Integrated Revenue Cycle: Coordination Between Insurers and Providers to Ensure Revenue Accuracy

Traditional revenue cycle management arrangements that focus solely on billing and collections are no longer reliable in the world of delegated risk models, especially for Medicare Advantage (MA) populations. That’s why Pareto recommends an innovative approach to managing value-based payments, which improves the overall accuracy of MA premium payments by millions of dollars annually.

To ensure revenue accuracy, healthcare providers should focus on the following activities:

• Improving internal processes: Complete and accurate documentation and information transfer from one system to another is crucial to securing accurate revenue data.
• Solving for any imbalances in information: Providers must have timely access to data to ensure payers are fulfilling the necessary operational and reporting requirements that impact revenue capture.
• Establishing oversight controls: Monitoring processes to identify problems that can affect revenue accuracy internally should be done on an ongoing basis.

Across each of these activities, it’s important to focus on the key factors affecting revenue accuracy. These include:

• Risk coding and documentation: Ineffective Hierarchical Condition Category (HCC) documentation can lead to lower Risk Adjustment Factor (RAF) scores for a population, which will negatively impact revenue. An improved risk documentation process to prevent insufficient coding is also vital to maintain compliance.
• Encounter reporting: Both the insurer and provider are responsible for ensuring data that is collected at encounter makes it through the various systems before reporting to CMS. Data quality issues can exist within provider or insurer processes, so it’s important to have proper oversight controls in place.
• Medicare Secondary Payer (MSP) designation and coordination of benefits (COB): If an insurer has incorrect enrollment categorizations or does not properly coordinate Medicare benefits for an MA member, the premium revenue passed down to providers in value-based arrangements is impacted. Providers should take the initiative to ensure this data is being correctly reported to CMS.

In our recent article for hfm Magazine, we go into greater detail about the strategies for providers to ensure revenue accuracy. The financial opportunity cost of not taking greater responsibility of these processes is too significant for providers taking on more risk. Click here to read the full article.