The Blind Spot of the Hospital Revenue Cycle
What is the “Hospital Revenue Cycle Blind Spot?” It is the intersection of clinical decision-making, regulatory compliance, payer interactions, and billing requirements that is typically managed by utilization management (UM). The common approach in healthcare utilization management is to assess every case using commercial screening criteria and refer failed cases to a physician advisor for a second review. This “one-size-fits-all” approach has worked for years, but is it still the appropriate process to address the myriad of complexities and challenges associated with UM today?
The result is a “blind spot” in the hospital revenue cycle that often leads to compliance vulnerabilities and lost revenue. For example, most organizations don’t have clear visibility on the following:
- Are our short-stay inpatient cases with no CMS exceptions compliant?
- Do we have patterns of risk on Monday discharges or discharges to skilled nurse facilities?
- Do we have risk in our TKA or other procedures that have come off the Inpatient-Only list?
- Which physicians are driving compliance or revenue integrity risk?
- Are we conducting peer-to-peer appeals on commercial cases that pay the same for observation and inpatient status?
- Do we have physicians that are statusing Medicare Advantage and Medicare patients differently based on financial class?
Until now, most solutions have focused solely on outsourcing or automating a routine process but have failed to shed light on this “blind spot” and provide the information and guidance required to secure revenue integrity. Versalus Health combines the power of technology and analytics with regulatory, compliance, and managed care expertise to help clients clear the confusion and improve revenue integrity.
Versalus Health’s leaders realized that UM is an integral component of the healthcare revenue cycle and developed a solution that leverages and complements our clients’ in-house talent while providing visibility into processes, risks, and opportunities.
How It Works
Baseline Assessment & Benchmarking
Evaluate compliance risks and healthcare revenue integrity relative to OIG/CMS guidelines or evaluate performance across payers.
Identify specific sources of compliance risk or revenue opportunities across payers that can be addressed.
Revamp operational processes to close gaps and benefit from identified opportunities.
Education & Training
Ensure hospital teams and attending physicians understand new processes and get it right up front.
Ongoing Monitoring & Audit
Continuously monitor performance toward goals and identify other areas of opportunity.
The result? A program that uses your resources efficiently, enhances Medicare compliance, and ensures that you receive the revenue that you are owed.
Do you have your own Physician Advisor team? No Problem
Versalus Health complements your Physician Advisor and Utilization Management teams by providing them with the visibility and targeted expertise they need. Our solution allows them to prioritize the cases that have high impact on compliance and revenue integrity and monitors outcomes to ensure optimal performance.
Don’t have your own Physician Advisor team? No Problem
If you don’t have a Physician Advisor team or your team needs additional support, Versalus Health offers Physician Advisor services on a case review by case review basis or dedicated Physician Advisor Staffing services.
A new approach to Compliance and Revenue Integrity for Medicare Fee-For-Service
Versalus Health offers a more intelligent approach to managing compliance and revenue integrity for the CMS Two-Midnight Rule. The Versalus Health Medicare solution helps you address questions such as:
- Are our short-stay+ Inpatient cases appropriate under the Two-Midnight Rule? (+less than 2 midnights)
- Are some of our long-stay* Observation cases more appropriate for Inpatient under the Two-Midnight Rule? (*greater than 2 midnights)
- Does the physician documentation concur with my UM process/outcomes?
- Are we identifying and appropriately billing all Inpatient-Only Procedures?
- Do we have patterns of delay with Monday discharges, Skilled Nursing Facility discharges, or other population of patients?
Versalus complements your own Physician Advisor team or provides physician advisors to perform reviews.
Reduce Compliance Risk
Monitor for outlier patterns, potential gaming, and to ensure high-risk cases are appropriately statused and billed.
Improve Revenue Integrity
Ensure that you are receiving all the revenue that you are owed.
Improve UM Efficiency
Prioritize efforts on the most important revenue integrity and compliance issues.
Ask Versalus Health for a fee Utilization Management Program Assessment?
Medicare Advantage, Commercial, and Managed Medicaid
Versalus’ Private Payer solution relies on payer-specific analytics to prioritize efforts in areas with the largest revenue opportunity. Our solution focuses on addressing the following questions:
- How are my Medicare Advantage Payers performing relative to Medicare Fee-For-Service? and/or how are my Commercial Payers performing relative to each other?
- Where am I losing revenue today?
- What can I do operationally and contractually to improve performance?
- Where do I prioritize my efforts?
Identify sources of revenue loss and create a plan to stop shortfalls.
Streamline Operational Processes
Develop payer-specific strategies and prioritize efforts to improve contract performance.
Hold Payers Accountable to Contract Terms
Identify and quantify egregious payer behavior so that contract terms can be clarified to improve future revenue.
Interested in learning how your Payers are performing?
Our Strategic Payer Assessment quantifies how payers perform relative to Medicare and each other and identifies opportunities for revenue improvement.
Net Inpatient Realization ® Services
Versalus Health provides Net Inpatient Realization ® (NIR) services to measure the net impact of each payer’s denial tactics and influence across internal functions of the clinical revenue cycle. Versalus Health’s Net Inpatient Realization ® services monitor the hospital’s performance by payer, including initial status assignment in Utilization Review/Utilization Management, initial denial and appeal rates, whether the denial was appealed at any stage, win rates in both the peer to peer and written appeal process, and whether cases were billed and ultimately paid appropriately and according to process. Through Versalus’ Net Inpatient Realization ® services, each payer is assigned a performance indicator, which allows the hospital to compare payers and measure payer-specific performance against a defined benchmark. Versalus Health’s Net Inpatient Realization ® services also inform hospital stakeholders specifically where revenue leakage is occurring for each payer along the revenue cycle continuum and how to develop and implement payer-specific escalation strategies.
Interested in learning more about Net Inpatient Realization ® ?
From time to time, Versalus’ clients require assistance understanding the impact of the latest regulatory changes, new private payer behavior, or updates to auditors’ approaches. Versalus Health’s regulatory, managed care, and billing experts review issues and give you the information you need to make sound business decisions.
Some of our most recent projects include:
- Length of Stay Assessment/Audits
- Malnutrition Assessment/Audits
- DRG Integrity Assessment/Audits
- Behavioral Health Assessment/Audits
- Inpatient Rehab Assessment/Audits
- Pediatric Performance Assessment/Audits
- Contract Renegotiation Support
- Payer Litigation Support
Interested in any of these projects?
“Unlike my experience with [vendor name excluded], Versalus partners with our UM team to improve our workflow and ensure that we focus on the highest risk and highest opportunity cases. Versalus analytics provide us the visibility we need to continuously improve. It’s no longer about how many cases they or we review. It is about the right review on the right case at the right time that improves our compliance and healthcare revenue integrity outcomes.”
“Traditionally, utilization management (UM) has not been viewed as an integral part of the hospital revenue cycle. I selected Versalus to help me in my dual role as Director of Revenue Cycle and UM. Versalus brought the visibility I needed to manage the complexities between UM, billing, reimbursement, and compliance. They helped me identify high priority issues, fix them quickly, track our progress or any deviations and address them promptly. Our ROI on their program has been impressive and our providers and leaders have been extremely receptive and happy with the partnership.”
Director Revenue Cycle/Utilization Management
Pacific Northwest Health System