The Most Effective Tips For Capturing Medicare Revenue

7/19/2019 By Wilson

Charge capture is a vital part of the revenue cycle process, as all public health agencies that fail to appropriately and accurately document information on the care provided at their facilities can potentially lose millions in revenue.

But more effective revenue system could have a massive impact on a health agencies bottom line. For that matter, a recent report conducted by the Advisory Board Company discovered that the average health agency misses out on $22 million revenue capture opportunities. While under-coding and missed charges present a significant amount of financial risk for health systems, they aren’t the only problems that healthcare leaders need to keep an eye out for. Over-coding can also lead to overpayments, which can result in some serious penalties.

A recent case of this occurring was the Office of Inspector General (OIG) stated that Madison, Wisconsin-based University of Wisconsin Hospital and Clinics submitted erroneous bills to Medicare, and were required to refund the Medicare contract $2.4 million. From another case, the OIG stated that New York based Mount Sinai Hospital owed the government almost $42 million for improperly billed Medicare claims.

While these cases due seem grim, there is good news. There are some small steps you can take to ensure your health agency is capturing the appropriate charges and not the wrong ones. Here are some tips on how to capture medicare revenue.


Discuss Charge Capture More Often

Give the effect that charge capture can have on a health agency’s bottom line, it would be natural to assume that most leaders discuss it on a regular basis during meetings. Although, a recent survey conducted by Ingenious Med of more than 100 healthcare leaders revealed that while over three-quarters believe charge capture is important to their organization’s ongoing success, nearly half meet only once a month or less to discuss charge capture.

Discussing charge capture at more frequent times with leaders and physicians can have a massive impact on charge capture. One of the main reasons? It sends a clear message to clinical and coding staff that charge capture is a priority at all levels of the organization. Once the message has been made clear, everyone can work with a common goal in mind.

Just keep in mind that discussing charge more often doesn’t mean the agency needs to have a formal charge capture meeting every single week. But they do need to at least be included as an agenda during important leadership meetings, and the appropriate individuals should be invited to provide an update on how the process is being handled.


Make It Easy For Staff To Raise Concerns

If leaders aren’t aware of what the problems or barriers are to effective charge capture, improvements will never be reached. Physicians and staff who are in charge of capturing revenue on a daily basis must have the capability to raise concerns and ask for more resources when necessary. Some approaches to consider are:

Forming a focus group made up of the billing staff with representation from each department that shall meet quarterly in order to discuss charge capture challenges and then have to those challenges brought to the attention of senior leadership.

Implementing a virtual feedback system or even a virtual chat system so that when staff members encounter any challenges, they can request help from experts. If the experts aren’t capable of helping out, they should bring the problem to someone in leadership. At the very least, the communication between clinical and billing staff should be electronic and real-time.


Have A Good Relationship With Payors, And Renegotiated Managed Care Contracts

While public health agencies aren’t capable of controlling the underpayments from Medicare, Medicaid, and other governmental payers, they have some semblance of control over one major outlet, commercial and employer-based payors. Private insurance carriers comprise, on average, 35 percent of health agencies revenue.

Health agencies must take the time to understand existing contracts, benchmarks managed care contracts against each other, conduct appropriate research to know what percentage of the insurer’s business comes from the agency, routinely update stagnant and evergreen contracts and look for carve-out opportunities. Health agencies and any of their managed care departments must be fully prepared when renegotiating contracts, but at the same time, a level of respectful dialogue must be maintained. Otherwise, fallouts will happen, leading to some serious costly periods of no reimbursement and public relations nightmare.

At times, most people don’t consider the fact that there is a mutual respect that needs to happen with payor and institution. That is earned over time in a manner that allows you to help collaborate, design and develop appropriate care delivery models and product designs that those payers will end up using.


Sharing Performance Feedback With Clinicians

If clinicians don’t have a clue on what they are doing wrong, it’s quite impossible for them to improve. Make data transparency a top priority, and ensure physicians have insight into their performance when it comes to dealing with charge capture. Send them either monthly or quarterly reports so they can show them how they are performing. To capitalize on their inherent sense of camaraderie and competition, show them how they are performing when compared to their peers.


Revamp Care Coordination

Ensuring successful care coordination is vital in saving costs. It’s very important because if it’s not coordinated, then handoffs are poor and there are duplicative tests and delays, which stack on to the length of stay and costs. By improving the care coordination policies, such as the discharge process, health agencies can avoid possible readmissions, which will be penalized center of medicare and Medicaid (CMS).

There are various models made to improve care coordination, including accountable care organizations, patient-centered medical homes, and private payor-provider relationships. While health agencies should consider these long-term projects to significantly change the coordination of care, some short-term options can produce savings and improve patient safety.

For instance, MedeAnalytics has suggested using checklists and auditing to verify medication information, follow-up appointments, the main caregiver at home, diet and exercise parameters, need for home healthcare visits and notification for call the physicians. Furthermore, discharge summaries should be sent to primary care physicians so the transition from the agency to home is done with little to no error.


Perform Regular Billing Audits

Public Health agencies can ensure they have proper charges for each patient by performing regular billing audits using patient census, emergency department and admission/discharge information. Additionally, health agencies should conduct an audit for services that should be a technical and professional component (such as radiology) to ensure both charges were reported and accurately billed.


Review The Current Billing Workflow

Health agencies should also take the time to identify charge capture processes for multiple streams of revenue, such as acute, ambulatory, pharmacy and ancillaries. Furthermore, make sure you have a workflow that ensures the proper charge is identified at the correct time, whether a technical and professional component is accurately reported or needed, and appropriate safety nets to ensure the billing and coding are appropriate and accurate.


Review Lag Times

Consider inspecting lag times from date of services to billing/coding and lag times from service date to posting date and claim submission. Health agencies should also compare their lag times to industry benchmarks to identify problem areas.


Get Documented Processes

Public Health agencies that are most successful with charge capture have managed to grasp that there has to be a true process bridge between what’s happening clinically and what that’s intended to engender financially. This can be formalized with service line clinical representation at revenue cycle steering committee meetings, or it can be a less formalized where processes are solidified and reflected in the system. But this mutual understanding of what your charge capture processes are and what charges should be automatically dropped, versus those that require someone interoffice mailing a paper to someone in the financial office so they can manually enter charges, is vital to ensuring minimal breakdown for charge capture.


IT Systems

Leverage IT system to automatically drop charges when it is possible. Public healthcare agencies today can leverage virtually any healthcare information system and automatically drop a charge. For example, dropping the charge for an electrocardiogram off either order or read. When a health agency decided to drop a charge for an EKG off of an order, the agency has created that charge before it’s completely certain the EKG has occurred.

So if someone were to order the EKG and the patient could get tired of waiting or something else came up. There, the EKG never happened, but the charge was dropped automatically at the point of order. Similarly, if you dropped it at reading you’re pretty much stated “we’re not going to charge until a physician reads, interprets, and subsequent documents that. It is possible for you to do the EKG and incur all the costs but if you have a physician who isn’t good at finishing documentation or the system is not conducive to them accurately marking that it was done then you can never drop a charge for something you have done.


Monitor Metrics

Don’t simply wait for an OIG audit to locate any potential problems with charge capture. Proactively monitor how your agency is performing against key metrics.

Not sure how to go about this? A recent survey conducted by Ingenious Med has utilized the results they gathered to identify the top-performing organization when it comes to this. Here’s what they discovered.

●     More than 50 percent of top performers capture charges within 24 hours.

●     70 percent of top performers send out bills within one to three days.

●     Most top performers have an average duration in accounts receivable of less than 30 days.

●     Most top performers have less than 1 percent of their charges under-coded and over-coded.

●     Most top performers have a denial rate less than 3 percent.

These metrics should give you a good idea for a starting point to determine how an agency is doing compared to top performers, and where it needs to make some improvements.



Medicare is a great source of revenue but it’s also something that needs to be managed carefully. By having your staff and leaders carefully navigate through charge capturing and having this goal in mind, you should have an easier time managing. Just remember to not overdo it or you could be charged with some serious penalties, which will lead to damaging your health agency in the long run.