Pursuing revenue cycle innovation
HFMA Roundtable Participants
Kimberly Bliss is director, hospital billing for Rochester Regional Health in Rochester, New York.
Caroline Balfour is corporate vice president, revenue cycle services for KPC Healthcare in Santa Ana, California.
Sue Gillies is vice president revenue cycle for Crystal Run Health in Middletown, New York.
Michael Kos is vice president revenue cycle for Memorial Health System of Illinois in Springfield.
Billie Jean Mounts is chief revenue officer for Bon Secours Mercy Health in Cincinnati, Ohio.
Deborah Robinson is vice president, revenue cycle for Rochester Regional Health in Rochester, New York.
Jonathan Zimmerman is vice president, product management, for athenahealth in Watertown, Massachusetts.
Increasing patient responsibility, evolving payer requirements and emerging payment models are just a few of the current dynamics prompting healthcare organizations to look for revenue cycle innovation opportunities. Organizations are engaging in a range of initiatives to reduce cost-to-collect, limit revenue leakage and meet patient and payer expectations. In this roundtable, sponsored by athenahealth, several healthcare financial leaders discuss the challenges involved in revenue cycle improvement, offering strategies for streamlining operations and enabling better performance.
Where is your organization most challenged to keep cost out of revenue cycle operations?
Caroline Balfour: KPC Healthcare focuses on reducing cost-to-collect, which can be influenced by many things, including vendor costs, employee costs, inefficient processes and, of course, denials. The days of sending bills to payers and getting checks back in 30 days have been replaced by a more complex set of obligations we have to navigate. We are constantly seeking ways to use technology and efficiently deploy staffing resources. Since our hospitals treat Medi-Cal patients, we must be careful with our spend because the margin is extremely tight. One aspect of our approach is to house the entire revenue cycle in the revenue cycle department. Meaning, it’s not just patient access, coding, health information management (HIM) and the business office, our case managers report to the revenue cycle as well. One of the difficulties with case management is these nurses often get called to do a lot, including discharge planning, concurrent review, assessing compliance with pre-authorization criteria and meeting all other criteria needed for payment. If those nurses also are being pulled into other clinical areas throughout the hospital, we’re always going to be behind and the denials and review requests will start to stack up. By putting case management within the revenue cycle, we have more control and can train these staff members to be effective given our tight managed care environment.
Deborah Robinson: At Rochester Regional Health, we strive to have fewer manual touches and more automation to be more systematic about our processes and workflow. We have an integrated electronic health record (EHR) and billing system, and there is a lot of capability there. We continuously aim to take advantage of everything the system has to offer, and that can be challenging sometimes, especially finding the resources to keep up with the programming needed to prevent coding errors and avoid denials. We’ve made some progress in this area, but since things are always changing, it can be difficult to keep up.
Michael Kos: Memorial Health System of Illinois onboarded a new patient accounting system in early January, leaving a 20-year-old legacy solution behind. As a result, our big priority is balancing system stability with optimization while still working down the legacy accounts receivable (A/R). We’ve taken this opportunity to reexamine the revenue cycle from beginning to end, with department leaders thinking through how to reengineer their processes to not only squeeze out inefficiency but make things more patient-centered. We are being cognizant of costs, but also trying to deliver a better patient experience that’s in line with our mission and vision.
Sue Gillies: Patient payment responsibility is where Crystal Run Health struggles. Although we continue to refine payer processes, it’s patient payment that’s drawing the most attention now. About a year ago, we revised our processes with the goal of increasing patient payment. We’re now collecting from individuals at the time of check-in, using centrally located kiosks for patients to sign in and pay. Mats and rugs direct patients to the kiosks. It’s a more aggressive approach, but we’ve found it to be helpful. We also put a new billing system in place that offers electronic communications to patients about what they owe and how to pay. As soon as bills are adjudicated and the patient responsibility is known, we can send a text to patients — provided they have signed the consent form — to let them know the bill is available to pay. We can also send emails — only mailing out paper statements as a last resort. To further change the culture, we’re working with the marketing department to get the message out to patients via social media that there are payment portals, which make it easy to pay healthcare bills. The idea is to establish the expectation that patients will pay in a timely manner. The hope is with these new processes we will see an increase in upfront payments and a decrease in bad debt.
Billie Jean Mounts: At Bon Secours Mercy Health, we look at payer realization as an opportunity for improving revenue leakage. Because we outsource our revenue cycle operations, managing payer payment tactics has become our central focus. We have payers that will institute policies around pre-bill audits, for example, and will hold up the collection of cash for a time until they review medical records. We also are seeing increasing denials around medical necessity and missing authorizations and pre-authorizations. To address these, we work with the managed care team and escalate issues through the payer customer service area. We also examine our contract language to see if there are limits that we can put on the payer in terms of the number of medical records it can request at any given time. We also challenge payers on policy changes if they’re not included in the contract and reject those policy changes and appeal if need be.
What’s the mix for using people, processes and technology?
Kimberly Bliss: I would say all those factors come into play, but the largest portion involves technology. Every time we have an issue, or we see a denial trend, we’re trying to figure how we can be more proactive and efficient to mitigate it. At Rochester Regional Health, we like to avoid having to use people to address issues on the back end. Staffing is a concern for us. There is a lot of turnover right now, and the training and retraining costs are significant. If we can utilize the system more effectively and keep the people piece out of it, we find that to be beneficial.
Robinson: To expand on that comment, we’re a large organization with five hospitals, and we have a good-sized billing department. Billing and patient access positions are generally entry level and don’t require a college degree. We were spending substantial time and money educating people to perform busy and repetitive work, and then they would leave because they wanted a promotion opportunity. To address this, we are trying to raise the classification level for these types of jobs. As healthcare has changed and claims processing has become more complex, we need to look for people who have more of an analytical skillset. However, we’re not going to be able to recruit or retain those people at the rate we historically have paid for billing and patient access positions. We’re now pursuing a strategy where we have a smaller, but more skilled workforce. Not only do we hope this helps with efficiency and performance but also that it reduces turnover. We’ve started small, but we’re starting to see success. We recently took three vacant entry-level positions, converted them into two higher-level positions with an overall decrease in salary and benefit costs due to the smaller number of people. These individuals are producing great analytical reports that target improvement efforts, and they are committed to the organization. Making this change is a slow process, because you can’t convert everybody at once and you still need some entry-level positions to handle the more repetitive tasks.
Gillies: It comes down to using technology to optimize the staff you have. We’ve been adding a range of analytics to our back end. Where we used to pay significant overtime to complete tedious transactions, we’ve started using technology to streamline processes. Once you see workflow that’s consistent and you can apply logic to it and have it run overnight, that dramatically improves efficiency. For instance, we no longer manually write off small balances or anything that’s uncollectable on aged A/R; it’s all done with automated processes that run daily, weekly and monthly. This automation has saved us five or so FTEs over the past two to three years and decreased overtime from 5% down to 1%, allowing us to redeploy staff to higher-level tasks.
What are the most important lessons you’ve learned for improving productivity and preventing revenue leakage?
Balfour: A strong clinical documentation improvement and chargemaster strategy is important. To use a sports analogy, the first line of defense in revenue leakage is a strong offense. If we don’t get everything captured and coded correctly at the point of service, we’re going to lose money right off the bat. To ensure accurate clinical documentation, organizations should be running accounts through criteria early in the patient encounter and having real-time communications about missed or incorrect documentation. Case managers should be out on the floor with physicians, providing direct feedback and input, so they can catch issues early and check that both patient needs and revenue cycle requirements are being met.
Robinson: If an organization is experiencing revenue leakage, a comprehensive denial review is critical. Are you writing off things that you shouldn’t be? Are there certain problems you can prevent? Having a team of people focused on analyzing data and putting process improvement plans in place are key. As part of this work, you need to verify that any new processes are implemented and consistently followed — and they don’t fall apart later down the road. If you don’t continue to monitor process compliance, you’ll think a denial was addressed, then staff changes, and six months later, the process is no longer being followed and the denial is back again.
Jonathan Zimmerman: One of the most powerful insights we have learned from our customers is that improving productivity requires not only great technology and great processes, but insight into the human mind and cognitive processes. We’ve been working with a large regional health system for more than a year to introduce elements of game play into the revenue cycle, and we are seeing that making the work fun, and competitive, is not only helping them with employee engagement, it’s translating into tangible productivity and quality improvements. It’s helping them reinforce adherence to gold standard workflows, and their teams say they love it. Even to the point where when they lost a couple of team members to natural attrition, the rest of the team said, “Hey don’t replace them — we can do the work and get the points!” Truly amazing stuff.
How are you methodically identifying improvement opportunities for cost efficiency or process automation?
Balfour: We’re a health system that is growing quickly. Ongoing process improvement, even amid the weight of almost constant change is crucial. We need to be nimble with improvement as new dynamics emerge. To that end, we are moving away from weekly meetings to almost daily huddles to assess our most immediate needs for the day, based on the patients we have in-house. For example, we automatically analyze cases over certain dollar thresholds, such as surgical cases that include implants and biologics, to make sure we don’t have missing or lost charges. We also have a physician who is part of the revenue cycle and having that ability to quickly pinpoint issues and speak to other physicians in a way they’re comfortable has been extremely helpful for us.
Bliss: This is another area where you can use technology. For example, our integrated EHR and revenue cycle system has robust dashboards that allow us to see a snapshot of our performance. We huddle with our key leaders each day to look at these financial indicators. Where are our receivable totals, days-in-A/R, payments, aging, adjustments? We can then drill into each bucket, getting down to the plan or even patient level. We’ll assign things based on our priorities to ensure that the right concerns are getting worked, and they’re getting worked on in a timely manner. We have representation from our HIM department and from our revenue integrity department in those meetings. We look at the trends and figure out how to get on the same page about our goals.
How do you define and benchmark key metrics?
Bliss: We set our own benchmarks every year, continuously challenging ourselves to improve. We’ll always have a days-in-A/R target and an aging target, and we compare those two to national benchmarks such as the HFMA MAP criteria. Our integrated technology solution has a set of benchmarks as well that rates us against peer organizations that use the same tool. Quite honestly, we rate well against these external measures, so we push ourselves to do even better, establishing internal benchmarks that push us further.
Mounts: We have a set of KPIs and service level agreements that we review with our revenue cycle outsourcing partner each month. Where metrics are not in line with planned improvement, we work together to develop action plans that address the shortfalls. Our partner has a robust report card package that has at least two to three dozen different metrics, which we examine at a facility and system level. We also boil the various metrics down to a handful of indicators that we’ve determined are crucial to the overall success of the operation. Those are the ones that we dive into on a monthly basis, tackling the metrics that fall behind at any given month to determine the root cause.
Kos: The sheer number of possible metrics to measure can get overwhelming. I have found that when communicating about performance, it’s best to pick a few metrics that globally describe the issue at hand. For example, senior leaders respond to cash collection metrics because it’s something every piece of the revenue cycle system has in common — and succinctly demonstrates that all the pieces within the revenue cycle are working together and well. It’s also wise to let the metrics tell a story. You want to coalesce all the pieces of information to clearly communicate the message you’re trying to convey, whether to your chief financial officer or your board of directors. Approaching metric sharing from the perspective of telling a story is clearer and more impactful than merely throwing a dashboard of metrics onto a screen.
To inform our stakeholders, we use a hybrid of HFMA MAP criteria and internal benchmarks. We also look for third-party KPIs that are published in research. One area we’ve been focused on is our revenue cycle system implementation. We monitored internal metrics first, which revealed we stabilized rapidly, but then we also considered external validation metrics to gut check our progress and make sure we were doing as well as we thought we were.
Are you looking for any specific technology to help you reduce the cost of your operations?
Kos: Patient access tools that augment existing mobile and electronic applications will be helpful as we all aim to make the healthcare experience more patient friendly. Price transparency is another area where technology is going to play a role. Giving patients clear, timely and accurate information about their healthcare costs will be essential in meeting CMS requirements and also enabling a better patient experience.
Balfour: We’re just starting to explore the ways artificial intelligence can be used to drive improvement and reduce costs, and I’m interested to see where things go in the future. I’m also intrigued by the idea of using a savvy work-listing tool to facilitate more timely communication between organizational departments. This kind of technology could allow us to better understand daily where accounts are being worked and what the status of those efforts are. Using this type of tool, we could more quickly identify and resolve bottlenecks, speeding up turnaround times and process flow.
What’s the secret to effective partnerships with adjacent business functions that could impact business office performance?
Robinson: The way our revenue cycle is structured, I’m the vice president of the back-end billing functions, and then we have a vice president of front-end patient access positions. We work extremely closely together, meeting at least weekly and sometimes daily. Because there is a tight partnership between the back-end and front-end areas, we often can limit miscommunications and missteps. For instance, we have a regular, biweekly meeting in which we talk about IT issues — tickets or requests that we’ve put in for improvements. There are members of both teams as well as the IT department within this meeting. The group makes sure that billing isn’t trying to implement something that’s going to have a negative effect on patient access or vice versa. The groups are talking about things together and collaborating instead of being siloed.
Kos: The key: involve people — not just leaders. We involve our front-line staff from patient access and billing into decision-making, asking for their input and ideas and that builds a trusting partnership. When department leaders are willing to get into the weeds on an issue, it helps. That’s probably my biggest recommendation for revenue cycle leaders is building those relationships and not living in an office — lead by walking around, touring, getting in the trenches and learning a new skill, making a connection. You would be surprised how many times some of the best ideas come when people feel empowered to share their opinions without fear, and without feeling like they’re going to get brushed off. As leaders, we must be willing to hear opinions, even if it’s criticism of how things are currently functioning. The goal should be to make the entire revenue cycle function — and the people who drive it — perform better for the benefit of the patients we serve.
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