Creating and managing an effective clinical revenue cycle (CRC) requires the following fundamental steps.
Establish a CRC governance committee
The governance committee should be co-chaired by a clinical leader, an administrative leader and a revenue cycle leader, and it should comprise key stakeholders from each CRC business function and clinical service line, with ad-hoc members including supply chain, pharmacy, decision support, IT and compliance. The committee leaders should encourage a strong environment of collaboration to promote the necessary transformation of systems and processes. The committee should meet monthly, and all members should have space in their schedule and daily activities to dedicate time to providing oversight and guidance for the CRC.
Look for and fill policy and business process gaps
Policies and business process workflows should be stored in a central repository, accessible to all business process owners, operators and consumers or end users. These stakeholders also should receive education on the policies and processes. Policies should be broad enough to cover the entire organization or enterprise, while allowing for workflows to be specific to clinical departments or ancillary systems. Current policies and workflows should be examined to determine gaps in the core CRC operating model capabilities. Should new policies or business processes need to be added, they should be vetted by both the governance committee and the clinical departments to ensure maximum buy-in and adoption.
Establish SLAs, KPIs, and decision rights
The governance committee should create service-level agreements (SLAs), establish the key performance indicators (KPIs) that will be used for measuring performance and define decision rights within the CRC functions and clinical departments. Ultimately, the clinical stakeholders should be enlisted to focus on:
- Shortening days to final bill
- Reducing the number of incorrect or missing charges
- Increasing accuracy of hospital acuity metrics (CMI, CC/MCC capture rate, RAF scores)
- Reducing late charges as a percentage of total charges
- Reducing clinical denials
- Improving accuracy and timeliness of departmental charge capture
The governance committee should define decision rights for each function within the CRC to document accountability for both the team and clinical departments. A RACI matrix (a tool that defines roles according to whether a person is expected to be “responsible, accountable, consulted or informed” regarding project progress) can be helpful when gaps are identified, to help determine which CRC stakeholders are responsible for deploying resources or providing support to address outstanding needs.
CRC functions and clinical departments should understand their KPIs, expected performance levels and the levers available to achieve expected performance, while being fully informed about how existing resources are to be allocated.
Address underperforming clinical departments and providers
As KPIs are established and performance monitoring is activated, clinical departments and providers with lagging performance can be easily identified. The committee then should be responsible for deploying resources to resolve any such performance deviations.
Establish regular communication and ongoing training and education
All staff, including provider staff, who are responsible for revenue capture within the CRC should receive ongoing training and education to keep them apprised of system updates, new regulations and routine CPT code or pricing changes. To promote high performance standards, these practices should be followed:
- Establish a core CRC curriculum for providing training to clinical departments and clinicians on well-defined business processes they are expected to follow in performing CRC functions.
- Onboard new entrants to the organizational charging process quickly and efficiently, with such training included as part of the process.
- Provide reminders and information on upcoming training sessions and resources for addressing clinical department and clinician questions. This task is a function of the governance committee.
- Implement regular touchpoints between the departments and clinicians with CRC analysts, who can help them apply best practices, support reconciliation and drive performance management at the local level.
