Award-Winning Healthcare Providers Offer Insights for Improved Revenue Cycle Performance
All U.S. healthcare providers can take a lesson from winners of the 2017 MAP Award for High Performance in Revenue Cycle on improving point-of-service collections, enhancing health plan relationships, and promoting price transparency.
If there were just one motto shared by all the diverse winners of HFMA’s 2017 MAP Award for High Performance in Revenue Cycle, it might well be “Persistence pays off.” Despite juggling greater requirements from health insurers along with heightened pressures from patients for better customer service, this year’s MAP Award winners continue to improve in every category.
In 2017, the MAP Awards for the first time recognized total revenue cycle performance in the integrated delivery system (IDS) category. Results demonstrate that an IDS’s performance level can match or surpass that of any other facility-based provider. For example, IDSs reported 34.0 net days in accounts receivable (A/R), cash as a percentage of net patient service revenue amounting to 103.7 percent, average time for discharged-not-submitted-to-payer (DNSP) accounts of 3.1 days, 11.7 percent of A/R aged 90 days or more, bad debt write-off of 0.2 percent, and point-of-service (POS) cash collections amounting to 47.8 percent. Such strong performance might provide further fuel for the continued mergers and acquisitions that have given rise to large IDSs across the country.
HFMA MAP Keys and the MAP Awards
Performance also was strong among hospital systems, individual hospitals, and physician practices that shared a common goal with IDSs: to apply innovative, collaborative approaches to address stubborn problems, such as denials and bad debt. The following are tips for performance excellence based on the practical solutions applied by this year’s award winners.
Improving the Patient Experience
Three tips can be gleaned from organizations whose performance produced an improved experience for patients.
Highest Individual Performance Reported by Winners in Each Provider Category
CHRISTUS Trinity Mother Frances Health System: Mine patient comments for gold. MAP Award winners recognize that patient satisfaction surveys can offer highly constructive suggestions for improving patient financial communications and other aspects of the patient experience. Texas-based CHRISTUS Trinity Mother Frances Health System in Tyler, Texas, surveys patients on the front end at registration on staff courtesy, wait times, and other factors. On the back end, the health system uses call codes to categorize reasons patients call in so revenue cycle staff can address any failures in the process. Revenue cycle leaders also maintain a patient-experience dashboard that tracks key indicators around the revenue cycle, such as call hold time, registration wait times, and the accuracy of estimates. “The patient experience is very important to us, and we don’t want the revenue cycle to be the weak link in our healthcare delivery model,” says Drew von Eschenbach, vice president of revenue cycle at CHRISTUS Trinity Mother Frances Health System.
Revenue cycle leaders at the health system use a survey analysis program that sorts positive and negative comments from their patient satisfaction surveys for team review. If a patient leaves a negative comment, a revenue cycle team member typically will reach out within 24 hours to solicit more feedback from the patient. During these calls, patients might offer simple suggestions like adding more coffee selections to the waiting area or suggest ideas for more in-depth projects to improve the patient experience.
Geisinger Health System: Train staff to be better listeners. Patient financial communications can be stressful for both patients and staff. The patient experience team at Geisinger Health System in Danville, Pa., led several interactive training sessions designed to improve the revenue cycle staff’s listening, empathy, and compassion. The team also hired an outside company to conduct an all-day customer service seminar that covered topics such as overcoming compassion fatigue and the importance of listening to understand rather than listening to respond. Revenue cycle leaders say the investment in training helps staff manage some of the stressors associated with patient interactions.
St. Elizabeth Healthcare: Give staff strong incentives to drive better performance. For some organizations, bonuses are a valued tool to drive greater accountability for the patient experience. St. Elizabeth Healthcare in Edgewood, Ky., has established a gainsharing program at its hospitals and ambulatory sites that rewards its associates, or employees, for improving the patient experience and the health system’s quality and financial performance. The most recent annual payout amounted to more than $700 per full-time associate.
In the incentive program, the patient experience counts for 50 percent of the total gainsharing payment (the inpatient experience counts for 20 percent, the outpatient experience counts for 15 percent, and the emergency department experience counts for 15 percent). When St. Elizabeth Healthcare meets or exceeds its annual financial goal (based on budgeted income from its hospitals’ operations), the health system allocates 10 percent of the income from operations to the gainsharing pool. That pool shrinks if the system does not meet its patient experience or quality goals.
Enhancing Transparency and Improving POS Collections
Improving transparency and point-of-sale (POS) collections is a fundamental revenue cycle goal for any provider. Organizations can take valuable tips from five MAP Award winners that demonstrated excellence in this area.
Lowell General Hospital: Increase POS collections with an advanced outreach approach. As an innovative way to boost POS collections, Lowell General Hospital in Lowell, Mass., provides obstetricians with welcome packets for soon-to-be parents that include information to be completed by the patient to enhance the preadmission process. From this information, staff create the account, preregister the patient, and develop an inpatient estimate for the mother and infant. Four weeks prior to the estimated day of delivery, the patient receives a letter with her estimated financial responsibility and a request for advance payment. Staff follow up by phone prior to delivery.
Virginia Eye Institute: Use technology to speed processes. Many MAP Award winners have implemented technology to streamline the front end of the revenue cycle. Before Virginia Eye Institute in Richmond, Va., added kiosks at registration, patients often had to wait in long lines while the registration process took eight to 10 minutes per patient. But registration time has been cut in half, thanks to the new technology and process. Using the self-serve kiosks, patients can now complete the full registration process, including scanning their identification and insurance cards, verifying and updating their demographic and insurance information, completing questionnaires, and even paying any self-pay fees, copayments, and past-due balances. Long registration lines have been eliminated, with 80 percent of patients using the kiosks. The physician practice also is testing a mobile app that allows patients to preregister for their appointments. In the next iteration of the app, patients will be able to pay outstanding balances as well.
Legacy Good Samaritan Medical Center: Test customer service representatives on the accuracy of their estimates. Several MAP Award winners have made it a priority to increase price transparency in their organizations. Portland, Ore.-based Legacy Good Samaritan Medical Center uses secret shoppers who call their customer service department through the operator each month to test representatives’ ability to provide estimates for different CPT codes. This approach helps keep staff sharp for the variety of calls that come their way.
When providing estimates, the team follows robust scripts that advise patients about their out-of-network risk and the possibility of third-party bills and additional charges. To promote continuous learning, the team discusses any deficiencies during weekly staff huddles. During the past year, Legacy Good Samaritan’s customer service team provided more than 2,500 estimates, not including quick calls for common procedures such as mammograms.
Princeton Baptist Medical Center: Implement a courtesy discharge process for bedded patients. This initiative launched in FY16 helped Birmingham, Ala.-based Princeton Baptist Medical Center achieve an overall 53.9 percent POS collections within seven days for the year. As part of the process, registrars document the financial status of the patient during preregistration or registration and indicate which patients need further assistance from a financial counselor. The financial counselors then visit the patient’s room to discuss payment options. If the patient completes the financial arrangements at that time, he or she receives a courtesy discharge. If the patient does not make arrangements, an indicator card is placed in the patient’s chart instructing the transport team to escort the patient to a financial counselor upon discharge.
Murray-Calloway County Hospital: Centralize the cashier. A comment from a patient on the inconvenience for patients of paying hospital and physician bills in separate locations prompted leaders at Murray-Calloway County Hospital in Murray, Ky., to centralize their cashier in one place for all hospital and physician collections. The centralized cashier not only offers patients an opportunity to combine payments, but also ensures consistent communication back to the patient regarding collections, payment options, and discounts for prompt payment.
Promoting Improved Collaboration
A healthcare organization cannot expect to achieve exemplary revenue cycle performance without effective collaboration with health plans. Here are tips from three MAP Award winners on how to cultivate this critical requirement for revenue cycle success.
Sharp HealthCare: Work with health insurers to streamline operations.To partner effectively with health insurers and achieve a high-functioning revenue cycle, Sharp HealthCare in San Diego is working with two of its largest HMOs to open up its electronic health record (EHR) for concurrent authorizations.
“We have to be able to find mutual ground with payers to create efficiencies around the care we deliver to our patients and how that care is compensated,” says Gerilynn Sevenikar, vice president, hospital revenue cycle.
Each day, the health system sends the HMOs a census report that lists their current members in the facilities.
“We open up the record to them so that they can review the documentation on their own and gain agreement that the inpatient status is appropriate,” Sevenikar says. If the HMO reviewer cannot find supporting documentation in the EHR, he or she contacts the utilization review nurse at Sharp to ask clarifying questions and proceed accordingly. “It’s about making sure we can all get it right the first time and get away from the inefficiency of going back and forth on the status of the patient,” she says.
After six months, the health system saw a dramatic reduction of medical record requests and denials, and a notable improvement in its relationship with one HMO. The process is still being rolled out with the other HMO.
Sevenikar also is on Blue Shield of California’s Partnership in Operational Excellence and Transparency (POET) advisory committee to review and discuss standards and reporting for health plan claims rejections. She and her team also had weekly calls with one insurer and a large employer to discuss timely payment, resulting in a $2 million advancement while issues were being resolved.
St. Luke’s Hospital: Help insurers speed claims processing of lower-cost devices. A major health plan for St. Luke’s Hospital in Chesterfield, Mo., pended all devices and implants for medical record review, leading to a significant delay in the hospital’s claims payment. After the hospital and health plan discussed the issue during monthly meetings, the health plan agreed to train its staff to review only high-dollar devices while processing other devices without delay. Before implementing this solution, the health plan might have as many as 20 to 30 claims in review per month. Currently, fewer than five claims require attention each month. The hospital’s health information management (HIM) department now uses a shared network drive to upload health plan record requests, saving time and eliminating duplicate requests.
Saint Francis Health System: Create a multidisciplinary team to reduce denials. MAP Award winners recognize the importance of cross-functional collaboration. Weekly meetings among the clinical documentation improvement, HIM, case management, and patient accounting teams have helped Saint Francis Health System in Tulsa, Okla., identify leading causes of denials. The teams also identify opportunities to improve physician education to ensure more accurate and complete documentation to meet the broad range of payer requirements. They track trends in payer denials and set up work queues to ensure accounts are reviewed prior to submission of claims.
One area of focus has been correcting coding, medical necessity, and documentation issues that could downgrade payments for sepsis, sometimes at the cost of $10,000 to $15,000 per case. The health system also is reallocating authorization issues back to the front end.
“Having the right department work on the right denial has contributed to our success,” says Renee Edwards, health system director of patient financial services. “By having the pre-arrival staff correct their own errors rather than having the business office chase those authorizations, we have drastically reduced some of our errors.”
Revamping Back-End Processes
Back-end processes are an important area of focus for MAP Award winners. Valuable tips can be gleaned from the activities of three organizations in particular.
Presbyterian Healthcare Services: Leverage technology to develop smarter workflows. MAP Award winners recognize that their A/R systems offer opportunities to enhance their back-end workflows. Presbyterian Healthcare Services in Albuquerque, N.M., recently built all its payer contracts into its A/R system. Leading this project was a team of leaders from patient accounting, cost accounting, and IT. For 18 months, the group worked on interpreting, building, and testing the contract loads. They also developed a revenue recovery team whose role is to validate payment variances, appeal legitimate underpayments, and work with health plans to correct any system configuration errors. After just five months, the team validated and appealed approximately $3.8 million in underpayments. Since implementation, this team has been able to successfully recover more than $3.6 million in incorrectly paid claims.
St. Clair Hospital: Give patients the ability to pay at their convenience, 24 hours a day, 7 days a week. Providers that excel in the revenue cycle offer more payment options to patients. At St. Clair Hospital in Pittsburgh, for example, online payments generated $1.6 million in FY16. To implement this patient-friendly billing strategy, leaders picked a tool to help them process credit card payments, record payment transactions, post POS credit card and cash transactions, and enable online payments on the hospital’s website. The implementation of new cash management technologies and processes also helped St. Clair trim 1.5 hours of manual balancing and preparation of daily bank deposits for cashiers. Electronic posting of POS payments cut one hour a day for the cash posting team, giving them more time to reduce backlogs.
St. Elizabeth Physicians: Restructure workflows to improve over 90-day A/R. In the revenue cycle, success often hinges on efficient workflows. St. Elizabeth Physicians in Crestview Hills, Ky., started 2015 with $5.6 million in over 90 days A/R. To bring this number down, the assistant vice president of revenue cycle services, the director, and three managers of insurance follow-up worked with a business analyst to review denials by payer and the most commonly denied CPT codes.
“We spent a lot of time working on the front-end charge-entry edits in the A/R system to get the claims right from the beginning so the insurance companies would not have a chance to deny them,” says Maria Rankin, assistant vice president of revenue cycle services.
The physician practice also assigned trainers to work one on one with the insurance follow-up associates and set higher productivity goals. “We spent a lot of time setting the productivity measures and testing the productivity report to make sure it was accurate,” Rankin says.
The organization created a new workflow, assigning associates specific claims to work. For example, Mondays were dedicated to highest-dollar claims, Tuesdays to the oldest claims, and so forth. It also removed worker’s compensation claims as a separate class and incorporated these into each associate’s work queue, freeing up two associates to work on other specialties. As a result of its efforts, the practice ended 2015 with $4.9 million in over 90 days A/R.
Empowering Staff and Improving Accountability
The success of MAP Award winners underscores the importance of staff in driving an effective revenue cycle strategy. This point is exemplified in approaches used by three MAP Award winners to empower revenue cycle personnel and improve their levels of accountability.
ENT & Allergy Associates, LLP: Enlist management in setting quantifiable, meaningful goals. Establishing targets that drive real changes requires buy-in across an organization. At ENT & Allergy Associates, LLP, in Tarrytown, N.Y., the revenue cycle director asks mid-level managers to identify goals for the upcoming year, with every department accountable for the practice’s revenue cycle strategy. The revenue cycle team then meets with the COO and operations staff to discuss how they will accomplish their most important goals, which include the following:
- Ensuring proper verification of insurance at the first point of entry
- Using training to support continuous process improvement
- Deploying a deductible application with contracted rates so staff know what to collect in real time
- Increasing time-of-service collections by more than $1 million per year
Privia Medical Group: Make employee engagement a priority.To help set the right tone for employee engagement, Privia Medical Group in Arlington, Va., has a dedicated “culture crew,” a committee that focuses on building inclusion and enhancing organizational culture through events like fundraising walks, community service events, peer recognition awards—and even a 50th birthday party for Medicare back in 2015. The committee includes staff from all departments, including revenue cycle management.
“Revenue cycle is driven by the patient and practice interaction,” says Maureen Clancy, senior vice president of revenue cycle management at the medical group. “Making sure you have employees who are engaged, committed, well trained, and enthusiastic is going to make the patient experience so much better.”
The practice takes an individualized approach to career development, with the annual performance review playing a major role. In the practice’s most recent engagement survey, more than three-quarters of revenue cycle staff agreed or strongly agreed that that their most recent performance review helped them improve (the national benchmark is 65 percent). The practice’s talent team also works closely with managers to ensure staff career growth and opportunities. “Engagement is central to retention, and retention is central to success—not just for the company but for the employee as well,” Clancy says. In Privia’s Mid-Atlantic market, 100 percent of the organization’s current middle managers rose from internal ranks.
OhioHealth Riverside Methodist Hospital: Use career ladders to attract and retain talent. The value of retaining well-trained, dedicated employees is clear to this year’s MAP Award winners. OhioHealth Riverside Methodist Hospital in Columbus maps jobs into a set of eight career bands that illustrate potential career progressions across the organization, with revenue cycle leaders further defining these paths. One example of a career ladder progression is as follows: registration representative > team lead > registration supervisor > patient access manager > patient access director > patient access senior director > vice president, revenue cycle. The HIM department and the central business office maintain similar ladders. Other career opportunities include roles as quality assurance coordinator, education coordinator, and project manager. By defining these career progressions, the hospital can effectively promote from within and attract highly qualified external candidates.
Borrowing From Best Practices
Based on these winners, revenue cycle departments that emphasize the cornerstones of high performance—the right people, processes, technology, communication, culture, and metrics—are more likely to be successful, regardless of the scale or scope of the organization.
Revenue cycle leaders that wish to learn from these best-practice organizations should recognize the value of steady, incremental changes and collaborative problem-solving as they focus their efforts to improve performance.
Laura Ramos Hegwer is a freelance writer and editor based in Lake Bluff, Ill., and a member of HFMA’s First Illinois Chapter.