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Hospitals and health systems are under siege, facing unprecedented challenges from every direction. Staffing constraints, supply chain issues, and escalating labor costs continue in this post-pandemic era. Meanwhile, payers are intensifying their audits and denials, and hospitals remain constrained to billing compliant with Medicare and Medicaid regulations. These major economic factors impact large and small hospitals’ operating margins, leading many to the edge and operating in the red.
Denials cost the industry $20 billion in 2022, according to a recent analysis by Premier. Hospitals can better fight for fair reimbursements and save time, money, and resources when they break down silos and foster collaboration among UM, CDI, Coding, and Denials Management teams. Additionally, complete and accurate patient records ensure clinical excellence, minimize audit risks, and safeguard revenue. These records improve clinical decision-making, streamline care coordination, and help avoid regulatory penalties. Further, accurately representing patient acuity improves quality metrics and patient safety indicators, strengthening the foundation of patient care quality.
The importance of improving documentation practices cannot be overstated. A proactive approach supports the organization’s overall health and success, turning potential challenges into strengths and opportunities. However, implementing this transformation alone can be difficult. Partnering with a valuable ally equipped with resources, expertise, and technology can help hospitals and health systems achieve their goals and save on administrative time, errors, and costs.
The CorroHealth CDI Playbook provides hospitals and health systems with cutting-edge strategies for developing an effective CDI program. It emphasizes strategic impact using regulations, analytics, technology, and insightful planning. By implementing these strategies, hospitals and health systems can enhance operational efficiency, ensure precise documentation of patient acuity, elevate compliance standards, financial outcomes, and the quality of patient care. Additionally, the Playbook guides the development of a robust CDI program that encourages interdepartmental cooperation, incorporates technology and data-driven methods, and focuses on continuous assessment and enhancement of the program’s influence on the hospital’s financial health.
Collaboration between UM, CDI, and Coding teams is essential to ensure a smooth flow of accurate information. These teams, while having distinct responsibilities, must work together to capture the patient’s journey accurately—from status determination to coding application. Each step in this process is vital, as it influences everything from reimbursements and compliance to patient and hospital decision-making.
Beyond processes, synergy across these teams is a potential game-changer for a hospital’s financial health. True synergy facilitates accurate patient documentation, captures metrics, and minimizes revenue loss. Teams must align on processes, definitions, and regulatory applications. Establishing intra-departmental relationships and effective communication keeps teams aligned, documentation precise, and the organization well-prepared for regulatory reviews or audits. Furthermore, this approach can help hospitals streamline workflows, reduce administrative burdens, and optimize reimbursements, ultimately driving financial stability.
For Medicare beneficiaries, both FFS and Managed, assigning the correct patient status from the onset is crucial. It begins by assigning the correct patient status from the onset for traditional Medicare patients. Medicare Advantage payers frequently scrutinize inpatient and outpatient status decisions to find grounds for denials, pushing hospital teams to classify patients as observation, even when inpatient status is warranted and consistent with regulatory guidance. Hospitals can ensure compliant inpatient status by adhering to CMS’ definition of the Two-Midnight Rule. All teams must thoroughly understand and adhere to the hospital’s status determination process.
Be vigilant about payer denial tactics, especially when Medicare Advantage payers’ patient status determination processes change. Don’t let payer behavior influence your UM team’s management of patient statuses. Trust the CMS guidelines, particularly the two-midnight rule, and be prepared to appeal when necessary.
Leveraging data and analytics enables hospitals to prioritize utilization reviews and measure outcomes effectively. The goal is to ensure accurate patient identification for inpatient care, which leads to proper documentation of patient acuity and compliant and correct payment.
Identify and utilize supportive KPIs that align with the hospital’s goals. When hospitals consistently align with CMS’ definition of the 2-MN rule, their quality metrics reflect the true health of the hospital’s population, which leads to consistent, accurate data, compliance, and revenue. Not all hospitals are equipped with analysts or have the expertise on staff to develop the appropriate KPIs. CorroHealth offers Analytics as a Service to help hospitals develop, track, and extract insights from the appropriate metrics aligned with their strategic goals, enabling real-time, informed decision making.
Historically, solving CDI problems meant increasing people power—the theory being more reviewers led to more compliant revenue. This reactive approach tackled immediate issues without addressing root causes, focusing on capturing complications and comorbidities (CCs and MCCs) to boost the case mix index (CMI) and reimbursement. Over time, automated tools improved efficiency but remained largely transactional.
In many organizations, the objective is to achieve a 35% query rate. Clinical Documentation Integrity Specialists (CDIS) typically handle around 25 cases daily, aiming for a 90% physician response rate and an 85% agreement rate on queries. While these metrics measure productivity, they do not identify areas needing improvement to accurately depict a patient’s acuity, and this leads to missed opportunities to capture revenue and assess risk accurately. This outdated approach to CDI results in inconsistent revenue and compliance performance.
This means hospitals must transition from outdated tactical approaches to a modern, strategic approach. A strategic model is efficient, data-driven, and monitored with analytics. It is also supported by clinical audits and ensures consistent compliance and revenue integrity. By clearly defining problems and aligning projects with strategic objectives, hospitals can use resources efficiently and effectively to improve compliance, financial health, and overall patient care quality.
A strategic approach involves creating a feedback loop, starting with identifying high-risk cases and prioritizing them for review. It’s unnecessary to review every case—focus on complex clinical cases with high risks of denials, underpayment, or compliance issues. This iterative process refines case selections based on performance trends, keeping teams focused on high-impact cases. Hospitals can pinpoint trends and internal education needs, sharing insights with providers, CDI, Coding, and Denials Management teams for consistent, high-quality documentation.
Integrating AI-driven CDI technology leads to consistent processes, compliant revenue, and quality ratings by aligning DRGs and codes with the documentation. It reduces administrative burdens, saves valuable time, and lowers costs.
Technology reaches its full potential when it’s shaped and utilized by CDIS and clinical experts. These experts bring nuanced understanding and strategic insights that directly influence and refine the technology. The partnership-driven approach, where technology and professionals work hand in hand, ensures that CDI processes, especially case reviews and DRG assignments, are compliantly optimized for success. This integration facilitates precise documentation and compliantly optimizes reimbursements to safeguard against payer denials, truly maximizing the technology’s impact.
VISION Clinical Validation Technology™ is a specialized AI-driven DRG Integrity technology. By adopting VISION, hospitals can instantly select, score, and prioritize high-impact cases for review. This technology automates time-consuming case selection processes and provides guidance as to when new DRGs or queries are warranted. It employs clinically-driven algorithms to compliantly enhance DRG and revenue opportunities, increasing ROI by up to 10x. Results are also driven by its analytics and benchmarking capabilities. Compliance is assured because VISION incorporates the latest healthcare regulations, coding guidelines, and payer contracts. This technology streamlines workflows, allowing CDI, Coding, and HIM teams to concentrate on more crucial tasks. CorroHealth offers a range of flexible engagement models to work with including full Software as a Service (SaaS) option, complete service solutions, or a hybrid model.
Effective metrics and KPIs must align with strategic goals and go beyond merely measuring processes. Traditional CDI metrics like CMI, queries performed, and provider response rates may not fully reflect a hospital’s financial health or patient population. A modern approach uses actionable analytics and cohort benchmarking to drive fair revenue, compliance, and process improvements while supporting clinical decision-making.
Analyze top-performing peers to track your program’s progress. Start with cohort benchmarking to identify areas for improvement. Ensure metrics are comparable within the cohort and communicate the benchmarking process across teams, particularly with physicians, to foster understanding and engagement. Aim to reach the top quartile of your peer group by comparing the 50th and 75th percentiles. Regularly revisit and adjust your cohort to maintain relevance as performance evolves.
Align critical metrics to revenue goals. CMI is a popular metric but doesn’t fully address performance due to factors like surgery schedules, patient acuity, and external events. Acuity-Adjusted CMI™ from CorroHealth offers a more refined approach. It benchmarks a hospital’s CMI against comparable institutions, adjusting for patient acuity and care complexity. This method provides a clearer picture of actual performance by highlighting discrepancies between clinical evidence and recorded data. For instance, while a standard CMI might show a decline, an Acuity-Adjusted CMI could reveal that this decline is due to an improved observation rate, not poor documentation or coding. This is just one of the many proprietary KPIs CorroHealth has developed to drive real financial impact.
A CDI program’s financial impact relies on identifying revenue-increase and revenue-decrease opportunities, revealing vulnerabilities and educational needs. Track metrics based on your strategic review process and aim for an eight- to ten-to-one ROI on reviews to ensure costs are covered and the program is effective.
Detailed analysis helps pinpoint areas needing further education or process adjustments. Analyzing documentation discrepancies and physician responses to queries can identify educational needs. Engaging physician champions can drive these discussions and improvements.
Analyzing and understanding the root causes of documentation discrepancies will further drive improvements. For instance, consistent physician responses of “unable to determine” to queries often indicate the need for targeted education on specific diagnosis codes or general query responses. Regularly reviewing these data points reveals common areas to achieve the greatest ROI.
Hospitals can measure their impact in two ways:
Program improvement should be communicated in terms of dollars, differentiating between revenue-increase opportunities and revenue-decrease opportunities as they represent different vulnerabilities, risks, or areas that require education.
Specific questions about data help identify what to track for improvement. These include questions like “Where do we have changes?” “What diagnosis codes are we using?” “Was it a principal diagnosis?” “Was it a secondary diagnosis?” and “What’s the nature of the change?” The metrics will help uncover root causes and identify program process improvements for targeted education across teams.
Lastly, evaluate the effectiveness of the review process itself. Are the right cases being selected for review? Is there a good hit rate that justifies the continued performance of these reviews, ensuring they pay for themselves and generate additional value?
Hospitals can use VISION to make the case review process more efficient, reducing the workload for CDI, HIM, and Coding teams. Our unique CDI methodologies are built into proprietary algorithms based on comprehensive CDI insights, DRG methodology, and clinical knowledge. It accounts for encounter data characteristics, review outcomes, and changes in coding rules and guidelines. Its extensive knowledge base allows the scoring engine to pinpoint smaller clinical populations accurately, identifying opportunities efficiently and flagging cases for expert reviews.
At CorroHealth, we know that adapting to change and rolling out new processes is no small feat. Partnering with us is key to boosting your CDI programs and effectively managing the intricate financial aspects of your revenue cycle. Our solutions span the entire revenue cycle and are customizable to address the unique challenges your hospital faces. We focus on ensuring compliance, accuracy, and maximizing clinical value, all tailored to fit your needs.
The seasoned CDI experts at CorroHealth are an extension of your hospital’s team and VISION AI technology streamlines decision-making, enhances DRG integrity, and compliantly optimizes revenue opportunities. By integrating a people-first approach with advanced technology, CorroHealth delivers tangible improvements in financial and clinical outcomes, fostering revenue integrity and reducing compliance risks.
CorroHealth is the leading provider of clinically led healthcare analytics and technology-driven solutions, dedicated to positively impacting the financial performance for physicians, hospitals, and health plans. With over 11,000 employees worldwide, CorroHealth offers integrated solutions, proven expertise, intelligent technology, and scalability to address needs across the entire revenue cycle. Our global presence extends over 10 locations, including the United States, India, and the United Kingdom, enhancing our ability to deliver exceptional service on a large scale.
The CorroHealth CDI Program is data-driven, strategic, and is tailored to solve your specific issues or can be offered as end-to-end services, which include:
Holistic Assessment to uncover pain points
Inpatient and Outpatient
Providing CDI specialists for inpatient and outpatient services
CDI and query auditing for education and financial opportunities
Customized training and development
HEDIS Abstraction and HCC
VISION – DRG Integrity (Full Staffed, SaaS, Hybrid)
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