Finding new revenue opportunities and avoiding claims denials has taken on greater urgency as hospitals and other healthcare organizations face growing reimbursement shortfalls in the wake of the COVID-19 pandemic.
It is why Hayes, makers of the industry’s leading integrated compliance and revenue integrity platform for the nation’s premier healthcare organizations, has launched Revenue Optimizer to equip healthcare organizations with actionable insights that help eliminate barriers to revenue integrity and manage overall financial performance.
A study commissioned by the American Hospital Association (AHA) found that many U.S. hospitals were struggling with ongoing operational losses well before COVID-19, and the median hospital margin overall was a razor-thin 3.5%.
Even with government support from the CARES Act, these margins were projected to drop to -7% in the second half of 2020 without further federal intervention. The study also concluded that, post-pandemic, at least half of the nation’s hospitals would continue operating with margins in the red without any additional support.
“Adding to existing bottom-line struggles, the Centers for Medicare and Medicaid Services identified $29 billion in improper payments in 2019—a trend that will continue as regulatory scrutiny turns to COVID-19 incentive payments.
Further, the addition of nearly 750 new CPT and ICD-10 codes—on top of COVID-19 changes—has created a compliance nightmare that will only exacerbate a devastating financial impact if healthcare organizations can’t stop the hemorrhaging,” said Hayes CTO Ritesh Ramesh, noting that Hayes identified a 20% increase in denials totaling $2.5 billion related to COVID-19 coding and reimbursement challenges alone in the first half of 2020 among MDaudit Enterprise cohorts.
He added: “Our overarching goal with Revenue Optimizer is to reverse these negative trends by providing healthcare organizations with the insights and learnings needed to uncover payment issues for corrective action that can help improve their margins even within this challenging climate, positioning them for long-term financial sustainability.”
Integrated with MDaudit Enterprise, Hayes’ flagship revenue integrity software platform, Revenue Optimizer leverages natural language processing and augmented intelligence technologies to improve management of a healthcare organization’s overall financial performance.
It tracks the case mix index (CMI), elective surgery trends and average lag days from denial resubmission to adjudication, year-over-year and year-to-date trends for Medicare and commercial payers, detecting data anomalies and outliers that are barriers to revenue integrity.
It also monitors and predicts denial trends by various functional areas, such as patient access, coding, compliance and patient financial services, over multiple years to enable better management of revenue risks. Revenue Optimizer tracks HCC (hierarchical conditional category) and COVID-19 related denials to maximize value-based reimbursements and integrates with audit workflows so corrective action can be taken to accelerate cash flow.
In addition to allowing executives to rapidly drill down across more than 30 denial attributes over large volumes of historical data, Revenue Optimizer’s user-friendly interface makes it easy to access and visualize denial trends across an organization. Curated content and targeted business insights and mobile access via an iPhone or iPad round out the solution’s executive-friendly features.
“There is no question that the pandemic has wreaked havoc on the revenue growth and profitability for healthcare organizations, but some of these challenges existed long before COVID-19 and will continue long after,” said Ramesh, adding that an MDaudit Enterprise cohort had processed 1.2 million COVID-19 cases by the end of Q2 2020, creating a total of $12.1 billion in charges and generating a net revenue exposed to regulatory audit of approximately $4.2 billion. “Leveraging the targeted and actionable insights generated by Revenue Optimizer can help lift revenues by ensuring no monies are left behind and identifying new revenue opportunities.”