Bill Klaproth (Host): This is AAOMS On the Go. I'm Bill Klaproth, and I'm pleased to welcome with me Vanessa Moldovan, Head of RCM Strategy at the automation platform, Magical. Vanessa has spent her career in the heart of healthcare revenue cycle operations. And she is here to talk with us about revenue leakage in OMS practices. Vanessa, welcome.

Vanessa Moldovan: Hi. Thank you so much, Bill, for having me.

Host: Absolutely. Great to talk with you. So, let's start with this. What exactly is revenue leakage, if you could explain that to us? And how does it typically show up in OMS practices?

Vanessa Moldovan: Yeah. So, revenue leakage is kind of different than what we would typically look at in a practice of like money that's hard to collect or something. So it's not like a denial – a straight-out denial – or like missing payments or something like that.

Revenue leakage is money that is there for the practice to collect but oftentimes goes unnoticed. Just like a leak, you know, it kind of sneaks through. And if you're really not looking for it, it'll be too late to collect it. You won't be able to fix the problem in order to collect that money that the organization is owed. So, that's kind of how it differentiates from, like, accounts receivable or outstanding AR, is that it kind of seeps through. It can go unnoticed and in ways you have to be kind of creative in figuring out, “Where is it that we could be missing revenue?”

And then, in OMS practices in particular – as you said, you know, I've been in revenue cycle for a long time, so across all kinds of specialties. I don't know that OMS, oral and maxillofacial surgery, right, has particularly in their revenue cycle something that's different from other revenue cycles, what they would have challenges with for revenue leakage.

A couple things that do stand out – so, things that are common, right – would be underpayments. We all need to be looking at our underpayments. We need to be looking at credits, unresolved rejections; missed opportunities in coding, such as like modifiers, missing charges, undercoding.

And so, I would say, specifically for the OMS world, because they do a lot of surgery, right, really concentrating what would be specific to that specialty is the coding. So, missed opportunities because we're not trending or we're not tracking root causes in our coding – not just all throughout the revenue cycle, but especially in the coding, because it's complex coding. And so we want to make sure that we're not missing those modifiers, that we’re appropriately, you know, looking at bundling and stuff like that.

So, one thing to really keep in mind with keeping track of that revenue and making sure it doesn't leak is that it's not big things. Oftentimes, it's these small, repeated things that we're doing that can just have this slow financial bleed and it's like, before you know it, we've lost revenue. So, really needing to think outside the box of that typical operational causes in order to look at the revenue leakage.

Host: Yeah. Just like a leak, it's kind of a drip, drip, drip of loss. Basically, as you said, it is not the big misses. It's these small, repeated things that add up. Okay. So, you were talking about coding or billing errors as one of the main reasons of this. Can you share some common examples of coding errors that contribute to revenue loss?

Vanessa Moldovan: Yeah, absolutely. So, some of the most common are failure to capture missed revenue. So, procedures that are actually documented in the operational notes, in the operative report, or in the visit note. So, we're missing that documentation. And why that's really common these days is, like, now EMRs have been around for a long time, but it's really, really common that the clinician – so the provider, the clinical provider, the surgeon – they're the ones who are choosing their CPT codes or their billing codes. So that's very common.

And so, what can happen is because they aren't certified trained coders, what can happen is they actually miss opportunities of something that they performed that can actually be billed. And so it's really important that we're actually reviewing that documentation even after a provider has chosen those codes. So, that's what we would refer to as missing charges, right?

So, another common is undercoding. Sometimes we have providers and coders out there who can be kind of conservative. And so, because they're concerned like, "Oh, I don't want to get audited. You know, I don't want a payer to think that I'm trying to get too much money out of them," so they might undercode. And where they could actually be getting more reimbursement, they're being a little bit conservative. So that's pretty common too.

Incorrect usage of modifiers is also really common. So, there are some modifiers that we use a lot, especially in surgical coding, like modifiers 59, 79, 51. And if they aren't used appropriately, you can definitely miss revenue. And it is definitely that kind of revenue that can go just under the bridge and you're not going to notice it because, those types of usages, you have to review the documentation in order to make the decision. So sometimes it can be really tough to identify with some of the current – maybe more antiquated – automations that we have to catch errors.

Another thing too, so kind of on that billing side, some very common examples that can contribute to revenue loss, one is rejections. So rejections are those errors that sit in your clearing house, so your payers have rejected, so it hasn't even gotten to the payer yet. And that is something that we really need to be on the lookout for because of the dangers of timely filing. So, those who work in the industry, you know, they know that if you don't get that claim to the payer in a timely manner, you have no recourse to collect that revenue. And rejections are the most common place where you can run into that timely filing. Like, nobody wants a timely filing denial. But if you're not on the lookout for them and you're not resolving them in a timely manner, that's just a very common place that revenue can be lost.

And then, finally, I think that one place that we can miss some revenue is overreliance on software that we're using. And the reason that I bring this up is because we have been using technology for a really long time to provide additional efficiencies, additional effectiveness, more productivity, relieving some burden for our frontline workers, for our providers. And I think sometimes we kind of fix it and forget it, for lack of a better word. And I think that it's important that we not rely too heavily on some of that software and just make sure that we are using smart automation that can fill in the gaps of some of the automation that may not be as smart.

And I can give you an example of what I mean is, like, where I was saying before about reviewing documentation to be sure that you've captured all of those appropriate charges so that you get all of that revenue, you need really smart automation and really smart technology that can behave more like a coder would and can catch those missing charges. So, those are just some examples.

Host: Yeah, absolutely. So, a lot there, Vanessa – undercoding, incorrect modifiers, rejections, incorrect CPT codes. So, you talked about all those things. So, there's a lot of areas for an OMS practice to pay attention to.

So, let's talk about the fix or what they can do to help resolve some of these issues. How can OMS teams then identify and address this revenue leakage before it becomes a bigger problem? How do they look and find these gaps and inconsistencies and incorrect codes, et cetera?

Vanessa Moldovan: Yeah, absolutely. And it's super important. I think number one would be to conduct regular audits within the organization. And not just coding audits, but we need to be conducting operational audits from the time that the patient is making their appointment all the way to the time that we're resolving that encounter.

You know, there's all kinds of processes within there and workflows and things that we're doing. And they all need to have a really close look at them. And it's kind of from what I was saying earlier is that revenue cycle, it may seem like that it is just, "So which is your coding and your billing," right? That's your revenue cycle. And it may seem like it's pretty straightforward. But every organization has these workflows that are like in between your typical, what we would say, like registration, coding, billing, payment, posting, you know, those are like your typical steps, right? But in between all that, every single organization is doing all kinds of different workflows. Those are the workflows where the revenue can really leak. So it's important that  – yes, of course, we're taking a look at coding, we're taking a look at payment, posting, kind of those bigger operational workflows. But we also need to be looking at those smaller ones, and those kind of in-between ones. And that's where you can usually find something where we're missing something. The revenue is getting through.

And then, once you do those audits, right, we need to be sure that we're focusing on those problem areas that you do discover. It's like, okay, after you identify, then you also need to take action and be sure that you are being really smart about how you are putting fixes in place, right? So we want to make sure that we're utilizing people and we're utilizing technology. We're being smarter and not working harder. And we have to really be careful with this, because oftentimes we'll go out and we'll be like, "Okay, we think that this fix is actually going to make things better for us." But actually, as we go down the line, it kind of created something else, you know, further down the line. So, really being sure that you bring in all of your departments – we’re bringing in all the appropriate people  – when making those decisions and putting things in place that you're not creating more cracks and more leakage down the line.

Another thing is that just really be sure, you know, I mentioned those rejections. That's a really common place that we can lose revenue. And so, just be sure that you're reviewing those responses and those reports on a regular basis – again, to find the trending. Trending is really important because that's really going to show us the good, bad and the ugly, right? It's going to show us our root causes. It's going to show us: Where is that leakage? Where are our problems?

And that's also going to allow us to be proactive to prevent the leakage, to prevent the problems, because it is much better to be in an organization where we're being proactive and not being reactive. Because reactive is definitely where you're going to lose money, right? We're going to be able to keep more of our money if we're being proactive and preventing these errors.

And then, finally, it's important that you establish KPIs, which are key performance indicators. And establish those benchmarks within your organization, so that you're able to trend, like, "How are we doing?" Right? So, how do you even know what is your measure of success? You might be suspecting that you're losing revenue and you might feel like we're not making what we used to be making. But you really can't know that for sure unless you're tracking data, which is in these KPIs and is in these benchmarks. So, examples of those might be your clean claim rate, your denial rates, your first pass resolution rates, your charge lag time. I mean, literally, there's so many KPIs. But what's important is that you look at your organization. And you're like, "Okay, what are the areas of opportunity that we have?" And those are the KPIs that we want to track. And we want to track and trend them really on a regular basis. And some KPIs, you're going to look at daily, some you're going to look at weekly, you know, monthly, quarter. So they all have these different timelines that you look at. But that is so, so, so important to embrace your data and use it to empower you to really prevent losing revenue in the organization.

Host: So many KPIs, so little time. That's what I like to say. So much there, Vanessa. You know, regular operational audits, as you said, make sure you are reviewing those rejection reports and establish those KPIs like you were talking about, and then take action. And you said be smart in how you put the fixes in place. So, when OMSs don't do that, when practices don't proactively address some of these revenue leakage concerns, tell us what is the potential consequence then that they might face?

Vanessa Moldovan: I mean, you could be subject to audits from payers. You could be subject to audits from other organizations that you work with. So maybe you have surgeons who work inside of other facilities, you know, ASCs or hospitals. They might audit the work that you're doing. Also, you might get refund requests from payers because they do audits on their end and they're like, "Hey, something's going on here." So – and a refund request – it does not feel great to give money back. It doesn't feel great to get a post-payment audit either, which basically means they're requesting your documentation. They're requesting all of your billing information and making sure that the money that they paid out really was accurate. Because – I'm sure you know – if it isn't documented, then we can't bill it. And we shouldn't be getting reimbursed for it if it wasn't documented. So, those are a couple of ways that it'll kind of manifest. Some of these continuing to have these errors. And it's just really important – and I mentioned this earlier – it's really, really, really important to be proactive.

First of all, if you are receiving refund requests, you are receiving post-payment audits, I just want to say, first and foremost, do not panic. Just because they're requesting to audit or they're requesting for money back, does not mean that they're correct. Take a look at what they're saying. They could be wrong. They're just checking it out. They just want to make sure that they paid out that money correctly. I mean, they don't want to lose money either. They're there to make a profit. So, don't panic. Get your resources together. Get your experts together to help you with those requests from the organizations.

And also, frankly, there's a lot to learn from that as well. You may totally have not been aware that maybe there was a payer policy that you missed and you weren't following. And when you get that post-payment audit, you learn from that, right? So, it's not all like horrible, horrible. And so, first of all, don't panic. Be calm.

But to prevent those types of things, be proactive. Right? We want to proactively be reviewing credits within your system. That can also help with some of those audits, some of those refund requests. Making sure that you're not missing revenue in your credits as well.

And also, those audits that we talked about before – like internal audits that you do within your organization – that can, of course, help to prevent those post-payment audits and those refunds. Some of the other things we talked about, right? So, the routine checks of your processes, and making sure that you're filling in gaps and being very creative of where might we be making errors.

Host: So you said it's really, really important to be proactive. So, I'm sure we probably have an OMS or two, or maybe more than that, listening to this saying to themselves, "Hmm. I need to get on this. I think I might have some leakage." So, if a practice suspects they're losing revenue or unsure or feeling like, "Hmm, I better check into this," what are the first steps they should take to investigate and correct the issue?

Vanessa Moldovan: So, I would say, first and foremost, whenever I do any kind of an assessment of a revenue cycle, I look first at denials. So, I feel like denials are really the good, bad and the ugly. They're just a great barometer of, like, “What's going on? How are we doing?” There's no part of the revenue cycle that goes unseen when you're reviewing the AR. Like, it all, you know, goes downstream there. So take a look at your denials, you know, from the last 30 to 90 days and identify those repeat issues. So of course, we would look at, like, what are our top denials and kind of what category are they going in?

But on top of that – because it's kind of easy to put together a denial report per se – what you really need to do on top of that is look for root causes. So, a denial reason is different than the root cause of that denial. So a denial reason from a payer might be, “We denied this for being inclusive” or what we might call bundling. Or, “We denied this because the patient's policy was inactive.” That's a reason. Our root cause is: What caused that denial? Why did we get that denial to begin with? And that's when we need to go back to our processes and our workflows and look at like, "How can we fix this?” Again, to be proactive. Right? So, how can we go back to that process, fix it so, in the future, we don't get those inactive denials or those bundling denials.

And the reason why I really am focusing in on this root cause, and I'm sure some of our listeners are kind of like rolling their eyes, like, "Okay, Vanessa, that's not so easy" – and I get that it is not easy –  because typically identifying root causes is a manual process. You have to dive into the notes, you know, all of the history of the claim, the history of the denial. And so it can be a very time-consuming research process. And this is where tying back to what I said earlier about embracing smart technology, because there is now tech out there who can help us with identifying root causes. And I love this that we're now in a day and age where technology can help us with some of these just really important things that we need to diagnose. And this is really close to my heart, you know, because I was in operations for almost 25 years. And anytime we're like, "Okay, we need to look at where we're losing revenue," it was just like, "Oh my gosh, who has the time to investigate and to really look into this?" And we rarely had the time, right? And it was always this big project if and when it did get done.

So, I'm just really happy to say to everybody who's listening, is now we do have solutions out there that can help us get to that root cause and really help us to get to that diagnosis in a much more automated way. It isn't as manual. And then we can fix that root problem and truly prevent these denials, prevent that leakage.

And then, finally, I just want to say too that, to really fix these challenges, which in my career I've done a lot of assessments, a lot of process improvement projects, it's so important to listen to your teams before you put any changes in place. And I'm even talking about like implementing technology, changing a process, bringing in new people, getting rid of people, if you do that.

Listen to your teams. I mean, the people who are on the front lines, they're the ones who really know what's going on. They know those workflows. They know the little things that they're doing in order to fill in the gaps, in order to make it happen. They're amazing people. They're super smart. They're problem-solvers. They're critical thinkers, right? So, sit down with them and be, like, "Hey, we've identified this in our data. We've looked at the root causes. This is what we think would be a great solution. What do you guys think? Do you think that our findings align with, frankly, what's really going on?"

So in my opinion, if you really want to solve your problem, solve your challenges, make sure to include those teams who are really on the front lines and seeing what's going on.

And then, finally, just don't waste any time. In this day and age, unfortunately, there are so many ways that organizations are losing revenue. And so you just don't want to waste any time. As soon as you identify that there could be a problem, dive in, take a look, put processes in place. Be very intentional and smart. We want to make sure that it's actually going to fix the problem and not create more problems to prevent it from being recurring.

Host: Just a great list, an easy way to start on this process. Number one, you talked about denials, look for the root causes, and you said now there's tech to help with that. So, that's good news, because you said it was really laborious to do this before.

Listening to your teams, it's always a great idea. They're on the front lines. They're the ones that'll say, "Hey, I found this," or "I know this," or "How about this?" So, another great idea. And then, don't waste time. Like you said, be very intentional. So, really good steps. If you think you're losing revenue, this is how you should start to investigate and correct the issue.

Vanessa, this has been great and really informative. Thank you so much for your time today. We really appreciate it.

Vanessa Moldovan: Absolutely. Thank you for having me on. It was great.

Host: Once again, that is Vanessa Moldovan.

And to learn more, you can visit AAOMS.org/codingbilling – codingbilling is one word – AAOMS.org/codingbilling.

And if you enjoyed this podcast, please share it on your social media and make sure you subscribe so you don't miss an episode. I'm Bill Klaproth. This is AAOMS On the Go. Thanks for listening.