Optimizing healthcare reimbursement is essential for financial sustainability and high-quality patient care. Drawing on expert insights from BESLER, here are actionable best practices for hospitals and healthcare organizations:
- Stay Current with Policies and Regulations
- Regularly review Medicare and payer policies, regulations, and reimbursement methodologies.
- Monitor updates from CMS and other regulatory bodies to ensure compliance and optimize eligible reimbursements.
- Enhance Documentation and Coding Accuracy
- Ensure comprehensive and accurate clinical documentation for all patient encounters.
- Invest in ongoing education and training for coding staff to stay updated with the latest coding guidelines and regulations.
- Conduct regular coding audits to identify and correct errors before claims submission.
- Streamline Revenue Cycle Management (RCM)
- Implement efficient RCM workflows covering patient registration, insurance verification, coding, billing, and collections.
- Automate repetitive tasks such as eligibility verification and claims submission to reduce errors and speed up processes.
- Perform zero balance reviews to confirm accurate reimbursement and contract compliance by payers.
- Monitor key performance indicators (KPIs) like denial rates, days in accounts receivable, and clean claim rates to identify trends and areas for improvement.
- Leverage Advanced Technology
- Utilize technology solutions such as robotic process automation (RPA), artificial intelligence (AI), and machine learning (ML) to streamline processes, reduce error rates, and increase revenue.
- Employ analytics tools for real-time insights into operational and financial performance, helping to identify and plug revenue leaks.
- Optimize Case Mix Index (CMI)
- Ensure accurate documentation and coding of diagnoses and procedures to reflect patient severity and complexity.
- A higher CMI can lead to increased reimbursement rates, so regular reviews and updates are essential.
- Reduce Denials and Manage Claims Effectively
- Analyze denied claims to determine root causes and implement corrective actions.
- Develop processes to track and appeal denied claims promptly.
- Foster open communication with payers to clarify coverage policies and resolve disputes efficiently.
- Foster Interdepartmental Collaboration
- Encourage collaboration between departments such as revenue cycle, pharmacy, case management, and reimbursement teams.
- Joint efforts can improve billing accuracy, reduce claim denials, and ensure compliance with programs like 340B.
- Participate in Value-Based Payment Programs
- Engage in programs such as Accountable Care Organizations (ACOs), bundled payments, and quality incentive initiatives.
- These programs can offer additional revenue opportunities based on improved patient outcomes and cost efficiency.
- Invest in Staff Training and Education
- Provide regular training on documentation requirements, coding guidelines, and claims submission processes.
- Empower staff with the knowledge and skills needed to navigate the reimbursement landscape effectively.
- Regularly Analyze Financial Performance
- Monitor reimbursement trends, payer mix, and revenue variances.
- Use data-driven insights to identify opportunities for operational efficiency and financial improvement.
By implementing these best practices, healthcare organizations can enhance operational efficiency, minimize revenue leakage, and ensure they receive the full reimbursement they are entitled to—all while maintaining compliance and supporting high-quality patient care.
Contact BESLER to learn more about how you and your healthcare organization can better retain the revenue you’ve earned.
