Hidden Figures: Uncovering Your Missing Revenue

By: Briauna Driggers

​RCCS President Melody W. Mulaik, MSHS, and Director of Revenue Cycle Consulting Mary Early Suhr, MBA, CPC recently presented a webinar tackling the timely topic of revenue recovery. This article provides a recap of the presentation and additional resources to help your organization identify and recover missing revenue. 
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Watch the full recording

Understanding Revenue Recovery

The term "revenue recovery" extends beyond the typical consulting services that identify problems. It involves a detailed evaluation of how revenue flows within your system and includes the active component of helping organizations quickly realize a positive return on investment by posting identified missing revenue within timely filing guidelines. This proactive approach ensures that past oversights are corrected going forward and offers a quick infusion of revenue. "There’s no ‘I wish I could go back and do x, y, z differently'," explained the speakers. "Instead, we actually go back and post as much as possible to help capture that missing revenue."
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Every organization should be recovering revenue, but sometimes you need a little help and an outside perspective. When you work with RCCS for revenue capture and reconciliation, we create custom tools to optimize the charge capture and coding workflows that your organization can continue to use after our services conclude.

Key Areas of the Revenue Cycle

​Revenue recovery occurs throughout all parts of the revenue cycle:

• Front-End: This includes checking for actionable corrections like ensuring the appropriate authorization ID was present on the claim, the correct services were authorized, the appropriate payer was billed, and that patient information was accurate.
• Mid-Cycle: It is important to have a unified system footprint across all “books of business,” which can be facilitated using a reconciliation tool. Arguably the most important portion of this process, mid-cycle revenue recovery, includes coding corrections for appropriate and adequate reimbursement.
• Back-End: This involves looking at write-offs and understanding their causes, reviewing provider documentation, and managing denial appeals effectively. Here is also where KPIs and financial analytics come into play, painting a comprehensive picture for your organization.  For example, you can have a low Pre-A/R days metric, but if the first pass denials metric is high, the Pre-A/R metric is truly negative.

 
Recovering revenue is not just about identifying missed or inaccurate codes. It spans the entire revenue cycle, from authorization to documentation to denial management. Along the same lines, revenue recovery is not always just identifying denied claims. Sometimes there are charges waiting to be billed, resulting in missing revenue before a claim is even created. Several touch points can hold charges from being sent out the door, a few of which are outlined below:

Tools for Improvement

​One notable tool introduced during the webinar was the "Reconciliation Matrix." This tool helps organizations understand the locations of service, pinpoint where charges are initiated, and ensure that nothing is missed during the charge capture process. 

​The "Reconciliation Matrix" is an essential tool designed to enhance the thoroughness and accuracy of revenue capture across the various types of service within healthcare organizations. By systematically reviewing clinical notes and related documentation, this tool helps ensure that all potential revenue opportunities are identified and captured. For office visits, the matrix prompts a thorough review to confirm that every aspect of the encounter has been billed accurately. The matrix addresses several critical questions: 

• What activities are generating charges?
• How are these charges entering the system?
• Where might potential revenue be overlooked within the system?
• What reconciliation workflows are in place to ensure all charges are being captured? 

​By providing structured answers to these queries, reconciliation aims to optimize the charge capture processes and improve overall revenue recovery efforts.

Data-Driven Decision Making

​Key Performance Indicators (KPIs) such as Pre-A/R days, open encounter reports, write-offs, net revenue per RVU or unit of service, and days in A/R are crucial metrics to understand and optimize. "It’s not just about the KPIs themselves, but understanding what drives these numbers," Suhr noted during the presentation. This understanding helps pinpoint where improvements are needed and how to implement them effectively.

Identifying Opportunities for Revenue Recovery… Show Me the Money!

When exploring opportunities for revenue recovery, it's crucial to target areas with the highest yield first, examining the most valuable book of business before diving into more detailed reviews. Start by identifying top denial categories – like Pre-A/R or Claim Holds – and then determine which books of business are contributing to those denials.
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Opportunities for enhancing revenue exist in every organization, regardless of size. To systematically identify these opportunities, the webinar introduced the "Opportunity Identification Matrix." This tool aids in pinpointing potential areas of revenue recovery, helping organizations methodically explore these avenues.

​Additionally, understanding and integrating individual payer requirements beyond standard Centers for Medicare & Medicaid Services (CMS) guidelines into your systems can significantly enhance charge capture efficiency. Incorporating specific rules into your Electronic Medical Record (EMR) systems based on these unique payer demands ensures that billing processes are not only compliant but also optimized for maximum revenue recovery. 

Specialty-Specific Opportunities

​Identifying areas of opportunity for revenue recovery truly depends on the organization, and some specialties have unique recovery opportunities specific to that department. Certain specialties, such as Radiology and in-patient hospital-based services, often present more substantial levels of recovery due to the volume and cost of procedures. The unique challenges of documenting for such specialties require specific strategies to ensure all potential revenue is captured.

Revenue Recovery Process

​It is recommended to conduct a high-level analysis to quickly identify and prioritize areas for potential revenue recovery. This process can yield significant findings in 30-60 days. Based on initial findings, each department is then prioritized for review. Detailed departmental analysis follows, with specific attention to charge posting and process correction for each area. Finally, tools created during the analysis are handed off to the organization and any necessary training will be scheduled. 

Let’s Work Together to Identify and Recover Missing Revenue in Your Organization

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The webinar provided comprehensive insights into the intricate process of revenue recovery in healthcare. By focusing on the full spectrum of the revenue cycle, employing strategic tools, and understanding the data behind the numbers, healthcare organizations can significantly enhance their financial outcomes. The expertise offered by RCCS can be a valuable resource in navigating these complex processes and achieving successful revenue recovery.