By Angela Jordan, Senior CDI Consultant, TRUSTEDi10, abeo
Joe Ferro, President, TRUSTEDi10, Chief Technology and Innovation Officer, abeo
As many can agree, revenue cycle management (RCM) departments have been facing a perpetual storm of ever-expanding and complex reimbursement rules, creating an increased need for internal bench audits. As if the reimbursement equation wasn’t difficult enough, providers are having to document to multiple standards, and they struggle to appease all stakeholders. Put it all together and they now have a seemingly impossible task of getting reimbursed appropriately and in a timely manner for the quality services that they deliver.
Healthcare organizations continually strive to improve clinical outcomes and patient satisfaction, all while trying to contain and/or reduce costs. These efforts, along with over a year of revenue loss due to the public health emergency, have forced organizations to search for accelerated solutions to automate and streamline workflows within their revenue cycle.
What needs to be done?
With technology advancing at breakneck speed, innovative solutions are available for RCM, providing new levels of efficiency and high standards for accuracy. Advancements are leveraging artificial intelligence (AI) and natural language processing (NLP) technology to automate complex, repetitive, and data-intensive tasks. All of these exciting opportunities for customization should be explored.
It can be precarious looking for a solution without knowing the heart of the problem. Acknowledging there is a problem is the first step but an organization needs to perform a root-cause assessment to better understand how to improve the viability of the revenue cycle.
When it comes to finding a solution, one of the top concerns is the claims process. Challenges and roadblocks are all along the way, from provider documentation to coding, payer rules, charge entry obstacles, and claims submission, all of which must be accurate, compliant, and timely. During the exercise of process mapping or other process improvement methodologies, the spotlight often lands on the accuracy and cost of coding and charge entry. Organizations need to identify and quantify the financial impact of inaccurate claims, and then act swiftly, as they send shockwaves throughout the health system when it comes to lost revenue or inaccurate payment.
Manual coding process, what can go wrong?
Face it, providers do not want to be coders. Providers already feel overworked, overwhelmed, and underappreciated. While the Centers for Medicare and Medicaid Services (CMS) and the American Medical Association (AMA) have recognized this by reducing documentation burden, change is slow. But as the documentation may lessen, it seems to come at a cost: increased scrutiny of claims by CMS and other payers. If the documentation doesn’t fully support the service according to the payer, repayments can escalate and be devastating to the organization. Having qualified coders could decrease an organization’s risks.
In most specialties, employing highly skilled certified coders to review documentation and determine the appropriate code(s) is a must-have. This versatile person can identify documentation deficiencies that impact the specialist’s ability to bill all services. They act as communicators and provider educators when it comes to documentation improvement. Certified coders stay abreast of CMS national and local coverage determinations (NCDs/LCDs) and the national correct coding initiative (NCCI) updates, as well as commercial payer guidelines. They typically surround themselves with a network of coders to expand their resources; a benefit to themselves as well as their employer.
Today, more than ever, programs that focus on quality improvement drive data processes through clinical documentation. Having a clinical documentation improvement (CDI) expert will assist in attaining quality goals as well as enhance coding opportunities by developing best practices in documentation. Thorough documentation allows for precise coding, creating a more accurate payment model.
The coding process itself can be a hurdle to overcome. Every step of a manual process relies on the employee completing each component, and there is no room for error. In today’s environment that focuses on productivity, quality has been sacrificed for quantity. This is where having the right technology will streamline the process and improve the outcome.
Artificial Intelligence and Natural Language Processing?
Copious amounts of information are available on both AI and NLP. In terms of revenue cycle, AI informs technology that allows a computer to interpret a complex series of thoughts and provide us with the ability to action those thoughts into smaller sets of concepts. NLP allows the computer to act upon those concepts.
For example, RCM solutions can use AI to quickly scan a medical record to find the patient’s current medications along with the prescribing reasons. The list of medications and reasons can then be passed to the NLP engine that confirms that the chart contains supporting documentation. In this scenario, the AI and NLP systems worked together, instantaneously, with a high degree of accuracy to identify and validate that the data is present and compliant.
Using the technologies, in tandem or alone, will yield better results with these repetitive yet skilled tasks. The coding and billing departments are prime examples of high-quality and expeditious standards. In other words, they demand a quick turn-around time when it comes to coding, billing and payment within the confines of compliance.
Technology using AI and NLP benefits, can it actually help?
Programs using AI and NLP are a beneficial and cost-effective way to streamline the coding, charge entry, and chart audit functions for the revenue cycle. While AI cannot do everything a human can do, it can automate complex and repetitive tasks with a high level of accuracy.
Intersecting points to consider for advanced technology in the revenue cycle is its ability to:
- Automate a process to validate that the most accurate (specific) ICD-10 code was used to describe the patient’s diagnosis
- Confirm documentation of procedures that were done or ordered
- Assess the level of evaluation and management (E/M) services
- Compare clinical documentation to a facility or practice’s standards (CDI)
- Ensure that all documented (billable) services were accounted for
- Certify that only documented and compliant services were billed
This is an exciting time!
RCM professionals should not let past negative experiences with technology taint their search. With the rapid evolution of platforms powered by AI and NLP, the RCM department will find that its improvements are impressive. With a thorough understanding of the revenue cycle process, its challenges, and initiating due diligence, a compliant and cost-effect computer-assisted coding solution is available.
Joe Ferro is the Chief Technology Officer at abeo, President and Founder of TRUSTEDi10. Angela Jordan is Senior CDI Consultant. abeo is an indispensable partner for advisory, analytics, billing and collections, and technology solutions. TRUSTEDi10 is abeo’s computer-assisted coding application that uses AI and NLP technology for evaluation and management coding.
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