In this episode, Meliza Weiner, BESLER’s Senior Manager of Revenue Cycle & Clinical Review Nurse, provides us with a glimpse into webinar, The Role of Case Management in the Revenue Cycle, presented live on Wednesday, May 29, at 1 PM ET.
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Learn how to listen to The Hospital Finance Podcast® on your mobile device.Highlights of this episode include:
- What is the Revenue Cycle
- Revenue cycle factors to consider
- What is case management
- Regulatory requirements to consider
- Payers and health plans requirements
- How case management plays a role in the revenue cycle
Kelly Wisness: Hi, this is Kelly Wisness. Welcome back to the award-winning Hospital Finance Podcast. We’re pleased to welcome back Meliza Weiner, BESLER’s Senior Manager of Revenue Cycle and Clinical Review Nurse. In this episode, Meliza will provide us with a glimpse into our next webinar, The Role of Case Management in the Revenue Cycle, that we’re presenting live on Wednesday, May 29, at 1 PM eastern time. Welcome back and thank you for joining us, Meliza.
Meliza Weiner: Thank you so much for having me back, Kelly.
Kelly: All right. Well, let’s go ahead and jump in. So, revenue cycle is a hot topic in healthcare, but what exactly is the revenue cycle?
Meliza: Let’s first talk about revenue without the cycle word. If we look up or even google the word revenue, it basically means that it is the total amount of money, or should we say income, that you get or income generated by selling something like goods and services. By the way, I did get that from Webster and Oxford definition. So now when we talk about revenue cycle, the word cycle means series or sequences. So, in essence, revenue cycle is a series of steps or stages, like a process by which healthcare organizations use to manage their financial operations.
Kelly: Thank you for that explanation. Are there revenue cycle factors to consider?
Meliza: Absolutely, Kelly. So, there are three groups of factors to consider. So, I’ll start off with people. The first factor people, so one of the groups of people in this factor are your customers. And what needs to be considered with this individual is, is the organization meeting the needs of their customers so they keep going to that organization? It’s that simple. Right? But a lot is really involved when it comes to healthcare needs. Another factor is the group of people that provides the goods and services and the care. It could be the person that does the registration, which these are the individuals that are making sure that the correct information is gathered. Then the individuals that are providing the services, like the physicians and the nurses and your technologists, are they documenting what they did? So once that happens, now you have the coders, right? The coders who make sure that everything documented is coded correctly in order to bill. And then after that, you have the billers that send out for the payment. Now, I can go on forever, but those are just some of the numerous people within the organization that can influence revenue. But I do want to mention also that most of these people work behind the scenes, like individuals in IT, who make sure that the technology and the software in place are being used. And when they’re used, they actually work.
The other factor is equipment. Does the organization has the latest up-to-date and working equipment for the sale of these services, like your CAT scan, radiology, your cardiac monitors? And how about those computers, right? Rolling laptops? Does it have the latest software for registration? Does it have the latest update when you’re charge capturing for billing? Is it also in compliance with HIPAA? That’s very important nowadays because you don’t want any personal information floating around all over the world. And the last factor that I want to mention is the actual process itself. Is the organization’s process streamlined? Are there multiple steps? Are there roadblocks that the individuals affected by the process have to make provisions for, or do they have to jump through hurdles? Does it slow down the ability to provide the service? How about the ability to document? Does it slow down the ability to code? Then, of course, there’s the billing and ultimately making sure that the organization gets paid. So, all of these factors that I’ve mentioned really affect revenue cycle in some shape or form.
Kelly: Thank you for that overview of those very important factors. So, case management is another topic that comes up when discussing revenue cycle. Can you explain what is case management?
Meliza: Well, you are correct by saying that case management is a topic that goes hand in hand with revenue cycle. There are several descriptions and definitions of case management. And to be honest, whenever I get this question, I always reference two known case management groups that are considered to be leaders in case management. But in the essence of time here, I’ll use the definition by one of them, and it’s the American Case Management Association, who basically defines case management as a collaborative practice model. That includes the patients, the nurses, the social worker, physicians, other practitioners, caregivers, and the community. So, Kelly, case management really involves communication and facilitation of care along the healthcare continuum, and more so by ensuring there is effective resource coordination.
Kelly: It sounds very important. Are there regulatory requirements to consider?
Meliza: Oh boy, there are a lot. Regulatory agencies such as the Centers for Medicare & Medicaid Services. We know them as CMS. They have a mandate for Medicare and Medicaid conditions of participation, which is Title 42, the Social Security Act, which has section 1861 regulation, and then you have the Quality Improvement Organization. All of these agencies, they require that hospitals and health systems have an actual utilization review plan in place. And so, for those who are not familiar with that, utilization review falls under the umbrella and is a function within case management itself. So now there are elements that are part of the foundation of utilization management review, and that basically involves medical necessity, looking at resource utilization, length of stay, working on denials and outcomes. All of this actually affects reimbursement, thus affecting revenue.
Kelly: Wow, thank you for those requirements. So, what about payers and health plans?
Meliza: Good thing that you mentioned that. You know what? Payers and health plans set forth a lot of requirements in their contracts, which affects reimbursement and revenue. So having utilization review, these individuals that are in this group, they’re actually equipped with the knowledge of payer and health plan intricacies. They can bridge the gap between the quality of care provided and the clinical medical necessity, the intensity of services, coverage, and ultimately reimbursement. Also, with these management processes that are tied to financial policies, it actually ensures compliance from a regulatory quality and risk perspective. And it provides a course for hospitals and health system operations. Now, different hospitals interpret and implement utilization management review in different ways. But the basic utilization management review could just be a plan, a process, or an approach, if you will, used for claims processing, resource utilization, denial prevention, risk management, and quality review.
Kelly: I think I got it. So how does case management play a role in the revenue cycle?
Meliza: Well, since we’re talking about revenue cycle, we might as well start with cost containment. With utilization review function, that actually helps with managing cost and the delivery of services. The integration of this function within the hospital operations can increase care efficiency and actually decrease revenue loss. For example, when you’re reviewing medical necessity, that is one of the utilization review processes. It involves three ways. You can do a review of medical necessity for procedures and services before admission, which we call prospective review. Then you have a concurrent review, which basically means they’re doing the review while the patient is in the hospital. And then there’s a retrospective review, which is taking a look at it at the case after the patient gets discharged. So, all of this alone can significantly decrease the length of stay. It helps manage the appropriate use of resources and services, as well as preventing denials and protecting your revenue.
Now, some of the other various activities beyond that also include pre-admission certification, admission certification, discharge planning review, making referrals for social work services, pharmacy, physical therapy, respiratory services. And then there’s also other influences where they work within the operations of the hospital. They can work with the healthcare team, facilitate and coordinate resources and services. And a good example also beyond the healthcare team, they can work within the quality department. They can be involved in quality assessment, quality improvement, like evaluating patient care services and systems. That includes taking a look at standards, taking a look at protocols, looking at documentation efficiency, looking at the EMR, with admissions and registration and scheduling, having appropriate communication, and especially the documentation of the patient’s status, whether the patient has to be an inpatient, an observation, maybe needing outpatient services, the discharge disposition. This actually helps ensure accurate coding, reducing denial, and improving the reimbursement potential.
See, revenue cycle in finance, there’s a lot of impact with their work. So basically, it is important that collaboration exists. In today’s revenue cycle teams, they have access to lots of data. And also, taking a look at today’s information technology that we have, this can tremendously really assist with managing length of stay, appropriately allocating the resources, again, preventing denials and ensuring that the documentation is there for coding and appeals. Now, originally, this department, case management, started with a narrow focus to the point, and at times has worked in silos. Now that this department’s functional activities really have increased and influenced reimbursement and actually affect revenue, the impetus of case management playing a role within the finance area, specifically in revenue cycle, really should be highlighted. So, Kelly, in a nutshell, it is important to have case management play a role, be involved, and there really is nothing wrong. And I think it is right with case management aligning with revenue cycle.
Kelly: That makes a lot of sense, and it does seem like it plays a pretty important role. We really appreciate you coming on, Meliza, and sharing your sneak peek into the upcoming webinar, The Role of Case Management in the Revenue Cycle, that you’re presenting live on Wednesday, May 29, at 1 PM eastern time. And as a bonus, you can earn CPE. So, thanks again, Meliza.
Meliza: Thank you.
Kelly: And thank you all for joining us for this episode of The Hospital Finance Podcast. Until next time…
[music] This concludes today’s episode of the Hospital Finance Podcast. For show notes and additional resources to help you protect and enhance revenue at your hospital, visit besler.com/podcasts. The Hospital Finance Podcast is a production of BESLER | SMART ABOUT REVENUE, TENACIOUS ABOUT RESULTS.
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