Revenue integrity: A holistic path to top

REVENUE INTEGRITY
Revenue integrity: A holistic
path to top-line growth
Every day, healthcare providers
are leaving money on the table.
Are you maximizing your
available revenue?
In today’s uncertain healthcare environment, providers
need to ensure that they are getting paid appropriately for
the services they deliver.
Prices are
integrated into
managed care
contracts
Services
are
captured
Provider
delivers services
based on
contract
At KPMG, we look at the full
cycle of revenue integrity—from
documentation and coding
through to pricing and managed
care contracting—to help our
clients create and maintain high
levels of revenue integrity.
Yet our experience suggests that most providers are
leaving money on the table by not taking a holistic
approach to optimizing revenue integrity.
Services are
coded
CDM is used
to translate
codes into
prices
Six key focus areas for improving revenue
1
2
3
4
5
6
ocumentation: Making sure that what happens to the patient is fully and
D
appropriately documented for billing and quality purposes
oding: Ensuring that codes are properly and accurately applied against services
C
and costs, particularly in the shift to ICD-10
harge capture: Verifying that outpatient services are being properly
C
documented and that all charges are being captured
harge Description Master (CDM): Reviewing and updating CDMs based on
C
changes in the market and environment
trategic pricing: Leveraging insights from benchmarking and demographic
S
trends to set appropriate prices
anaged care contracting: Securing the optimal terms and conditions for
M
managed care contracts
Services are
documented
Focus on contract
management
Our experience suggests
that approximately 10% to
12% of all hospital claims
are underpaid due to poor
contract management.
really drive top-line growth,
“Tohealthcare
providers need
to think more broadly about
the relationship between
documenting, coding, pricing,
and contracting as they strive
to maximize their revenue at
every step.
”
© 2015 KPMG LLP, a Delaware limited liability partnership and the U.S. member firm of the KPMG network of independent member firms
affiliated with KPMG International Cooperative (“KPMG International”), a Swiss entity. All rights reserved. Printed in the U.S.A.
– Randy Notes, Principal, KPMG
REVENUE INTEGRITY
Combining a variety of capabilities for a holistic approach
Improve net revenue
At KPMG, we take a holistic approach to helping our clients improve revenue integrity.
Our teams combine specialists in documentation, coding chargemaster, pricing and
contracting with deep industry experience to deliver tailored solutions that help our
clients achieve top-line growth.
Our clients choose us because:
Many hospital and provider groups
have successfully used strategic
pricing to generate an additional
5% to 10% of net revenue.
1. We focus on helping them overcome their unique challenges, not selling a piece
of software or template solution.
2. We understand the changes in the industry and use this insight to help our clients
develop long-term, sustainable strategies.
3. We start by understanding their strategic plan and then work to help them
achieve their strategic goals including improved financial performance.
4. We consistently bring the right people for the job, with the right skills
and experience.
Documentation
Charge
Description
Master
(CDM)
Revenue
Integrity
Reaping recurring revenues
High-level outcomes from revenue integrity activities require providers to
focus on all six focus areas at once in order to improve potential revenues for
services being captured, coded, and charged at the right rates and under the
right contracts.
Charge
capture
Payer
performance
Contracting
Coding
Strategic
pricing
And since much of the potential revenue gains achieved through revenue integrity
improvements are ultimately “recurring” items, providers will want to pay close
attention to how they ensure all six areas operate in concert going forward.
Are you leaving money on the table?
• Is your clinical staff fully and appropriately documenting their activities?
• Are your prices both competitive and strategically aligned to the services you
provide?
• Do the terms and conditions of your managed care contracts support your
pricing and strategic plan?
• Are you and your coding staff ready for the shift to ICD-10?
• Do you review and update your CDM to reflect recent changes in the industry?
If you answered “no” to any of the above questions, you likely need to think
about implementing an automated workflow approach.
only tackling one or
“Iftwoyouofarethese
key six focus areas,
there is a good chance you are
missing revenue opportunities.
Given the changes now underway
in the sector, providers should be
striving to leverage every possible
opportunity to find and maximize
these recurring revenue items.
”
– Patrick Spoletini, Managing Director, KPMG
For more information about
revenue integrity, contact:
Michael Duke
Managing Director
[email protected]
Sue McBride
Principal
[email protected]
The information contained herein is of a general nature and is not intended to address the circumstances of any particular
individual or entity. Although we endeavor to provide accurate and timely information, there can be no guarantee that such
information is accurate as of the date it is received or that it will continue to be accurate in the future. No one should act upon
such information without appropriate professional advice after a thorough examination of the particular situation.
Some or all of the services described herein may not be permissible for KPMG audit clients and their affiliates.
Randy Notes
Principal
[email protected]
Patrick Spoletini
Managing Director
[email protected]
© 2015 KPMG LLP, a Delaware limited liability partnership and the U.S. member firm of the KPMG network
of independent member firms affiliated with KPMG International Cooperative (“KPMG International”), a
Swiss entity. All rights reserved. The KPMG name, logo and “cutting through complexity” are registered
trademarks or trademarks of KPMG International. Printed in the U.S.A.