Leveraging Experienced Revenue Integrity Professionals to Enhance CDM Technology

1. Strategic pricing

CDM technology often has the capability to perform limited price modeling and provide benchmark pricing based on public CMS data. These functions can assist organizations with setting prices for new charges and/or making price adjustments. Alone, however, the data is not enough. A professional familiar with revenue integrity must evaluate the information and determine how to utilize it. 

When performing price adjustments, it’s important to step back and evaluate the overall goals of the organization. Are you trying to drive additional net revenue? Secure market share in a particular service line? Are there certain shoppable services that need to be priced at a lower rate to drive volume? Are the prices defensible and based on a well-documented pricing policy? 

Answers to these questions and many others will dictate the best way to strategically adjust the CDM charges to achieve the organization’s goals. CDM technology can assist with this process, but oftentimes it does not have adequate modeling tools built in to calculate the net/gross revenue impact, and the breadth of benchmark data does not adequately provide insight into the true market landscape. Pure reliance on technology for strategic pricing can significantly limit financial benefits to the organization.    

2. Charge additions/removals

CDM technology does a great job identifying compliance issues within existing charges, but it does not find missing revenue opportunities or charges that should be evaluated for removal based on best practices. Often there are billable services that clinicians are performing multiple times a day, but are not being captured in the CDM. As a result, it’s imperative that an open line of communication is kept with clinical departments to identify common activities that aren’t appropriately captured in the charge entry process or new services that do not have a charge in the CDM.

A best practice approach is to set up regularly scheduled meetings one to two times per year with the clinical departments to discuss the charges in the CDM and any services that pose a charge capture opportunity. In addition to the department interviews, an annual line-by-line deep dive into the CDM is also recommended to identify line-item issues that may have been missed by the technology. This also provides a great opportunity to remove or inactivate any items/services from the CDM that have not been used in at least two years, which promotes a more efficient and streamlined charge-capture process. The cleanup process and identification of charge capture opportunities can lead directly to increased revenue on the bottom line.

In addition to identifying new charge capture opportunities, organizations should seek to remove charges that are incorrectly being captured and billed separately. For example, CMS guidelines for supplies are vague and open to interpretation for providers. It’s important to develop a supply charging policy for your organization that minimizes confusion and streamlines the charge capture process. Many organizations are opting for a minimum charge threshold anywhere from $25-$150 that classifies low-dollar supplies without a dedicated CPT code as non-billable. There are also supplies and equipment that should not be billed based on regulatory guidance that need to be considered in the policy. Removing these charges will also require a pricing evaluation to ensure any gross/net revenue associated with the inactivated charges is reallocated to other services. CDM technology is not going to provide the guidance for establishing a defensible charging structure, so utilizing highly experienced revenue integrity professionals is imperative.

3. Validation of recommendations CDM management technology is designed to evaluate the CDM and make recommendations for changes within the patient account systems (PAS). Recommendations are placed in a work queue for evaluation, and someone is expected to evaluate each flag for validity and make the changes. Each recommendation should be thoroughly evaluated by an experienced CDM professional to ensure any changes made are compliant and align with the services being performed at the organization. 

Unfortunately, qualified revenue integrity resources are often stretched thin or there isn’t a person dedicated to reviewing the flags, so the recommended changes are not evaluated in a timely manner. This can cause a delay in updating the charges within the PAS and create the possibility of non-compliance or missed net revenue. Furthermore, integration with the PAS is often minimal, and the changes must be manually keyed in. This task is sometimes handled by a data management or IT resource that does not have the revenue integrity knowledge to identify issues with the changes or understand how a change could affect revenue and compliance. As a best practice, experienced charge integrity resources should be utilized for the entire process to ensure accuracy.