Whitepaper | LaTonya O’Neal, RHIA
Vice President, Revenue Integrity and Centralized Coding, Change Healthcare
LaTonya leads coding, compliance audit, charge capture, and clinical documentation improvement services for facilities and professional services.
In the arduous, complex process of submitting claims, charge accuracy is rarely at the top of providers' concerns. Other challenges, such as denials, are often the priority, since their impact on the bottom line is easier to calculate than revenue loss due to underpayments.
Of course, missed charges are only half of the equation; overcharges can be as detrimental, if not more so, to your organization's financial health. Once you consider staff time spent reimbursing the payer and responding to auditors, plus any government fines, interest and penalties, and/or hiring outside counsel and an auditor, the cost of overpayments becomes clearer. Even more alarming: when the Office of Inspector General conducts an audit that reveals a percentage of claims contain overcharges, it can extrapolate an overpayment estimate for the audit period. This can result in hundreds of thousands or even millions of dollars in fines, interest, and legal and audit fees, in addition to the havoc wreaked on your finance team.
There are three main causes of charge-capture errors:
Many hospitals are using automated auditing systems to help improve charge capture. Traditionally, these systems flag issues against set parameters, enabling staff to correct errors, capture all appropriate charges, and submit complete claims. Recently, solutions have been developed that take this model to the next level by leveraging artificial intelligence. These AI-infused solutions are trained on massive amounts of claims data to deliver much greater precision and specificity.
Of course, there’s still a role for human reasoning in the charge-capture equation. For example, expertise is needed to recognize connections between charges that may appear correct individually, but which make no sense together, and to investigate root causes, correct them, then re-educate coders/billers.
Charge-capture accuracy depends on a combination of technology and human expertise. This two-pronged approach is a best practice to have confidence you are capturing all valid charges while mitigating compliance risk.
Payers invest in auditing technology and skilled experts to assist in identifying overpayments and to enhance their data-driven analytics. Therefore, providers must do the same if they hope to avoid overcharge audits and the accompanying chaos and expense. Plus, what hospital can afford to allow hundreds of thousands (or millions) of dollars in missed charges to fall through the cracks?
Here's what to look for in a vendor:
Without a robust, proactive approach to chargecapture accuracy, it’s difficult to know just how much revenue you’re missing, or the annual financial impact. Working with an expert vendor could bring a return on investment that surprises even your top financial administrators.
To learn more about our revenue integrity technology and services, call 844-798-3017 or visit changehealthcare.com/solutions/revenue-cycle-management/revenue-integrity