Top 10 CDI/DRGV Pain Points for Hospitals & Health Systems: The PHS Fix (Part 1)

Hospitals and health systems shoulder many risks as part of their business model. As a healthcare consulting firm specializing in CDI/DRGV and HIM, Paramount Health Solutions (PHS) knows very well what you’re dealing with.

PHS was founded and is owned and operated by physicians and other experts who have a combined 50 years of experience in healthcare, clinical documentation improvement, DRG Validation, auditing and compliance, denials management and training. We’ve held leadership positions in well-known hospitals and health systems and large consulting agencies. Find out more about our leadership team here.

We knew there had to be a better way than what was currently offered in the market to work effectively with in-house physicians and staff to improve the mid-revenue cycle process and capture more revenue opportunities. That’s why we started our own company, Paramount Health Solutions!

In this two-part article, Paramount shares the top 10 issues we’re seeing in the industry – and how our practical solutions mitigate the sting of these challenges. Part 1 focuses on issues 1–5 from the list below, and Part 2 covers issues 6 – 10.

Paramount Health Solutions can address and improve these issues head-on, without adding more risk, more time to the cycle, or burdensome expenses to your operations.

Top 10 pain points at hospitals and health systems identified by PHS:

  1. Increased payor denials
  2. More OIG audits
  3. Thin margins
  4. Unpredictable revenue cycles
  5. HIM staffing difficulties
  6. Physician clinical documentation errors/omissions
  7. Ever-changing standards and regulations
  8. Coding compliance issues
  9. Limited window for coding and billing
  10. Missed coding, upcoding and severity opportunities resulting in lost potential revenue

How Paramount can improve Pain Points 1 through 5:

  1. Increased payor denials – With our physician-led, full-scope audit process, our MD reviewers will make recommendations that result in exceptionally clean, accurate and specific charting, coding and billing. DRG validation includes clinical validity of diagnoses that are on the Payor Target List for denials – ensuring that a clean bill will be sent. With PHS as a partner, you’ll see a substantial reduction in denials. For any PHS recommendations denied by a payor, we will develop an appeal at no additional cost to the client.
  2. More OIG audits – Of course, we can’t control what federal agencies choose to audit. However, clients that work with Paramount Health Solutions have peace of mind that their charts receive a deep second level of review by industry experts. Our team audits the coded ICD-10 CM and PCS abstracts against the documentation presented in the record – and all are compared with the specific, current CMS coding standards. When we notice over-coding patterns or instances with a lack of clinical significance, we provide recommendations on how to address the issues, downgrade appropriately, or query. We submit a report to the client showing how the documentation and coding with appropriate diagnosis better reflects the true clinical picture of a patient’s stay. About ninety-five percent of our recommendations are accepted by our clients, and they make the suggested changes. This results in fewer issues for auditors to flag.
  3. Thin margins – Paramount Health Solutions typically finds between $2,500 to $4,500 in opportunities per chart, resulting in millions of potential revenues for clients. In addition, clients have seen their CC and MCC capture rates, and Case Mix index percentile increase, resulting in significant financial uplift.
  4. Unpredictable revenue cycles – Working with your physicians, coders and HIM staff, Paramount’s consultants show them specific changes to improve and maximize accuracy and revenue opportunities. Accurate documentation and coding mean a higher percentage of receivables will be paid and a smoother, more predictable revenue cycle.
  5. HIM staffing difficulties – Staff reductions, turnover, lack of experience, not being up to date on new coding standards, communication problems. These are some of the serious issues hospitals are contending with. Paramount Health Solutions is comprised of highly trained and experienced physicians and clinical auditors who supplement the work of current hospital coding, CDI and DRG teams to provide operation assessment, feedback, and training for overall program success. We can also fill in when there are staff vacancies and help onboard new employees in these roles.

The second part of this article addresses the other five problems related to CDI/DRGV/HIM that hospitals and health systems are experiencing, and how Paramount Health Solutions can remedy them. Click here to see Part 2 of this article, which focuses on issues 6 – 10.

We have even more great news to share with you! To schedule a brief live presentation, connect with us online or call (615) 347-4867. You can also download our brochure and other materials here.