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Care Management’s Role in Aligning Clinical Revenue

With remote work more common now, utilization review staff should assess whether their processes are helping or hurting their organizations. Read on for more.
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Prior to the pandemic, many utilization review (UR) staff were working remotely—but now that remote work is even more common, your organization may face additional costs as a result of foregoing the concurrent review process in favor of the retrospective review process. The concurrent process can be time-consuming, but in reality, it can be cost-beneficial when factoring in avoided denials and level of care downgrades. Reaching an attending physician prior to discharge can be much easier than reaching them after a patient has been discharged.

The financial difference of a concurrent process versus a retrospective process can be consequential. For example, with a concurrent Condition Code 44 process, a single outpatient Part B claim is submitted upon discharge. If completed early in the inpatient stay, a new order for outpatient with observation services may be written, allowing for an APC payment including observation time. With the retrospective self-denial/rebill process, there would be no observation, room and board, or nursing care charges to bill for, resulting in a significant reduction in reimbursement through the rebilling process. Thus, the retrospective process could result in a significant revenue loss for hospitals—based on some estimates of more than $1,300 per claim—as well as a delay in payment due to the layered claim processing requirements. For the self-denial/rebill process, a hospital stay must first be billed as a self-denied claim, which is processed by the Medicare Administrative Contractor. Then hospital coders and billers must prepare two rebilled claims resulting in hospital stays being coded and submitted a total of three times, which can significantly increase staff workload and reduce efficiency.

It's crucial that UR staff and hospital leadership understand the implications of concurrent versus retrospective review prior to choosing one. Consistently utilizing a selected process can help patients receive the correct level of care at the correct time and help hospitals deliver appropriate and cost-effective care while reducing claim denials for improper billing or inappropriate services. Detailed policies, procedures, and staff job descriptions are necessary for developing and implementing an effective utilization review process.

Forvis Mazars can Help

The Healthcare Performance Improvement Services team at Forvis Mazars is available to assist you in developing and implementing an effective utilization management process for your facility.

Reach out to a professional at Forvis Mazars or submit the Contact Us form below to get started.

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