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.