(3 Minute Read)
HOW DID YOU GET INTO THE FIELD OF REVENUE CYCLE MANAGEMENT AND RISK ADJUSTMENT?
“I started as an underwriter and eventually grew to be Chief Underwriting Officer responsible for several departments: Statistical, Actuarial, Underwriting, Medical Economics, Data Management and Reporting, Financial Planning and Analysis, Security and Facilities. In the late 90’s I noticed that the PIP-DCGs payment models that CMS was moving towards would significantly impact Medicare revenue streams, so I started learning everything I could about how I could optimize processes to ensure proper payments.”
WHAT ARE YOUR SPECIALTIES?
“My specialties? I save health plans money so that they can pass those savings along to their members through reduced rates and added plan benefits. One of the main ways I do this by identifying RAPS / Encounter gaps. Understanding why a plan is missing necessary diagnosis codes helps reduce cost and provider abrasion, as well as increase revenue earlier in the payment cycle. Issues with data quality and encounter accuracy and completeness and the inherent and ever-changing complexity of risk adjustment calculations can all impede the ability of a health plan to minimize revenue loss and improve revenue integrity.”
WHAT SOLUTIONS HAVE YOU DESIGNED TO HELP PREVIOUS CUSTOMERS IMPROVE THEIR REVENUE CYCLE PROCESSES?
“One solution is what I like to call the “Leaky Bucket” analysis. The objective of the analysis is to identify gaps in revenue capture and who to work with to resolve those issues. This analysis is a vital component to the work we do. This helps plans to both reduce costs and provider abrasion, while increasing revenues earlier in the payment cycle – CFOs love this!”
CAN YOU GIVE AN EXAMPLE OF HOW YOU’VE BEEN ABLE TO IDENTIFY MISSED REVENUE OPPORTUNITIES?
“One of the biggest areas where I discover missed revenue opportunities are in payment & member attestation. Plans are usually very adept at recognizing member data discrepancies prior to submissions but often don’t have the tools or ability to do a retroactive review of payments. I will review the payment file to identify any demographic mistakes that might have occurred—e.g: Mary is being treated for diabetes, but the payment received as part of the CMS Hierarchical Condition Category (HCC) risk adjustment model doesn’t reflect that. This payment model is retrospective, so if that error isn’t caught promptly it can cost the health plan lots of missed revenue. Inversely, if a plan is receiving payment for a disease category that a member doesn’t actually have they then have a compliance issue and are at risk during a RADV audit.”
TELL US ABOUT AN EXCITING PROJECT YOU WERE INVOLVED IN RECENTLY?
“Health systems are losing tens of millions of dollars every year due to hazards along the revenue cycle pathway- some without even knowing it. A start-up health plan reached out to me because they suddenly found themselves losing over $100k a month. Upon my arrival, I was able to identify the problem and discovered that the plan had recently changed to a new claims system, and failed to realize that some of the new operational changes would cause such a negative financial impact. At the conclusion of my engagement I was able to increase their annual revenue stream by over $2M, enabling them to cancel the imminent layoff of part of their workforce.”
WHAT DO YOU LOVE ABOUT WORKING AT IMPRESIV HEALTH?
“What I love about Impresiv Health is that everyone within the company is an expert in their field. Each member of our team is an industry veteran, uniquely positioned to assist our clients with assessing, planning, and implementing strategic initiatives within complex and demanding business environments. We’ve brought together the leading Subject Matter Experts in project management, staffing solutions, payer operations & technologies, medical management, process improvement, and HealthRules™ (just to name a few). When you have that much expertise in one place you can’t help but achieve amazing things.”
WHAT CAN YOUR SERVICES BRING TO THE MARKET?
“At Impresiv Health we’ve built a team of revenue SMEs who can step in and act as an extension of a plan’s staff. We bring with us a proven toolset of analytics, best practices, processes, and custom reports that can ensure accurate risk adjustment, reducing risk and improving revenue stability. We can minimize the risk of a RADV audit by examining your end-to-end operations, leading mock RADV audits, and ensuring that your records are compliant, clear, and consistent.”
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