In the healthcare industry, finances and revenue are one of those topics that are ever looming. Healthcare Revenue Cycle Management is more important now than ever because of tightening margins, an increase in debt and bad debt, and the continuous decline of cash flow. Healthcare organization those continue to seek new ways to not only increase their revenue streams but also reduce the loss of revenue. These revenue losses or leakages sometimes appear to be small or inconsequential but they add up pretty quickly and can represent significant revenue loss to the revenue cycle.

Clinical Documentation of Healthcare Revenue Cycle Management

Healthcare Revenue Cycle Management 

Proper clinical documentation is supposed to show the correct illness of patients, the past treatment that they received, all the treatment they are currently receiving and any information on tests, medication, allergies etc. The information stored on a patient’s clinical documentation not only helps the doctors and nurses provide proper care to the patient but also helps with the billing.


Take for instance a patient is transferred to a hospital from another medical facility, the transfer should be accompanied by all the documentation on the past treatment the patient has received on that facility. This is usually not the case as the transfer of documentation and data does not go as smoothly as expected. Most hos[pital systems are not compatible with outside systems and so this means there can’t be an easy transfer of data. What does that lead to? It leads to the doctors or nurses manually entering the information into their own system. This is a waste of man hours that can be avoided and sometimes leads to errors such as not properly reflecting the state of a patient’s treatment.


Another instance is when the doctors or nurses have to manually enter the data of the patient’s health record and the treatment they are being given. When this is done manually, some things are missed with means the hospital loses money. Leasks like this tend to add up.


To solve this, hospitals should have a comprehensive and responsive data storage system that makes receiving data, storing data, and accessing data easier. All data on a patients treatment and time in the hospitals such as doctors notes, medications, allergies,  the number of comorbidities, operations etc should be properly stored in a patients file and updated regularly. Sometimes there are different doctors both internal doctors and doctors from other facilities who are all involved in the care of a patient, this should be properly reflected in the patients file and in addition this patient file should be comprehensive, up to date, and readily available to all the doctors and nurses who are delivering care to the patient or who might have need for it for billing purposes and so on. That way the hospital also gets properly reimbursed by the insurance providers for all the work they do.


Item Documentation and Billing

When a hospital performs a procedure on a patient, they have to record that procedure using a specified billing system code. The code has to be correct at all times and also match the billing code on the receiving end (i.e the payer system, insurance agency, or government agency in charge of reimbursements like Medicare and Medicaid). Sometimes there are small variations in the code which leads to a mismatch with the receiving end’s code. Other times the wring code is inputted for the wring procedure leading to a mismatch in billing. When a mismatch occurs, the paying office or health funds office rejects the bulling meaning the hospital has to either reapply and resubmit or they lose that revenue.  This is self-evident from the explanation leads to a leak in revenue.


Another issue with documentation is when a patient stays overnight in a hospital for a condition that is recorded in billing as “non-admitting”. In cases like this, the hospital will have to submit a certificate of justification to accompany the billing invoice. If this certificate does not accompany the invoice, the health fund or insurance company will refuse to pay the extra cost leading to revenue loss as the hospital will have to foot the bill themselves. Constant mistakes like this lead to significant revenue loss.

Audits and Documentation Gaps

Healthcare Revenue Cycle Management 

As we already mentioned above, incomplete or inaccurate documentation minimizes the effectiveness of a hospital as they cannot teat the patient effectively using all data available and they cannot document the billing correctly. Without proper documentation, hospital staff can not accurately determine the complexity of a patients condition or the severity. Patient conditions are assigned codes which are used for billing purposes after treatment has been done. These little gaps in documentation and quirks in the system cause a ripple effect of more errors which leads to further revenue loss.


In some hospitals, when there are discrepancies in the clinical documentation and codes inputted, doctors are asked to re-enter the data or are given a form to fill to help clarify the errors. For doctors who have a very busy workflow or for doctors who are visiting from other facilities, it's harder to get them to fill out these queries and gaps in documentation. Without these clarifications of documentation and billing codes,  a hospital or healthcare organization will be vulnerable to audits from Health Funds that can expose gaps in the documentation/coding process, even if it is obvious that the patient had the condition. Sometimes this coding processes and documentation as so complicated and fragile it can be easy to miss. Hence, hospitals must properly and constantly train their staff on how to properly document conditions for billing purposes.