This is part 3 of our Moneyball for Acute and Post-Acute Care. We hope you have enjoyed part 1 and part 2 so far.

Risk-Adjusted Readmission

If patients are being readmitted to your facility in less than 30 days, you need to know why. What are the driving factors and what does this do to your outcomes and sustainability?

  1. Are you accepting individuals with such high acuity that you are not able to maintain clinical stability or take care of their clinical needs in your facility, and thus send them out to other providers? Being able to slice and dice the information can be the difference between sustainability and financial challenges – both of which will impact your ability to discharge people back into the community with positive outcomes.
  2. Are you struggling with pre-authorizations and trying to discharge patients before they are ready? Have you established a step-down program and justified it within your payor contracts? Typically, payors will expect more documentation for such programs, so enabling your Utilization Management and Case Management teams to collect and defend these types of clinical denials is imperative. The Hospital Readmissions Reduction Program currently only focuses on the following procedures, but expect the scope to expand:
  3. Acute Myocardial Infarction
  4. Chronic Obstructive Pulmonary Disease
  5. Heart Failure
  6. Pneumonia
  7. Coronary Artery Bypass Graft Surgery
  8. Elective Primary Total Hip Arthroplasty and/or Total Knee Arthroplasty

It matters more now

With the increase in need for transparency comes a greater need to organize your data into meaningful, readable information. As the care setting expands, and we follow up facility-based care with home outreach and telemedicine, tightly controlling process from a central business operation is important.  You need tools to manage this, and support to help move you into the new paradigm.

Imagine a new type of denial based on going over a posted price. What about a new reimbursement based on complying with patient requests for information? These are not a stretch from where we are today, and we need to be ready to tackle these.

Transparency starts with knowing your business. Do you have the right tools to understand why you are paid the way you are? What your costs are? How you should negotiate with private payers? What a change in reimbursement will do to your bottom line?


Understanding the key data points and how to turn them to information you need can be the difference between just surviving or building a long-term sustainable business. More importantly, it can make the difference in your patient outcomes.

The most significant data you have comes during the preadmission assessment, and during the delivery of care. Failure to understand and utilize the information can generate a host of healthcare and financial difficulties. Providers who lack the full picture run the risk of negative outcomes, poor survey results or ratings, and financial hardship.

Use your data wisely and elevate your organization to major-league status: one with excellent outcomes, HEDIS ratings, all-star Press Gainey survey results, and sustained financial success. Want more in-depth information? Download the full white paper.

Almost one-quarter of US healthcare facilities have not yet implemented a full-fledged revenue cycle management solution. We are excited to help hospitals achieve long-term success through our award-winning Optimum RCM solution. Revenue Cycle Management (RCM) refers to the process of identifying, collecting, and managing a facility’s revenue from payers based on the services provided. A successful RCM process is essential for a healthcare practice to maintain financial viability and continue to provide quality care for their patients. In essence, your RCM should optimize collection strategies, decrease revenue leakage, and implement time-saving automation

Optimum RCM is a single, yet robust, financial suite for health systems to reduce operational expenses while increasing operational revenue. Simplify the business of healthcare with a platform that seamlessly integrates with EHRs, includes a multitude of services; incorporates cost accounting, materials management, general ledger, predictive analytics, claims processing, and more. To learn more about Optimum RCM, fill out the form on the right.




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