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Ready to make the next step in your journey? Join the 400+ financial professionals of the revenue integrity movement.

Craneware invites you to join the movement to prevent revenue leakage. Problems with pricing, charging, coding and other business processes can result in loss of legitimate reimbursement. By joining the movement, you’ll have opportunities to learn about solutions to these challenges and to share thoughts with your peers.

Movement members can also elect to receive a free welcome packet with desktop Revenue Leakage sign and an exclusive paper, The Top 5 Sources of Hospital Revenue Leakage. So why not join the movement today?

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Welcome to the Journey to Revenue Integrity blog.

The Revenue Integrity blog is the place to go for discussions related to the many facets of preventing revenue leakage. Here, Craneware experts share their thoughts and report on industry trends… and encourage you join the conversation with your own unique experiences and opinions. Craneware client or not, there's something for everyone to learn and discuss.

About that HAC, and that hacking cough…if you snooze, you lose in 2015

by Craneware20. February 2015 15:32

Did you know 1% of your total Medicare DRG payments are at stake in 2015?

Not to take away from actual hospital acquired conditions (HACs), like the recent endoscopy superbug infections that manufacturers’ sterilization protocols won’t prevent, which are making headlines. Yet, it appears that one fourth of US hospitals are now coughing up their inpatient reimbursement, plus suffering penalties, often unknowingly and needlessly. Why? For HACs that often may not be Hospital Acquired Conditions at all, but rather a coding and documentation problem.

In 2015, CMS’ HAC Reduction Program begins. This is a pay-for-performance initiative, which penalizes DRG reimbursement for those in the lowest quartile of the HACs with the most incidences.

HACs carry nasty implications of sub-standard care, and certainly everyone wants those incidences reduced. The thing is that often the problem is not actually the quality of care, but instead that the documentation and coding that unknowingly make it look as if HACs are being treated.

Here is how this is happening. When medical issues are present upon the patient’s admission, but are not documented as such; then subsequent treatments are often coded as if the first-time that the medical conditions presented was during the hospital stay.

To avoid lost reimbursement, penalties, and perceptions of poor quality, the people responsible for coding and documentation must correctly represent the conditions present at the time of admission, and specify the conditions that treatments are addressing.

Today’s 2015 performance, will determine the penalties assessed in 2017.

Read more in the AIS Report on Medicare Compliance. Volume 24, Number 3. January 26, 2015.

We all work so hard to ensure quality care, but when something like the recent unforeseeable endoscopy problem in Calif. happens, it will hurt you financially.

If your margins are low, simply because you’re not effectively capturing charges and pricing appropriately, this affects your ability to weather the inevitable ups and downs any health system will experience. Revenue integrity processes help you understand the real state of your revenue cycle.

We appreciate you participating by sharing your thoughts with this community.

 

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Connecting the Dots so The Price is Right

by Craneware3. February 2015 15:24

On the TV game show, “The Price is Right,” people guess the price, and if they get it right, they earn valuable prizes and vacations. In healthcare, guessing about the price just isn’t fun for anyone - providers, patients or payors alike.

Optimal pricing involves many factors, with multiple interdependencies. To assure optimal margins across diverse payor plans, and be competitively priced for consumers, the necessary calculations for defining effective pricing must be performed on an ongoing basis, rather than just when a key payor contract is renewed or renegotiated. Healthcare leaders are now connecting the dots on their costs and pricing, and factoring in fresh perspectives on pricing as informed consumerism gains momentum.

Charge like everyone is watching. Informed consumerism requires healthcare organizations to take a fresh approach to pricing. Everyone has a lot at stake in ensuring that the price is right.

As consumers look at hospital pricing, the lack of consistent pricing models across the industry causes confusion.  One way to reduce this confusion is to establish pricing standards and a frame of reference about what the standards encompass.Traditional roles are changing rapidly and to retain relevancy healthcare leasers are elevating relationships with patients to even higher levels.

For sustainable service-lines, leaders are connecting the dots between operational performance and financials. They are ensuring that information is current and complete as clinical encounter data is captured and then transformed it into financial transactions in the chargemaster.

Patients today want confidence that the price is right, that their healthcare experience will be well-handled, and that their information will be correct, current and accurate – all of the way from their clinical encounter through to their billing.

In the weeks ahead, we’ll discuss this further, so check back for the latest on this blog. Meanwhile, read more in the Executive Insight article, "Revenue Cycle and Pricing Transparency."

Is your organization ensuring its pricing is competitive? Let us hear your pricing story.

Stay tuned by following Craneware on LinkedIn and Twitter @craneware.

Thank you for participating in our community.

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Top Five Reasons for Denials

by Craneware22. January 2015 14:21

Help your hospital get out of denial by addressing the top five reasons for claim denials.

When the causal reasons are understood, most denials are both preventable and appealable.

The top five reasons given for claim denials are:

  1. Inpatient versus Outpatient assignment
  2. Authorization issues such as day/s not considered medically necessary, or untimely clinical update
  3. No admission order
  4. 2–Midnights rule
  5. Medical necessity not met

Read more about each of the top five reasons for denials and how to address issues before they occur in a claim, in the following online article on utilization management: http://www.craneware.com/resources/white-papers/rac-utilization-management

Do you have an interesting denial story to share? We’d love to hear from you.

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