Our Solutions: Revenue Integrity and Charge Capture

 

Note: Hospitals may refer to these program as Charge Capture Audit, Internal Audit, Revenue Reconciliation, Case Management, Utilization Management, Accelerated Cash Collections, and Performance Improvement.

After services are delivered, ESI’s Revenue Cycle Solutions maximize revenue capture and streamline the billing and collection process with coding compliance, online secondary billing, remittance posting, document imaging retrieval, contract denial management, and financial analysis. This program includes a complete review of all inpatient, outpatient, and ancillary billing details with clinically based rules technology, providing key education and workflow back to the department level and clinical staffing areas.

ESI’s Business Process Outsourcing Solutions within the revenue cycle help to prevent denials at the source by applying rules and lessons learned through the challenge process to services before they are rendered and/or billed. These programs extend into the clinical department, with service Dashboards to promote “Open Book Management,” to monitor services as well as workflow.

ESI provides:

• Monitoring of all services prior to discharge for charges that could result in a denial or reduced reimbursement. ESI analyzes the service data received from the legacy system or manual booking process for missing information that is critical for revenue management to prevent denials.
• The revenue cycle is dependent on the charge entry process. Accuracy and verification of charges is necessary and critical for reimbursement.
• ESI will associate rules for automated policy and procedures for each key missing data element or claim type to ensure the collection of such information. Workflow tools are integrated to automatically distribute the workflow for these real-time problems such as insurance eligibility and authorizations, to the appropriate follow-up staff.
• ESI monitors and analyzes the payer’s contract and compliance policies. ESI will identify key data requirements for each carrier and procedure in the service based on the contract management rules. ESI will trigger workflows to gather the missing data and ensure compliance with contract terms and policies.
• For Medicare patients, ESI ensures that all required data is available to test medical necessity with available tools and data. If medical necessity is not determined, ESI initiates the self-pay, Medicaid, and charity workflows based on facility policy.
• When the service has been rendered, ESI monitors for changes or additional procedures associated with the service. If a change is detected, it will automatically trigger additional workflows to ensure that such changes stay within established limits.
• Case management is coordinated with the entire revenue cycle process. Case management may be provided by ESI or coordinated for your facility staff, and includes the following:
  • All denials and reimbursement terms are monitored to assure maximum reimbursement for all approved cases.
  • Patients’ length of stay is monitored and days are approved by clinical case managers.
  • Managed care plans stay informed by ESI and clinical case management for accuracy of reimbursement.