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Mid Revenue Cycle Epic Leading Practice Strategies March 16, 2017 Draft
Mid Revenue Cycle Epic Leading Practice Strategies
March 16, 2017
Draft
PwC
Page
Table of Contents
Executive Summary
Legacy vs Epic
Post Go-Live Optimization
New Era of Data Analytics
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Executive Summary
PwC
Executive Summary
As a result of the government meaningful use mandates to implement electronic medical records (EMR), providers have started to adopt a single integrated enterprise EMR systems, with Epic Systems being one of the more popular adoptions. These implementations are resulting in unforeseen considerations, costs, and disruptions in clinical services in the revenue cycle space. To achieve the highest level of success, revenue cycle has many milestones, opportunities, and decisions ahead to position their individual organizations for long term success and viability in the Epic universe. Three critical success factors of the organization include:
Review of Epic vs Legacy– Understanding the key differences and considerations around the migration to Epic’s complex and dynamic system from a legacy system is vital to preparing an organization for a successful implementation. Key areas include 1) Charge Description Master (CDM) structure in layout, 2) work queue oversight, ownership and management, and 3) revenue integrity team integration for a single unified structure and function in support of the new Epic-based revenue cycle.
After Action Review- Post Go-Live Optimization- The Epic migration present a strong opportunity to improve revenue cycle processes and performance by utilizing Epic functionality to its fullest capacity. Ongoing maintenance and review processes ensure a smooth transition and operation of the Epic system. Areas for review include: 1) master files completeness and accuracy, 2) pre/post service volume alignment 3) charge capture processes and education.
Entry into a New Era of Analytics- A single enterprise-wide EMR system allows for robust canned and custom analytics driving new methodology and approaches to gain mid revenue cycle insights and support organizational revenue integrity. Utilization of additional bolt-on technologies complements an organization’s Epic future state technology revenue cycle vision and support superior outcomes.
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• Charge Description Master (CDM)
• Understand the difference between traditional department and facility based procedure codes and how they translate to Epic’s dynamic fee schedule CDM
• Consider the use of shell codes to increase operational efficiency among pharmacy and OR supplies
• Work Queue Management• Assign roles and responsibilities
around work queue management and ownership
• Revenue Integrity Skillset• Assess current roles and
responsibilities and determine needs of new cross functional revenue integrity team and structure
Critical success factors to consider for success with Epic in the mid revenue cycle
• Master Files Review• Ensure the accuracy and
completeness of Epic master files with legacy systems and current ancillary systems
• Pre/Post Service Volume Alignment
• Post-Epic review of clinical service volume against KPI and historical legacy benchmarks
• Charge Capture Reconciliation• Ensure the accuracy and
thoroughness of charge captured against clinical documentation
• Review opportunities for education of new clinical workflow
• Reporting Enhancements• Utilization current Epic and
custom reporting capabilities to continuously monitor mid revenue cycle metrics and protect organization revenue integrity
• Additional bolt-on technologies drive new business intelligence insights and data approached problem solving
Post-Go Live Implementation
OptimizationEpic vs. Legacy New Era of Analytics
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Mid Revenue Cycle
As a claim progresses through the revenue cycle, it can interact with many different departments, systems and
people. Every interaction has the potential for issues to arise Revenue Integrity is an integral piece of the
Middle revenue cycle where clinical and revenue cycle processes intersect.
Claims Processing
Denials Management & Resolution
Insurance Verification / Pre-
CertificationFinancial
Counseling
Point of Service Collections
Start
CDM Maintenance
& Pricing
Inpatient & Outpatient
Coding
Back-End
Front-End
Middle
Scheduling / Pre-Registration
Registration
Payment Posting
Third Party Follow-up
EndSelf-pay / Bad
Debt Management
Charge Capture &
Entry
Financial Reporting
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Legacy vs Epic
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Understanding CDM & Charge Capture
Legacy vs Epic
Post-Epic Optimization
New Era of Analytics
What is a CDM?• Comprehensive listing of items billable to a patient or insurance provider usually grouped by department
• Billable items include hospital services, medical procedures, drugs, supplies, and diagnostic evaluations
• Developed, maintained and monitored via a CDM maintenance process and controlled by revenue integrity / charge master
coordinator
Several factors to consider when moving from a static procedure based CDM…
… to a dynamic Epic Master Procedure File (EAP)
Static CDM Structure
• Unconsolidated CDM: one-to-one match
between charge codes and departments
• Departments are restricted to selecting only
charges in their department CDM
• MedAssets/Craneware interface streamlined
the CDM maintenance process
• Revenue Integrity has direct access to
maintain the CDM
Dynamic CDM Structure
• Consolidated CDM: one charge code can be used by
many departments
• Unrestricted CDM: departments can select any charge
code in the CDM; opportunity for increased charge
capture
• Cost centers are dynamically assigned based on
system build
CDM 2060192 5085170 2181014
Service
Description
Therapeutic
Activity- 15 Min
(Physical
Therapy)
Therapeutic
Activity- 15 Min
(Occupational
Therapy)
Therapeutic
Activity- 15 Min
(Speech
Therapy)
CDM 2060192 5085170 2181014
CPT Code 97530 97530 97530
Cost Center 10023 10049 10023
Rev Code 0420 0430 0410
Price $27.50 $32.00 $25.00
Cost Center, Pricing, Revenue Code Assignment
Therapeutic Activity- 15 Min
CDM 42000033
CPT Code 97530
Physical Therapy
Cost
Center 97530
Rev Code 0420
Price $27.50
Occupational Therapy
Cost
Center 97530
Rev Code 0430
Price $32.00
Speech Therapy
Cost
Center 97530
Rev Code 0410
Price $25.00 8
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Shell Codes Utilization
Legacy vs Epic
Post-Epic Optimization
New Era of Analytics
Traditional labor intensive process to update individual medications and
supplies in the CDM…
… can be simplified through the use of Epic EAP shell records
Static CDM Structure
• Unconsolidated supplies and medications in
the CDM: One line for each individual supply
and medication item
• Strong controls and maintenance process
required between pharmacy and materials
management team
Dynamic CDM Structure
• Shell codes allows for the separation of the
management of medications and supplies from
management of EAP records
• New medications and supplies will flow through the
existing shell records
• Updating of the shell records and appropriate mapping
required
Itemized Bill
Example Shell Record - 278000004 SCREW
UB04
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Epic Structural Nuances
Structured provider documentation• Flow sheet, Medicine Administration
Record (MAR), physical therapy note, etc.
Orderable/chargeable• Charges usually triggered based on
completion or result
Charge navigators• Charges selected by provider online;
workflow dictates that providers complete documentation prior to using charge navigator
Level of Service calculator – Pro & Tech fee• Calculates appropriate level of service based
on designated criteria pulled from documentation
Coding workflows• Visit coding (system completes diagnostic and
provider based coding based on established rules) • HIM integrated software (3M, CAC, etc.)
• Coders enter charges via charge navigators
Charge router/charge entry• Allows normal charge router edits to be
applied; charge entry compared against tables, displays descriptions to minimize errors
Charge Capture Process
Legacy vs Epic
Post-Epic Optimization
New Era of Analytics
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Work Queue Management
Legacy vs Epic
Post-Epic Optimization
New Era of Analytics
Charges are evaluated against Charge Review Work Queue Edits and exceptions to the logic and
rules-based charging present themselves in work queues. This creates opportunities for organization
to develop policies to review work queues for correction and process improvement by the right
individuals within a timely manor.
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Revenue Integrity Skillset
Legacy vs Epic
Post-Epic Optimization
New Era of Analytics
Integration of clinical and revenue cycle resources and improved critical thinking skills for revenue
performance management resources allows for a new centralized dynamic cross- functional team that
actively engages with the system to continuously improve charge capture and manage charge
reconciliation processes to support organizational revenue integrity.
Four strategies to proactively manage revenue:
RevenueReconciliation:
• Monitoring of revenue issues
• Remediation support for identified issues
• Defined KPIs and
metrics to monitor
Charge Capture Implementation:
• Targeted implementation to improve charge capture
Focused Audits & Assessments:
• Assessments and audits to identify and prioritize opportunities for improved capture of revenue
Strategic CDMMaintenance:
• Review CDM maintenance requests
• Ensure compliance• Ensure optimal &
defensible pricing
Revenue Integrity Function
Data Analytics
Enables rapid identification of opportunities
and performs root cause investigations
Clinical Expertise
An understanding of clinical workflows & translation to improve charge capture outcomes
Regulatory
Surveillance and communication of billing, coding, and regulatory changes affecting charging
Business Skills
Proactive relationship building, change management, critical thinking, and project management skills
Collaboration
Support active collaboration with IT, HR, Finance, Education, and other supporting functions
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Post Go-Live Optimization
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Common post EPIC installation challenges
6 key considerations
Internal controls
Master files
Charge capture
Charge capture audits
HealthInformationManagement
Clinical documentation
CDM analysis of CPT/HCPCS and revenue code assignment prior to build
Compliant process for developing and maintaining linked orderable, performable and chargeable records
Comprehensive Testing strategy
Accuracy and thoroughness of charges compared with clinical documentation
Opportunities to enhance capture of services
Accuracy of associated coding
Determine HB and PB Coding workflows for soft coded procedures
Coding quality
Epic master files (ancillary files and CDM) structure and layout requirements
Crosswalk accuracy between ancillary files and CDM
Strategic charge router design (incorporate billing rules and CCI edits)
Procedure master file design
Proper data flow from ancillary systems to CDM
Logical description and synonym structure to facilitate charge selection
Epic validation messages (critical check rules)
Charge error work list and activities
Charge reconciliation
Quality of documentation to support corresponding charges and coding
Documentation triggers for charging
Legacy vs Epic
Post-Epic Optimization
New Era of Analytics
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Master File Calibration
Reco
nc
iliatio
n
Client Scenario: To ensure charge master file integrity, ancillary system master file was assessed for
accuracy and completeness against regulatory compliance, legacy master files (pre Epic) and the Epic
EAP (post Epic).
Accuracy
Completeness
Ancillary Fee
Schedule(418 Distinct Fee
Codes)
Post Epic
Ancillary(532 Distinct Fee
Codes)
Legacy CDM(403 Matched
Billing Codes) Laboratory Orders System
Ancillary Billing System
Exceptions
CDM
Maintenance
Review and
Opportunity
Evaluation
1
Reco
nc
iliatio
n
Legacy CDM
Reco
nc
iliatio
n
Epic EAP
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Epic EAP(517 Matched
Billing Codes)
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2014 Pre-Epic Epic Conversion 2015 Post-Epic
Key
Legacy vs Epic
Post-Epic Optimization
New Era of Analytics
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Pre- / Post-Epic Services Alignment
Clinic
Inpatient Bed Census
Emergency
Laboratory
Imaging
Pharmacy
Service Area Reconciliation Methodology
Outpatient
Inpatient
Therapy
Legacy Epic
Inpatient Bed Charge Volume
CPT / HCPCS based services with grouping by Revenue Code (where applicable)
Operating Room
Operating Room
OR Times / Treatment room Volume
OR Times / Treatment room Vol
Variances/Exceptions
Revenue and volume Variances
& Exceptions determine the design
of additional
targeted queries
Billing System
Reconciliation Items
Key
Reconciliation methodology differs by service area in order to appropriately trend services across both billing systems
Specialized Supplies / Implants
Legacy vs Epic
Post-Epic Optimization
New Era of Analytics
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$(2,000,000)
$3,000,000
$8,000,000
$13,000,000
$18,000,000
$23,000,000
-
10,000
20,000
30,000
40,000
50,000
60,000
70,000
80,000
90,000
100,000
Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15
Ancillary Orders, Charge Volume and Charge Revenue Trended
Sunquest Charge Vol Charge Amount
Legacy to Epic Transition
Ord
ers
an
d C
ha
rge
Vo
lum
eC
ha
rge A
mo
un
t
Pre- / Post-Epic Services Alignment
Historical legacy volume and charge trends are indicators of post-Epic implementation target benchmarks. Review variations and deviations from historical behavioral patterns as they are early indications of system or process issues
Legacy vs Epic
Post-Epic Optimization
New Era of Analytics
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Case-in-Brief
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45 days after go-live, there was a revenue variance (actual v. expected) of:
-$66M
Key areas of concern were:
Clinical: gaps in educating clinical processes led to
clinical and patient safety concerns (medication administration)
Charging: misalignment among by clinical applications
led to charging issues at go-live and beyond. Physicians were not adequately trained in charging workflows leading to inadequate/missing charging at go-live.
Workflows/Interfaces: sample user lab testing was
completed but did not identify physician access and workflow issues
A top ranked 800-bed academic and research medical center struggled significantly during the pre
Epic implementation causing major setbacks during go-live and stabilization with huge financial
consequences.
Legacy vs Epic
Post-Epic Optimization
New Era of Analytics
Source: PwC Analytics for Internal Audit – Epic Implementation Testing Services Offering
PwC
New Charge Capture Processes
Charge capture processes moves from a highly manual process in legacy system…
…to an emphasis on charge trigger based automated charge activity in Epic
• Most charges are manually selected within the
CDM and entered into the system
• Staff charging tools include paper charge tickets
or charge slips
• Charging errors are caught downstream during
the billing and claims process
• Charges automatically generate based on
clinical documentation or activity
• Charges generate based on system edits
and/or registration information
• Preference lists and Charge Navigators ease
the charge selection process
• Charging errors are caught in department work
queues prior to billing
The adoption of a new system comes with new practices, new charge capture workflow and charge
processes education opportunities frequently cited as the leading request among front line staff
adjusting to the Epic system
Legacy vs Epic
Post-Epic Optimization
New Era of Analytics
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New Era of Analytics
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Case-in-Brief
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~Two years after go-live, a one month look back revealed missing professional billing charges:
13,000+
Key areas of concern were:
Revenue Leakage: Default Crystal reporting produced
a 3,000 page detail line-item reconciliation pdf report of instances for which work was performed but a charge session was never initiated and therefore claims could not be created. This format was prohibitive for analyzing trends and aggregating results.
Revenue Optimization: Current reports were less
effective for segmentation and root cause analysis of claims denied by payors and claims in work queues that were reworked for errors.
Current State Analysis: Current AR reports were less
effective at providing peer group aggregate comparisons as well as detailed drilldown, leading to disjointed follow up.
A top ranked 470+ acute bed non-profit, academic, multi-specialty, healthcare system’s post-
implementation internal audit assessment reviewed the current state of Epic utilization, it’s impact on
charge capture and revenue reconciliation process, as well as utilization of the Epic system and
tools.
Inpatient notes
Legacy vs Epic
Post-Epic Optimization
New Era of Analytics
Source: PwC Analytics for Internal Audit – Epic Implementation Testing Services Offering
PwC
Reporting Enhancements
Legacy vs Epic
Post-Epic Optimization
New Era of Analytics
End-to-end enterprise-wide EMR allows for a new breed of revenue cycle analytics that previously
was not possible with individual silo-ed systems
The first section displays distinct outpatient clinic services performed
The second section displays surgical procedures performed and associated coding
The last section reconciles IP census days and associated notes
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Custom Reporting SolutionsCustom reports have helped to evaluate post-implementation charge capture and revenue
reconciliation. Using data extracted from the Epic EMR system, organizations have built reporting
capabilities that included dynamic aggregation, segmentation (peer group analysis), and root cause
analysis for: active accounts receivables, missing charges, claims in work queues, and denied claims.
Data Extraction and
Transformation
1
Business Case
Assessment
2
Data Mining and
Controls Testing
3
Agile Results
Delivery
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Legacy vs Epic
Post-Epic Optimization
New Era of Analytics
Source: PwC Analytics for Internal Audit – Epic Implementation Testing Services Offering23
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Questions?
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Tel:(858) 314-8532
E-mail:[email protected]
Clement Lee, MPH
Senior AssociateLos Angeles, CA
Clement Lee is a Senior Associate in the PwC’s Health Industries Advisory Group. He focuses on Provider Mid-Revenue cycle data analytics and healthcare management and has over 5 years of experience in the healthcare industry. His professional experience includes charge capture assessment of Charge Description Master (CDM) and charge capture processes for completeness and accuracy within various provider organization. He specializes in leveraging Big Data to conduct a data sciences approached automated charge reconciliation through Epic system’s Clarity report writing. He also has experience working with payer organizations including leading Medical Management cost reduction initiatives and designing member profiles for health insurance exchanges.
PwC Healthcare Advisory – CDM & Charge Capture
M
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