Mid Revenue Cycle - Complete Guide to Smarter Operations

Organizations often focus most of their attention on patient registration and claims management to reduce revenue leakage.

It’s a common pitfall in revenue cycle management, as the main source of preventable revenue loss happens after the patient leaves the front desk and before the claim is submitted. Therefore, mid-revenue cycle management should be a higher priority.

This post explains what the mid-revenue cycle is and offers strategies to strengthen it and improve revenue performance.

What is Mid Revenue Cycle and Why is It Important?

The mid-revenue cycle includes the processes that occur between care delivery and claim submission. It includes revenue cycle activities ranging from clinical documentation to ensuring claims are compliant.

Streamlining these processes is valuable for the following reasons:

• Reimbursement accuracy: Optimized documentation and coding help you tell the clinical story completely and accurately, ensuring you can be reimbursed for all care services delivered.

• Lower compliance risk: Effective mid-revenue cycle processes help you avoid significant documentation and coding errors, reducing the risk of invasive audits and financial penalties.

• Denial prevention: A streamlined mid-revenue cycle helps prevent avoidable denials, a far better strategy than waiting to appeal rejections.

Core Tasks That Shape Mid Revenue Cycle

You should treat the mid-revenue cycle as a structured workflow that begins at the point of patient encounter and continues through to ensuring claim readiness.

Generally, you should prioritize the following key tasks:

• Capturing clinical documentation: Involves translating your patient encounters into a clinical record. Because clinical specificity is required, you must detail the patient’s condition acuity and complexity, as well as the procedures/services rendered.

• Charge capture: It ensures that what your team has done is accounted for financially. You’ll capture procedures/services, Evaluation and Management (E/M) levels, supplies/medications, facility and professional charges, and time-based services.

• Medical coding: Using the above data as raw material, record diagnoses/conditions with ICD-10 codes, procedures/services with CPT codes, and supplies and medications with HCPCS codes.

• Clinical validation: It helps you confirm if the above narrative makes sense clinically. For instance, do the symptoms and labs align with the diagnosis? You can use automated “scrubbing” tools for this process.

• Utilization review: It helps you stay compliant with payor and regulatory requirements by ensuring that the services you provided were medically necessary. You also want to ensure that services are provided in the appropriate setting.

Common Mid-Revenue Cycle Leakage Points

Because mid-revenue cycle errors are hard to correct once they reach the billing stage, you can use the 5 tasks above as checkpoints to address discrepancies that may lead to revenue losses later.

These discrepancies typically arise due to the following gaps:

• Documentation gaps: When your documentation is incomplete or lacks specificity, everything downstream becomes less accurate. A lack of specificity (e.g., “heart failure” without specifying acuity or type) may cause undercoding, increased queries, and denied claims.

• Charge capture gaps: Charge capture issues lead to missed billable services. If a service you deliver isn’t captured entirely, it’s basically an invisible revenue loss, as you won’t even send a claim for it.

• Inaccurate coding: There’s a risk of undercoding or overcoding. Undercoding leads to missed reimbursements as you won’t capture the full extent of services delivered, while overcoding exposes you to compliance risk.

To avoid these gaps, you should streamline workflows by reducing manual processes that increase the risk of human error. Advances in healthcare technology now make implementing such workflows possible without massive capital outlays.

At DeliverHealth, we offer the following cost-effective AI-powered solutions that can help you implement seamless documentation-to-coding workflows:

• InstaNote: An AI documentation solution that listens to your patient encounters and generates accurate clinical notes instantly in your preferred format. It supports both ambient and dictation workflows and includes coding suggestions.

• InstaCode: An AI-driven solution to support seamless documentation-to-coding workflows and scale coding capacity without scaling cost.

You can deploy either InstaNote or InstaCode as a standalone solution, or combine them to create end-to-end workflows that reduce revenue leakage at source.

Schedule a demo today to see how AI-powered solutions can fit your existing clinical and revenue cycle operations.

Clinical Documentation Improvement (CDI) Optimization Strategies

As we’ve discussed, you can significantly reduce downstream denial risk by improving documentation quality.

Let’s now explore some of the CDI optimization strategies you can implement in your healthcare organization:

• Real-time intervention: The traditional approach is to use retrospective CDI, where you review charts after discharge. The better strategy is real-time intervention, where you use concurrent CDI to review documentation while the patient is still receiving care. It can help you spot mid-revenue-cycle issues early, when they are still fixable.

• Standardized query processes: You want to standardize queries by using consistent query formats and workflows and by clearly defining triggers. It’s important because ad hoc query processes are error-prone and may be difficult to interpret.

Consider embracing artificial intelligence technology as a strategy to improve documentation quality, as it can now help you spot gaps in real-time.

One of the benefits of AI-driven documentation solutions is decision support tools, which can request more specificity or make suggestions. For instance, InstaNote can surface coding suggestions after you complete a note.

Technology Solutions for Mid-Revenue Cycle Management

Aside from decision support tools for documentation and coding, artificial intelligence and other adjacent technologies have wide applications in the mid-revenue cycle.

You can capitalize on these benefits by implementing the following solutions:

Autonomous Coding Engines

It’s the next step beyond traditional coding support tools, using advanced AI to automatically assign codes directly from the documentation you’ve created.

You’ll need a reliable way to interface with such an engine, and we recommend InstaCode.

InstaCode runs on the PerformPlatform, which is the industry’s leading autonomous coding engine. It can help your team to scale coding quickly while reducing denial rates.

Revenue Integrity Platforms

When you want a system that sits across the entire mid-revenue cycle to ensure you accurately capture, code, and validate all services, you can use a revenue integrity platform.

Depending on the features offered, such a solution can help you with the following tasks:

• Reconciling charge captures

• Monitoring and ensuring compliance

• Validating documentation and coding

• Orchestrating workflows, such as routing tasks

• Scrubbing claims to detect missing data, incorrect codes, and payor-specific demands

Key Performance Indicators for Mid Revenue Cycle

So, how can you tell whether the mid-revenue cycle strategies we’ve discussed are working when you implement them?

Consider using the following key measures to gauge performance:

• Query response rate: It represents the percentage of queries you generate that receive a provider response within a given timeframe. You want a high query response rate since it indicates lower documentation gaps, undercoding, and missed diagnoses that lead to more accurate reimbursement.

• Missed charges rate: It represents the percentage of billable services you provided that were not captured. You want a lower missed-charge rate, as uncaptured services are unbillable, leading to revenue losses.

• Coding turnaround time: It represents how long it takes you to move the encounter from discharge to final coding. You want a faster turnaround time because it helps you submit claims more quickly, thereby accelerating revenue realization.

• Denial rate: You can have denial rates tied to documentation and/or coding. For both, it represents the percentage of claims rejected by payors. You want it to be lower, as it is best to be paid on the first attempt.

How to Audit and Strengthen Mid Revenue Cycle Over Time

Tracking the KPIs above provides a clear framework for identifying gaps and continuously strengthening your mid-revenue cycle.

Nonetheless, there are systemic issues that may only be solved with a deeper audit as follows:

• The root cause analysis: Instead of treating each denial as an isolated event, use root-cause analysis to identify the reasons for consistent failures. You can conduct such an audit by reviewing multiple cases, looking for patterns, and checking whether the same issue repeats across them. If it repeats, it is likely the root cause and should be resolved.

• The external audit: In some instances, a third party can identify issues you may overlook because of your/your team’s systemic bias. The audit should look into all relevant revenue cycle operations, including documentation, charge capture, and coding. You can hire an independent consulting firm or a compliance specialist for such an audit.

Frequently Asked Questions (FAQs)

Let’s now answer some commonly asked questions about the mid-revenue cycle:

How Does Mid-Revenue Cycle Affect Claim Denials?

The mid-revenue cycle includes charge capture, documentation, coding, and utilization review.

These processes impact clinical integrity, which helps determine whether a claim denial is reversible.

Who Owns Mid Revenue Cycle in a Healthcare Organization?

Your clinical and financial/accounting team should share responsibility for the mid-revenue cycle.

That said, you want to designate individuals who can be accountable for strategy and daily operations, such as a Director of Health Information Management and a Director of Clinical Documentation Improvement.

What Is the Difference Between Front-End, Mid-End, and Back-End Revenue Cycle?

The differences lie in where they fall in the revenue cycle and the activities they handle. The key activities break down as follows:

• Front-end revenue cycle: Patient scheduling and registration, insurance eligibility verification, and prior authorizations.

• Mid-revenue cycle: Clinical documentation improvement, charge capture, medical coding, and utilization review.

• Back-end revenue cycle: Claims submission, payment posting, denial management, and patient collections.

Conclusion

Ultimately, smart mid-revenue cycle operations boil down to your ability to turn clinical documentation into accurate, timely reimbursement.

It requires you to install systems for resolving documentation gaps and coding inefficiencies. You can do this without disrupting your existing workflows.

At DeliverHealth, we offer AI-powered documentation and coding solutions that you can easily adapt to your clinical and revenue cycle operations. InstaNote can help you write clinical notes instantly during patient encounters, while InstaCode supports seamless documentation-to-code workflows.

Explore our AI-driven solutions to see how they can help you optimize the mid-revenue cycle while reducing your documentation time by up to 75%.