While many healthcare organizations employ QA analysts that routinely check for accuracy, compliance, and departmental process adherence on an employee level, most organizations do not also conduct account-specific QA that follows a claim through the revenue cycle, highlighting opportunities for improvement and training within each revenue cycle area. Situations like this often lead to instances where staff are scoring 99% on their QA reviews for the quarter, but A/R increases by a sizeable amount in that same timeframe, the cause of which goes unknown. How can that be? The employees are doing their jobs right according to their QA scores. Like the three blind men trying to describe an elephant by telling the others of their partial experience touching a different part of the giant creature, conducting only employee process adherence QA tells a small part of the story within those specific departments.
When an organization focuses solely on the departmental process adherence of its employees and does not spend time monitoring how quickly, easily, and accurately a claim flows through the different departments of the revenue cycle, it misses a huge opportunity for process improvements, denials mitigation, A/R resolution, and waste reduction. Trending issues like inputting the wrong insurance as primary that leads to a denial, not updating authorization numbers when changes are made to a patient’s care plan, or not responding to payer correspondence regarding a patient’s medical records can often go unnoticed when the auditing is not performed on a holistic claim level and only on the individual doing the work. For example, the employees that worked a claim that required an update to the auth number probably all scored 100% on their QA reviews because the workflow was followed properly, but the mistake of not updating the authorization number went unnoticed and the claim required recoding and appeals to get the it paid. Errors like this one cause hours of valuable work, and if it happens on a regular basis it could heavily impact the organization’s bottom line. Those employees in Utilization Management would benefit from additional training, and the department’s workflow could use some improvements, but the organization won’t know about these opportunities without a focused QA on the claim’s lifecycle.
HBI encourages organizations to regularly check the health of their revenue cycle by conducting account-specific reviews in addition to departmental process adherence QA. That way, organizations can uncover training and process-enhancement opportunities that affect the ability to resolve A/R without requiring unnecessary rework.
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