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At a GlanceTo be effective, a professional fee billing operation requires the following elements:
The recent frenzy of physician practice acquisitions has created a sense of urgency for hospitals and health systems to complete these transactions quickly to remain competitive. As a result, these organizations have often focused their initial attention on negotiating contract terms, drafting legal documents, conducting asset appraisals, and assigning vendor contracts while deferring considerations on how to manage the revenue cycle aspects of physician practices.
Organizations that do not engage in thoughtful preliminary planning regarding revenue cycle operating standards for physician practices, however, can find themselves with a mixed bag of acquired practices that are both difficult to manage and unprofitable. In particular, inadequate planning and preparation can lead to poor performance in physician billing operations, as reflected in cash collections that are lower than desired, high accounts receivable balances, frequent write-offs, and patient and physician dissatisfaction. Such performance can necessitate major investments to right the physician revenue cycle ship.
Hospitals and health systems should take key action steps in the early stages of building a physician enterprise to ensure six essential elements of a well-run professional fee billing operation are securely in place.
As a health system’s physician enterprise expands to include more practices across a variety of specialties and locations, the complexity of the billing operation increases significantly. This environment, in turn, requires a revenue cycle director with a level of management skill and sophistication typically not found in smaller, independent physician practices, where billing managers (assuming a dedicated billing manager even exists) may have little or no formal training or experience in larger organizations. In an era of reform, several areas related to physician revenue cycle operations require new skills. For example, a health system’s physician practice revenue cycle director should be able to:
The person who performs these duties should be much more than an effective manager of the physician billing shop; he or she should be a leader whose opinion is sought and respected by physicians, peers, and executives. Without effective leadership from the revenue cycle director, it will be much more difficult to establish any of the other essential elements described herein.
Unfortunately, revenue cycle management is often a thankless role with an unclear career path and therefore does not always attract top talent. Consequently, as physician practices are rapidly consolidated under hospital or health system ownership, the demand for people with the requisite skills is almost certain to exceed the supply, and it will be common to find revenue cycle managers (and even directors) who struggle to see the way forward for their operation.
In an effective revenue cycle operation, activities are organized in a way that ensures the right skills are available where they are needed while allowing for effective oversight. Among the most important decisions are those addressing questions of centralization versus decentralization and insourcing versus outsourcing.
Centralization versus decentralization. If the acquisition is an early one and the hospital has never handled professional fee billing for physicians, decentralized billing operations—in which the practice sites continue with their legacy billing systems under a single tax ID—may be appropriate. Decentralized billing also may be warranted, at least in the near term, when the organization takes on a practice whose billers have specialty-specific expertise that does not exist elsewhere in the organization.
However, as the organization grows, so does the need for a centralized and functionally organized billing office to ensure each task is addressed and economies of scale are achieved. A centralized approach can promote increased expertise within the organization as a whole, reduce errors, provide flexibility for new payment methodologies, and minimize exposure to compliance issues.
Most organizations find success in deploying a hybrid strategy that leverages economies of scale while simultaneously locating functional responsibilities where they can be performed most efficiently, as is shown, for example, in exhibit 1.
The rationale for a hybrid model is that revenue cycle performance typically improves when all billing functions follow common guiding principles, which is most easily accomplished when these functions and the staff who perform them are managed as part of a single team. In a hybrid model, functions that do not require face-to-face patient or physician interaction are centralized, while locally managed clinical support staff are still expected to adhere to common revenue cycle policy. This reporting relationship ensures that financial matters do not become a secondary priority, particularly among staff who have other patient-facing duties, such as check-in.
Hospital-based organizations are often tempted to centralize operations further by merging back-office functions for facility and professional fee billing operations. Although this type of consolidation can be accomplished successfully within the customer service and patient collections functions, consolidation beyond those functions should generally be avoided. Professional and hospital billing operations are in some ways similar, but they are sufficiently specialized that billing staff rarely have the skills required to perform both effectively. More important, due to its high-volume and low-dollar nature, professional fee billing would almost certainly take a backseat to hospital billing if the two operations are commingled.
Insourcing versus outsourcing. Healthcare organizations that outsource portions of their revenue cycle operations typically do so to access advanced practice management capabilities more quickly or more economically than they could if they developed the operations on their own. When deciding whether outsourcing the revenue cycle is appropriate, organizations should consider three factors:
If two or more of these factors display significant weaknesses that cannot be strengthened quickly, then outsourcing may be the best option. Health systems also would have good reason to consider outsourcing the revenue cycle if the current in-house costs are higher than benchmarks or if collections percentages have deteriorated.
Nonetheless, outsourced billing is by no means a panacea, and the buyer should proceed with caution when selecting a billing agency. One of the most common misperceptions about outsourcing the billing operation is that it provides a turnkey solution requiring little involvement from the clinic or health system staff. Although less hands-on involvement is needed when the billing operation is outsourced (e.g., for staff recruiting and training), the requirement does not go away altogether, and the relationship with the billing agency demands ongoing attention.
Moreover, most billing agencies are paid a percentage of collections—an approach that would appear to align incentives, but may not always work in practice. Because the billing company keeps only a small fraction of what it collects, claims that are difficult to collect are actually money losers for the billing company, so the company has an incentive to write them off rather than make an effort for a small and uncertain return. Given these considerations, no healthcare organization should outsource billing functions without first having negotiated a sound, performance-driven contract that holds the vendor accountable.
The impact that IT decisions can have on the revenue cycle is also important to consider. Allowing acquired practices to continue using their existing practice management systems may be necessary in the short term, but this situation can quickly go awry. Maintaining disparate systems challenges economies of scale and the ability to monitor performance across multiple practices and promptly identify problems in the revenue cycle. The most effective approach is to transition all acquired practices to a single practice management system that facilitates, provides, or enables the following:
Maintaining a single system also enables an organization to efficiently navigate (or at least prepare for) the changing regulatory environment under the Affordable Care Act and other recent healthcare legislation. By contrast, implementing necessary regulatory changes across multiple platforms could pose a daunting challenge.
A key advantage of a large coordinated revenue cycle model is that it enables the division of labor and specialization of skills to a degree that is not possible at a smaller scale. For organizations to realize this benefit, they must carefully manage productivity, backlogs, processing time, and error rates. This point is true not only for the billing office but also for the clinics themselves.
Clinics should be held responsible for certain tasks, such as those shown in the top exhibit at right. Moreover, when possible, edits and denials related to front-office errors should be routed back to the clinic for resolution. Although this process may increase the lag time for correction, it ensures that the clinic staff know about their errors and resolve them, rather than becoming lax because “someone will fix it on the back end.”
Similarly, appropriate standards and controls should be established for billing office staff. Establishing and enforcing productivity standards is among the most important management steps for physician billing office managers, yet it also is all too commonly overlooked. Standards are needed not only to ensure that workers are being fully engaged, but also to aid in personnel planning. Without productivity standards, there is no rational basis for determining how many staff members are needed and when to hire, other than a general notion that “everybody’s really busy.” Examples of controls that can be used in managing the back-end process are shown in exhibit 3.
In general, it is best to implement two to four key control measures for each function. Because these controls are so data-driven, they require a fairly sophisticated reporting and analytical infrastructure. Unfortunately, most practice management systems still do not have robust reporting capabilities, necessitating the implementation of “bolt on” business intelligence tools or the extensive use of spreadsheets to manage data. This issue is further confounded if the practice uses multiple systems.
A major challenge in running an effective revenue cycle operation is in engaging leaders throughout the organization in their roles regarding the revenue cycle. This effort requires periodic management reviews whereby leaders can track revenue cycle performance and identify where errors are originating and what is being done about them.
It also requires an effective reporting and analytical infrastructure to ensure that these review sessions are effective. The revenue cycle director’s leadership in facilitating these sessions also is essential.
The professional fee coding process is no easy task: More than 7,500 CPT codes and 13,000 ICD 9 diagnosis codes are currently available, and myriad complex payer and regulatory guidelines must be followed. This complexity will only be exacerbated with the transition to ICD-10 in October 2014. Moreover, physician practices use a wide array of resources and processes to complete this work; some groups require physicians to select codes via an EHR or encounter form, while others use support staff to abstract directly from the medical record.
Each approach has its benefits and limitations. In short, the “tug-of-war” that occurs as a result of trying to maximize revenue without crossing any compliance boundaries—while simultaneously trying to manage overall billing costs—can be daunting. Finance leaders are familiar with many of the challenges, as inadequate attention to coding has always tended to have costly repercussions, such as an increased billing lag and unnecessary denials. Yet new challenges have also been introduced with recent focus of the U.S. Office of Inspector General on evaluation and management coding, which signals the likelihood of greater scrutiny on physician billing in the ambulatory setting, thereby adding the high costs for audits and recoupment to the list.
Experience shows that better-performing organizations maintain coding programs that are designed to balance regulatory compliance with revenue maximization and take several key attributes into consideration, such as those shown in exhibit 4. In short, they make sure the documentation for each visit supports the coding submitted for payment.
Appropriate investment in coding and compliance (whether internally developed or outsourced) will ensure that the charge submission process is efficient, claims are billed and adjudicated appropriately, and risk and subsequent expense are mitigated. These enhancements also will improve patient and provider satisfaction.
Oct. 1, 2014, marks the compliance date for ICD-10. Given that professional fee reimbursement tends to be driven by CPT codes rather than than by diagnoses, many in the industry tend to underestimate the effect that ICD-10 will have on physician practices. However, accurate diagnosis coding is still a fundamental component of the physician billing process, and the transition to ICD-10 could significantly affect short- and long-term cash flow and overhead costs if not addressed appropriately.
by diagnoses, many in the industry tend to underestimate the effect that ICD-10 will have on physician practices. However, accurate diagnosis coding is still a fundamental component of the physician billing process, and the transition to ICD-10 could significantly affect short- and long-term cash flow and overhead costs if not addressed appropriately.
The American Medical Association has voiced objections to the 2014 implementation date, based on estimates that implementing ICD-10 will cost physician practices up to $80,000 per physician.a Implementation costs include the cost of training, business process analysis, IT system upgrades, increased documentation, and cash flow disruption. Some considerations—such as whether a practice’s IT systems, vendors, clearinghouse, and payers will be able to support ICD-10—are well understood by administrators. But it also is critical for administrators to acknowledge less obvious effects, such as the impact that increased documentation standards are likely to have on physician productivity, particularly at the outset, and the subsequent impact on revenue and physician compensation plans driven by volume metrics.
In short, key considerations for establishing an ICD-10 implementation plan include the following:
Despite being given a three-year reprieve on implementation, many organizations—particularly small physician practices—have not made progress on their ICD-10 transition plans. There is no room for further delays: Preparing for the change to ICD-10 now is essential for creating a smooth transition.
Health systems that acquire physician practices often underestimate not only the challenges of developing an effective professional fee revenue cycle process, but also the consequences of not doing it right. Developing an effective physician practice revenue cycle requires sophisticated leadership skills, including strategic vision, organizational design, management discipline, and infrastructure development. Most important, developing a smoothly functioning revenue cycle process can have a profoundly positive impact on the bottom line of the organization. It therefore is well worth the time and attention it requires—not just after a practice acquisition has been finalized, but from the very start of the process.
Benjamin C. Colton is senior manager, ECG Management Consultants, Inc., Seattle.
David A. Wofford is senior manager, ECG Management Consultants, Inc., San Diego.
a. Bresnick, J., “AMA Continues Protest Against ICD-10 Implementation,” EHR Intelligence, Nov. 14, 2012.
Publication Date: Sunday, September 01, 2013
In this business profile, Amy Gross, senior vice president of Key Government Finance, discusses the benefits of private placement transactions to support large-scale financing projects.
Patient financial engagement is more challenging than ever – and more critical. With patient responsibility as a percentage of revenue on the rise, providers have seen their billing-related costs and accounts receivable levels increase. If increasing collection yield and reducing costs are a priority for your organization, the metrics outlined in this presentation will provide the framework you need to understand what’s working and what’s not, in order to guide your overall patient financial engagement initiatives and optimize results.
In this business profile, Doug Polasky, executive vice president at Xtend Healthcare, explains the importance of having sound workflow processes in a consolidated business office to ensure optimal performance and reduce costs.
No two patients are the same. Each has a very personal healthcare experience, and each has distinct financial needs and preferences that have an impact on how, when and if they chose to pay their healthcare bill. It’s no longer effective to apply static billing techniques to solve the complex challenge of collecting balances from patients. The need to tailor financial conversations and payment options to individual needs and preferences is critical. This presentation provides 10 recommendations that will not only help you improve payment performance through a more tailored approach, but take control of rising collection costs.
TriMedx helps health systems control costs and uncover savings opportunities by optimizing the clinical engineering function.
This white paper, written by Apex Vice President of Solutions and Services, Carrie Romandine, discusses the importance of patient segmentation and messaging specifically related to the patient revenue cycle. Applying strategic messaging that is tailored to each patient type will not only better educate consumers on payment options specific to their billing needs, but it will maximize the amount collected before sending to collections. Further, targeted messaging should be applied across all points of patient interaction (i.e. point of service, customer service, patient statements) and analyzed regularly for maximized results.
A leader from McKesson discusses how healthcare reform is forcing hospitals and health systems to take a different approach to capacity management and patient flow.
This white paper, written by Apex President Patrick Maurer, discusses methods to increase patient adoption of online payments. Providers are now seeking ways to incrementally collect more payments due from patients as well as speeding up the rate of collections. This white paper shows why patient-centric approaches to online payment portals are important complements to traditional provider-centric approaches.
Emad Rizk, MD, president and CEO of Accretive Health, discusses the uncertainty facing hospitals and the transitions affecting revenue cycle management.
Increased electronic engagement between healthcare providers and patients provides significant opportunities for improving revenue cycle metrics and encouraging patients to access EHRs. This article, written by Apex Founder and CEO Brian Kueppers, explores a number of strategies to create synergy between patient billing, online payment portals and electronic health record (EHR) software to realize a high ROI in speed to payment, patient satisfaction and portal adoption for meaningful use.
Jim Bohnsack, vice president, solution & corporate development for Conifer Health Solutions, explains how the company helps healthcare providers leverage data to deliver better outcomes while optimizing reimbursement for all payment arrangements.
Faced with a rising tide of bad debt, a large Southeastern healthcare system was seeing a sharp decline in net patient revenues. The need to improve collections was dire. By integrating critical tools and processes, the health system was able to increase online payments and improve its financial position. Taking a holistic approach increased overall collection yield by 10% while costs came down because the number of statements sent to patients fell by 10%, which equated to a $1.3M annualized improvement in patient cash over a six-month period. This case study explains how.
Steve Scibetta, senior director of channel sales for Ontario Systems' healthcare product line, shares insights into effectively managing receivables.
With the ICD10 deadline quickly approaching and daily responsibilities not slowing down, final preparations for October 1 require strategic prioritization and laser focus.
Elena White, vice president of risk, quality, and network solutions for Optum, discusses how healthcare providers can leverage data and technology as they enable risk in their organization.
Read how Gwinnett Medical Center provides clear connections to financial information, offers multiple payment options for patients, and gives onsite staff the ability to collect payments at multiple points throughout the care process.
Somnia President and CEO Marc Koch, MD, MBA, explains how hospitals can drive transformative change in the perioperative experience for outstanding clinical and financial outcomes.
Read how Orlando Health was able to perform deeper dives into claims data to help the health system see claim rejections more quickly–even on the front end–and reduce A/R days.
PMMC President Roger L. Shaul discusses the effects of healthcare reform on revenue cycle management and how PMMC's products help clients adapt to a changing financial environment.
To maintain fiscal fitness and boost patient satisfaction and loyalty, healthcare providers need visibility into when and how much they will be paid–by whom–and the ability to better navigate obstacles to payment. They need payment clarity. This whitepaper illuminates this concept that is winning fans at forward-thinking hospitals.
Greg Burgess, Founder and Chief Product Officer at Burgess Group shares insights and opportunities for payment integrity in the rapidly changing healthcare IT landscape.
Financial services staff are always looking for ways to improve the verification, billing and collections processes, and Munson Healthcare is no different. Read about how they streamlined the billing process to produce cleaner bills on the front end and helped financial services staff collect more than $1 million in additional upfront annual revenue in one year.
Effective revenue cycle management can be a challenge for any hospital, but for smaller providers it is even tougher. Read how Wallace Thomson identified unreimbursed procedures, streamlined claims management, and improved its ability to determine charity eligibility.
Before launching an energy-efficiency initiative, it’s important to build a solid business case and understand the funding options and potential incentives that are available. Healthcare leaders should consider taking the steps outlined in the whitepaper to ease the process of gaining approval, piloting, implementing, and supporting sustainability projects. You will find that investing in sustainability and energy efficiency helps hospitals add cash to their bottom line. Discover how hospitals and health systems have various options for funding energy-efficient and renewable-energy initiatives, depending on their current financial structure and strategy.
Health care is a dynamic mergers and acquisitions market with numerous hospitals and health systems contemplating or pursuing formal arrangements with other entities. These relationships often pose a strategic benefit, such as enhancing competencies across the continuum, facilitating economies of scale, or giving the participants a competitive advantage in a crowded market. Underpinning any profitable acquisition is a robust capital planning strategy that ensures an organization reserves sufficient funds and efficiently onboards partners that advance the enterprise mission and values.
The success of healthcare mergers, acquisitions, and other affiliations is predicated in part on available capital, and the need for and sources of funding are considerations present throughout the partnering process, from choosing a partner to evaluating an arrangement’s capital needs to selecting an integration model to finding the right money source to finance the deal. This whitepaper offers several strategies that health system leaders have used to assess and manage capital needs for their growing networks.
Announcements from several commercial payers and the Centers for Medicare and Medicaid Services (CMS) early in 2015 around increased efforts to form value-based contracts with providers seemed to point to an impending rise in risk-based contracting. Rather than wait for disruption from the outside in, health care providers are now making inroads on collaborating with payers on various risk-based contracting models to increase the value of health care from within.
Yuma Regional Medical Center (YRMC) is a not-for-profit hospital serving a population of roughly 200,000 in Yuma and the surrounding communities.
Before becoming a ZirMed client, Yuma was attempting to manually monitor hundreds of thousands of charges which led to significant charge capture leakage. Learn how Yuma & ZirMed worked together to address underlying collections issues at the front end, thus increasing Yuma’s overall bottom line.
Kindred Hospital Rehabilitation Services works with partners to audit the market and the facility’s role in that market to identify opportunities for improvement. This approach leads to successes; Kindred’s clinical rehab and management expertise complements our partners’ strengths. Every facility and challenge is unique, and requires a full objective analysis.
As the critical link between patient care and reimbursement, health information enables more complete and accurate revenue capture. This 5-Minute White Paper Briefing shares how to achieve cost-effective revenue integrity by your optimizing HIM systems.
Speedier cash flow starts with better CDI and coding. This 5-Minute White Paper Briefing explains how providers can improve vital measures of technical and business performance to accelerate cash flow.
Qualified coders are getting harder to come by, and even the most seasoned professional can struggle with the complexity of ICD-10. This 5-Minute White Paper Briefing explains how partnerships can help improve coding and other key RCM operations potentially at a cost savings.
The point of managing your revenue cycle isn’t just to improve revenue and cash flow. It’s to do those things effectively by consistently following best practices— while spending as little time, money, and energy on them as possible.
How Lucile Packard Children’s Hospital Stanford increased payments received within 45 days by 20% and reduced paper submission claims by 70% by using ZirMed solutions.
The reasons claims are denied are so varied that managing denials can feel like chasing a thousand different tails. This situation is not surprising given that a hypothetical denial rate of just 5 percent translates to tens of thousands of denied claims per year for large hospitals—where real‐world denial rates often range from 12 to 22 percent. Read about how predictive modeling can detect meaningful correlations across claims denials data.
Emergency Mobile Health Care (EMHC) was founded to be and remains an exclusively locally owned and operated emergency medical service organization; today EMHC serves a population of more than a million people in and around Memphis, answering 75,000 calls each year.
Since the Physician Quality Reporting Initiative (PQRI) introduction, CMS has paid more than $100 million in bonus payments to participants. However, these bonuses ended in 2015; providers who successfully meet the reporting requirements in 2016 will avoid the 2% negative payment adjustment in 2018, so now is the time to act! Included in this whitepaper are implications of increasing patient responsibility, collections best practices, and collections and internal control solutions.
Getting paid what your physician deserves—that’s the goal of every biller. Yet even for the best billers, achieving that success can be elusive when denials stand in the way of success, presenting challenges at every turn. Denials aren’t going away, but you can learn techniques to manage and even prevent them.Join practice management expert Elizabeth W. Woodcock, MBA, FACMPE, CPC, to: Discover methods to translate denial data into business intelligence to improve your bottom line, determine staff productivity benchmarks for billers, and recognize common mistakes in denial management.
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