Data Validation Edits and Where They Should Live in your Revenue Cycle

By March 20, 2019 March 29th, 2019 Healthcare

The collection of accurate data prior-to, at-the-point-of, and after service is key to getting your claims paid the first time it is submitted to the payer. This is no revelation, and everyone knows the importance of a high “Clean Claim Rate.” It is evident in efforts most hospitals put in staff training, especially in registration departments and on nursing floors. Training is great! Your staff should know what’s important, when the data should be collected, and that they have the contextual prowess to recognize bad data. But, training can only take you so far. At some point, the staff will make mistakes, and this is where Data Validation Edits (DVE’s) come in.

As a rule, DVEs should live as close to the point-of-data entry as possible. The quicker the issue is identified, the more options you will have to evade a denial. Depending on where and when the data is entered, dictates the type of edit which can be used.

Listed below are five types of DVEs:

  1. Attributes Edits: These are triggered instantaneously —as soon as the data is keyed incorrectly or a “required” field is skipped. When applicable, this is the most effective edit, and it requires a staff member to enter the correct data before he/she can continue their process. Examples of this include: a patient’s DOB, city, state, or zip code.
  2. Encoder: This is your next option for DVEs. Most encoders provide an excellent opportunity to identify potential denials and focus on procedure level data, as well as the patient’s diagnosis. The encoder has many payer-specific rules that generate warnings and “hard stop” edits. This is a great place to validate data because the billing process hasn’t yet been finalized.
  3. DNFB Edits: These edits live in DNFB (discharged but not final billed) and are invoked after the patient has been abstracted, and the coding has been completed. Accounts that fail edits for DNFB are easier to change because they are not final billed. Once billing processes are final, data cannot be changed without reversing the bill—this is a good time in the billing process to develop a revenue cycle team. Most systems support DNFB work-lists that can be distributed to key revenue cycle departments, scheduling, registration, coding, and patient accounting.
  4. Claim Checks: These types of edits are challenging to manage because they are only available to billing staff. Data entry issues can be created anywhere in the organization; but claim checks are typically a restricted function of the billing staff requiring them to send a manual notification to the department where the data was entered. Edits that live here should be relentlessly evaluated for converting to a DNFB edit. Most claim checks can be programmed into DNFB edits if the system allows, or vendor support is available.
  5. Clearinghouse Edits: Accounts that fail edits here should be evaluated for the root cause quickly. You do not want your accounts to be stuck in your clearinghouse system. When the account fails into your clearinghouse, most times, it is either resolved by the biller or requires input from another department before it’s considered fixed. Workflows around your clearinghouse need to be tight, otherwise, you may have aging accounts receivables that are not being tallied by your EMR. Always try to leverage your clearinghouse edit logic to develop your own edit that lives in your encoder, DNFB, or even as a claim check. Allowing clearinghouse edits to fail poses a risk to maintaining your EMRs financial integrity.

Use This Information to Audit Your DVEs

Evaluate your edits to determine if they can be moved up in your revenue cycle. Efficiency will be gained every time you can move an edit from your clearinghouse to your claim checks or a claim check to your DNFB. Timing equals options in system functions, and the earlier in the revenue cycle you can identify invalid data the more options you’ll have to get it corrected before it becomes a denial.

For more information related to DVEs or to have your revenue cycle audited for optimal efficiency, please contact Tim Bavosi at (508) 561-1822 or by email at tbavosi@revspringinc.com.

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