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Over the last few years, many provider organizations have encouraged collaboration among the revenue cycle team, clinical documentation improvement (CDI), case management, utilization management (UM), and coding staffs. There are many different and unique goals that each one of these lines of business have, yet they also have the mutual goal of lower lengths of stay, accurate coding substantiated in the clinical documentation, and proper handoffs of proper notification and authorizations. 

Working together and sharpening skills significantly improved workflow, yet it did not address all the denials coming into the organizations for lack of authorization and/or inaccurate or incomplete coding. This was a frustrating ongoing issue experienced by providers across the country. Slowly but surely, it became clear that the only real solution was moving many critical steps upstream in the revenue cycle workflow.  

The greatest opportunity now is for the aforementioned teams to work collaboratively to design and deploy a workflow redesign in health information management (HIM) and revenue cycle with a new pre-bill review process.  Long gone are the days of releasing a claim as fast as you can without regard to the clinical documentation integrity (or lack thereof) impacting future denials.

There is a comfort level around the country seeming to suggest that we transitioned to ICD-10 with ease! Although many hospitals have not experienced too much of an increase in coding denials as a result of the transition, I believe that we all may be creating a future of denials avoidance, as organizations will not be in a position to have the resources to continue to manage retrospective denials and appeals management simultaneously. The cost of conducting the reviews and appeals after the fact is not reasonable.

If you have not assessed your need for a technology-enabled pre-bill process, consider this: on Feb. 12, the Centers for Medicare & Medicaid Services (CMS) published a long-awaited final rule implementing the Patient Protection and Affordable Care Act’s (PPACA’s) statutory requirement that certain overpayments be reported and returned within 60 days of being identified. The final rule took effect on March 14, and today it requires providers and suppliers receiving funds under the Medicare program to report and return overpayments no more than 60 days after the date on which the overpayment was identified – or the date any corresponding cost report is due, if applicable. The requirements in the rule are meant to ensure compliance with applicable statutes, promote high-quality care, and protect the Medicare trust funds against fraud and improper payments. 

The final rule’s “lookback” provision indicates that an overpayment “must be reported and returned … if a person identifies the overpayment … within six years of the date the overpayment was received.”  In order to avoid these overpayments and/or denials in the future, the best approach is to stop them now by instituting a technology-enabled, pre-bill clinical documentation integrity review process.

The 60-day clock begins to run either when “reasonable diligence” is completed (i.e., when the provider has bothdetermined that an overpayment has been received andhas quantified the overpayment) or if the provider fails to conduct “reasonable diligence” on the day the provider received “credible information” of a potential overpayment. In either case, the provider must have received an overpayment, as the failure to exercise “reasonable diligence” alone, without an overpayment, does not expose a provider to liability. This is another compliance challenge: for organizations to meet the requirements while at the same time introducing a denials avoidance approach for the future.

According to CMS, the following scenarios should trigger a provider’s duty to exercise “reasonable diligence:”

  • A review of billing or payment records uncovers incorrectly coded services, resulting in increased reimbursement. Most of these are retrospective reviews and are avoidable if a collaborative, technology-enabled, pre-bill review process is in place.
  • A patient death occurred prior to the date of service on a claim that has been submitted for payment.
  • Discovery that services were provided by an unlicensed or excluded individual on the provider’s behalf.
  • Overpayments are uncovered through an internal audit.
  • Overpayments are uncovered through a governmental (or contractor) audit.
  • There is a significant increase in Medicare revenue with no apparent reason.

The 60-day rule does notexpressly create any affirmative duty to monitor for overpayments; rather, it provides only that provider must report and return any overpayments within 60 days of the date such overpayments are “identified.’ 

Establishing a manual pre-bill review process is your best place to start, following an assessment to determine the types of discharges and encounters that should be routed for pre-bill review. While working on this, seek workflow tools for routing the “right cases” and opportunities to create flags and edits in your existing clinical and financial systems. Technology-enabled, pre-bill clinical documentation integrity and coding review, coupled with a CDI and coding component supported with an approved revenue cycle bill hold, will represent a critical component needed to allow providers to be successful for the this new Medicare program.

  • Overpayment examples include:
    • Payments for non-covered services
    • Payments in excess of the allowed amount of a covered service
    • Errors and non-reimbursable expenditures in cost reports
    • Duplicate payments
    • Receipt of Medicare payment when another payor is primary

The only way to identify and catch many of these and other issues is with a pre-bill clinical documentation and coding assessment and the creation of a dedicated team to work pre-bill denials avoidance. It truly is time to be thinking about denial avoidance, as long gone are the days of managing these questions on a retrospective basis.


Bonnie S. Cassidy, MPA, RHIA, FAHIMA, FHIMSS

Bonnie Cassidy is the president of Cassidy & Associates LLC. She was the former president of AHIMA and received the 2015 Distinguished Member Award from the Georgia branch.

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