Depending on the payer, 40-80 percent of accounts receivable do not achieve the status of meaningful work because there is nothing that staff can do to resolve them.
Let’s face it: The daily work life of the typical healthcare business office staff can be fraught with complexity. The result may be exhaustion and lack of engagement. For the healthcare institutions they serve, this translates into lower productivity, greater claims denials, and lost revenue.
To combat entropy, a high-performing business office will find ways to simplify workflow and analysis, allowing revenue cycle professionals to prevent denials and encourage payments. That means changing processes and introducing automation to remove performance obstacles so that staff can focus on meaningful tasks with immediate purpose.
Achieving that goal is easier said than done in today’s more complex payer landscape that puts greater pressure on operating revenues, which in turn demands more of revenue cycle staff. They must identify, correct, and communicate errors generated from the scheduling process through to claims resolution. They also must keep abreast of increasing regulatory and payer expectations.
These often-dedicated employees review electronic or paper reports listing the accounts their managers want them to work. They tackle the accounts as best they know how, sometimes asking their peers or supervisors for help, in person, via phone or through e-mail. They often try to implement their own quality improvements with whatever resources they possess.
Meanwhile, supervisors who assign work and monitor employee production often spend hours generating and analyzing reports to unclog bottlenecks and improve productivity. They are under the gun from senior leadership, who frequently ask managers to characterize outstanding receivables in more detail and explain their challenges.
Contrast this situation with simplified business offices where staff start their days by generating worklists of their accounts that require action. The automated system allows them to see claim status easily. If they need to appeal denials, instead of looking for the proper dispute forms, the system pre-populates the correct dispute forms for submission to payers. Staff log the status of accounts, explain their actions, and move on to other meaningful accounts.
The pillars of simplified business office processes include creating meaningful work, developing knowledge, removing obstacles, and advancing analytical capabilities.
Generating Meaningful Work
Depending on the payer, our data show that 40-80 percent of accounts receivable do not achieve the status of meaningful work because there is nothing that staff can do to resolve them. For example, if a claim has been received by an insurance company, but the insurer has not acted, staff can do little more than ask the insurer to adjudicate the claim. If staff spend as much as 80 percent of their time investigating claim statuses, but take no actions, they find little meaning in the work they perform.
A business office can improve this situation through advanced workflow tools that pull together payer and claims data and apply sophisticated algorithms to structure work that optimizes staff efforts.
Developing Knowledge and Removing Obstacles
Managers must have time to ensure staff perform quality work. Simplified business offices will remove many traditional responsibilities from management teams to free up managers’ time. For example, instead of managers distributing and collecting worklists from staff, optimal business offices automate worklists but provide sufficient flexibility for staff to act on trends they identify. Those trends include claim data issues, missing payments, unusual denials, authorization rule changes, and other major payer challenges. The system tracks staff activity automatically.
With their extra time, managers should consistently perform quality reviews of staff performance. By auditing the choices staff make to solve individual accounts, managers will identify where they can better define processes and enhance training. They might look at how staff determined why claims have not been paid. Did staff make the right choices to resolve unpaid claims? Are they escalating their responses or just going along with what payers are saying?
An automated business office also allows managers to have time to simplify staff work. However, they need processes to streamline work and share and track problems. Managers should categorize and prioritize the issues that impact the most employees and save the most processing time. Furthermore, managers must communicate the status of issues and not discount or ignore challenges shared by staff. When managers respond to employee feedback, they demonstrate that they value staff input, which supports a culture of continuous improvement.
Implementing Advanced Analytical Capabilities
In simplified business offices, revenue cycle teams combine data so that it can be analyzed simply. A useful database contains more than traditional accounts receivable dashboards that enable drilldowns into financial classes, aging reports, and/or balances. It contains additional fields to enhance business intelligence, including the following.
Claim status. Has the insurer confirmed receipt of the claims, and what decisions has the insurer made?
Denial reasons. If the insurer denied the claim, what reason did it provide? The business office might want to map detailed denial codes into general categories that make sense to executives.
Last action. If the account was worked by staff, what action did staff take to resolve the account?
Last toucheddate. How long has it been since staff worked the account?
Using these fields as examples, data can be organized to show aging of the receivables, and executives know the status of the receivables, the actions taken on the accounts, and when they were taken. A database enables executives to obtain the information they need without disrupting the staff focus on their priorities.
Boosting Staff Satisfaction, Achieving Results
Organizations that develop technology-enabled, simplified business offices where staff have meaningful work, that allow managers to spend time enhancing quality, and that ensure data is accessible for advanced analyses are the ones that can successfully conquer revenue cycle complexity, boost employee satisfaction, and achieve results. Within my own organization, effective workflow tools have eliminated 41 percent of our staff’s meaningless work and allowed them to resolve more priority accounts for our clients.
In another example, a struggling urban health system has reaped the benefits of simplified workflow and staff engagement through 38 opportunities for improvements within three months. Those opportunities revolved around claim data issues, missing payments, payment issues, unusual denials, and authorization rule changes.
Solutions for this health system included establishing new front-end processes to ensure claims are clean by examining information coming from patient access, utilization review, and coding. Revenue cycle leaders also ensured that the billing process followed provider rules and addressed problems with systems not supporting workflow appropriately.
With new challenges that may impact hospital revenue, a central business office that delivers optimal results is crucial. It is a complex area, but with some simplification, it can become an integral part of successful healthcare organizations.