With seemingly constant changes in the areas of technology, regulations, and reimbursement-to name only a few-providers are constantly required to modify processes to ensure both efficiency and effectiveness. Amidst this turmoil, high-performing revenue cycle hospitals attempt to go the extra mile by creating patient-friendly processes aimed at improving the overall patient experience.

Enhancing the patient experience requires that hospital revenue cycle leadership and staff be simultaneously inquisitive, responsive, innovative, and flexible. High-performing revenue cycle hospitals have and continue to make tangible improvements to their revenue cycle processes. Although there is no set formula for making improvements, many hospitals are refining processes in similar ways.

High performers generally use formalized structures to obtain stakeholder input, target improvement efforts around those areas of the revenue cycle with greatest effect on the consumer's experience, and rely on widely recognized improvement methodologies as a means to examine and redesign processes.

Using formal structures to obtain stakeholder input

Most executives with high-performing revenue cycles have very specific ways they leverage relationships, focusing at the organization, consumer, physician, and payer levels around process improvement needs.


Typically, hospitals and health systems with high-performing revenue cycles rely on two types of teams to address process improvements. The first type is a team that performs oversight functions. Members monitor and evaluate key financial and revenue cycle metrics, with an emphasis on identifying trends and developing overall strategies for improvement. Typically this team is led by the CFO or a senior revenue cycle executive and includes directors or managers from the key revenue cycle departments, such as scheduling, registration, financial counseling, billing, and customer service. The team typically meets at least once per month.

The second type of team is project based. These teams focus on a specific area of the revenue cycle or are specially created to address a particular issue or task, such as managing response to a new software implementation. Regardless of whether the project-based team meets routinely or on a temporary basis, it generally includes participants from financial service areas as well as IT, physician relations, regulatory compliance, and/or clinical departments. Most high performers also have periodic mechanisms in place for soliciting employee input or feedback into processes.

Research shows high performers tend to have fewer overall revenue cycle meetings, but more meetings targeted on specific issues than other organizations.

Case Study: Revenue Cycle Leadership Structure at Spectrum Health Grand Rapids

Exhibit: Research Finding: Revenue Cycle Teams: Design and Meeting Frequency


It may not come as much of a surprise that high performers rely on formal processes for soliciting consumer feedback around process improvements. After all, hospitals frequently use focus groups to assist in setting strategic direction, enhancing services, and gauging community perceptions of the organization and its programs.

What is notable is the frequency and depth to which individual organizations involve patients in their revenue cycle activities. High performers often use focus groups when attempting to create more consumer-friendly bills. Typically, patient focus groups will be convened to provide input at the time that the initial bill redesign begins as well as throughout various stages of the improvement process. Ultimately, "approval" of focus groups is often sought regarding final design edits.

Although many focus groups, such as those involved in bill redesign, tend to be temporary and project-specific, some high-performing revenue cycle hospitals have established patient advisory groups on an ongoing basis to assist in a variety of areas, including revenue cycle.

Case Study: Patient Advisory Councils at Spectrum Health Grand Rapids

Exhibit: Research Finding: Use of Patient Focus Groups


To make the most of revenue cycle relationships with physicians, high performers make communication a high priority. They typically collaborate on the content of patient scheduling forms and surrounding processes to support consistent expectations around the gathering of patient insurance and clinical information. They also routinely solicit feedback from physicians and their office staff to ensure that their needs are being met.

As one example, when high-performing Iowa-based Henry County Health Center redesigned its business processes, it worked closely with its community physicians. The organization sought input from physicians regarding changes to the hospital admitting and registration processes, and it worked with them to develop similar policies around discounting services and charity care. Most important, Henry County Health Center kept physicians informed of how process changes would affect their patients. This collaboration has been integral to the revenue cycle enhancements.

Some organizations view revenue cycle and physician relations as so important to success that they have even developed systems to support integration within their organizational structure.

At HCA's Redmond Regional Medical Center, a high-performing 230-bed acute care facility located in Rome, Ga., relations are supported through employment of a physician development representative. As a liaison between the hospital and its physicians, the physician development representative carries responsibility for routinely visiting physicians and their staffs to assist with any revenue-cycle-related problems that may be occurring. Issues may include difficulties associated with scheduling patient appointments or the timeliness or accuracy of either party when sharing patient financial or clinical information.

At least quarterly, the physician development representative, accompanied by representatives from Redmond Regional Medical Center's scheduling/ registration department and HCA's regional customer service center, holds physician luncheons. At these get-togethers, physician office staff and hospital personnel discuss issues and concerns and brainstorm potential solutions. If not solved immediately, problems identified are addressed on an ongoing basis.

Case Study: Physician Dynamics Support Seamless Patient Experience at Geisinger


High performers are more likely to routinely communicate with payers about payment issues or technology processes than others. During site visits, all of the high performers told interviewers that they routinely engage in scheduled and impromptu communications with their largest payers, whether by phone or in person.

The focus of these conversations typically is on ways to reduce the number and causes of payment denials. Frequently these exchanges are either led by or include the executive in charge of managed care contracting, and are supported by revenue cycle personnel who can provide the necessary data and, in some cases, clinical staff.

Some of the high-performing hospitals also work collaboratively with insurers to electronically exchange data, thereby enhancing both the timeliness and quality of shared information and reducing impediments for payment. Clearly, much is being done to improve interfaces between hospitals and insurers.

That said, many of those interviewed at the high-performing revenue cycle hospitals indicated that insurers generally are more interested in transaction flow issues than consumer-focused practices. Several high performers reported success in getting payer attention to these areas only after locating the right party willing to engage in these discussions.

Regardless of the type of issue being discussed, high performers generally attributed their successful relationships with payers to such factors as frequent communication, a collegial mind-set, and staff willingness to view issues from the insurer's perspective.

Case Study: Redmond Collaborates with Insurers

Exhibit: Research Finding: Collaboration with Payers

Targeting improvements around those revenue cycle areas most affecting the consumer's experience

High performers generally have focused their improvement efforts on such areas as front-end processes, point-of-service collections, and charity care.

Front-end processes

First impressions matter. As such, many providers, including the high-performing revenue cycle hospitals, are recognizing that patient satisfaction and understanding of payment obligations is enhanced when increased emphasis is placed on improving front-end processes. This front-end focus includes:

  • Emphasizing scripting for patient interactions to support clarity, consistency, and completeness of communication
  • Increasing training and continuing education of front-end staff
  • Upgrading front-end personnel requirements
  • Enhancing pay scales and/or implementing incentive programs for schedulers, registrars, and financial counselors
  • Developing integrated revenue cycle processes and teams that include both front-end and back-end personnel to enhance communication and continuity
  • Streamlining scheduling processes to reduce the number of persons with whom a patient, patient's family, or physician office staff must communicate
  • Introducing or upgrading technology to better serve front-end processes, including software related to address and/or insurance verification

Research shows high performers are much more likely than other hospitals to have made significant changes in registration, admitting, and financial counseling. It's also interesting to note that a high percentage believes investments in front-end technology and software have provided greatest financial return.

Exhibit: Research Finding: Relative Performance of Investments in Terms of Financial Return

Exhibit: Research Finding: Comparative Level of Improvement Efforts

Point-of-service communications and collections

Along with this front-end focus, most high performers are educating their patients about what their insurance covers as well as the meaning and amount of copayments, deductibles, and coinsurance. High performers accomplish this by conducting insurance verification on most procedures prior to services being rendered. Such efforts aid collection at the point of service.

The focus is on providing patients with cost estimates at the time of scheduling or preregistration and improving clarity of communications regarding payment expectations and processes. In addition, front-end personnel are being provided with significant training and scripting to alleviate any potential discomfort associated with seeking payments from patients.

Although most hospitals seek to collect patient copayments (and, in a few cases, deductibles) up front, the rigor associated with these efforts does vary by organization. Some hospitals will seek to postpone elective procedures in instances where patients do not provide payment, but most remain relatively flexible.

Regardless of methodology or process, almost all of the high-performing hospitals have indicated that they have experienced improved point-of-service collections and that, in almost all cases, patients are surprisingly amiable to such efforts.

Case Study: Improving Patient Payment at Oaklawn Hospital

Exhibit: Research Finding: Relative Use of Point-of-Service Collection

Charity care and financial counseling

Another key focus for many high performers has been updating charity care practices. Over the past few years, virtually all of the organizations visited have modified their charity care policies and financial counseling processes.

Most high performers are attempting to more openly communicate the availability of charity care through actions such as providing brochures at registration, posting policies on their web sites, and including language referencing availability of charity care on patient bills. Also, some organizations are empowering patient access staff to identify potential recipients and administer the charity care policies.

In addition, high-performing revenue cycle hospitals generally have sought to enhance financial counseling capabilities within their organizations. Many hospitals are improving the pay, training, and scripting that they provide to financial counselors. Further, many organizations with high levels of self-pay activity or a high Medicaid population are supporting onsite availability of state and/or other third-party personnel to assist patients with applying for Medicaid, payment arrangements, or other types of funding.

Charity Care as a Community Benefit Commitment

HFMA views charity care as a community benefit commitment. In 2009, HFMA's Principles and Practices Board created "Sample Hospital Charity Care and Procedures." The document serves to help hospitals establish their own policies and procedures for offering charity care to their patients.
Learn more.

Adopting formal process improvement methodologies

Regardless of the particular process areas they select for improvement, high performers generally rely on proven redesign methodologies to support these efforts.

Typically, these methodologies consist of bringing together temporary, high-performing teams to examine, measure, and improve on current processes. Team composition may include revenue cycle staff, nonrevenue cycle business staff, clinicians, and process engineers. Some of the common methodologies used by high performers are Lean, Six Sigma, and Kaizen.

No common methodology is used among all high performers. In fact, in several instances, high performers even looked toward improvement approaches common to other industries but not traditionally employed in health care. Perhaps, as one revenue cycle leader noted, "The simple fact of creating a framework and a high level of rigor around process measurement and redesign is what is important."

Case Study: A Fresh Perspective on Performance Improvement at CHRISTUS St. John

Exhibit: Research Finding: Use of Process Improvement Teams

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Publication Date: Thursday, November 05, 2009