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If a hospital doesn’t have a revenue cycle management committee, case managers can approach leadership and suggest that they propose that the hospital administration create a committee to review all contracts and denials.
The revenue cycle committee should meet at least once a month to evaluate all new and renewing payer contracts and keep a handle on denials. It’s essential for a case management representative to be an active participant, says Brian Pisarsky, RN, MHA, ACM, a director at KPMG Healthcare Solutions.
He recommends that the team include the director of the business office, the chief financial officer or his or her designee, the director of health information management, charge capture leadership, and the director of case management. Include corporate compliance as well as the individual who negotiates contracts with payers, along with ad hoc members who are invited to the meetings when there are areas of concern in their department.
For instance, if there is a significant number of physical therapy denials, invite the physical therapy director to review his or her processes and discuss potential process changes, Pisarsky says.
Start the revenue cycle committee by creating a charter to set up the team. Include the membership of the team, goals, and procedures, he suggests.
At each meeting, the case management director and other department leaders should present the denials that fall under the responsibility of their department, he says. Review your internal audits, which are either state or federal requirements.
Review denials from the various Medicare auditors and from commercial payers and look for patterns, he adds. Identify times when you didn’t appeal a denial as well as when you did appeal. Drill down and find out why you didn’t appeal and come up with ways to avoid the issue in the future.
Many organizations develop monthly dashboards with 20 to 25 metrics they measure monthly, Pisarsky says.
Many of the metrics come from five areas: case management, health information management, charge capture, patient access/business office, and denials by payer, he says.
“These organizations also review the denials that were overturned on appeal and compile a spreadsheet that includes the total amount recouped,” he says.
Financial Disclosure: Author Mary Booth Thomas, Editor Jill Drachenberg, Editor Jesse Saffron, Editorial Group Manager Terrey L. Hatcher, and Nurse Planner Toni Cesta, PhD, RN, FAAN, report no consultant, stockholder, speaker’s bureau, research, or other financial relationships with companies having ties to this field of study.