Pharmacy, Finance, IT, Compliance, Operations, HR and Providers. We can support your organization through the HRSA enrollment process, train resources who will be supporting the program, support the sourcing and implementation of technology, identify and execute on strategic retail and specialty contract pharmacy relationships and help establish day to day oversight processes.

340B Program Optimization and Continued Support

Organizations well established in the 340B Program often have opportunities to further optimize their programs or need support navigating the ongoing changes to the 340B Program. Our team works with hospitals to identify missed opportunities for 340B benefits as it relates to both outpatient administered drugs and prescription drugs.

Retail and Specialty Pharmacy Development

A hospital or health system owned retail or specialty pharmacy can lead to significant benefit for both patients and providers. Our team works with organizations to assess opportunities to build an in-house retail or specialty pharmacy. We support implementation of pharmacies including coordination of construction, technology, accreditation, payor contracting, staffing and training. Our team collaborates to ensure strong integration into specialty clinics, high patient and physician awareness and alignment with employee benefits programs for maximized benefit.

Employee Benefits Alignment

For self-funded employee benefits plans, pharmaceutical drug costs can be significant. Our team works with your pharmacy and human resource teams to identify opportunities to control drug costs among the most expensive at-risk patients and employees. We evaluate your current plan and contract design to identify any opportunities for alignment with your hospital’s 340B Program.