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Membership Continuing Education
Revenue Optimization: Creating Synergy Between Case Management and Revenue Recovery

Publication Date: 5/6/2021


Length: 60:24


Content Level: Intermediate 1 General CE


Abstract
Maximizing reimbursement, including denial mitigation, is key to hospital operations. The mindset that “inpatient” admissions drive revenue often leads to inaccurate admission status. Accurate admission status may result in reduced inpatient charges but can increase reimbursement for observation charges and reduce writeoffs to increase net revenue. In December 2017, a team of stakeholders at four metropolitan hospitals representing hospital and physician leadership, Utilization Management (UM), Case Management (CM), and Revenue Recovery launched a Steering Committee focused on improving UM and CM operations and reducing inpatient medical necessity denials with the goal to improve financial performance. The session will focus on implementation of standardized work, outcome metrics, and process improvement strategies to improve performance. Results for 2018 included an 8+ million dollar net benefit, and set the stage for continued improvements in 2019.


Learning Objectives:
1. Identify key team members and departments integral to improving synergy between clinical care and revenue recovery.
2. Describe quality, productivity, and performance metrics that measure Utilization/Care Management and Revenue Recovery improvements.
3. Identify three strategies to improve performance in status accuracy and denial mitigation.


Speakers
Rhonda Kamenick, RN, BSN, CRCR, Manager, Advocate Aurora Health
Rhonda Kamenick is a registered nurse with clinical background in oncology, hospice and obstetrics. She is responsible for team of nurses and clinicians who appeal outpatient and inpatient clinical denials for level of care, high dollar drugs, procedures and services performed at 15 hospitals and their related hospital outpatient departments as well as managing RAC, government, and commercial post-payment audits for hospital, professional, DME, home health and hospice. She is also an HFMA Certified Revenue Cycle Representative.

Lynn Sisler, RN, BSN, MS, ACM-RN, CCDS, Executive Director, Advocate Aurora Health Care
Lynn Sisler, Executive Director Inpatient Care Management, Enterprise Population Health Advocate Aurora Health Care is a master’s prepared registered nurse with 34 years of acute care experience including clinical expertise in emergency department and ICU. She is responsible for strategic management of inpatient care management, utilization management and care coordination for 15 Wisconsin hospitals. Lynn is a member at large for Wisconsin ACMA & Board Member for ACMA Compare.

Keywords: revenue recovery, clinical care, utilization, denial mitigation

Revenue Optimization: Creating Synergy Between Case Management and Revenue Recovery

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