Revenue Cycle Optimization Services
End-to-end revenue cycle expertise
From patient access through coding, claim submission and payment reconciliation, B. Riley offers end-to-end revenue cycle expertise. Clients benefit from solutions that strengthen their core foundation, aligning people, process and technologies for peak revenue cycle performance. We understand the impacts of healthcare reform and the shift from traditional fee-for-service payment models to value-based care. B. Riley assists clients in successfully navigating the ever-changing coverage and reimbursement guidelines of both government and private payers, minimizing risk from regulatory exposure while maximizing efficiencies and collections. We offer deep expertise in the following areas:
- Strategic planning
- Organizational assessment and design
- Merger and acquisition related planning and integration
- Staffing assessment, training and education
- Policy and procedure development
- Technology acquisition, implementation and optimization
- Validation testing post go-live or upgrade
- Data analytics and financial analyses
- Key performance indicator reporting and accountability
- Internal controls and safeguard development
- Payment integrity
- Eligibility, referral and authorization best practices
- Clinical documentation improvement
- Charge capture optimization
- Coding schemas - including CPT, HCPCS, Revenue Codes, ICD-10, and risk adjustment hierarchical condition category (HCCs)
- Charge Description Master (CDM) design and maintenance
- Denials management
- Appeals and recoupment defense
- Patient friendly self-pay collection practices
- Revenue recognition
- Credentialing
- Contract negotiations
- Fee schedules
Representative Engagements:
- Conducted an end-to-end analysis of the people, processes and technologies involved in risk adjustment data capture between a large integrated delivery system's hospitals, clinics and their respective health plan. The engagement included onsite observations and interviews with key stakeholders across the provider and payer organizations. The team completed a comprehensive assessment of the population health model leveraged to encourage patients to schedule their annual wellness visits, followed the patients through the continuum of care, reviewed templates and charge capture mechanisms within Epic (electronic health record "EHR"), assessed clinical documentation standards, employee training (both provider and payer) and traced data from capture in the physician office visit through receipt in the claims adjudication platform, into the data warehouse and through the final filtering process for submission. Prospective, concurrent and retrospective auditing processes were also reviewed, as well as supplemental submission practices. A comprehensive report and work plan was provided aimed to strengthen internal processes, controls and improve risk adjustment data capture, as well as compliance with program requirements. Recommended strategies to improve community health record sharing leveraging technologies available. Completed similar engagements for multiple integrate delivery systems, as well as Medicare Advantage plans.
- Redesigned the front and back-end revenue cycle department structure for a large multi-specialty clinic with ancillary services, including laboratory, imaging and an infusion center. Aligned people, processes and technology to improve front-end insurance verification, eligibility, authorization, referrals and patient financial counseling. Analyzed denial trends for identification of downstream gaps hindering clean claim submissions and implemented solutions to improve first pass paid claims rates.
- Consulted with a large independent physician practice group on the assessment of their existing third party billing company. Assisted in the procurement of a replacement vendor. Served as liaison for contract negotiations. Updated provider credentialing, insurance contracts and fee schedules. Evaluated workflows and designed training to assist practice with the implementation of a new EHR.
- Served as interim Manager of Government Audit for a large academic medical center campus for three years, managing investigations and recoupment requests from appeal through administrative law judge hearings.
- Served as interim Compliance and Coding Audit Manager for one of the nation's largest multi-institutional Catholic healthcare delivery systems; oversight included $1.6 billion annual revenue; four acute hospitals; a licensed in-patient rehabilitation hospital; 1,642 beds; 837 employed providers; 1,500 affiliated providers.
- Managed accounts receivables run down for defunct healthcare entities.
- Retained by counsel to investigate and serve as expert in matters related to coding and billing practices, as well as recoupment defense, multiple engagements.
- Provide services as an Independent Review Organization (IRO) for providers entering into Corporate Integrity Agreement (CIA). Conduct reviews of coding, systems, focus arrangements and marketing practices for compliance with regulatory requirements in accordance with the terms of the specific CIA. Issue annual reports to the Office of Inspector General (OIG).
- Served as an extension of the Special Investigation Unit (SIU) for the largest single health carrier in the US, among others, providing independent and objective opinions related to provider recoupment disputes. Analyses include review of medical records, claims data, licensure, accreditation, state and federal regulatory guidelines, as well as payer coverage and reimbursement policies.