A PYA case study demonstrates how PYA teams assisted a healthcare client with identifying underlying revenue issues stemming from the conversion to a new electronic medical record (EMR) and billing system and provided robust solutions to remediate the problems.
After converting to the new EMR/billing system, the client organization’s gross charges and net reimbursement decreased nearly 20% from historical levels. PYA was engaged to help determine what happened with the conversion process that would create the observed negative revenue impact.
Initially, PYA assessed data related to patient transaction level encounters and mapped the data to a common set of standards. Using PYA’s Revenue Management Tool, the team modeled the data to compare charges and volumes by department and type of service during a common pre-conversion period to a post-conversion period.
PYA found many instances of incompatibility of methods used to charge for key items in the new EMR/billing system compared with the legacy system, causing the new system to classify, charge, and track to different gross revenue levels. Data often was not being captured consistently, resulting in impacts to gross revenue and net reimbursement.
PYA’s Revenue Management Tool found inconsistencies in many hospital departments. Specifically, key findings for the outpatient surgical and anesthesia departments include these:
- Outpatient surgical procedures: PYA observed the surgical charges in the new system were significantly lower than in the legacy system on a per claim basis.
- Anesthesia: PYA found anesthesia charges were at a lower level than expected when adjusting for a small reduction in like-for-like volumes.
In close collaboration with the client, PYA determined the root causes of these and other issues and resolved them through chargemaster adjustments, recalibration of charges, and other means to remediate any future losses in gross and net revenue.
Monitoring the impact of the changes using the Revenue Management Tool will be essential to ensure revenue levels are rebalanced to historical levels and maintained. As part of the monitoring process, PYA’s Contract Management Tool will be used to compare reimbursement to Medicare reimbursement to better understand the value of each key payer agreement.
Regular monitoring and analysis post-implementation can help highlight issues that may indicate the need for a process flow change, staff or physician education, or in certain instances, renegotiation of the contract terms with the payer. As demonstrated in the case study, PYA’s expert analysis using key analytics tools can help prevent a significant loss of net revenue.
PYA can help.
Through PYA’s Revenue Management Overwatch, PYA brings nationally recognized subject-matter experts and world-class data intelligence tools to assess clients’ current situation, identify tangible solutions to their problems, assist with implementation and remediation, monitor for ongoing optimal performance, and provide additional capacity when needed. PYA also helps manage denials, underpayments, and changes in benefit design, among other payer initiatives that impact revenue. Monitoring tools can be customized to meet the specific needs of the client.
Learn more about PYA’s Revenue Management Overwatch and how it can help you.
For assistance with net revenue issues, reimbursement, information systems, payer contracts, or any other matter regarding operations, transactions, or compliance, PYA executives can help.
