[Q&A] Steps to Operationalize Your Coverage Analysis and Achieve Compliant Billing Outcomes

April Schultz
March 28th, 2018

During our recent webinar, Steps to Operationalize Your Coverage Analysis and Achieve Compliant Billing Outcomes, Shanley Curran of Research, Operations & Compliance Solutions, Inc. discussed ways organizations can improve their billing compliance processes and operationalize their coverage analysis across critical points of communication. Here we transcribed four of the valuable responses Shanley provided during the question and answer portion of the presentation.

You can also watch the full, on-demand recording of the webinar and download the presentation slides, including all links to resources mentioned during the webinar, here.

 What are the first steps to finding problem areas and implementing billing compliance process improvements?

Your first step is to identify who is impacted by the process and bring those folks together for current state mapping to identify the steps that are missing. I think it’s a huge “aha” moment when people have the first opportunity to meet each other in one place to discuss the process. When you get everyone together in one room, you should set aside at least four hours to initiate that current state mapping.

Some organizations are pretty complex and it’s difficult to get everyone together at one time, and some are smaller community hospitals and it’s easier to get people together. It’s important to cater your approach to your organization’s needs. Regardless of your approach, once you have those individuals in the room together, I’d suggest using the Revenue Cycle Diagram I referenced in the presentation and walk through each piece of it. Initially, reach out to the people that make sense to get involved and then ask them who else should be involved. I always suggest having a subject matter expert involved because they have done this before and they understand who needs to be at the table talking about it. I also support a candid approach to the discussion through a cloud-based, anonymous approach. This typically provides more honest and open discussion.

 Do you have any recommendations for fostering trust between stakeholders in situations where billing compliance or systems issues are identified and need to be addressed?

This question goes back to relationships, and I think that there is a tradition in academic medicine of silo-ed operations. It has been well-observed across the industry that the silos create a lack of transparency in communication within organizations where everyone shares at least some of the same objectives. In order to develop trust, it is an investment of time and effort and it starts by coming together in the same room and getting to know each other face-to-face. In academic medicine, culture also comes from the top. If you’re developing a leadership style within your organization of collaboration, compliance, transparency, ethics and a commitment to civility, over time you’ll get to a better place.

Be mindful of people’s time and knowledge. I strongly encourage enterprise-wide education as a first obligation. You can provide required, generalized education to bring everyone onto the same playing field without anyone losing face. A group task force [as mentioned in my presentation] is also important to bring the different stakeholders together and make them actively responsible for outcomes. This task force also encourages them to play a leadership role in building culture, in addition to the underlying purpose of avoiding risk. You cannot avoid risk effectively if you don’t have the relationships within your organization that allow successful, transparent communication to get the job done correctly. So, essentially: education, a task force, civility, culture of compliance and responsibility.

Could you provide more advice on how to develop standard procedures for risk issue resolution?

In my experience, the procedures people struggle with are some of the gray areas in coverage analysis that present risk or have been believed to present risk. Over time, as we get more information about coverage analysis and the outcomes of billing, the risk areas and considerations have shifted a little bit. It’s helpful to have decision makers and a decision-making process for the basic, everyday approach that occurs. Then, to have an escalation process when there’s an outlier.

Take, for example, the area of therapeutic intent in coverage analysis. If the investigator and coverage analyst agree on the findings about therapeutic intent on a phase two or three clinical trial, there’s really not a whole lot to discuss after that, so long as it’s appropriately documented and can be referenced in the future in the case of an audit or question. In the case of a phase one clinical trial, I know some sites have implemented forms for specifically documenting the consideration about therapeutic intent. Then, when certain components of that form are met, it goes to an objective reviewer or reviewing committee to consider the risk issues, make a decision and then document it on that same form. The procedure for doing all of this is documented in an ordinary procedure underlying an overarching clinical research billing policy at the organization. These procedures and policies are evaluated on an annual basis, just like everything else should be.

It’s really just about getting the right people in the room to determine how the process should be at your organization and how risk escalation, review of outcome and ongoing review of process will be managed. 

Do you have any tips for finding and hiring effective coverage analysts?

Part of a good coverage analyst profile is their communication style and ability to communicate clearly, effectively and completely in a number of different formats, whether it’s documentation in a template or mindful communication in an email. For example, if a coverage analyst evaluates a study and disagrees with the investigator’s determination of therapeutic intent, how are they going to communicate with that investigator in an email, call, face-to-face meeting or group setting? These can be very difficult conversations, and some of the quality of those conversations can be dramatically improved with some training in communication style and techniques. In addition to having the clinical research, coding and revenue cycle background, they should be willing and capable of building their understanding in competencies they may be lacking. They also need to be amenable to developing their communication style and learning in an open, willing way.

However, communication style can be hard to gauge. I know some organizations use examinations of personality and professional style before they bring these folks on. Others will simply say, you have the skillset, so come on board. If you take this second strategy, be prepared to handhold them in understanding the sensitivity of some of these situations and give them the tools and examples to help them understand it. I’m big on email templates and forms for these types of communications, because it removes the ego out of the equation.

Want more answers?

To learn more, watch the full, on-demand recording of the webinar and download the presentation slides, including all links to resources mentioned during the webinar.