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Rules-Based Approach to Finding Revenue Cycle Opportunities

HWC's proprietary approach to revenue cycle improvement combines the benefits of standardized edits along with a focused audit customized to address our clients' specific needs.

Based upon our many years of experience, HWC has developed a broad range of automated edits designed to identify a variety of clinical modalities in which a hospital may be due additional reimbursement entitlements. These include flagging individual patient accounts based upon the presence of coded attributes (e.g. ICD-9, rev code, HCPCS, etc.), cross-referenced to the payers where the revenue opportunities are present. The standardized edit features can be applied almost immediately to the hospital-specific claims data, providing immediate benefit.

Once our standardized approach has been fully implemented, we develop a customized audit plan designed to help assess where hospital/payer and service-specific opportunities exist. This phase is flexible; and is handled on a case-by-case basis for each hospital.

Our Standard Approach to Revenue Cycle Improvement includes:

  1. Assessment

  2. Revenue Recovery

  3. Process Improvement


The Objectives of an HWC Revenue Recovery Engagement

During the Assessment phase, HWC typically identifies revenue recovery opportunities which may be captured “outside the normal billing process”. These opportunities may allow for cost report revisions, settlements, and in some instances arbitration and/or litigation. We will let you know our findings, and if further work outside the scope of our initial engagement is deemed necessary, we will create a proposal specific to the needs of your hospital.

In the Revenue Recovery phase, HWC will provide a comprehensive retrospective review of your accounts receivable files for the purpose of identification, rebilling, and recovery of underpayments. HWC calls this the FIT Revenue Recovery Service. In this regard, HWC will review managed care & governmental patient accounts. Our proven FIT system has found tens of millions of dollars for our clients.

Upon completion of the first two phases, HWC will prepare a hospital-specific “Process Improvement” report which summarizes our findings and recommendations for process and/or operational changes within the hospital, developed as a result of our collective works. In a manner similar to the Assessment phase, we will provide a proposal and/or change order addressing the scope of work outlined in the Process Improvement report.


HWC's Revenue Recovery Methodology & Approach

We utilize a systems-based approach to the 3 Phases as outlined below.

1.

Assessment
In order to complete the Assessment, HWC typically performs the following activities:

  • Set-up a web-based data warehouse containing a broad range of patient billing data.

  • Set-up HWC’s Pricer, our contract management capability so that we can quantify patient level expected reimbursement.

  • Obtain various reports/documents submitted to third parties (e.g. cost reports, financial statements, etc.)

Once these steps are completed, we will review these data for “non-patient billing” related revenue opportunities.

2.

Revenue Recovery
HWC will perform its FIT Revenue Recovery Service, its automated and cost effective methodology to perform revenue recovery on paid accounts.  In our experience, the key steps for performing this type of an engagement successfully are as follows:

  • Maintain a historical database for the Hospital that contains the demographic, clinical, and financial transaction level detail for each patient episode (admission/discharge, visit). Note: this is a more comprehensive version of the data warehouse established to perform the Assessment phase.

  • HWC will set-up and maintain the FIT contract management pricing functions for all material contracts and governmental rates for the purpose of retroactive pricing of all inpatient and outpatient claims and revenue entitlements.

  • HWC will set up a Virtual Business Office behind the scenes, gather all necessary documentation to complete the billing process start to finish, as well as follow-up with the Payers to see that the bills are appropriately paid directly to the hospital.

HWC will meet with the Hospital's Patient Accounting staff to explain the "patient specific" billing issues noted.

3.

Process Improvement
In order to complete this objective, the first two objectives of the engagement must either be completed and/or well underway. This is because HWC needs to have had an opportunity to fully understand the issues identified within the hospital’s revenue cycle before preparing its report for Process Improvement.

HWC will prepare at least one “process improvement” report within the first three (3) to six (6) months of this engagement which will include such areas as: patient access, HIM, documentation improvement, patient billing, managed care contracting, denials management, off balance sheet / vendor management, reimbursement, and other related activities. We will summarize our findings and recommendations for changes within the Hospital’s processes, developed as a result of our collective works. Please note that over the contract term, additional process improvement reports are likely.

As you can see, HWC's Methodolgy & Approach is comprehensive and is designed to bring significant benefit to your organization.

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Client Case Study #1

HWC identifies hospital's use of the wrong Grouper and performed a retrospective review to recover in excess of $4 million dollars.

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Client Case Study #2

Through cost-finding analysis, HWC identifies a negotiated contract was never entered into the hospital's system, resulting in over $2 million dollars in additional reimbursement due. HWC negotiated with the Payer and had a successful outcome on a material portion of the items.

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Client Case Study #3

Managing new contracts can take time, and most hospital systems aren’t equipped to go backward. Because we are leveraged by the HALCYON DSS, it was not nearly as time-consuming or tedious as it could have been, and our team quickly identified over $2.0 million in recovered revenue.

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Client Case Study #4

We work our clients’ accounts regularly, so we are aware of trends that may be occurring in a hospital. All of a sudden, we noticed the same opportunity for underpayment occurring again and again. It seemed as though CLIENT D was no longer billing for trailers.

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