healthcare consulting as alternative career path for rhia/rhit

Healthcare Consulting as alternative career path for RHIA/RHITSiobhan Byrne, MHA, RHIA

27 June 2014

Agenda

► EY – Building a better working world► Healthcare industry challenges► Importance of Health Information Management expertise

in healthcare consulting

About EY

30k people

$5.3b revenue

Americas11,200people

EMEIA13,800people

Asia-Pacific4,200people

Japan800

people

Advisory = consulting

Advisory - Accelerating business performance

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We are focused on helping companies grow, protect and optimize their business

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EY implements technologies that enable business performance

IT transformation

Enterprise intelligence

Enabling technologies

Technology riskand security

EY optimizes processes that drive business outcomes

Supply chain

Customer

Finance

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Internal controls

EY develops strategies that drive transformational change

Strategy

Program management

People and organizational change

Risk transformation

We drive transformational change and business outcomes

Healthcare industry challenges

Presentation title

The healthcare environment is constantly changing

The healthcare environment is being constantly challenged by a number of current forces of the business world and the ground continues to shift under the feet of today’s executives. Some examples of these forces include:

►Innovation and competition require changes in how providers and payers define, drive and prove value

►Social media enable closer interaction with consumers

►Complex regulatory requirements challenge long-term decision making

►Organizations must share and analyze unprecedented amounts of data more quickly

►Rapidly evolving business product launches can unsettle business processes and models

►Providers and payers must accelerate the rate at which their technology matures and the rate at which they implement technology

►Population health outcomes dictate product performance and influence consumer behaviors

►These forces are making healthcare firms think about and organize their business performance efforts in more proactive and structured ways.

►We help clients find ways to respond to these forces in innovative ways that will help them assess and protect their businesses, grow revenues, and optimize processes.

Are you able to move quickly and carefully?

Is your reputation authentic and managed?

Are your plans aggressive and risk-adjusted?

Healthcare organizations need to find new ways to innovate — and do it quicklyHow do organizations react to these ever-present forces and transform their businesses to succeed in spite or because of them?

Is our growth strategy patient-centric?

Where do we invest to improve competitive position in the evolving healthcare market?

Which emerging markets present the best opportunities for our competencies?

How do we respond and act on the volumes of data?

Are we nimble enough to adapt new business models and technologies as they evolve?

Grow

Do we have the information we need to evaluate the effectiveness and efficiency of our company activities?

How can we more effectively capture and share data with patients and providers to improve care?

Are we positioned to deliver and manage care in an efficient and cost-effective way?

How will new technologies influence the industry, and how can we stay at the front of those movements?

Optimize

How do we influence regulatory reform to protect our business?

How do we balance the cost of compliance with the demand of regulatory needs?

How do we maintain or improve compliance as the regulatory environment becomes more complex?

How can we affect behavioral change with member - patients and caregivers?

How can we plan for outcome-based service delivery and payment models?

Protect

Healthcare Advisory delivers services that address key healthcare industry issues

Our services, competencies and depth in the healthcare industry addresses each of these issues from organization, people, technology, process and metrics standpoint.

Thriving Through Changing

Regulation

Improving Operations

Attacking Healthcare Costs

Importance of HIM expertise in healthcare consulting

Mid-revenue cycle is comprised of care delivery, documentation and coding

Utilizationreview/

case mgmt.Documen-

tationchargecapture

Financialcounseling

Copaymentcollection

Registration

Pre-registration

Contractmgmt.

Appeals

Denialsmgmt.

Paymentposting

Third-party collections

Claimsediting

submission

HIM/coding,CDI

Scheduling

Why we’re hired for mid-revenue cycle work

► Charge capture► “Are we charging appropriately for the care being delivered?”► “What happened to our revenue post implementation?”

► CDM standardization► “Patient statements should look the same for the same service across our system.” ► “We need to be able to manage our hospitals as a system.”

► Pricing studies► “How can we defend our prices, while also meeting budgetary needs?”

► Vendor selection assistance► “All the vendor presentations are impressive, but how do we decide?”

► Compliance reviews► “Are we prepared for RAC audits?”

► Assessments► “Are we ready for ICD-10?”► “Are we getting the most value out of our EMR (e.g., meaningful use)?”► “Are we leaving money on the table anywhere across our revenue cycle?”

Mid-revenue cycle challenges

► Many changes in the healthcare terrain have increased the pressure on mid-revenue cycle improvement.► Commercial insurers transitioning to reimbursement structures based on Medicare

► Changes focus from chargeable to reimbursable► Fixed payments (e.g., DRGs, APCs, per diems) reduce financial benefit of price increases

► Shifting of more financial responsibility to patients requires more transparency► High deductibles and co-insurance increase visibility of charges► May lead to a more consumer-driven industry

► Transition from fee for service to value-based models will completely change role► Approaches being tested (e.g., ACOs, population health management and bundled payments)► Charge capture, pricing and CDMs need to be revisited under new lens

► New care delivery models are challenging the status quo► Stand-alone imaging centers, surgical hospitals and independent labs► Many services can now be bought piecemeal at rates hospitals cannot compete against

► Increased/changing regulatory requirements► Meaningful Use► ICD-10► Pricing transparency regulations (e.g., CDM disclosure, price publication, reference prices)

Example of common charge capture issues/solutions

Provider issue Project solutionsBudget shortfall

Revenue is down due to various reasons and provider is looking to enhance revenue.

► Analyze volume and revenue by department and compare to benchmarks

► Select departments with largest charge capture potential

► Identify high value services and review their charge structure

► Audit patient sample from chart to bill► Isolate missed charges► Design improvement recommendations and estimate

revenue impact

Documen-tationchargecapture

Charge capture market developments/challenges

► Changes in the healthcare industry could potentially impact charge capture services significantly.► Large IT implementations increase opportunities, risks and budgets.

► Implementing a new EMR is expensive, time-consuming and risky.► Entire revenue streams can dry up instantly if implementation and training are

not handled appropriately.

► Shift away from fee-for-service reimbursement models will limit value.► Population health management and ACO incentivize, reducing charge volume► Fixed payments do not increase for new charges, but may increase for higher

acuity service

► Market share is currently low due to high competition.► Labor intensive projects drive up hours/cost► Projects require specific competencies► Larger systems often have revenue integrity teams focused on charge capture


Example of common CDM/pricing issues/solutions

Provider issue Project solutionsLack of standardization

Hospital system charges differently at each of its locations, causing patient dissatisfaction/confusion, not allowing for comparisons and increasing cost and risks of maintenance.

► Define system objectives and policies► Select service area groupings ► Design conceptual design of standard CDM (Thought

Leadership Group)► Develop detailed structure for the standard CDM for

each service area (Mapping)► Calculate new prices, where needed, for each line item► Implement and monitor standard charge codes


CDM/pricing market developments/challenges

► The public profile of the CDM and hospital prices has never been higher.► Time Magazine’s “Bitter Pill: Why Medical Bills Are Killing Us” article (4 March

2013)► Provided a national platform for an issue that has existed for years, but had not

gained traction previously on a large scale► Resulted in public releases of Medicare data, creation of national transparency task

forces and summits and forced providers to reassess their approach to pricing► May actually lead to provider price decreases

► Shift away from fee-for-service reimbursement models will change role of CDM► Revenue generation may not be the primary purpose, but billing regulations will

require its continued use► Data generated will still be useful for productivity, cost allocation and utilization

review► Health plan designs putting more patients into consumer role in selecting care

► High deductibles require all patients to pay cash for initial care► Narrow networks may still limit choices for patients► Price sensitivity may drive volume out of the hospital setting


Example of common utilization review and case management issues/solutions

Provider issue Project solutionsIneffective management

Concerns that CM/UM staff are not effectively managing IP length of stay

► Process improvement assessment, including data analysis of LOS by DRG, key stakeholder interviews and analysis of CM/UM staffing assignments to verify that the processes and staffing are appropriate for current mix of patient needs

Utilizationreview/

case mgmt.

Utilization review and case management market developments/challenges

► Changes in the healthcare industry could potentially impact utilization review and case management services.► 2 Midnight rule

► CMS attempted to minimize the impact of “observation” status on beneficiaries with the new guideline. While it clarifies the patient status assignment approach for seniors with multiple chronic conditions, it raises operational and reimbursement questions regarding other patients requiring inpatient care for a short period of time (e.g., deliveries, surgical cases).

► Population health management/ACOs► CM/UM focus has typically been on inpatient care and the transition to the next level

of care. New delivery models will be dependent upon management of case, regardless of the care setting.

► RAC audits► Compliance with standard criteria helps hospitals minimize, but not eliminate, the

risk of negative audit findings. Assisting organizations communicate across various disciplines to understand high risk areas and implement appropriate, consistent practices is necessary to remain compliant in an ever-changing regulatory environment.

Utilizationreview/

case mgmt.

Example of common HIM/coding issues/solutions

Provider issue Project solutionsInaccurate coding

Incomplete and/or inaccurate coding by the HIM coders causes inaccurate reporting of services performed that could result in non-compliant billing and incorrect reimbursement.

► Work with the client to identify risk areas for audit and appropriate sample sizes

► Obtain three to six months of coding/encounter data and select a sample of claims for each coder► Sometimes samples will be random, but look for

certain predetermined areas► Obtain copies of claim forms, as billed, for sampled

claims and access to related medical records► An EY certified coder then assesses each encounter for

completeness and accuracy of coding, as well as quality of medical record documentation

► Variances are shared and validated with the client► If not already in place, develop and implement policies

and procedures for ongoing quality assurance coding audits; perform remedial training, if needed

HIM/coding,CDI

HIM/coding market developments/challenges

► Coding is getting a lot of press coverage related to implementation of ICD-10 scheduled for October 1, 2015.► Coding assessments are typically a subset of a larger revenue cycle engagement.

► With the exception of ICD-10 assessments and implementations, coding is usually just one piece of a larger charge capture revenue cycle assessment.

► Incorrect and/or inaccurate coding is one possible way that a client may be leaving money on the table.

► Large scale coding assessments are frequently conducted for compliance purposes by EY’s Fraud Investigation and Dispute Services (FIDS).

► Transaction Advisory Services (TAS) sometimes requires a coding assessment as part of its due diligence program for clients considering purchasing a healthcare provider.

► Compliance is always an aspect of a coding assessment.► Clients that are aware of non-compliant billing practices that result in overpayments may

be required to self report, if federally funded programs such as Medicare are involved.► Coding assessments are frequently performed under attorney-client privilege for this

reason.► Clients appreciate inclusion of a certified coder on revenue cycle engagement teams.

► Due to the link between coding and reimbursement, most provider clients appreciate having access to the specialized skills of a medical coder on these engagements.

HIM/coding,CDI

Example of common CDI issues/solutions

Provider issue Project solutionsCase mix index

Case mix index (CMI) lower than expected for hospital type and complexity

► Data analysis to identify trends in inpatient volume, medical versus surgical volume, changes in complexity – including the use of CCs/MCCs

► Documentation review to determine the processes clinicians use for documentation and what CDS uses to support documentation completeness.

► Provide recommendations regarding role, process, staffing and areas of focus based upon the complexity of the organization

HIM/coding,CDI

Questions?

healthcare consulting as alternative career path for rhia/rhit

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