The Path to Revenue Cycle Systemness - Advisory · 2019-09-11 · The Path to Revenue Cycle Systemness ... Revenue cycle’s system advantage Revenue Cycle Advancement Center research

Presented by

Revenue Cycle Advancement Center

Eight imperatives for generating efficiencies through

sustainable change

The Path to Revenue Cycle Systemness

© 2019 Advisory Board • All rights reserved • advisory.com • WF953632-b 09/11

2

Road mapRoad map

The Case for Systemness1

2 8 Imperatives for generating efficiencies through sustainable change

3 Coda

http://www.advisory.com/



3

1. Moody’s preliminary.

Source: Moody’s Investors Service, “Preliminary Medians – Profitability Holds Steady as Revenues

and Expenses Converge,” April 25, 2019; Moody’s Investors Service, “Revenue Growth and Cash

Flow Margins Hit All-Time Lows in 2013 US Not-for-Profit Hospital Medians,” August 2014.

Getting a handle on cost growth, yet margins remain slim

Facing our own affordability issues

Median revenue and cost growth

2009-2018

2018 median operating margins

among not-for-profit hospitals¹

1.7%6.1%

4.6%5.0%

7.1%

5.7%5.1%

0%

1%

2%

3%

4%

5%

6%

7%

8%

2009 2010 2011 2012 2013 2014 2015 2016 2017 2018

Revenue growth Expense growth

Revenue Cycle Advancement Center research and analysis.

DATA SPOTLIGHT




4

Source: Ellison A, “Washington health system files for bankruptcy, cites issues with revenue cycle vendor,” Becker’s Hospital Review,

https://www.beckershospitalreview.com/finance/washington-health-system-files-for-bankruptcy-cites-issues-with-revenue-cycle-vendor.html.

Dire consequences when collections are neglected

Focus on cost at the expense of revenue cycle?

“Washington health system

files for bankruptcy, cites

issues with revenue cycle

vendor”

Becker’s Hospital Review

Although hospital leadership has actively managed the supply chain… this delay

in cash collections has now become severe enough to potentially disrupt the

organization’s ability to pay for crucial items in a timely matter.”

— Astria Health


Ominous Headlines for Astria Health

• 3-hospital health system based in Sunnyside, Washington filed for Chapter 11

bankruptcy protection on May 6, 2019

• System will use bankruptcy process to restructure its finances, enter into a

plan of reorganization with its creditors, and replace its billing company

COMPANY IN BRIEF




5

Source: 2017 Hospital Revenue Cycle Benchmark Generator; “The Rise of Self-Pay Accounts,” The Association of Credit and Collection

Professionals, Collector Magazine. http://insurancenewsnet.com/oarticle/2015/02/09/the-rise-of-self-pay-accounts-a-592260.html.

Revenue cycle leaders surrounded by challenging forces

The market is not making it easy


• Significant patient obligations puts ever

greater portion of revenue at risk

• Patient collections no longer just additional

revenue; comprises significant portion of

total patient revenue

Patients becoming payersChallenging payer relationships

90% Increase in denials write-

offs, 2011-2017 30% Of average health care bill now

comes from the patient's pocket

• Automated denials result in difficult to

manage volumes

• Complex criteria, requirements makes

prevention more difficult




6

Source: Deloitte Center for Health Solutions and the Healthcare Financial Management Association, “Hospital M&A: When done well, M&A can achieve

valuable outcomes,” https://www2.deloitte.com/content/dam/Deloitte/us/Documents/life-sciences-health-care/us-lshc-hospital-mergers-and-acquisitions.pdf.

Efficiency was never the goal, and was not achieved

Living in the aftermath of the consolidation wave

30% 31%

11%

14% 15%

Don't Know Less than 25% 25-50% 51-75% 76-100%

Percentage of organizations reporting portion of expected

savings actually realized

Anticipated cost savings post-transition

29%Of hospital executives surveyed

sought mergers to improve efficiencies

Bargaining power the main play





7

Source: Physician Advocacy Institute, “Updated Physician Practice Acquisition Study: National and Regional Changes in Physician Employment 2012-2016,”

March 2018; Practice Velocity, “Changing ownership trends in urgent care,” February 27, 2017; “Ambulatory Surgery Center Special Report: 2017 Benchmarks,”

Avanza Healthcare Strategies; MedPAC, A Data Book: Health Care Spending and the Medicare Program, June 2017; Tenet Health Q1 Earnings Call 2018.

Revenue cycle no longer confined to a hospital’s four walls

Expanding into an array of ambulatory assets


Physicians

Urgent care

locations

Ambulatory

surgery centers≈31%Of 10,080 urgent care locations

owned or partially owned by

health systems, 2015

≈ 41%Of 5,602 ASCs owned or

partially owned by health

systems, 2017

≈ 47%Of physicians employed

by hospitals, 2018

Increased diversity of health system investments outside the hospital




8

Proliferating sites of care mean complications for revenue cycle

Systemness challenges go beyond mergers

Multiple payer contracts

Each with its own rates,

carve-outs and exceptions

Integrated revenue cycle enterprise challenges

Different fee schedules

Requires knowledge of

different coding,

documentation requirements

Variable performance

expectations of staff

Revenue cycle staff across

different settings accustomed

to certain processes, metrics

Disparate IT systems

Multiple EHR, billing systems,

chargemasters add

complexity





9

Defining some key terms

Health system

Any health care organization that

provides services at more than one

facility, including acute, outpatient,

and/or ancillary sites


Systemness

The ability to make decisions that are

optimal for the organization as a whole,

rather than for individual service lines,

facilities, or stakeholder groups




10

Defining the integrated revenue cycle enterprise

Hallmarks of revenue cycle systemness


• Divisions of authority between various

leadership structures expressly articulated

• Thoughtful balance of powers between

functions, sites, departments

• Incorporates site-level and functional (e.g.

coding, patient access) representation

• Appropriate level of centralization

according to revenue cycle function

• Elimination of redundant departments and

appropriate levels of staffing

• Consistency in process and performance

measurement

Effective governance Operational efficiency

• Clinicians understand the importance of

compliance with revenue cycle requests,

including comprehensive documentation

• Metrics and incentives are designed to

encourage collaboration, joint success

Clinician alignment

• IT systems facilitate exchange of data across

sites, functions, such as integrated billing

systems, EHR

• Culture of knowledge-sharing extends

beyond transparency to curiosity, reflection

Accessible, interoperable data




11

Barriers on the road to revenue cycle systemness


Lack of

commitment

Lack of access

to critical dataUnclear roles and

inefficient processes

No bandwidth

for change

Initiative

loses steam

Misaligned

org structure

Siloed

operations

Unsure

where to start




12

Generating efficiencies through sustainable change

Revenue cycle’s system advantage


Creating a unified vision

1. Secure commitment from key

stakeholders

2. Clearly chart the course to

systemness

3. Leverage early wins to bolster

support

4. Create capacity for transformation

1Organizing for efficiency

5. Align organizational structure to

critical metrics

6. Where you can’t own, collaborate

7. Standardize roles and processes

to boost productivity

8. Calibrate degree of centralization

2




13

Road mapRoad map


28 Imperatives for generating efficiencies through

sustainable change

3 Coda




14

Source: Ewenstein B, et. Al, “Changing change management,” McKinsey & Company,

https://www.mckinsey.com/featured-insights/leadership/changing-change-management.

Best intentions doomed by lack of unified vision


Consequences of pursing change without a unified vision

Executives do not devote

dedicated resources

Frontline staff fight each

step of the way

Proposal doesn’t solve the

root-cause issue

Proposal is predicated on

unrealistic expectations

Odds not in your favor

70%Percentage of change efforts

that fail, largely due to

employee resistance and lack

of management support




15

Stakeholders have different sets of concerns, require different approaches

Customize your approach to your audience

Frontline staffC-Suite leadership

Top-of-mind

questions

• Does this proposal align with our

strategic goals?

• How much will this cost?

• What’s the expected ROI?

Tactics to

gain buy-in

• Does this threaten my job security?

• How does this affect my day-to-day?

• Can I weigh in on proposed changes?

1. Align proposal to organizational

strategic priorities

2. Show how the status quo isn’t working

#1: Secure commitment from key stakeholders

1. Display commitment to right answer,

not your answer

2. Avoid top-down approach





16

1. Force ranked from most important to least. Source: 2019 Annual CEO Survey, Health Care Advisory Board, Advisory Board.

All 2019 C-Suite priorities bolstered by revenue cycle systemness

Align your proposal to organizational priorities


2019 C-Suite agenda1 Benefit gained from revenue cycle systemness Overlap

Revenue growth Eliminates revenue leakage through improved operations

Cost containment Identifies redundant and unnecessary costs

Population health and risk strategy Standardizes strategy for risk-based revenue capture

Physician partnership strategy Increases physician engagement with documentation

Consumerism and retail strategy Improves patient financial experience and collections

Enterprise-wide systemness Bolsters revenue cycle coordination across system

Innovation Reveals operational challenges prime for creative solutions

Overlap assessment of current C-Suite agenda and revenue cycle systemness




17

Analysis revealed

denials rate for

revenue cycle owned

clinic registration

consistently

outperformed clinic-

owned registration

Chief Revenue Officer at Stanford shows clinic registration denials hurt organizational goal

Using data to highlight current weakness creates urgency

Restructuring patient access at Stanford Health Care

Denials data showed

unacceptable number

of registration denials

Chief Revenue Officer

(CRO) decided clinic

owned patient access

needed to report to

revenue cycle

CRO tied change to

organizational goal of

improving revenue

capture. Demonstrated

expected decrease in

registration denials

System leadership

cleared restructuring





Case in brief

18

• Chief Revenue Officer (CRO) decided clinic-owned patient access

registration areas needed to report to revenue cycle to improve clinic

registration denials stemming from system’s clinics.

• In her proposal, the CRO tied the restructuring initiative to Stanford’s

broader organizational goal of improving revenue capture. The CRO also

demonstrated expected decrease in clinic registration denials.

• As a result, the C-Suite allowed the CRO to take over clinic patient

access registration functions in clinics for key areas.

2-hospital health system in Palo Alto, CA

Stanford Health Care





19

ED/Registration leadership agreed to the change

VP of Revenue Cycle emphasized the need to try a different

model and communicated flexibility and willingness to

change if unsuccessful after six months

ED/Registration leaders initially pushed back against changing

the historic workflow

1. Frontline staff buy-in

VP demonstrates commitment to right answer, not her answer

Performance before personalities

Emergency department coordinator

manages both registration and

clinical tasks in ED

Registration tasks often incomplete and

overlooked in place of clinical tasks

Flexibility gains frontline buy-in at UW Health

Status quo

Steps toward change

System’s front-end model redesign initiative resulted in

recommendation to split the coordinator role in two: one staff

member for clinical tasks and one for registration

1

2

3

4Early indicators are that ED staff like the new model and

registration metrics are trending in a positive direction.5





Case in brief

20

• System’s emergency department registration tasks were often incomplete and

overlooked in place of clinical tasks.

• System’s front-end model redesign initiative resulted in recommendation to split

the coordinator role in two: one staff member for clinical tasks and one for

registration.

• ED/Registration leaders initially pushed back against changing the historic

workflow.

• VP of Revenue Cycle emphasized the need to try a different model and

communicated flexibility and willingness to change if unsuccessful after six

months.

• ED/Registration leadership agreed to the change.

• Early indicators are that the ED staff like the new model and registration

metrics are trending in a positive direction.

3-hospital health system in Madison, WI

UW Health





21

CONNECTING THE DOTS

What was the most difficult

function you’ve had to integrate?





22

Ultimately realized problem

stemmed from patient access staff

not reporting to revenue cycle team,

which meant staff often pulled into

other clinic duties, leaving little time

for necessary attention to detail

1. Pseudonym.

Understanding current operations and identifying pitfalls saves wasted time and resources

Study where you are, to know where you need to go

Crenshaw1 Health struggles to lift patient access performance in clinicsNext, asked corporate

revenue cycle team to lead

hands-on training for patient

access staff

VP of Revenue Cycle

wants to decrease

eligibility denials in clinics,

assumed issue stemmed

around lack of education

First asked clinics to lead

monthly training sessions for

patient access staff

Then, assigned

eligibility denials to

clinic managers to

encourage

accountability





23

Site visits and workflow study enables effective change

AFTERBEFORE

Chief Revenue Officer (CRO) and

Executive Director of Patient Access

& Financial Clearance physically

visited clinics to study

• Patient access workflow

• Patient volumes and workflows

• Patient demographics

1

• Reported up through clinic

managers

• Clinics lacked sufficient training,

revenue cycle support/knowledge

from their respective clinic

manager, and understanding of

the impact of their work

• Exhibited higher rates of

registration denials than their

revenue cycle-owned clinic patient

access counterpart

• Majority of clinic patient access

registration staff report to CRO

across system, with more clinics to

be added over time

• Clinics under the revenue cycle

report decreased registration

denial rate

• Clinic patient access registration

staff now able to seamlessly

transfer to hospital registration,

depending on preference

Restructuring clinic patient access registration at Stanford Health Care


Identified adjustments needed to

mirror revenue cycle-owned clinic

patient access function

2




Case in brief

24

• Clinic patient access registration staff

reported up through their clinic managers.

As a result, staff did not have adequate

training, sufficient support, and clinic

managers were not sufficiently

knowledgeable of revenue cycle practices.

• Clinic registration was often inaccurate and

incomplete, resulting in a higher

percentage of registration denials than

revenue cycle-owned clinic registration

areas.

• Chief Revenue Officer (CRO) decided

patient access in clinics needed to report

through the system’s revenue cycle

department.

• CRO and Executive Director of Patient

Access & Financial Clearance mapped out

the transition by physically visiting each

clinic to understand their patient access

workflow, patient volumes and workflow,

and patient demographics.

• Majority of clinics were transitioned to

revenue cycle leadership, with additional

clinics to be added over time.

• Clinics under revenue cycle now report a

decreased registration denial rate. Clinic

patient access revenue cycle staff are also

able to seamlessly transfer to hospital

registration, depending on preference.

2-hospital health system in Palo Alto. CA






25

Impatience risks premature project abandonment

Expect productivity dip after implementation


Productivity curve throughout change initiative

Pro

ductivity New process

implemented

Time

Productivity dip

2

Productivity

breaks even

New benchmark reached

3

4

1

Measurable returns

Consequences of premature

judgement on ROI

• Change leaders discouraged

by lack of results

• Change initiative deemed a

failure and abandoned

• Organization never reaps

benefits of change, despite

investment

CAUTION




26

1. Pseudonym.

Hooks Health1 reports unparalleled performance after call center centralization

A year of patience is rewarded

System relocates all

patient billing call centers

to centralized location

Centralizing patient billing call center at Hooks Health

Center metrics exceed

baseline performance

Center reported initial dip in metrics:

• Increased patient wait time

• Increased call abandonment rate

• Increased staff turnover

One year later


Hook’s current metric

performance

57 secondsAverage patient wait time

<20%Abandonment rate

<13% Average staff turnover

DATA SPOTLIGHT




Case in brief

27

• System recently centralized all patient billing call centers.

• After the initial change, the center reported a dip in performance metrics,

including increased patient wait-time, increased call abandonment rate,

and increased staff turnover.

• However, the VP of Revenue Cycle stayed patient and allowed an

adjustment period before judging ROI on the centralization.

• One year later, the center’s metrics now exceed baseline performance,

reporting an average wait time of 57 seconds, an abandonment rate less

than 20%, and a staff turnover rate less than 13%.

Medium-size health system in the West

Hooks Health1

1. Pseudonym.





28

On the journey to systemness, things will

often get worse before they get better.

How long does it take to create lasting change?





29

Staff may lose interest as they wait for results

Stakeholder buy-in isn’t static

Tomorrow’s engagement is not guaranteed

Initial stakeholders agree to change

Stakeholders discouraged by delayed

results, no broader buy-in achieved

Early wins are crucial to maintaining

organizational commitment

Early wins:

• Validate the proposal’s vision and strategy

• Give emotional lift to initial supporters

• Attract new supporters through

demonstrated success

• Take power away from cynics





30

Systemness initiatives easier when invisible to patients and doctors

Assessing easy wins for systemness

Potential functions to integrate into health system

Clinical Documentation

Improvement

SchedulingFacility coding Prior authorization Patient accessBusiness office

Increasing difficulty





31

Partnership will make the first win that much easier

Recognize an opportunity when a volunteer approaches you

Measure your success

Build infrastructure together

Director of Patient Access

worked with clinic leadership

to standardize patient

scheduling templates Additional specialties

continue to volunteer.

System hopes to have

most outpatient clinic

prior authorization

centralized in 3-5

years.

Clinics suggested

prior authorization

be centralized

under revenue

cycle team

Multiple clinics

lacked the time and

expertise to secure

prior authorization

for patient visits

UW Health’s transition to centralized outpatient clinical prior authorization

Director of Patient

Access and VP of

Revenue Cycle

agreedRevenue cycle leadership

tracked decrease in prior

authorization denials





Case in brief

32

• Multiple clinics lacked the time and expertise to secure prior authorization

for patient visits.

• Clinics suggested prior authorization be centralized under revenue cycle

team.

• Director of Patient Access and VP of Revenue Cycle recognized

opportunity and agreed.

• Director of Patient Access worked with clinic leadership to standardize

patient scheduling templates.

• Revenue cycle leadership tracked decrease in prior authorization denials.

• Additional specialties continue to volunteer. System hopes to have most

outpatient clinic prior authorization centralized in 3-5 years.


UW Health





33


CONNECTING THE DOTS

Creating short-term wins is different from hoping

for short-term wins:

• Where can you create short-term wins?

• How have you leveraged early wins in the past?




34

Who’s got time for change?

Overwhelmed is the norm


Number of individual change

initiatives hitting a manager

at any one time5-15 400

Number of annual change

initiatives at one representative

health care organization

Everyone is too busy with day-to-day work…We’ve got to collect $4.1 billion, but we

also have to spend a lot of time thinking about going to a combined system. That’s not a

normal task. It’s a BIG lift. My number one concern right now is the pace, and when that

happens combining becomes just a ‘nice-to-have’.

VP of Revenue Cycle, 3-hospital health system in the West




35

Stanford Health Care creates in-house “revenue cycle strategy and analytics” division

Internal teams “keep the knowledge here”


Stanford’s Revenue Cycle Strategy and Analytics

I still use consultants, but not as

much as I did before. I get more

consistency by having it built in.

The knowledge stays here.

Jill Buathier, Chief Revenue Officer

Stanford health care

Composed of one director, several program

managers, and seven FTEs

Oversees revenue cycle strategic planning

efforts, strategy, performance improvement,

analytics/reporting and special projects




Case in brief

36

• Stanford recently created a Revenue Cycle Strategy and Analytics team,

which is comprised of a director, several revenue cycle program

managers (who oversee performance improvement), and seven FTEs.

• The team oversees revenue cycle planning efforts, strategy, and special

projects that were previously handled by IT Clinical and Business

Analytics and external consultants.

• The team allows Stanford to improve project efficiency and retention of

critical expertise.

2-hospital health system in Palo Alto, CA






37

1. Pseudonym

2. Note: This is an ongoing initiative for Lorde Health and not yet complete.

Lorde Health1 leverages HR and Enterprise team over multiple years

Centralizing pre-authorization requires diverse skills and dedication


Study

• Current workflow

• Volume

• FTE utilization

• Job descriptions

Revenue Cycle

VP utilized enterprise team for revenue cycle

Strategize

• Standardize policies,

workflows

• Calculate required FTEs

• Reconfigure job

descriptions

Train

• Epic training

• Policy and workflow

training

Pilot

• Roll out in one dept.

• Log lessons learned

TASKS

TEAMS

Revenue Cycle HR Health Services Engineering

Repeat




Case in brief

38

• System currently working to centralize prior authorization across the revenue cycle.

• Initiative utilizes a range of Lorde’s teams, including Human Resources and

Lorde’s enterprise team, the “Health Services Engineering” team.

• HR, the Health Services Engineering team, and Lorde’s existing revenue cycle

staff are beginning the initiative by studying current operations to understand

workflows, patient volumes, and FTE utilization.

• Change leaders will then standardize policies and workflows, calculate the required

FTEs, and reconfigure job descriptions. They will also train staff on new Epic and

workflow changes.

• Finally, the system’s revenue cycle team will pick a department to pilot

centralization, logging lessons learned before expanding scope to all departments.

Medium-size health system in Mid-Atlantic

Lorde Health1

1. Pseudonym.





39

“We couldn’t do it on our own…Operational staff alone

does not have the knowledge, skills, and abilities to

lead a transformation. You need expertise you don’t

have. You need bandwidth. You need political cover.”

VP of Revenue Cycle, large health system in the West

• Source: Revenue Cycle Advancement Center research and

analysis.





40

Weigh your options for building capacity


Comparison Benefits Drawbacks What it sounds like

Consultants

RISK

QUALITY

COST

• Immediate increase in

capacity

• Objectivity

• Deep expertise

• Agility

• Lack of continuity

• High short-term expense

“I know what happens when

consultants come and go…we

need a really strong discipline

in the organization to keep the

momentum going.”

Revenue cycle

strategy staff

RISK

QUALITY

COST

• Easily accessible

• Maintains knowledge and

discipline close to revenue

cycle team

• Must keep a continuous

pipeline of work

• Hiring difficult

“One of the things I would

have done differently is I

would have hired a dedicated

project director for

consolidation efforts.”

Enterprise

team

RISK

QUALITY

COST

• Specialized expertise

• Objectivity and institutional

knowledge

• Lower cost than external

consultants

• Must wait in queue

“They help drive a lot of

successful initiatives…they’re

unbiased in the process.”

Operational

staff

RISK

QUALITY

COST

• Requires no additional

resources

• Project likely to fall behind

other priorities

• May overload operational staff

“We did it all internally and I

think I almost burnt out all of

my staff.”




41

YOURSELF

ASK

WHO’S MOST LIKELY TO DO THE JOB WELL?

WHO’S LEAST LIKELY?

&

a b c d e





42

Generating efficiencies by achieving economies of scale

Revenue cycle’s system advantage


Creating a unified vision

1. Secure commitment from key

stakeholders

2. Clearly chart the course to

systemness

3. Leverage early wins to bolster

support

4. Create capacity for transformation

1Organizing for efficiency

5. Align organizational structure to

critical metrics

6. Where you can’t own, collaborate

7. Standardize roles and processes

to boost productivity

8. Calibrate degree of centralization

2




43

Division is a slippery slope

Signs of an inefficient revenue cycle

Poor accountability

Missed opportunities for synergy, cost reduction

Limited professional growth

Staff are not measured by the metrics they impact


Disengaged staff

Functional siloes




44

No standard definition for how we organize

The puzzle of revenue cycle governance

Clinic patient access

Health Information Management (HIM)

Physician credentialing and enrollment


?

?

It’s all very confusing as to who is

responsible. It’s almost like a

Rubik’s cube…I’m not at all proud

of how we structure ourselves.

VP of Revenue Cycle

3-hospital health system in the West




45

Some things ARE black and whiteFront office staff reporting to revenue cycle improves performance

“When it comes to denial rate for

registration, we outperform clinic

staff each and every time.”

Source: Becker’s Hospital Review, “Breaking Down Silos to Improve Patient

Flow, Hospital Efficiency,” https://www.beckershospitalreview.com/patient-

flow/breaking-down-silos-to-improve-patient-flow-hospital-efficiency.html;.


“Our pre-admitting call center does not

report up through the revenue cycle

leadership, and as a result, 40%-50%

of our denials are based on eligibility.”






46

UW Health aligned HIM to revenue cycle organization

Govern what impacts you

1

The path to systemness in action:

2

HIM reports to CIO

HIM reports to Revenue Cycle

BEFORE: Functional alignment

AFTER: Strategic alignment

External consultants recommended HIM be re-aligned

to report to revenue cycle; System executive

leadership directed VP to implement recommendation

Through integration and with HIM at the table with

other areas of the revenue cycle, it is now easier to

work towards common goals in the following areas:

• Identity management

• Missing/incomplete documentation

• Releasing information

• Denial management

• Overall EHR information governance

HIM previously reported up through Chief

Information Officer (CIO)

3





Case in brief

47

• HIM previously reported up through the Chief Information Officer (CIO).

• External consultants recommended HIM be re-aligned to report to revenue

cycle; System executive leadership directed VP to implement recommendation.

• Through integration and with HIM at the table with other areas of the revenue

cycle, it is now easier to work towards common goals in the following areas:

– Identity management

– Missing/incomplete documentation

– Releasing information

– Denial management

– Overall EHR information governance

• The restructuring’s full impact on revenue cycle metrics is still pending.


UW Health





48

Delays impact entire system’s metrics

New physician onboarding not just a clinic issue

Onboarding hurdle Consequence of delay

Credentialing

System obtains and validates

physician’s qualification and

experience

1

50-90 daysAverage turnaround time

Physician can neither see nor bill

patients but may still receive salary

Cost of a one month’s

credentialing delay for

primary care physician

$30,000


Payer enrollment

System submits physician’s

credentials to payer’s internal

credentialing review department

2

60-120 daysAverage turnaround time

Physician can see patients but cannot

bill payers for reimbursement

Disrupts cash flow and may

ultimately result in an untimely claim

denial from commercial payers




49

Elevate new physician onboarding to the system-level

Two tactics to systematize physician credentialing and enrollment

Assign new physicians a

credentialing coordinator

Coordinator acts as the physician’s advocate

Secure delegated status with

major commercial payers

Perform all credentialing and enrollment in

exchange for annual audit from payer





Case in brief

50

• System secured delegated credentialing

status with all 36 major payers.

• New physicians are assigned a

credentialing coordinator, who assists the

physician in the credentialing and

enrollment process.

• Physicians only fill out one batch of

paperwork for both credentialing and

enrollment.

• The physician’s paperwork is reviewed by

Medical Director. Director approves “clean

files,” or files without malpractice history,

within 24 hours. If additional time is

needed, the paperwork is reviewed by the

entire credentialing team, comprised of

Medical Director and five physicians.

• After approval, new physician is added to

system’s roster, which is sent to every

payer on a weekly basis.

• Between these two tactics, a new physician

with a “clean file” is credentialed and

enrolled within 20-30 days from date of

hire, compared to the industry average of

60-120 days.

51-hospital health system based in Renton, WA

Providence St. Joseph Health





51

Delegated status eliminates delays from payer non-responsiveness

Leverage system strength to decrease payer reliance


Providence St.

Joseph’s Health

New physician

joins system

Physician

completes

paperwork

System’s Medical

Director approves

“clean files”

New physician

joins system

Physician

completes

paperwork

Delegated credentialing at Providence St. Joseph Health

System’s credentialing

department approves file

Non-delegated

system

Physician added

to system’s

enrollment roster

Physician’s file

individually sent

to each payer

Physician’s

file signed off

by each payer

Physician cleared

to bill patients

10-12 days

60-120 days

Physician cleared

to bill patients




52

Providence St. Joseph Health assigns new physicians coordinators to streamline onboarding

Offer system assistance from the get-go

Credentialing coordinators at Providence

St. Joseph Health

• Each coordinator assigned 200 new physicians

in regional area

• Coordinators serve as the physician’s advocate

during the credentialing and enrollment process

• Assists the physician in filing out one dual

application for credentialing and enrollment

• Enrolls the physician in Medicare and Medicaid

• High school degree or GED required, Associate

or Bachelor’s degree preferred

Providence’s credentialing and enrollment

timeframe from hire date, compared to

industry average of 60-120 days

20-30 days

Physician only fills out one batch of paperwork,

decreasing delays in paperwork completion

System stays informed of the exact status of

the onboarding process

Physician’s early impression of system is

that of support and personalized attention

Benefits of a credentialing coordinator





53


CONNECTING THE DOTS

• Which functions do you own now?

• How hard would it be to get what you need?




54

Critical of top-down mandates to conform

operations to system-wide standard

Concern that clinic claims will be overlooked

for high-dollar hospital accounts

Reluctant to relocate staff to system level

Clinic operations prior to acquisition

Family mentality with unclear division of labor

Revenue cycle functions are wholly-owned

and often on-site

Assumption that acquisition will change little

in day-to-day operations

VPs not likely to receive clinic blessing for full revenue cycle ownership

Clinic integration easier said than done


Clinic objections post-acquisition

“It’s been a challenging and painful process. The doctors scream, ‘I used to have 25 staff and now I have

10.’ But that was because they weren’t making money in their practice. That’s why they sold it to us.”

VP of Revenue Cycle, large Midwest health system




55

Stakeholders monitor new strategies to

ensure changes corrected root issue

Staff specialized by denial type:

1. Pseudonym.

Steinman Health1 clinics own denials management, but denials mitigation is collaborative

Compromise with collaboration

Subgroups meet weekly to discuss how

adjustments impact their specific setting

Monthly meetings to root-cause denials

and brainstorm workflow adjustments

Denials management

Denials management owned and operated by clinics

Denials mitigation

$200K Recovered revenue from denials

coordinators in one month’s time

One system-wide workgroup with both professional

and hospital stakeholders

6% Steinman’s system-wide

initial denial rate


Denials coordinators work denials that require

clinical coding (e.g. medical necessity)

Clinic billers work mundane denials

(e.g. eligibility, registration errors)




Case in brief

56

• Denials function within clinics split between management and mitigation.

• Denials management owned and operated by clinics, with staff specializing by

denial type. Denials coordinators work denials that require clinical coding (e.g.

medical necessity) and clinic billers work mundane denials (e.g. eligibility,

registration errors).

• Steinman’s denials coordinators recovered $200,000 in one month.

• Clinic denials mitigation is operated via one, system-wide workgroup of

professional and hospital stakeholders.

• The workgroup holds monthly meetings to root-cause denials and brainstorm

workflow adjustments. Subgroups meet weekly to discuss how adjustments

impact their specific setting.

• Steinman reports a 6% initial denials rate across the system.

Large health system in Mid-Atlantic

Steinman Health1

1. Pseudonym.





57

System strength increases denial leverage over payers

Clinics own denials, with option to call in reinforcements

1Attempt appeal

• If denial trend remains

unresolved in the JOC

log, the issue is escalated

to the System CFO

Flag leadership

42Elevate to system

• PB Follow Up and Denials

staff first attempt to appeal

denial through typical

processes

• If denial trend remains

unresolved, the trend is

escalated to the system’s

payer representative

• Representative tracks the

denial trend and brings

issue to routine

conversation with payer

• Most denial trends are

resolved at this stage

• If needed, denial trend is

elevated to the monthly

joint operating committee

(JOC) meetings with the

payer and the system’s

managed care team

3Loop in JOC

Ochsner Health System’s appeal escalation strategy

2%-3%Ochsner’s PB initial

controllable denial rate





Case in brief

58

• System’s professional revenue cycle owns denials management with option to elevate

denial to the system level if needed.

• PB Follow Up and Denials staff first attempt to appeal the denial through typical

processes.

• If denial trend remains unresolved, the trend is escalated to the system’s payer

representative, who brings up the issue in routine conversations with payer.

• If needed, the denial trend is elevated to the monthly joint operating committee (JOC)

meetings with the payer and the system’s managed care team.

• If denial remains unresolved in the JOC log, the denial is escalated to the System CFO.

• Ochsner Health System reports a initial controllable PB denial rate initial of 2%-3%.

30-hospital health system in southeastern Louisiana

Ochsner Health System





59

• Source: Revenue Cycle Advancement Center research and

analysis.


“Everybody wore all the hats, and everyone pitched

in…but we didn’t collect the money, we had high

denials, and the patients weren’t satisfied.”

VP of Revenue Cycle, large health system in Midwest




60

• Clear accountability

• Reduced duplication of effort

• Streamlined workforce

• Improved quality

Standardizing roles and processes avoids overwhelm, lost productivity

From chaos to clarity

Ill-defined roles and

processesStandardized roles

and processes

• Endless requests

• Countless trade-offs

• Rampant juggling

• Lost productivity





61

1. Pseudonym.

Standardizing patient access at Morrison Health1

• Report to clinic manager

• Provide clinical administration support,

operational support, and revenue cycle support

• Report to revenue cycle

• Scheduling

• Insurance verification

• Registration

Clinical staff Non-clinical staff

Before: Generalist role After: Roles delineated by focus

• Report to clinic manager

• Patient medication questions

• General office support

Non-clinical staff able to switch patient access

settings, if desired

Improved performance on revenue cycle metrics

Staff collectively ignores unpleasant tasks

Unclear accountability

Shifting priorities

Constant interruptions

Patient Access staff





Case in brief

62

• Clinic patient access staff did not report up through revenue cycle. As a result,

staff rarely prioritized revenue cycle functions.

• VP of Revenue Cycle wanted to take over staff reporting and standardize role

across system’s settings.

• VP split the clinic’s patient access staff in two: clinical staff now report to the

clinic manager and do not execute revenue cycle functions. Non-clinical staff

report to revenue cycle and handle scheduling, insurance verification, and

registration.

• As a result, the system’s clinics report improved revenue cycle performance

and increased staff engagement in the clinic’s patient access, as non-clinical

staff are able to switch to the hospital’s patient access setting, if desired.

Large health system in Midwest

Morrison Health1

1. Pseudonym.





63

Source: Davidson, N, “The Funniest Video Game News Headlines Ever,” Ranker, https://www.ranker.com/list/funny-

video-game-news-headlines/nathandavidson/2017/01/31/how-video-games-can-save-the-world#1109cea9dddb.

Actually, a lot…

Games, what are they good for?

Rescuing the

revenue cycle?!?

AND…Getting a job

21-year-old gamer landed a job as

a football manager, after playing

the game “Football Manager”

Many companies consider good

guild-masters in the World of Warcraft

video game to be effective leaders.

Leadership development





64

Vendor agreed to

work with Sharp to

create platform.

Seven months from

commitment to pilot

group implementation

Source: Lopukhina, D. “How Gamification in the Workplace Impacts Employee Productivity,” Medium,

https://medium.com/swlh/how-gamification-in-the-workplace-impacts-employee-productivity-a4e8add048e.

Frustration – the other mother of invention

Gamifying pre-billing


I was talking to my daughter and she kept looking down at her phone. I was

starting to get annoyed and realized she was playing a game. She said she

was almost to the next level and it hit me that my employees are doing

something similar (working accounts) but they don’t know if they are almost

to the next level.

Gerilynn Sevenikar, VP of Revenue Cycle

Sharp Healthcare

90%Percentage of employees that are

more productive when they use

gamification

70% Percentage of business

transformation efforts that fail due

to lack of engagement

48%Average gamification boost to

engagement

Why gamify?

VP pitched the

idea to vendor




65

Effective gamification requires a definition of excellence

Building the game

Workgroup articulates the

gold standard workflow

Gamification layered on top of

trigger events in workflow

Gamification platform creates extreme clarity about expectations

Staff earns coins based upon

level of adherence to gold

standard workflow

1 2 3

Badges Real time feedbackLeaderboards

Staff sees performance against peers and gets recognition in real time





66

Level up!

10% Reduction in FTEs

10%–35%Increased productivity

18 months into three year

pilot with pre-billing


Previously, I would never know if employees had their

most productive day. The employee wouldn’t even know.

Now throughout the day, we both know if they are tracking

to have their ‘best day ever’ and we can celebrate it!


Sharp Healthcare

Staff proactively taking on

greater workloads




Case in brief

67

• VP of Revenue Cycle recently electronically “gamified” pre-billing functions of the

revenue cycle.

• VP pitched the idea to their existing vendor, the vendor agreed to develop the game

over a seven-month timeline.

• To develop the game, a system workgroup studied the pre-billing function and decided

on a gold standard workflow. The vendor then laid an analytics platform on top, so

when an employee executes the complete gold standard workflow, their avatar is

rewarded with electronic coins.

• Through this game, pre-billing staff see their performance against peers and get

recognition in real time.

• As a result, Sharp has measured a 10%-35% increase in productivity for all pre-billing

employees. This increase has allowed them to reduce staff by 10% while maintaining

best practice DNFB and clean claim rates.

7-hospital fully integrated health care system based in San

Diego, CA

Sharp HealthCare





68

Centralize according to your needs


One

location

Unified

workflow

Common

information Benefits Applicable to

Virtual

Centralization □• Reduce cost by saving space

• Avoid getting employees pulled

into non-essential tasks

• Coding

Centralization

• Minimize duplicative services

• Reduce FTEs

• Leverage scale

• Business office

• Prior authorization

• Patient call centers

Co-location □ □• Facilitate collaboration

between staff

• Billers

• Cash posters

Decentralization □ □• In-person communication

with physicians• CDI

Collaboration

Responsiveness

of physicians

Focus

Use when you

want to increase




69

1. Centralization Source: 2017 Hospital Revenue Cycle Benchmark Generator.

Central business office ubiquitous for a reason

No shortage of reasons to integrate the business office

Patient access0.7%

Mid-cycle0.8%

1.2% Business office

2017 Advisory Board Hospital Revenue Cycle Survey

Median cost to collect by area (% NPR) Benefits of a centralized business office

Biggest cost center within revenue cycle

Under control of finance

Farthest from physician involvement


“Any fully integrated health care delivery system will have at

least some version of a central business office.”


SHARP Healthcare




70

Unity Point chooses top-performing region as location for financial clearance center

Centralization not just for billing functions

Centralizing patient financial clearance

Before

• Unity Point’s financial clearance functions performed by patient

access staff in each site of care

• Each region reported differing performance on key metrics,

such as authorization denials and point-of-service collections

Executive Director of Patient Access proposed centralizing

financial clearance functions across the system

After

Director identified Quad Cities region as best location for patient

financial clearance center due to region’s

• Existing leadership structure

• Top-notch metric performance

Quad cities region

1

2

Benefits of centralized financial clearance

Improved performance of authorization

denials and POS collections

Reduced number of FTEs

Standardized patient experience

across system





71

Centralization provides consistent pre-access performance, patient experience across system

Two work streams cover six of the system’s regions

50%Measured reduction

in front-end denials

for one region,

within 6 months of

centralization

Patient schedules care

Must provide minimum data set

schedule non-emergent care

• Full demographics

• Full insurance information

Pre-access work stream

• 15 pre-access specialists

• Mail patient price estimates

• Attempt to collect portion of

obligation via phone

Pre-authorization work stream

• 12 authorization specialists

• Secure pre-authorization for

outpatient and inpatient

services

Financial clearance center

Financial clearance at Unity Point

Patient arrives for care

If patient obligation could not

be collected via phone, patient

access staff will request

payment at check-in





Case in brief

72

• Recently transitioned six of the system’s regions under a centralized financial

clearance center

• System’s Executive Director of Patient Access identified the top-performing

region as the location for the center

• Centralized financial clearance center has two work streams

– Prior authorization team oversees inpatient and outpatient authorizations

– Pre-access team generates patient price estimates and attempts to collect

portion of patient obligation before care

• Since the initiative, Unity has measured a decline in front-end authorization

denials for all regions under the centralized model, reducing one region’s denials

by 50% within 6 months. In addition, the system has measured a system-wide

increase in point-of-service collections

• Unity is currently working to bring all regions under the financial clearance center

20-hospital health system based in West Des Moines, IA

Unity Point





73

1. Pseudonym.

Morrison Health1 professional and facility billers address underpayments together

Boosting synergies and normalizing workloads


• Professional fee and facility billers

were physically siloed

• Each biller could only address

underpayments for their particular

payment type

Billers have increased payer

leverage and resolve underpayments

in a shorter timeframe

Co-located billers at Morrison Health

• VP of Revenue Cycle co-located billers

• If billers are struggling with a specific

underpayment, they will contact the

payer together, pulling up the entire

episode of care




Case in brief

74

• System struggled with payer underpayments across inpatient and

outpatient settings.

• VP of Revenue Cycle decided to co-locate professional and facility billers.

• As a result, billers enjoy increased leverage over their payers. When a

payer underpays a claim, the billers can pull up the entire payer record

and start talking about both facility and professional underpayments.

Large health system in Midwest

Morrison Health1

1. Pseudonym.





75

1. Virtual Centralization

Taking functions remote is the ultimate overhead reduction opportunity

Coding highly amenable to virtual centralization

Partners moves hospital coding offsite…

Hospital coding

100% remote

coding FTEs

84Encounters processed

per day

2,124

Estimated savings compared

to non-remote centralized

coding, per FTE

$10KEstimated savings for

offshore staff, per FTE

$55K

Removed physicians from charge capture,

reducing administrative burden

Improved accuracy and efficiency of coding;

expect to eliminate need for 10 coding FTEs

Professional fee coding

Staff manually inputs codes based on

documentation

In-house IT tool translates EHR-based

documentation into billing codes

Remote work strategy

Takes advantage of coding talent shortage in local

market by tapping national labor pool; offshore strategy

takes advantage of labor cost savings

Benefits

…and automates professional fee coding

Legacy process

Automated process





Case in brief

76

• System struggled with coding talent shortage in local market and wanted

to reduce costs across the revenue cycle.

• VP of Revenue Cycle moved all hospital coders to virtual centralization,

saving an estimated $55,000 per off-shored FTE.

• VP also automated professional coding to through an in-house IT tool that

translates EHR-based documentation into billing codes.

• Automation of professional codes has improved accuracy and efficiency

of coding; system expects to eliminate need for 10 coding FTEs.

11-hospital health system based in Boston, MA

Partners Health





77

CDI programs must maintain facility-level presence

CDI benefits from in-person interactions


CDI functions that require local support

Physician rounding

Provides an opportunity for specialists

to teach clinicians what details should

be included in the patient chart; helps

specialist understand patient status

Physician queries

While most programs use an electronic

or automated query process, in-person

physician follow-up, or escalation to the

CMO, may be necessary

Physician education

CDI specialists must provide multi-

specialty, specialty-specific, and

sometimes individual education that

shows link between documentation,

quality outcomes, and reimbursement

In-person education critical for program success

“80% of our educational events are held face-to-face. We tried using webinars, but

physicians were not engaged, and we saw no improvements in documentation.”

Manager, Coding and Clinical Documentation Improvement Department




78

Source: Prosci Inc., “Best Practices in Change Management,” 2014,

https://www.prosci.com/resources/articles/reinforce-and-sustain-change; .

Systemness must be sustained

Don’t let complacency kick-in


61%Percentage of successful

change projects that

implemented

sustainment efforts

Common causes of unsustained change

Premature judgement on project outcomes

Poor communication with key stakeholders

throughout the change process




79

Source: Sirkin, H et al., “The Hard Side of Change Management,” Harvard

Business Review, https://hbr.org/2005/10/the-hard-side-of-change-management.

Success is not just a roll of the dice

Four factors predict success in any transformation initiativeP

robabili

ty o

f success

DICE score

Duration

Integrity

Effort

The project team’s

performance

integrity; that is, its

ability to complete

the initiative on timeDuration of time until the

change program is complete

or amount of time between

reviews of milestones

The commitment

to change that

top management

and employees

affected by the

change display

Harvard study found that project

success was positively

correlated with the strength of

four metrics.

The sum of these metrics is

called a DICE score:

DICE = Duration + Integrity +

Commitment + Effort

Commitment


The effort over

and above the

usual work that

the change

initiative

demands of

employees




80

Road mapRoad map


2 8 Imperatives for generating efficiencies through sustainable change

3 Coda




81

Few systems boast unified IT

…leaving the patient lost in the middle

Hospital B

Patient Account

System

Hospital A EHR

Clinic C EHR

Clinic D Billing System

Many systems rely on multiple platforms…

Consequences of disparate IT systems:

Patient asked demographic data multiple times

Patient receives multiple bills

Staff unable to answer patient account

questions across settings

“When I think about the patient who sees Kettering Health

Network on the billboards and chooses us for their care—

they are trusting one brand. The more we look, act, and

perform alike, the better for our patient.”

JoAnn Yohn, VP of Revenue Cycle

Kettering Health





82

Overheard in a fragmented system





83

1. Survey data only: Includes all operational and depreciation revenue cycle costs, including staff salaries and

benefits, technology solutions, outsourcing costs, and overhead costs (space, office materials, etc.).

2. Low, median, and high performance categories correspond to 25th, 50th, and 75th percentiles

3. As a percentage of Net Patient Revenue, for an average 350-bed hospital with $350M in Net Patient Revenue Source: 2011-2017 Hospital Revenue Cycle Benchmarking Survey.

Cost-to-Collect stagnation: No more gains available, or lack of systemness?

Efficiency achieved?

Full cost to collect1,2

Percentage of net patient revenue

n=51 (2011); n=31 (2013); n=59 (2015); n=48 (2017)

2.8%

2.3%1.9%

4.2%

3.0%2.6%

4.0%

3.0%

2.0%

3.7%

3.0%

2.2%

Low performance Median High performance

2011 2013 2015 2017

2019 Revenue Cycle benchmarking coming soon

We are currently accepting submissions. Please email

[email protected] for more information.




mailto:[email protected]


84

1. Electronic Data Inquires

Source: Konda S, “Artificial intelligence can alleviate revenue cycle management

challenges“ Medical Economics, http://www.medicaleconomics.com/technology/artificial-

intelligence-can-alleviate-revenue-cycle-management-challenges.

Wide variety of capabilities on display

Opportunities across the revenue cycle spectrum

Envisioning a revenue cycle powered by AI

Machine learning

optimizes EDI1

queries

Documentation

Patient Access Mid-Cycle Business Office

Machine learning improves

patient price estimates

Natural language

processing generates

claims with computer-

assisted coding

Scheduling and

Pre-Registration

Registration BillingArrival CollectionsCoding Discharge

Natural language

processing automates prior

authorization questions

Machine learning

optimizes edits by payer

Machine learning

scores denials to

inform high

potential appeals





85

If insurance is discovered, technology updates the patient

accounting system and sends new coverage information to billing

Technology logs onto payer portals and checks all self-pay

patients eligibility within 25 minutes

System struggled with keep pace with

self-pay patients needing to be screened

for eligibility after registration

Legacy process was entirely manual and

required 2-3 hours of work each day

MedStar Health’s automated eligibility verification

Source: Becker’s Hospital Review, “Employing a Digital Workforce to Transform the Revenue Cycle,”

https://go.beckershospitalreview.com/employing-a-digital-workforce-to-transform-the-revenue-cycle.

MedStar uses RPA to automate eligibility verification for self-pay patients

The first step towards automation

Status quo Steps to change

System partnered with Olive, an AI vendor, to automate self-pay

eligibility verification with robotic process automation (RPA)1

2

3

4

Technology automatically assigned to examine self-pay

patients registered the prior day

Number of eligibility

transactions in first 9 months

of implementation

198,000

25 minutes Time required to check each

day’s batch compared to 2-3

hours under legacy process





Case in brief

86

• Recently partnered with Olive, an AI vendor, to automate self-pay eligibility

verification with robotic process automation (RPA).

• Technology was built and deployed within 22 days.

• Technology automatically assigned to examine patients registered the prior

day. It logs onto each payer’s portal and checks each day’s batch of self-pay

patients for eligibility.

• If insurance is discovered, technology updates the patient accounting system

and sends new coverage information to billing department.

• Technology can check each day’s batch within 25 minutes, compared to

previous timeline of 2-3 hours under manual verification.

• Within 9 months, technology has competed 198,000 eligibility transactions.

10-hospital health system in Columbia, MD

MedStar Health

Source: Becker’s Hospital Review, “Employing a Digital Workforce to Transform the Revenue Cycle,”

https://go.beckershospitalreview.com/employing-a-digital-workforce-to-transform-the-revenue-cycle.





87

1. **Requires complex data infrastructure

Revenue Cycle AI held back by our underwhelming data infrastructure

Are we standing in our own way?

Four degrees of AI technology

Robotic process automation (RPA)

Natural language processing (NLP)**

Machine learning (ML)**

Deep learning (DL)**

Incre

asin

g c

om

ple

xity

“AI isn’t just a black box that you plug in to

perfect operations. This technology is

actually predicated on your ability to

feed in comprehensive data. That’s why

vendors with giant clearinghouses of claims

are the only players we see right now in

revenue cycle automation.”

Senior Advisory Board Researcher

Overheard in the research





88

Look for additional research on AI in the revenue cycle in late 20191. Coming soon


CONNECTING THE DOTS

Have you explored using AI in the

revenue cycle?




Credits

89

Stefanie Kuchta

Design Consultant

Eric Fontana

Program Leadership

Anita Mago

Rachel Matthews

Research Team

[email protected]

Robin Brand

Project Director

Revenue Cycle Advancement Center



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