Summary

Tegria partnered with a large healthcare system in New York on a 12-week engagement of Coding Audit and Denials Remediation Services, with the primary focus of the engagement to identify root cause(s) associated with an increase in coding-related denials with a goal of identifying revenue opportunities, accurate coding, and denial reduction.

Methodology

To complete this assessment, Tegria performed an exhaustive review of the people, processes, and technology that impact workflows associated with charge capture and denial management. Specifically, this assessment is an overall summary of:

• E&M procedure and Bell Curve Analysis of 30 sub-divisions and specialties
• Focused E&M Audits of six sub-divisions; Neurology, Rheumatology, Orthopedics, Pulmonary, OB/GYN and Dermatology
• 500 encounter audit focused on opportunities:
  • E&M Coding
  • Revenue Enhancement
  • Denials
• A comprehensive review of three months of denials data
• Technical assessment of Epic Resolute Professional Billing, Claims, and Remittance configuration
• Interviews and surveys of department and division leadership
• Analysis of six months of coding workqueue throughput and productivity

Overall Impression

The organization’s coding performance overall was in line with national average benchmarks for key coding activities such as E&M code usage. No major risks or significant loss of gross revenue were identified; however, there were meaningful gaps in the coding program which if resolved would allow the organization to become a ‘Top Performer’ when evaluated against industry peers. These gaps within the coding program were focused on operations, education, and technology. Tegria’s recommendations to resolve these gaps would help the organization capture more revenue, prevent denials, establish better organizational controls, and allow Epic to better serve operational needs.

Key Gaps Identified

As a result of these gaps, our assessment found:

• Over $614K in additional annual gross revenue opportunities ($156K net collections) have been identified as potential missed billing and Revenue Opportunities
• More than 30% of coding denials ($7M gross/$1.75M net collections) are preventable through system and education changes
• A targeted review of services from six departments identified multiple trends – indicating a need for coder education across several specific service lines
• Overall coding staff productivity has been measured at 85%, but many divisions may be overstaffed