Breaking the Silos for Healthcare Success

Introduction

Historically, healthcare departments work with a focus on their specific roles and responsibilities. This practice negatively impacts business operations and the clinical teams, as exemplified by increased denial rates, length of stay, and back-end expenses related to work to correct work. In addition, this separation and silo system of work is suboptimal. It leads to a decrease in efficiency, duplication of effort, and potentially undoing of hard work put in place by one team by another without coordination of efforts. Developing strategies to improve processes within the Revenue Integrity Cycle, the team approach used in managing hospital functions from patient identification through reimbursement will drive financial stability and role satisfaction.  

The clinical care departments depend upon each other to provide the highest quality of care for patients and traditionally work within a single silo in delivering care and utilize the Multidisciplinary Rounds (MDR) or Interdisciplinary Team (IDT) to coordinate efforts. On the contrary, the business operations teams, unfortunately, are not as dependent upon each other daily and have not optimized actions within a single silo. Therefore, business operations departments still need to fully identify their impact on alternate business operations and clinical departments. 

The focus of this article is on the effect of silos on the Revenue Integrity Cycle and the throughput of patients with a specific focus on the negative impacts of suboptimization, or silos, of the Utilization Review (UR), Case Management (CM), Clinical Documentation Improvement (CDI), Patient Access, insurance verification, and denial management teams. 

As part of the Revenue Integrity Cycle, payors have recognized the silo approach of healthcare systems and utilize that practice to their benefit in “winning” the denial game. Payors encourage one hospital department to work against another to perform their focused role to the highest quality. It is time to optimize and align the silo thinking and find ways to unite the critical departments as a united team to meet the changing rules of the game. 

Methodology 

Data Collection 

Using the Electronic Medical Record (EMR) reports, spreadsheets, and denial information from payor information related to denial reasons, the timing of receipt, and length of stay, including discharge disposition, were analyzed and evaluated for opportunities. 

Denial Receipt 

Nine thousand (9,000) denial case data from various geographic locations, facility types, payor mixes, and DRG information collected over six years supports the coordination of efforts to mitigate denials and were compiled as data to review for this project. Key focus on Medical Necessity, Level of Care, Timely Filing, No Authorization, and No Notification denials reviewed. 

Length of Stay Management  

Inpatient (IP) actual length of stay (ALOS) information, as well as the geometric length of stay (GLOS) based on billing Diagnostic Related Group (DRG), was collected from 20 facilities in various geographic locations and settings. The data covers all service lines and patient level of service, and Inpatient level of care status. Additionally, the team further analyzed  outlier length of stay cases for impacting factors and opportunities for process improvement to prevent future occurrences, if appropriate. The below table includes the total number of cases reviewed with the ALOS, GLOS and the variance between those identified. The outlier cases represent the cases that drove the total variance in length of stay. Those cases were further analyzed to identify opportunities for process improvement to prevent future cases, if appropriate. 

Analysis: 

Optimal role focus  

Patient Access  – identify accurate, current payor source. 

Insurance Verification – validate accurate payor source prior authorization of scheduled admissions and payor contact information regarding admission for all patients. 

Utilization Review (UR) – reviewing documentation for medical necessity supported by nationally accepted criteria, payor-specific criteria, or CMS Two-Midnight Rule communicated with payors to obtain authorization currently; provide medical necessity status to CM/CC for MDR/IDT discussion; coordinate with CDI for documentation improvement to support medical necessity and alignment with DRG. 

Case Management/Care Coordination (CM/CC) – assessment and coordination of patient care across the continuum of care, including hospitalization and post-acute services based on GLOS and medical necessity; provide MDR/IDT information to UR for payor communication. 

Clinical Documentation Improvement (CDI) – review of documentation for accuracy and completeness to capture appropriate diagnoses to assist coding in the completion of the coding process; identity working DRG and GLOS and provide to CM/CC for MDR/IDT discussion; coordinate with UR for documentation improvement to support medical necessity and alignment with DRG. 

Coding – review documentation for coding accuracy to drive billing; review CDI information aligning with UR medical necessity.  

Billing – validation of billing accuracy based on coding, contractual guidelines, and compliance with regulatory agency requirements.  

Denial Management – review denials to identify appropriate “buckets” of accountability; facilitate the interdisciplinary team to discuss denials and develop mitigation strategies. 

Process Breakdowns/Gaps 

A major data finding related to denial mitigation opportunities lies within the collaboration between UR and CDI/Coding. In 44% of Medical Necessity denials, 67.4% of those had concurrent authorization in place and received a retrospective denial as the medical necessity for the billed DRG was not supported. Level of Care denials related to the same condition was 83.2%. The potential for collaboration between UR and CDI/Coding would have resulted in a 56.8% reduction in total denials. The potential financial impact of those cases was significant, $34,462,000.00. The financial impact increased due to the increased man-hours in back-end appeal costs. 

Patient access and insurance verification verify incorrect payor source; verify incorrect prior authorized codes as incorrect codes provided or payor site limitations for code selection; the patient’s current insurance is incorrect. (Notification denial). 

UR identifies incorrect payor source after receipt of a denial, obtains authorization, overturns a concurrent denial, or identifies denials needing next-level appeal beyond reconsideration and peer-to-peer attempts (Notification, Medical necessity, level of care denial.).  

CM/CC identifies incorrect payor source during discharge assessment. (Notification denial); lack of GLOS information guiding length of stay; lack of information regarding medical necessity for the continuation of stay (Medical necessity denial.) 

CDI and Coding identify alternate DRG from the medical necessity DRG supported by UR documentation; working GLOS information is not shared with CM/CC to drive the length of stay. (Medical necessity, level of care denial.) 

Bill finalization while the denial appeal is in process. (Medical necessity denial.) Bill held without payor notification related to appeal currently in process. (Timely filing denial.) 

Denial Management accepts denial and recommends rebilling at a lower level of care or write-off potentially without a next-level appeal attempt.  

Interventions: 

Mitigation Efforts Reducing Silo Suboptimization  

Establishing a team consisting of representatives from the Revenue Cycle departments was established to develop a process that utilized each department’s key responsibilities and information in a collaborative process which included: Contracting, Scheduling, Patient Access, Insurance Verification, HIM, Coding, Billing, Business Office, UR, CM/CC, CDI, Denial Management, Provider office management, and Physician Advisors (PA). Using a combination of process improvement approaches, the team will begin identifying gaps in the current process, areas of focus for improvement, and implementation of plans.  

Implement a review process at all portals of entry for patients and initiate steps to get from access point to reimbursement discussed with crucial departments; learning from the interaction how their role impacted the roles of other team members, the silos began to crumble. The team approach began to take on a comprehensive communication and collaboration process empowering all departments to look beyond their area to see the loftier scope of the denial issue within the facility. 

Alignment of the Team  

While each department brings knowledge and skills to the team, aligning the entire team is the focus of any process improvement. Each piece fits together in the cycle that often is not a one-way road but a back-and-forth process to get to the final product. Communication openly and respectfully is needed to get the highest quality outcome, in this case, reimbursement of services and care rendered for patients. There are multiple areas where department work processes and accountabilities overlap. Below is a graph identifying the key areas for coordination of efforts is imperative. Departments with an overlap in any column need communication pathways to share and support each other to ensure alignment with the information presented to payors for reimbursement. 

Denials Team 

Collaboration between the Utilization Review, Clinical Documentation, Coding, and Billing is needed to ensure the record supports medical necessity and coding accuracy. Engaging the facility PA in addressing documentation from providers will add support to address improvement opportunities. Sharing the CDI working DRG will allow UR to review cases under that area of medical necessity. If the documentation does not support using that diagnosis, then UR should share the diagnosis used, which does support the medical necessity of the admission with the team. The PA, UR, and CDI teams can work with the providers to improve documentation and align the medical necessity with the selected DRG. Working together with a give and take that both departments are right or wrong, they have a different focus. Still, they can support each other in communicating consistently with the payor and reduce the retrospective denials resulting in further expense and time in appealing and receiving appropriate reimbursement.   

CDI and Coding should work closely in aligning the concurrent CDI work with the retrospective coding and share any potential impact on the medical necessity with UR that may impact the concurrent authorization obtained. Again, while the focus of the roles vary, the goal is timely, appropriate reimbursement and reduction of denials requiring additional staff time and cost to appeal.  

In cases where medical necessity and coding are not aligned, the additional support for the admission should be documented in the record to provide the retrospective denial team with all pertinent information in attempting a next-level appeal.  

The alignment occurs with regular Denial Management team meetings with the process team to identify the actual root cause of denials, review for potential alignment and process improvement opportunities, and clarify the denials known to lead to multiple-level appeals.  

Engaging contracting with the outcomes of the deep dive into denials should guide future contract negotiations and regular payor-specific meetings to discuss consistent issues resulting in denials, inefficiencies, time use, and human resource expenses on both sides to conclude. This final alignment will be the most significant challenge and may result in only a partial alignment. 

 Patient Throughput 

Coordination between providers, nursing, CDI, UR, and CM/CC is needed to improve the throughput of patients starting at the point of entry through post-acute services. CDI teams have the expertise in identifying the working DRG, including the GLOS for each DRG. The medical necessity documentation support reviewed by the UR staff, in addition to the GLOS, will guide the MDR/IDT in managing cases and identifying a goal, target discharge date, and needs to meet the individual patient. Managing the movement of each patient from the point of entry through hospital units and discharge to the most appropriate community providers takes the entire team communication. Working as a united entity will improve overall patient care, use of patient insurance benefits, and facility revenue. 

 Conclusion 

It takes a team working towards a common goal with an open mind that change improves processes. Continually reviewing for opportunities to make adjustments to meet future challenges leads to further success. Optimizing the team processes and reducing the adverse silo effects positively impacts the quality of care provided and have a positive financial impact on both patients and the facility.  

Denials and increased length of stay identify breaks or gaps in our processes. The team approach without the barriers of the silos will allow the facility to determine the gaps, develop strategies to fill those gaps, and improve the process. 

Three teams are vital in tying the clinical and business operations together within the most optimized silo: UR, CM/CC, and CDI. Each department functions as part of both the clinical team, providing business information related to patient care and providing information to the business operations. The hospital will improve patient throughput and denial mitigation efforts by connecting the business operations and clinical team processes by performing work in lockstep and removing independent silo functionality. 

Ms. Garceau is Executive Director of Innovative Strategies Case Management Consulting (ISCM), LLC