Blog, Revenue Integrity

What Can a Hospital Do to Ensure That it is Optimizing its Reimbursements from CMS?

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To optimize reimbursements from the Centers for Medicare and Medicaid Services (CMS), hospitals can take several proactive steps.

Here are some strategies to consider:

  1. Stay updated on Medicare policies. Regularly review and stay informed about Medicare policies, regulations, and reimbursement methodologies. Be aware of any changes that may impact your hospital’s reimbursement rates or eligibility criteria.
  2. Understand Medicare billing and coding guidelines. Familiarize yourself with Medicare’s billing and coding guidelines to ensure accurate submission of claims. Adhere to proper documentation practices and use the appropriate codes for services rendered. This helps prevent claim denials and ensures maximum reimbursement.
  3. Improve coding accuracy. Invest in coding education and training for your staff, ensuring they have a thorough understanding of coding guidelines and updates. Accurate and detailed coding leads to appropriate reimbursement for services provided. Consider conducting regular coding audits to identify any areas for improvement.
  4. Optimize case mix index (CMI). Case mix index is a measure of the relative costliness of treating patients within a diagnosis-related group (DRG). Hospitals with a higher CMI receive higher reimbursement rates. Ensure accurate documentation and coding of diagnoses and procedures to reflect the severity and complexity of patients’ conditions, which can positively impact the CMI.
  5. Implement revenue cycle management strategies. Streamline your hospital’s revenue cycle management processes, including patient registration, insurance verification, coding, billing, and collections. Minimize claim denials and delays by implementing efficient workflows, improving coding accuracy, and utilizing technology solutions that automate and streamline revenue cycle tasks.
  6. Monitor claims and denials. Regularly review claims and denials to identify patterns, trends, and areas for improvement. Analyze denied claims to determine root causes and implement corrective actions to reduce denials. Develop processes to track and appeal denied claims in a timely manner.
  7. Engage in medical necessity reviews. Medicare reimbursement is contingent upon medical necessity. Conduct regular medical necessity reviews to ensure that services provided align with Medicare guidelines. Implement internal processes to review documentation and ensure appropriate utilization of resources.
  8. Participate in value-based payment programs. Consider participating in value-based payment programs such as accountable care organizations (ACOs), bundled payments, or quality incentive programs. These programs can provide additional opportunities for revenue generation and incentive payments based on improved patient outcomes and cost efficiency.
  9. Collaborate with payers and consultants. Foster strong relationships with payers, including CMS and commercial insurance companies. Stay informed about payer policies, contracts, and reimbursement methodologies. Engage with consultants or experts in healthcare reimbursement to assess opportunities for optimizing reimbursements and navigating complex payment systems.
  10. Regularly analyze financial performance. Monitor and analyze your hospital’s financial performance, including reimbursement trends, payer mix, and revenue and expense variances. Identify areas for improvement and implement strategies to enhance operational efficiency and financial sustainability.

Remember that optimizing reimbursements requires a multifaceted approach involving clinical documentation, coding accuracy, revenue cycle management, and compliance with Medicare regulations.

Regularly assess your hospital’s processes and workflows, stay informed about industry changes, and seek professional expertise, from organizations like BESLER, when needed to optimize reimbursements from CMS.

Contact BESLER to discuss how to best optimize your hospital’s reimbursement from CMS.

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