If your project involves moving to a common database for all sites, the EHR platform will typically require one common CDM across all sites while still allowing certain pricing variations. This will most likely force you to standardize data attributes and charge methodologies. If you don’t have an existing revenue integrity program in place to drive the work, create guiding principles that address compliance and revenue optimization considerations. Some key things to think through include charge methodologies by service line, how statistical charges should be handled, when services need to be duplicated versus consolidated, and how to tackle payer-specific claim requirements. Also, be sure to standardize revenue codes and descriptions and how you charge for services across all sites.
Reconciling the clinical system with the CDM system is also important. This process systematically links each clinical order to the CDM to identify where there are missing or incorrect links. To be most effective, you should completely validate all links versus using a sampling method. By fully reconciling, you can not only catch errors but also identify additional clinical build modifications that may not have been identified to date.
Shore up Clinical Documentation Processes
With a new EHR, the documentation workflow for clinicians will change, especially as physicians use more templates. Although templates can create documentation efficiencies, they can also generate systemic errors if they aren’t specific enough or unintentionally promote inaccuracy. To help you see where documentation process changes are negatively impacting coding, conduct parallel documentation reviews prior to and during golive. It can be beneficial to have additional clinical documentation improvement (CDI) support tackle these reviews and manage increased query volumes as providers acclimate to the new system.
It’s also critical to understand how documentation workflow impacts charges. In many of the newer EHRs, clinical documentation drives charges. So if you’re going to be using more templates, make sure you understand how that affects charge capture and whether the system is correctly picking up charges or if there are areas you need to tweak.
Be Involved During Testing
Once a system is designed and built, the testing work begins. This is the time to check that RCM processes will function as they should within the new system. Efforts should focus on charge testing, parallel testing, and then full integrated testing to proactively identify possible issues. Testing should encompass all processes from pre-access through charge capture to claims generation, validating that each outcome meets the acceptable criteria for a clean, complete, and compliant claim. Before you consider testing complete, make sure you have the revenue cycle steering committee sign off. In fact, their approval should be mandatory before your organization moves to the next phase of implementation.
Plan for Inevitable Slowdowns
Prior to go-live, you should try to work down as many outstanding items as possible. For example, clear coding backlogs and check that discharge not final billed (DNFB) is current and accurate.
Since staff are learning new documentation practices and system functionalities, it is important to anticipate and plan for coding productivity issues as well. Health information management (HIM) resources will often get pulled into situations that require immediate attention. Be sure they have the time available to handle these problems without having to fit the work between other priorities.
As mentioned before, it is essential to think through how to stratify your workforce to manage A/R in two different systems, tackling outstanding inventory in the legacy system while addressing new inventory in the new system. This is especially important if accounts are not being converted to the new system.
Having staff work in multiple programs at the same time can create convoluted, ineffective processes that result in increased A/R days and subsequently decreased cash collections. Conversely, a stratified approach yields more efficient workflow, and it can minimize the likelihood of errors. Depending on your resources, you may want to bring in outside support temporarily to handle the legacy volume. While your team focuses on the new system, an outsourced team can manage the old accounts receivable and help you preserve cash flow. Outsourcing your receivables during this time can help your staff stay focused on implementation and training in time to confidently go live on the new system.
Monitor. Monitor. Monitor.
Continuous performance monitoring is a key project success factor. Not only does it help you return to revenue neutrality as quickly as possible, but it ensures you are getting to target revenue in the right way. Effective monitoring involves comparing post-go-live performance to preproject levels, looking for concerning patterns that need to be addressed.
Prime areas to watch include
- Service-to-payment velocity. It’s always wise to understand how fast you are getting paid and whether that has changed. A/R days is the industry standard metric for this analysis. It is normal to see an initial increase in A/R days, but you should return to pre-implementation levels relatively quickly.
- Discharged Not Final Billed (DNFB). This illustrates how long it takes to get a claim out the door. Spikes in DNFB could indicate process or people problems that warrant attention.
- Charge-to-cash conversion. This metric compares outgoing dollars to net income and is a function of gross charges. If this metric is substantially higher post-implementation, you need to see if you’re actually collecting more on each dollar because you’ve got better collection policies or practices in the new system or if it’s because you have potential issues with your pricing methodologies.
- Payer mix. By checking payer mix, you are verifying whether you set your plan codes up properly. If you haven’t correctly captured your payer mix in the new system, then it will affect how you’re reporting revenue. For instance, if you have a Medicare Advantage plan, and you’ve got it categorized as a commercial plan, it will skew how you report your payer mix, bad debt, and charity care. If payers have different requirements for claims, a misclassified payer can also lead to an increase in denials and negatively impact reimbursement.
- Coding and documentation. By comparing current charts to pre-conversion ones, you can spot changes in coding, charging, and documentation patterns that can have a negative effect on revenue and compliance. Some trends may not immediately be apparent post go-live, so it’s important to review charts regularly for several months.
- Charge trends. Watch for any charge delays to pinpoint which departments may not be submitting charges as quickly as before. Clinical departments should be engaged in the charge monitoring process, and charge reconciliation should occur daily as a standard practice. To ensure clinical involvement, create charge reconciliation policies and procedures and offer educational workshops with each cost center’s primary and secondary revenue owner prior to go-live, providing hands-on education on how they should capture and reconcile charges in the new system. Even though this type of training is not standard curriculum in most EHR implementation plans, it is critical to achieve rapid revenue neutrality.
In addition to training, conduct charge audits that trace charges from the point of order through to the bill to validate charge capture and verify compliant reporting. Also monitor unresolved charge rejections and pricing errors. Note that it may be helpful to use a neutral third party to maintain objectivity.
- Underpayments and denials. If you see big differences in underpayments and denials, it could indicate you have process or build issues that are creating claims that aren’t getting adjudicated correctly. When you spot an anomaly, try to identify root causes as quickly as possible. This helps reestablish processes that may be knocked out of alignment during a system change.
- Overall revenue. When monitoring revenue, look beyond just the cost center level. Also compare revenue and utilization patterns at a service or procedure level. This can help you spot significant net revenue or compliance impacts.
To stay on top of the monitoring effort right from the start, task specific resources to identify variances, conduct root cause analyses, and drive corrective actions—whether those are related to systems, processes, or people. As you start to generate data, set up a daily meeting with revenue owners to review variances and assign corrective actions. This will establish accountability for the work and keep everyone focused on improvement.
Keep your eye on the prize
Making sure your RCM and EHR technologies work well together is critical to ensuring solid long-term financial performance after an EHR implementation. By following best practices that keep RCM front and center throughout the initiative, you can not only mitigate risk but seize improvement opportunities. While good planning can go a long way, so can the right resources. Check that you have the correct levels of people, processes, and technology to support a smooth and financially lucrative implementation.
For more information on how Change Healthcare can help ensure RCM success during an EHR implementation, go to changehealthcare.com/solutions/revenue-cycle-management.