Why Accountability 360 in Healthcare Billing Matters?

At CW1, with a strategic approach involving clear policies, technology, training, collaboration, and continuous improvement, Accountability 360 enables healthcare providers to maintain financial stability, compliance, and quality care delivery.

 

Managing the revenue cycle can be a constant uphill battle for healthcare providers. One effective strategy to boost revenue capture is a process called Accountability 360. This approach involves thoroughly reviewing patient accounts with a zero insurance balance to confirm that the provider has received the correct and full payment for the services provided. 

By implementing Accountability 360, providers can identify any instances where they may have been underpaid, where billing errors occurred, or where claims were improperly denied. With this information, providers can then take the necessary steps to resolve these issues and ensure they receive the rightful reimbursement for the care they delivered.

Accountability 360 acts as a essential safety net, helping healthcare organizations maximize their revenue while maintaining financial integrity and compliance. By making this a regular part of their revenue cycle management, providers can streamline their billing processes, minimize revenue leakage, and in the end enhance their total financial performance.

 

The Financial Burden of Underpayments and Denied Claims

 

Many healthcare providers face a troubling issue: substantial financial losses each year due to underpayments and improperly denied claims. The numbers are quite alarming. A recent study by the Advisory Board found that approximately 25% of nonprofit hospitals in the United States are operating at a loss, with negative margins.

 

Furthermore, a report from the American Hospital Association (AHA) revealed that hospitals across the nation provided an enormous $41.6 billion in uncompensated care in 2020. This figure emphasizes the substantial financial burden on healthcare organizations. To address these pressures and mitigate financial losses originating from underpayments, denied claims, or missed charges, it is essential for providers to implement strong processes. These processes should ensure that they receive appropriate reimbursement for the services they provide.

Without such measures in place, healthcare organizations risk losing out on substantial revenue, which can severely impact their ability to operate effectively and provide high-quality care to their patients. 

 

The importance of Accountability 360 cannot be said enough, as the healthcare industry faces huge statistics:

 

• According to a survey by the Healthcare Financial Management Association (HFMA), the average hospital denial rate is around 10-15% of total claims submitted.

 

• A study by Crowe Horwath found that up to 1% of net patient service revenue is lost due to charge integrity leakage, which can be addressed through revenue cycle analytics.

 

• Research by the Advisory Board Company suggests that healthcare organizations can potentially increase their revenue by 3-5% by optimizing their revenue cycle management processes.

 

• A report by Black Book Research states that around 80% of medical bills contain errors, costing the U.S. healthcare system approximately $210 billion annually.

 

The Benefits of Accountability 360

 

1. Revenue Recovery

 

Accountability 360 helps healthcare providers recover lost revenue from underpayments, coding errors, and billing discrepancies. Industry experts estimate hospitals can recoup up to 3% of net patient revenue through effective implementation of this process. By thoroughly reviewing zero-balance insurance accounts, providers can identify and correct instances of underpayment or improper claim denials, ensuring they receive appropriate reimbursement for services rendered.

 

2. Denial Prevention

 

Analyzing accounts with Accountability 360 allows providers to identify patterns and root causes of claim denials. They can then implement corrective measures to prevent future denials. With average healthcare claim denial rates ranging from 5-10%, this proactive approach minimizes significant revenue leakage. 

 

3. Compliance and Audit Preparedness

 

Accountability 360 helps healthcare organizations maintain compliance with payer contracts, coding guidelines, and regulations. By keeping accurate, up-to-date records through this process, providers are better prepared for audits and can minimize risks of penalties or fines for non-compliance. 

 

4. Process Improvement

 

The insights from Accountability 360 can inform process improvements and staff training for more efficient and accurate billing practices. Healthcare organizations prioritizing revenue cycle management initiatives like this typically experience an average 10% improvement in cash flow. 

 

Implementing an Effective Accountability 360 Process

 

To maximize the benefits of Accountability 360, healthcare organizations should consider the following best practices:

 

1. Establish Clear Policies and Procedures: Develop comprehensive guidelines that outline the scope, frequency, and methodology of Accountability 360, ensuring consistency and accountability across the organization.

 

Scope:

 

The Accountability 360 process shall cover all accounts, including:

• Operating accounts
• Payroll accounts
• Accounts receivable
• Accounts payable
• Credit card accounts
• Petty cash accounts
• Investment accounts
• Any other accounts held by the organization

 

Frequency

 

The Accountability 360 shall be conducted on a monthly basis, with the following schedule:

 

• Operating accounts: Reviewed within 5 business days after month-end.
• Payroll accounts: Reviewed within 3 business days after each payroll cycle.
• Accounts receivable/payable: Reviewed within 10 business days after month-end.
• Credit card accounts: Reviewed within 7 business days after statement closing date.
• Petty cash accounts: Reviewed within 5 business days after month-end.
• Investment accounts: Reviewed within 10 business days after quarter-end.

 

Methodology

 

Preparation

 

1. The Finance team shall compile all account statements, transaction reports, and supporting documentation for the review period.
2. Any known discrepancies or outstanding items should be identified and documented.

 

Review Process

 

1. Reconcile all transactions against the corresponding supporting documentation (invoices, receipts, contracts, etc.).
2. Verify the accuracy of transaction amounts, dates, and descriptions.
3. Identify any missing transactions or documentation.
4. Investigate and resolve any discrepancies or outstanding balances.
5. Document all findings, resolutions, and action items.

 

Reporting

 

1. Prepare a comprehensive report summarizing the review findings, including:

• Accounts reviewed
• Discrepancies identified
• Resolutions implemented
• Outstanding items requiring further action

2. The report should be reviewed and approved by the Finance Manager or Controller.
3. Distribute the report to relevant stakeholders (e.g., department heads, executives) for transparency and accountability.

 

Accountability

 

1. The Finance team shall be responsible for conducting the Accountability 360 process and ensuring its timely completion.
2. Department heads and account owners shall be accountable for providing necessary documentation and resolving any discrepancies or outstanding items related to their respective accounts.
3. The Finance Manager or Controller shall oversee the overall process, review the reports, and escalate any significant issues to the appropriate level of management.

 

Documentation and Record-Keeping

 

1. All review findings, resolutions, and supporting documentation shall be maintained for a minimum of 7 years for audit and compliance purposes.
2. Electronic records shall be securely stored and backed up regularly.
3. Physical records shall be kept in a secure location with restricted access.

 

Continuous Improvement

 

1. The Accountability 360 process shall be periodically reviewed and updated to incorporate best practices and address any identified gaps or inefficiencies.
2. Feedback from stakeholders shall be solicited and considered for process improvements.
3. Any changes to the process shall be communicated to all relevant parties and documented in the guidelines.

 

2. Leverage Technology and Automation: Implement advanced revenue cycle management solutions that can automate the Accountability 360 process, streamlining workflows and improving accuracy and efficiency.

 

Automated Account Reconciliation

 

Deploy an RCM platform with robust account reconciliation capabilities that can automatically:

 

1. Fetch Transactions: Securely connect to all bank accounts, credit card accounts, and other financial systems to fetch transaction data in real-time.
2. Match Transactions: Use intelligent matching algorithms and machine learning to automatically match transactions against invoices, purchase orders, contracts, and other supporting documentation.
3. Identify Discrepancies: Flag any unmatched transactions, duplicate entries, or discrepancies between transaction amounts and supporting documentation.
4. Reconcile Accounts: Reconcile account balances by verifying that all transactions have been accurately recorded and matched, with no outstanding or unresolved items.

 

Workflow Automation

 

Implement workflow automation features within the RCM solution to streamline the Accountability 360 process:

 

1. Task Assignment: Automatically assign tasks and action items to relevant team members or departments based on predefined rules and responsibilities.
2. Notifications and Reminders: Set up automated notifications and reminders for team members to ensure timely resolution of discrepancies and outstanding items.
3. Approval Workflows: Configure approval workflows for review findings, resolutions, and reports, ensuring proper oversight and accountability.
4. Audit Trails: Maintain comprehensive audit trails of all actions taken, changes made, and approvals granted within the system.

 

Reporting and Analytics

 

Leverage the RCM solution's reporting and analytics capabilities to gain insights and improve the Accountability 360 process:

 

1. Customizable Reports: Generate customized reports tailored to the organization's specific requirements, including account reconciliation summaries, discrepancy details, and action item statuses.
2. Real-time Dashboards: Access real-time dashboards and visualizations to monitor the progress of the Accountability 360 process, identify bottlenecks, and track key performance indicators (KPIs).
3. Trend Analysis: Analyze historical data to identify patterns, trends, and areas for improvement in the Accountability 360 process.
4. Exception Reporting: Set up exception reports to highlight accounts or transactions that require immediate attention or intervention.

 

Integration and Data Management

 

Ensure seamless integration and data management within the RCM solution:

 

1. System Integration

Integrate the RCM solution with existing financial systems, enterprise resource planning (ERP) systems, and other relevant applications to ensure data consistency and eliminate manual data entry.

2. Data Security

Implement robust data security measures, including encryption, access controls, and auditing, to protect sensitive financial information.

3. Data Backup and Recovery

Establish reliable data backup and recovery procedures to safeguard against data loss or corruption.

4. Data Governance

Develop and enforce data governance policies and procedures to maintain data integrity, accuracy, and compliance with relevant regulations.

 

3. Prioritize High-Value Accounts: Focus on accounts with higher reimbursement potential or those with a higher likelihood of underpayments or denials, ensuring that resources are allocated effectively.

 

Identifying High-Priority Accounts

 

1. Reimbursement Potential Analysis

• Analyze historical data to identify accounts or payers with the highest reimbursement potential based on factors such as claim volume, reimbursement rates, and payment patterns.
• Prioritize accounts with significant revenue contributions or those with potential for increased reimbursements through improved billing practices or contract negotiations.

 

2. Underpayment and Denial Risk Assessment

• Evaluate accounts or payers with a history of underpayments, denials, or payment delays.
• Identify common reasons for underpayments or denials, such as coding errors, missing documentation, or non-compliance with payer policies.
• Prioritize accounts with a higher likelihood of underpayments or denials based on this risk assessment.

 

3. Payer Contract Analysis

• Review payer contracts to identify accounts with complex reimbursement rules, strict documentation requirements, or potential for contractual disputes.
• Prioritize accounts with intricate contract terms or those with a higher potential for reimbursement discrepancies.

 

Focused Review Strategies

 

1. Dedicated Review Teams:

• Assign dedicated review teams or specialists to handle high-priority accounts, ensuring that these accounts receive focused attention and expertise.
• Provide specialized training and resources to these teams to effectively manage complex reimbursement scenarios and payer-specific requirements.

 

2. Enhanced Documentation and Audit Trails:

• Implement rigorous documentation and audit trail processes for high-priority accounts, capturing detailed information about transactions, discrepancies, resolutions, and communication with payers.
• Maintain comprehensive records to support appeals, contract negotiations, or legal proceedings if necessary.

 

3. Proactive Payer Engagement:

• Establish proactive communication channels with payers for high-priority accounts, addressing potential issues or discrepancies before they escalate.
• Collaborate with payers to resolve underpayments, denials, or contractual disputes in a timely and effective manner.

 

4. Continuous Monitoring and Reporting:

• Implement robust monitoring and reporting mechanisms for high-priority accounts, tracking key performance indicators (KPIs) such as reimbursement rates, denial rates, and payment cycle times.
• Regularly review and analyze these reports to identify areas for improvement and implement corrective actions as needed.

 

4. Collaborate with Payers: Maintain open communication channels with payers and actively participate in payer forums or advisory groups to stay informed about changing policies and regulations that may impact reimbursement.

 

Payer Collaboration

 

1. Establish Communication Channels:

• Identify key contacts within payer organizations, including provider relations representatives, reimbursement specialists, and policy decision-makers.
• Set up regular meetings or conference calls to discuss reimbursement-related issues, policy updates, and potential areas for improvement.

 

2. Participate in Payer Advisory Groups:

• Seek opportunities to join payer advisory groups or committees that provide input on reimbursement policies, coding guidelines, and claims processing procedures.
• Actively contribute to these groups by sharing insights, best practices, and feedback from the organization's perspective.

 

3. Collaborate on Pilot Programs:

• Engage with payers to participate in pilot programs or initiatives aimed at streamlining reimbursement processes, testing new technologies, or implementing alternative payment models.
• Provide valuable feedback and data to help shape these programs and ensure they align with the organization's needs and goals.

 

4. Address Reimbursement Challenges:

• Maintain open lines of communication with payers to address specific reimbursement challenges, such as underpayments, denials, or contractual disputes.
• Work collaboratively with payers to resolve issues, clarify policies, and identify opportunities for process improvements.

 

Industry Engagement

 

1. Participate in Professional Associations

• Join relevant professional associations or industry groups, such as healthcare financial management associations, revenue cycle management organizations, or coding and billing societies.
• Attend conferences, seminars, and networking events to stay updated on industry trends, regulatory changes, and best practices related to reimbursement and revenue cycle management.

 

2. Contribute to Industry Publications

• Share insights, case studies, and success stories by contributing articles or thought leadership pieces to industry publications or online forums.
• Engage in discussions and knowledge-sharing platforms to learn from peers and industry experts.

 

3. Monitor Regulatory and Legislative Updates

• Stay informed about regulatory and legislative changes that may impact reimbursement policies, coding guidelines, or compliance requirements.
• Participate in advocacy efforts or provide feedback to policymakers and regulatory bodies to represent the organization's interests.

 

4. Collaborate with Industry Partners

• Establish partnerships or collaborations with industry partners, such as technology vendors, consulting firms, or academic institutions, to explore innovative solutions, conduct research, or pilot new technologies related to revenue cycle management and reimbursement optimization.

 

5. Continuous Monitoring and Improvement: Regularly monitor and analyze the results of Accountability 360, identifying trends and areas for improvement, and implementing corrective actions as needed.

 

Monitoring and Data Analysis

 

1. Key Performance Indicators (KPIs):

• Establish a set of relevant KPIs to measure the performance and effectiveness of the Accountability 360 process, such as:
• Percentage of accounts reconciled within target timeframes
• Number and value of discrepancies identified
• Time to resolution for discrepancies
• Accuracy rates of account reconciliations
• Cost and resource utilization for the review process

 

2. Data Collection and Reporting:

• Implement a centralized data collection and reporting system to capture and consolidate data from various sources, including financial systems, revenue cycle management solutions, and manual processes.
• Generate regular reports and dashboards that provide insights into the KPIs and highlight areas of concern or opportunities for improvement.

 

3. Trend Analysis:

• Analyze historical data and trends to identify patterns, recurring issues, or systemic problems that may be impacting the Accountability 360 process.
• Investigate the root causes of identified trends and develop strategies to address them proactively.

 

4. Benchmarking:

• Participate in industry benchmarking initiatives or collaborate with peer organizations to compare performance metrics and identify best practices.
• Leverage benchmarking data to set realistic targets and goals for continuous improvement.

 

Improvement Initiatives

 

1. Process Optimization:

• Based on the monitoring and analysis findings, identify opportunities to streamline or optimize the Accountability 360 process.
• Implement process improvements, such as automation, workflow enhancements, or resource allocation adjustments, to increase efficiency and accuracy.

 

2. Training and Development:

• Provide ongoing training and professional development opportunities for staff involved in the Accountability 360 process.
• Ensure that team members are equipped with the latest knowledge, skills, and tools to perform their roles effectively.

 

3. Technology Enhancements:

• Evaluate and implement new technologies or system upgrades that can enhance the Accountability 360process, such as advanced analytics, machine learning, or robotic process automation.
• Collaborate with technology vendors or internal IT teams to identify and implement suitable solutions.

 

4. Stakeholder Engagement:

• Solicit feedback and input from stakeholders, including department heads, account owners, and payers, to identify areas for improvement and gather insights on potential solutions.
• Involve stakeholders in the decision-making and implementation processes to ensure buy-in and support.

 

5. Continuous Improvement Cycle:

• Establish a continuous improvement cycle that involves regular monitoring, analysis, implementation of corrective actions, and evaluation of results.
• Create a culture of continuous learning and improvement within the organization, encouraging team members to identify and suggest opportunities for optimization.

 

This game-changing approach enables providers to maintain financial stability, compliance, and quality care delivery while navigating the complexities of revenue cycle management. By thoroughly reviewing accounts, analyzing data, and implementing best practices, organizations can identify revenue leaks, streamline billing processes, ensure adherence to regulations, and enhance staff expertise. Embracing Accountability 360 future-proofs operations, drives improvements, and supports long-term sustainability in an ever-changing landscape.

 

References:

 

Advisory Board Study on Nonprofit Hospital Margins: https://www.advisoryboard.com/topics/finance/resources/2022/nonprofit-hospital-margins-hit-new-lows-in-2021

American Hospital Association (AHA) Report on Uncompensated Care: https://www.aha.org/fact-sheets/2022-01-12-fact-sheet-uncompensated-care-cost

Healthcare Financial Management Association (HFMA) Study on Revenue Recovery: https://www.hfma.org/topics/revenue-cycle/publication/revenue-cycle-strategist/2021/revenue-cycle-strategist-june-2021.html

Medical Group Management Association (MGMA) Report on Claim Denial Rates: https://www.mgma.com/resources/revenue-cycle/claim-denial-management

Healthcare Financial Management Association (HFMA) Survey on Revenue Cycle Management Initiatives: https://www.hfma.org/topics/revenue-cycle/publication/revenue-cycle-strategist/2022/revenue-cycle-strategist-april-2022.html