This year, 23 healthcare organizations won the 2020 HFMA MAP Award for High Performance in Revenue Cycle. The organizations ranged from integrated delivery systems to hospital systems, individual hospitals, critical access hospitals, and physician practices. They excel in meeting industry standards for revenue cycle performance, implementing patient-centered recommendations for financial communications and achieving high levels of patient satisfaction.
During HFMA Annual, 15 revenue cycle leaders shared lessons learned around ways to strengthen and sustain revenue cycle performance. Following are key takeaways from the discussion.
COVID-19 has had a personal and professional impact on all areas of the health system, and those in the revenue cycle have certainly been impacted. Could you please describe one area of your revenue cycle that you believe has been impacted the most?
Amy N. Assenmacher, FHFMA, CHFP, MSN, senior vice president, revenue cycle, Spectrum Health: At Spectrum Health, we shifted to a virtual footprint fairly seamlessly since we’d already migrated the majority of our coding and billing teams to more remote environments. We leveraged the Microsoft Teams platform to drive communication and connectivity. Yet, I think an opportunity area we encountered was instilling a sense of belonging and strong team cohesion during the pandemic, which is often easier to sustain when teams are in close physical contact. We became very intentional and purposeful about connecting with people and ensuring that we understood some of the pressures they were facing with the flurry of activity that accompanied COVID-19. This experience heightened our ability to think creatively and to collaborate more effectively during times of stress.
Anthony Helton, FHFMA, vice president, revenue cycle, St. Elizabeth Healthcare: We were lucky we have a very mature huddle system here. If you have a weekly or daily huddle system, that will help you maintain a sense of connectedness and community in the shift to a remote work environment. It also helped support strong levels of productivity.
Sue Freiberg, RN, CRCE-I, director, patient access, St. Mary Medical Center: Workforce management has been one of our toughest challenges throughout the pandemic. We found that a lot of our frontline staff who were working in the hospital setting wanted to be furloughed. They did not want to come into the hospital to work. And now, with a new school year starting, a lot of staff are starting to resign because they have to stay home with their children and help them with school. We’re finding new issues that are cropping up continually when it comes to managing our frontline staff during the pandemic.
Girish Dighe, PharmD, MS, senior director of hospital billing operations and revenue integrity, OhioHealth: From an OhioHealth perspective, we created a billing, charging and coding taskforce from the outset because we knew that dealing with COVID-19 was going to be a collaborative effort across the enterprise. We needed various stakeholders from our information services team, our EMR build teams, our managed care teams, finance and revenue cycle to weigh in on ways to address the COVID-related issues. For example, one of the things that most impacted our system was making sure that payers’ claim systems were ready to take on the new codes that were coming out during the pandemic. We also needed to make sure we had the right diagnosis coded, the right claim, and medical appropriateness substantiated. In instances where payers’ systems weren’t ready to accept claims with the new codes, we had to hold onto those claims until payers were ready. It was a very fluid situation, and it required us to work with payers individually.
Jeannette R. Wood, MBA, CHC, CHCO, vice president, revenue cycle management, Privia Health: One of the big issues we face is keeping all practices across our national markets updated on the ongoing changes resulting from COVID-19, such as updates related to telehealth. We created a digital, cloud-based COVID-19 workbook so our team has access to real-time updates. We created a section for each market that lists the CPT codes and modifiers for each payer. It really helps our physicians, our practices and our RCM staff with making sure claims are going out correctly as payers continue to make changes during the pandemic.
Select up to two metrics and describe processes and interventions implemented this year to affect performance on each respective metric.
Mindy Chandler, regional director, revenue integrity and optimization, St. Mary Medical Center: One of the new processes that we put in place this year was to have a really high level of focus on initial denials, which is an area that we struggled with. We actually put a new process in place while the majority of our staff was in a hybrid model, with some working from home and some working from the office. We implemented a model within the teams page, creating specific reports that were broken down by tiers and by areas of focus, such as care management, denials, eligibility. Each week, we hold a call with our ancillary access leadership as well as our patient accounting department, our revenue integrity team, our coding and our care management teams, and we pull out the top three denials and develop work plans to prevent initial denials. We’ve been really successful in doing that, and we’ve actually identified areas of opportunity to increase revenue as well. That’s been an exciting and challenging project for us.
Christy Pehanich, FHFMA, MHSA, CPC, associate vice president, revenue management, Geisinger: We’ve been working on point-of-service collections for quite some time. One of the major changes we’ve made in the last six to eight months is to incorporate a dashboard into an existing tool that operations managers were accustomed to using so they could see, in real time, how many copays staff are collecting compared to the total opportunity and how much past-due debt has been collected compared with previous payment amounts that have not yet been satisfied. We have a 100% copay collection goal, and we’re at about 82% now — sometimes 83% to 86%. We also set a goal for collecting outstanding patient pay amounts as patients present at a clinic, which is really difficult because you could get into a deep, technical conversation that patient access staff may not be expecting. We created scripts for patient access staff to just acknowledge the past due amount and ask the patient to make a partial payment or satisfy that balance today. And we gave them customer service business cards that they could hand out if there were questions. We set a goal to collect at least 3% of past-due amounts. The dashboard has really helped us in this effort. So has sharing the top-performing and bottom-performing locations with senior leaders because no one wants to be at the bottom of the list.
David Hitzel, senior vice president, revenue cycle, Ensemble Health Partners/Bon Secours Mercy Health: We’ve started leveraging a “black book” of known or identified trends or issues among various payers and look closely at our contracts to help avoid these risk areas. For example, we’ll look for things like carve-out language, stop-loss percentages — any criteria that would have hindered payment. We’ve also evaluated our chargemaster and CDM structure and compared it against our CPT codes, and we’ve asked ourselves, “How can we assess or diagnose reordering, where appropriate for the diagnosis or procedures, to maximize reimbursement?” In doing so, we were able to capture tens of millions of dollars across our system in a single year, going beyond most of the traditional modeling or variants out there. Those deep dives into contractual terms pay off.
Jonathan Frank, senior director, revenue cycle, HIM, professional and hospital coding, and authorizations, OhioHealth: We set up what we’re calling a pre-denial team that essentially reviews the case after it has been coded, and we have a work queue that explores account mismatches, comparing what is authorized to what is coded. We work those mismatches for coding accuracy to make sure we’ve coded the case correctly, and then if the coding is accurate, we try to get authorization on the case before we go to the payer to see if they’ll accept it. Some of them do, and some of them don’t. On the front end, we’re feeding this information back to departments to tell them, “Hey, there’s some opportunity here for you guys to maybe beef up your authorizations and make sure procedures are authorized by certain payers.” We’re also working to add functionality that triggers staff to obtain authorization for procedures in high-issue areas.
Steven K. Sinclair, CPA, CMPE, CFO, Graves-Gilbert Clinic: We’re working to automate the authorization process. We have completed the pilot, and it works as advertised; our next step is to get the appropriate interface in place with our EMR PM vendor. It’s an approach that will automate quite a bit of the authorization process, and it looks promising.
HFMA has unveiled a new consumerism maturity model and resources. This model incorporates many aspects of the Healthcare Dollars & Sense initiatives as well as Patient Friendly Billing. Could you please describe how your organization is embracing consumerism, and if you have assessed your organization using the maturity model, where you fall within the self-rating table?
Liz Thorpe-Greenwald, CRCR, CPFSS, customer relations coordinator, Liberty Hospital: This is something I’m extremely passionate about. At our location, we spent the past year looking at ways that we can give patients greater flexibility and opportunity in paying their bills. One of the vendors that we’re looking at for our long-term loan program is a company that gives patients the flexibility to create their own payment plans or payment terms according to what they can budget for medical expenses right now. That’s a really big deal, especially during COVID-19.
Consumerism is such a big deal in healthcare. If we can’t tell consumers what their care is going to cost right away, and if we can’t tell them how much they are going to have to pay out-of- pocket, we’ll have a hard time gaining their loyalty and trust. What makes them want to come back to you is how you treat them as patients or as customers.
Mary Cox, director, revenue cycle, financial assistance, bad debt and self-pay, OhioHealth: I’m the interim director for patient billing for OhioHealth, and we are dedicated to engaging our patients throughout the revenue cycle experience. We did complete the self-assessment on consumerism [part of HFMA’s Consumerism Maturity Model], and we fell into the emerging category. One of the areas that we embrace when it comes to consumerism is making it easy and convenient for a patient to understand their out-of-pocket responsibilities for care, pay their outstanding balances and apply for financial assistance. During registration, the patient is informed of any out-of-pocket expense and prior balances. If the patient is unable to pay, we provide the patient with financial assistance information and help them complete an application for assistance or check to see whether they may be eligible for Medicaid or other programs. We also enable patients to pay outstanding balances using a simple online bill pay tool that is available 24 hours a day and includes a quick-pay option that allows them to pay without logging in or creating a sign-on. Our call centers also are available throughout the week to answer patients’ questions or concerns.
Hitzel: We’ve made big strides around transparency readiness, such as the ability to enable consumers to shop for services and obtain quotes or estimates. What we’re really focused on —and, I think, where our next step is — is enabling consumers to shop for services not just by price, but also by the experience, such as the ease with which they can schedule a procedure, engage with the system or pay their bill. We’re trying to deploy a user-friendly mobile app that will enable online scheduling and form completion, and we’re looking at ways to expand digital engagement and online bill-pay options, such as Google Pay and Venmo.
Explain how you are measuring patient satisfaction as it relates to the revenue cycle. Describe how you are impacting patient satisfaction through the revenue cycle and reinforcing a culture of patient customer service.
Wood: In August 2020, we launched a patient and family advisory council that already included more than 2,000 participants. The council serves as a “consumer advisory group,” providing a way for patients and families to provide input and share their experiences, supporting us in our efforts to deliver an ideal, patient-centric experience.
Dighe: One innovative program that we launched in FY19 focuses on pharmaceuticals, which plays a significant role in a system’s financial portfolio. We looked at both the revenue and expense of hospital-based infusion centers — we have more than 10 across our system — to try to mitigate the patient’s exorbitant out-of-pocket costs, which may lead to financial toxicity, lack of treatment access and unfavorable customer experience. Our medication assistance program worked with pharmaceutical manufacturers and charitable foundations to assist patients in need through free drug replacement — in which the manufacturer/foundation subsidizes the drug, decreasing our expenses and inventory costs — or copay assistance, in which the manufacturer/foundation will subsidize commercially insured patients’ out-of-pocket expenses who meet eligibility criteria. Over the past year, these programs have equated to roughly $11 million in savings. Additionally, the program has reduced our overall expense while improving cash flow.
Sinclair: One of the things that has helped our organization is the use of audits. All of our billing and coding staff are audited; they are expected to understand how their performance ultimately impacts the patient experience. We also use a third-party revenue cycle management expert to verify our performance on a quarterly basis to help ensure we provide a positive patient financial experience.
Pehanich: We have a survey that is available to patients at the end of every phone call, and with our contact center system, we’re able to tie the results directly back to calls. We review the highest-ranking calls during our staff meetings as a reference point into what makes a great customer experience and how we can learn from each other. We also take a careful look at lower-ranking calls and use them as an opportunity to identify process improvements or training that may be needed to close gaps in service.
Assenmacher: We use patient satisfaction scores in designing action plans to improve the patient experience, partnering closely with our clinical operations team to form collaborative plans to improve that experience. We’ve developed an education tool that provides guidance to our staff on how to deliver an exceptional patient experience, and we created an audit tool to gauge the quality of the registration experience in three areas — know me, include me and empower me —to really personalize that exchange. We also engage with our patient family advisory councils to gather constructive feedback on ways to improve the process to be more patient-centric. This past year, we made some favorable improvements to our online bill pay features and patient statements as a direct result of engaging these feedback teams.
Briefly share any unique practices or innovations you have employed to improve revenue cycle effectiveness/efficiency, employee satisfaction or patient satisfaction. If possible, describe a measurable impact on one or more areas of revenue cycle performance (e.g., increased percentage of point-of-service collections, decrease in net days in accounts receivable). Share learning experiences where a project did not go as expected. What happened? What was learned?
Sinclair: A failed project that provided an important learning experience was the implementation of patient check-in kiosks. We had hoped this would provide a more private method to register patients, resulting in the need for fewer staff and improved point-of-service collections. However, there was a lack of acceptance on the part of the patients. Unfortunately, the kiosk workflow was never adequate to capture all of the registration nuances. During registration, there seemed to always be a need for staff to assist the patient with one thing or another. However, once a vendor announced and demonstrated to us their patient engagement platform, we quickly realized everything we wanted to accomplish through the kiosk could be achieved remotely on the patient’s mobile device. The kiosk turned out to be a steppingstone in learning that helped direct us to a better solution for the clinic and our patients.
Assenmacher: Our revenue cycle department is committed to increasing and sustaining the racial and ethnic diversity of our workforce at all levels to help improve access to care for communities of color. The patient access services representative (PSR) role was among those selected as an opportunity area to increase diversity, as this is an area where many revenue cycle team members get their start in growing through our career ladder. Additionally, the data proved that our revenue cycle workforce was underrepresented compared to our community demographics.
A workgroup was formed within the patient access department to develop and execute an action plan to address opportunities to make our workforce be more reflective of the communities we serve. Some of the tactics used include mandating unconscious bias and cultural competence training for all leaders within the patient access registration and financial counseling teams, training the hiring managers on more robust interviewing skills with panel interviews, piloting a talent pipeline program for patient access with employees from nutrition services and environmental services — the most diverse job family in the organization — and leveraging enhanced exit interviews to identify themes that could improve the department’s retention of diverse individuals.
Since these efforts began, we’ve realized a 4% increase in minority representation over time in the PSR role. Other metrics being tracked include turnover within the first year of employment, internal/department transfers, average time to fill, termination demographics and hiring demographics. It’s an important initiative that will strengthen the quality of service we provide for the communities we serve, and it reflects our deep commitment to enhancing the patient experience at every turn.