Hospital rev cycle teams are prized for their ability to keep revenue and payments flowing. Team members are selected for their technical expertise, knowledge of medical billing, and ability to navigate complex payer requirements. Yet virtually all of them lack the one thing most likely to help your rev cycle team increase revenue: clinical expertise.

Rev cycle teams rarely include someone with clinical experience.

It is so unusual for a rev cycle team to include someone with clinical experience that the mere suggestion is often dismissed as off the mark. Even the thought of contracting with a consultant to bring in that clinical expertise seems strange. Why invest the money for clinical expertise that isn’t going to be used on patient care? 

When hospitals hire for rev cycle, they want proof the applicant understands the claims cycle. They want them to understand registration and coding and collections. Yet, for many hospitals, it is that exact belief system that keeps them from increasing their revenue.

Clinical experience is essential to notice missed charges in OR and ER procedures.

A typical member of the rev cycle team is able to take the charges as presented to them, enter them into the system, and make sure they are processed. What they can’t do, however, is see what charges might have been left out. Sure, they may catch something missing that is usually there – but they will not be able to see what should have been there all along but isn’t. 

In contrast, a person with both technical knowledge of the rev cycle process and clinical knowledge will be able to see what else should have been included. For instance, if a hospital’s coding system does not allow for the actual complexity of a surgery, they will not be able to code for it properly and will not get full recognition for the cost.

How this plays out in the OR 

An example of this is with implant service lines. In many cases, the way these surgeries are processed guarantees that the hospital will lose money each time the procedure is performed. The issue lies in how their service line costs are set up. If these are not put in place properly, there is no way to collect on all the services that were delivered. And a rev cycle team that lacks clinical knowledge would never know.

How this plays out in the ER

Similarly, when a patient is seen in the ER, their charges are processed in accordance with their ER level of care. Yet these levels are frequently set up in ways that negatively impact hospital revenue. Again, this is not something the rev cycle team would have the skill set to recognize. 

Millions in recovered revenue.

When the rev cycle process is approached with a clinical perspective, it makes a profound difference to a hospital’s bottom line. Hospitals can recover millions of dollars in missed OR and ER charges. 

Why leave money on the table?

Rev cycle teams need more than technical skill and knowledge of medical coding. They need someone with clinical knowledge to flag missed opportunities. That missing ingredient is what is needed so the rev cycle and clinical teams can update their processes and ensure their health system is bringing in all the revenue to which they are entitled.

Photo by Sigmund on Unsplash.

Missed Opportunities

The Hospital CEO and CFO Guide to Recovering OR and ER Charges

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