Revenue Cycle

Admissions/Registration: Helping to Improve Accounts Receivable

One of the most important ways to improve A/R is the admissions/registration areas of any healthcare organization.

Many facilities band-aid issues within the admission/registration areas by correcting errors in billings, which is not effective nor is it cost efficient.  It is estimated that it costs healthcare facilities $15 per visit to track and collect co-payments and deductibles after the fact.  For many healthcare organizations, such as physician offices, this practice could result in a zero net revenue gain.  Additionally, it costs healthcare facilities approximately $15 – $25 per visit for billing staff to correct registration errors and approximately $15 per statement sent to patients for co-pays, deductibles and co-insurances that could have been collected upfront.

So what steps can a healthcare facility take to remove the admissions/registration area band -aids and ultimately improve their A/R?

Step 1:  Management should be open to change

Most admission/registration managers have vast experience in their field and want nothing but a well-run department.  However, for many managers the stress of running a high-volume department that can potentially be open 24 hours a day does not allow them the luxury of thinking outside the box.  Staff may not be willing to discuss issues with management, some applications do not provide error reports to managers, and some applications do not record who made the error(s) so they cannot be addressed with that individual.  For improvement and changes within the admission/registration areas, management must be open to change, permit their staff to assist in recognizing issues and require their application(s) or MIS department to provide error reports.

Step 2:  Assign an impartial third party

The first step in this process is to assign the task of meeting with the admission/registration areas to an impartial third party.  This is the most important step in this process as admissions/registration needs to feel comfortable in discussing all issues they face daily without fear of retribution or criticism.  The impartial third party should not only meet with management of these areas, but with 75% of the staff covering all shifts.

 Step Three:  Logging issues

This is not the time to address or correct issues that are discovered.  Although issues presented need to be clear and concise, they should not be demonstrated or dissected as this is purely a fact finding process.  All issues discussed are to be logged no matter how insufficient they may appear.

Step Four:  Organization

Issues need to be organized into categories such as process, system, staffing, training and education.  Once this is accomplished a meeting should be held with management to determine what issues are the priorities and can be addressed immediately versus issues that may take time to resolve (such as lack of staff).

Step Five:  Resolving issues

Process issues:  It is imperative that management and staff be open to resolving processing issues.  A process should not be kept in place because it has “always been done this way” but because it enhances the admission/registration process.  An impartial third party can assist management in looking at the processes, determining if they are assisting or hindering the workflow and changing what does not work.

System issues:  Are the admission/registration pathways specific to your site or are they generic?  Does the application provide “help” screens or pathways that are easy to maneuver and are they specific to your site?  Are required billing fields designated as “must enter” and won’t allow staff to bypass?  Is your IT staff knowledgeable of your environment and application?  Is your application vendor directly involved with improving your application pathways?  Can your staff search for a patient’s prior admission/visits within the application?

Staffing:  Are the errors the result of under or overstaffing?  Both can be issues for admission/registration areas as too much work per staff member can cause a hurried approach whereas too many staff can cause disruptions in daily work.  When are most of your admissions/registrations?  Can your facility add or deduct staff according to daily needs?  Are pre-admissions/registration the practice of your department so that most of the information can be input prior to the patient’s visit?

Training:  Has your staff been properly trained in the workflows of the department and admission/registration pathways within the application?  Does staff understand what fields are required and why?  Does your staff update prior admission/registration information or just process the data?

Education:  Correction of errors must be done by the admission staff and not billing.  This is very important because they need to understand what constitutes an error and why.  Some applications only record the last person who worked on the admission/registration versus who made the error.  This limitation should not stop management from requiring error correction.  Although the last person who touched the admission/registration may not have made the error it is the responsibility of anyone who touches the admission/registration to ensure all information is correct.

Holding registration responsible for errors is a proven tool that will assist staff in knowing what an error is, assist management in recognizing what staff training needs are and allows billing to concentrate on their job responsibilities.  As registration is made aware of their errors, it is imperative to teach them how to perform registrations and keep them from repeating the same errors over and over.  Correction of their own errors will assist in staff in adhering to policy, train them in proper registration processes, and will ultimately decrease billing errors and free up billing to perform their job responsibilities.

Why FSC Consolidation?

A front desk representative stares at the pick-list of Financial Status Categories (FSCs), trying desperately to match one of the myriad choices to a patient’s Aetna HMO plan. Should she choose “Aetna HMO,” “Aetna HMO/POS CAP,” “Aetna HMO/POS Non Cap,” “Aetna Medicare HMO,” or “Aetna Medicare HMO/POS?”  What is the difference between them?  What does all this even mean?  With so many choices, in all probability, she’ll choose the wrong one.

As a result, incorrect edits will be applied, the claim will be routed incorrectly and will be denied. Unnecessary man-hours will be spent correcting the error and resubmitting the claim.  But again, the problem of too many FSCs available remains.  More denials, more man-hours wasted.  Eventually, the patient is billed.  More time is spent in customer care calls before the charges are finally resolved, if they are resolved.  In a worst-case scenario, the patient refuses to pay for services which are covered by their insurance and the invoice goes into collection.  Nasty reviews on social media and bad word-of-mouth could be the least of the trials faced by a good practice that only wants to be able to focus on quality patient care.

All because the organization has too many FSCs.

The most common reply to an entity being informed they have too many FSCs is “So what?” How could having too many financial classes possibly hurt an organization?  The answer is “a great deal.”

The impact of too many FSCs include:

  • Confusion about which FSC to select for registration
  • Increased time needed to register a patient
  • Claims routed to the incorrect payer ID or address
  • Increased rejections or denials creating additional work for A/R staff impacting, productivity, days in A/R, and revenue/cash flow
  • Reduced customer satisfaction due to incorrect billing
  • Increased customer service calls
  • Possible compliance issues, as certain plans have specific regulations associated with them
  • Fines or lawsuits because of an audit or customer complaint
  • Inaccurate reporting reflecting insurance activity

Luckily, it is not difficult to resolve all these issues and reduce FSCs to a manageable number. Common scenarios indicating the need to consolidate are the sheer number of FSCs, poor claims submission resulting in high numbers of rejections/denials and high days in A/R rates.

Once a need for consolidation has been determined, all that is needed is to plan the future state of the organization’s FSC structure and then implement.

Part of setting the future state is determining which FSCs are obsolete. Useful tools for this decision are examining which FSCs have the most A/R, billing rules such as claim forms, state regulations, and payer rules/billing requirements.  Revenue activity, claim production, and payer rules all have direct bearing on determining if a FSC is obsolete or a living, useful component of an organization’s revenue cycle.

Once FSC requirements are determined and broad FSC groups are laid out, individual FSCs can be analyzed and consolidated into a surviving FSC. It is also possible to eliminate FSCs which are completely obsolete and can simply be deactivated.

The overall goal is to have a minimal number of FSCs in the future state. A simple optimization resulting in big payoffs across the full revenue cycle.



Creating and Implementing a Revenue Cycle Management Denials Committee

A denials committee is a necessity for effective revenue cycle management for hospital and physician groups. It is a great initiative to help organizations identify trends and issues surrounding specific denials, whether they are front or back-end denials. It provides transparency and opportunities for improvements, such as reduction in denials, increased cash flow and reeducation opportunities. With the right tools and participation, this can be a very successful endeavor. There are many crucial aspects and key players necessary in order to be effective. In addition, having the necessary reporting tools and analysis to provide the data are also essential components.

Recently, a hospital with multi-specialty departments in Arizona was seeking to implement a denials committee. Once key players were determined, we had to work with the leadership in the central business office to engage the key players or their designees. Initial communication was sent to executive leadership to explain the intent of this committee and what we were trying to help them accomplish with these bi-monthly meetings. The initial meetings were informational and the meetings that followed were considered working meetings in smaller sub-groups. With multi-specialty hospitals the start-up process can be a little more difficult, but not impossible. It is essential that there is a leader from the organization that is able to identify the leadership for each department.

At the first meeting, we gave an introduction as to who we were, our goals and the end result that we were trying to attain. The initial meeting sparked interest and created a sense of eagerness to find out where the denials were coming from and why. Once there is interest and buy-in from the senior leadership, then the meetings can move forward and be effective.

After the initial meetings, training was provided on the reporting tool that was being utilized as a data tool for denials. The training was broken down into separate sessions to ensure that the users had hands-on experience with the reporting tool. It is important for users to look at reports independently and prepare for upcoming meetings. After the training, we demonstrated the denial trending and provided assistance with report review.

Once the working meetings started, specific examples of the top five denials for the client were provided, including eligibility denials and the front-end staff. Detailed audits on hundreds of accounts were performed in order to provide the details on why the denials occurred and to discuss solutions to reduce these denials. We continued to do audits on the top denials to try and reduce the denial percentage for the client, while asking team members to also investigate on their end.

This is a prime example of how to successfully establish a denials committee. Organizations should consider implementing these committees since it is proven to be effective in reducing denials and increasing cash flow. It is important for health systems to also remember to continue the meetings so that no momentum is lost and their revenue cycle can flourish.



Engaging in Process Improvement & Organizational Transformation Prior to a Revenue Cycle System Implementation

In today’s healthcare environment, it is no longer as simple as designing, building, testing and going live on a new revenue cycle system (not that that is simple in and of itself), it is assessing and transforming all of the processes and structures impacted by it. Building the old Three-Legged Stool of People, Processes and Technology.

Having led multiple business and process transformations, I have found that the ideal time to begin this journey is a couple of months prior to the vendor implementation kickoff; this is true whether it is internal client resources, an outside consultant or a vendor team performing what amounts to an additional project. This allows time for a multitude of actions to take place and benefits to be reaped.

One, it gives you the opportunity to really understand what the current state of your business is, what is working well currently and where efficiencies can be made.

Second, this deep dive provides a good look at the skills of your resources and where they might be a better fit in a new structure. Much like in sports, putting a person in a position and system that is more suited to their skills as opposed to forcing a square block into a round hole can result in increased productivity and job satisfaction.

Third, without a doubt, during the system selection and SOW processes, specific KPIs and goals surrounding those metrics were identified as key reasons for a new system and areas of needed improvement. Early stage process and business transformation planning provides a more clarifying look into these metrics, what workflows are causing a certain metric to be lagging or shining.  This also provides the opportunity to shape your future state workflows and structure around the new system.

Fourth, you will engage all of the affected organizational entities and provide them a good understanding, or reinforcement, of why the change is taking place and what to expect during the implementation. It opens an avenue of communication that allows for shared goals to be made, demonstrate how it will bring value to not only their individual roles but to the organization’s overall goals and mission, this cultivates trust and project buy in to occur.

Fifth, it lays out a roadmap of recommendations to the future state of your processes and organizational structure and actions that need to occur throughout the system implementation; as well as a more immediate foundation for the revenue cycle system design about to take place.

Altogether, getting started with process and organizational transformation ahead of the system implementation alleviates having to perform this separate project concurrent to the system implementation. This will reduce stress and additional potential unknowns to pop up.  The implementation team of resources will be under an immense amount of pressure to design, build, test and go live with a new revenue cycle system.  Although the roadmap has been set prior to the implementation kickoff, implementing these decisions still must happen throughout project, but again, you are not gathering documentation and making decisions at the same time.

One other major benefit that is often overlooked is the cutover and post go-live need for a large amount of optimization. Upon cutover, you will see a smoother transition with less impact to metrics (A/R, cash, denials, etc.). Instead of reacting to the change in systems, you have anticipated them and put effective changes in place ahead of time.  No doubt you will need to perform health checks which will result in system and structure tweaks.  What getting your transformation started early and completed with the implementation accomplishes, is to exponentially decrease the post go live optimization needs.  Smaller adjustments as opposed to brand new committees, additional resource time, project ramp up, stress and of course dollars spent.

A couple of final thoughts that will be keys to making a process and business office transformation successful. Draw upon your well of knowledge and experience and relay specific examples of where you have seen this work; as importantly, really attempt to make a personal connection to the individual or groups you are communicating with.  Trust is a very big deal, change is difficult and for many people, scary.  Have a plan going in and execute it, work hard, take what you are doing seriously but don’t take yourself too seriously.

HFMA MA/RI conference 1/20 @ Gillette Stadium

Please stop by and see us at Table # 48 at the HFMA MA/RI conference.

Dr. Nancy Gagliano (CMO -Culbert) and Jaffer Traish (VP Consulting) will be presenting @ 2:45

Physician Change Management, EHR Documentation Opportunities and Revenue Cycle Optimization


Optimization with Provider and Patient Experience

After the implementation of an electronic medical record system, an optimization plan is the next key project that should take place in order to address a multitude of issues and to bring the system and its users to a more efficient and advanced state.   The concentration of these projects are usually geared towards increasing revenue and/or patient volume as the end goal but what is often overlooked are the provider and patient experiences.  By incorporating provider and patient experience with increasing revenue/patient volume as goals for optimization, a positive synergy occurs that will produce happier staff which correlates to better performance and revenue in the clinic.


There are several common things that most clinics struggle with post implementation; unable to get back to patient volume pre-implementation, check-in and wait times for patients are typically much longer than before, unable to close charts timely and efficiently, providers and support staff working long hours and many other issues that contributes to unsatisfactory experience for both the medical staff and patients.  In order to identify a thorough assessment of issues, these are some things that should be considered when planning an optimization project:

1.Assess the current state of workflows through shadowing the complete process from check-in to check-out. Shadowing should be done several times throughout the week to accurately capture an overview of workflows in different atmospheres. For example, the clinic may be busier on Mondays than on Fridays so both current states should be documented to understand how staff are being utilized, how long patients wait to see a provider and other useful information that can be revealed by the varying levels of patient volume.

2.Interviews with providers and support staff should be conducted on a 1 to 1 basis to identify trends of issues. Is there enough support staff to assist providers?     Are providers pushing work to the support staff? Are there enough workstations in the clinic? Are there issues with locating print jobs? This is important to allow the staff an opportunity to express issues that occur in the clinic without fear of being reprimanded. This will also give the staff a sense that their issues matter and that they are also have a stake in the improvements of processes that affect their daily jobs.

3. Surveys or other forms of metrics for patient experience should be gathered to identify issues. How was the process for registering and scheduling an appointment? Are patients leaving the clinic with meaningful office visit information? Was the communication and follow up with the clinic easy or difficult? These are some of the things that can be used to identify areas of improvement to minimize unnecessary follow up with the practice.

4.In addition to shadowing and conducting interviews, metrics from the system should be used to identify areas of improvement. There are dashboards and reports in the system that can be generated to further reveal issues. Is the build set up correctly that supports both providers and staff? Do they have the necessary tools to carry out their jobs? Are the providers’ orders-tracking and follow up manageable in their In Basket? Do patients have the ability to review their medical information and communicate with the clinic securely?

All of these steps above may seem to be an obvious way to approach optimization but most organizations jump to the conclusion that inefficiencies and the inability to increase revenue and satisfaction scores are solely due to the implementation of a new system since it was a significant and most recent change for the organization. By considering the provider and patient experience as a part of the optimization, this will create a more successful outcome.  The people who interact with the system on a daily basis  are the providers and patients so it is important that this should be considered and incorporated during an optimization plan.


Translating EHR Training Into Improved Revenue Cycle Metrics

Technology continues to drive mankind forward in ways unheard of from when the great millennium occurred in 2000! Who would have thought that we would be tied to our smart phones, performing a myriad of functions that once took precious hours of our time? Now, we do online banking, book air travel, hotels, rental cars, and many other daily tasks regardless of where we are!

These same technological advances have, in so many ways, impacted the healthcare industry too. And, arguably, the largest invention has been the creation of the Electronic Health Record (EHR). So, it stands to reason that most of the healthcare institutions have either implemented, or are in the process of implementing the latest and greatest EHR system for clinicians to record, track and share critical medical record information regarding their patients.

The installation of EHR systems may run into the millions of dollars. Often, they are integrated, or interfaced with Billing Accounts Receivable (BAR) systems to provide the tools needed for submitting claims cleanly, and in a timely fashion, for prompt payment. After all, as the saying goes, it truly is all about the Benjamins; it is about healthcare institutions having the funds necessary to succeed and to carry out their Mission Statements.

So, if State of the Art EHR and Billing systems are in place to optimize patient care and outcomes, and if they are designed to bring in a steady stream of required cash to run the institution, how is it that so many healthcare institutions have less than desirable revenue cycle metrics to show for all of the financial investment in the implementation of an EHR system?

During the many system implementation projects that I have led across the country, the single most neglected component of a complex system implementation is End-User Training. Although institutions will invest millions today to ensure that they have the latest and greatest software available for its end-users, tomorrow (after the system installation) they will attempt to minimize costs with a meager training curriculum. In some cases, training is a minimal consideration at best, offering a series of online tutorials; in other cases, training may be a couple of hour sessions for a given application. Often, trainers are limited in their knowledge of the software, or even worse, have no operational background to marry operational tasks with the new system.

In particular, clinicians who ought to become experts on EHR software, are often given minimal instructions regarding the many bells and whistles of a system that contains many wonderful tools for precise, complex clinical data gathering. By the time clinicians grasp the basics on how the EHR works, they are, easily, overwhelmed by the new system and have little time or patience to understand that part of the patient’s record keeping entails the ordering or charging for services rendered. This is where the rubber hits the road, or in many cases, the tires skid along and never connect to the road!

Recently, I was asked to evaluate the revenue cycle performance for an institution that had implemented a new hospital billing and EHR system. The billing and EHR System were designed to interface seamlessly with an existing providers’ BAR system. Unfortunately, the implementation team did not perform a thorough assessment of existing tasks that included the charge entry process. Under the old charge entry process, providers would manually complete encounter forms, submit them to a coding unit (where validation and manual entry were performed) before going through the remainder of the revenue cycle process. Under the new system, provider orders (charge entry data) were generated from the new EHR application into charge work-queues for designated end-users to review.

The training offered to the clinicians who generated the orders (charges) was inadequate. It did not take into account that providers were used to having support staff (coders/billers) complete the charge entry process. As a result, providers didn’t understand how to:

  1. Open an encounter, enter supporting clinical documentation and close the encounter for the system to continue the path of sending those encounters into work queues for review
  2. Link critical, required documentation to orders
  3. Complete and send encounters without creating duplicate orders.

At the receiving end, the coders and billers were not adequately trained to work their designated charge router queues. The results:

  1. Aged accounts receivable over 90 days reached a whopping 30% of the total AR. Prior to the implementation, it was closer to 20%.
  2. Days in Accounts Receivable were around 40 days. Prior to the implementation, this metric hovered in the low-to-mid 30s range.

The moral of this story is: The Best Implementation fails without a proper assessment of current workflows in order to design an adequate training curriculum.  All stakeholders should be proactive, performing their due diligence, identifying the knowledge base required for a successful implementation, and developing a comprehensive training program to meet end-users and institutional needs.

Today, clinicians are being asked to perform many tasks that once were delegated to support staff. Let’s make sure we give them a fighting chance!





Mitigating Revenue Risk During IT Implementation

Mitigating Revenue Risk During IT Implementation

From small practices to large integrated delivery networks, the ability to evaluate and select the appropriate IT applications is increasingly important. A number of drivers are pushing healthcare organizations to look critically at their IT vendor mix, especially their revenue cycle applications, including clinical integration initiatives (and the need to extend clinical and business applications to affiliates), the shift to value-based reimbursement, competitive merger and acquisition activity, and vendor market consolidation.

No matter the reason, developing a strategy to mitigate disruption to cash flow is a crucial component of any billing system or EHR implementation. The potential risk to revenue is no less an issue for private practices than for IDNs, yet, too often organizations devise their plans to protect revenue after the vendor selection has been completed and contracted. A better option is to address your Risk to Revenue Mitigation Strategy as part of the vendor selection and contract negotiation processes.

For example, practices should include both implementation staffing needs and ongoing staffing demands (i.e., for application maintenance and user support) in their “total cost of ownership” analysis. Keep in mind that, although most vendors have pre-defined implementation approaches that include helpful standard workflows and staffing structures, these vendor-defined best practices may not adequately address an individual practice’s unique workflow or business requirements. Organizations with a single billing office, for instance, will have vastly different workflows and training requirements than those with decentralized hospital/professional billing and customer service.

To mitigate risk to revenue during revenue cycle or EHR implementations, consider adopting a comprehensive strategy inclusive of these seven elements:

1. Create a business intelligence blueprint prior to go-live. This is the number-one mechanism for mitigating revenue risk, but it’s often overlooked. While most vendors offer robust reporting and BI tools, during the sales process, these same vendors often do not set realistic expectations as to the work effort required to build them before go-live.

2. Don’t skimp on training. In fact, training should be the last place to look for cost savings. In reality, IT implementations always involve changes to workflows, policies and procedures, user roles, application navigation, and personalization tools. Practices must balance vendor recommendations and methodologies against these changes because lost productivity doesn’t just impact financial performance — it also impacts the patient experience. Whenever affiliated practices or hospitals are included in an implementation, the negative PR of a less-than-successful implementation can — and often does — impact future clinical alignment plans and opportunities.

3. “Accelerate” cash flow before go live. As early as eight to 12 months prior to go live, organizations should begin cleaning up their A/R and identifying opportunities to accelerate cash flow. The goal is to create a cash buffer to offset any dips in cash flow caused by declines in clinical productivity or billing performance once billing begins in the new system.

First, design a plan to aggressively work down legacy A/R in the old system before the new system is activated. If internal staff don’t have the bandwidth to shoulder the responsibility, consider outsourced opportunities for an interim period.

Then, decide how to handle the period of time between when some staff must work out two separate systems to work legacy A/R out of the old system and current billing out of the new system. Operating in dual environments — with two different workflows and two different sets of policies and procedures — presents challenges. Old habits are reinforced through use of the old system, just as you’re trying to instill new roles, workflows, policies, and procedures. To overcome these challenges and hasten the learning curve on the new system, many practices outsource A/R from their legacy system after the first two or three months, during which most of the easier-to-collect accounts are resolved.

4. Develop application talent internally. The key is to tap trusted employees who fully understand the practice’s business, values, and culture. Outside assistance is best used to streamline your team’s learning curve on the new system, to advise you on alternative implementation decisions (and their strengths and drawbacks), for peak periods of build, for date conversion or short term technical expertise, for training, and for go-live support and stabilization.

5. Convert clinical activity to cash through focused integration of clinical and revenue cycle functionalities. Don’t make the mistake of replicating legacy workflows; use the implementation as an opportunity for process improvement, such as the consolidation and/or standardization of visit types. Look at your documentation, charge capture, charge triggering, and charge routing for ways to improve physician efficiencies, and to produce thorough, timely, and clean claims. The ability to close encounters in a timely manner is a necessity. In addition, validate vendor recommendations to make sure your organization’s unique operational requirements — not just application best practices — are supported. Conduct integrated testing with real-life scenarios.

6. Automate data conversions. Some vendors advise against the automated conversion of certain patient and scheduling information. This may be due to the extensive amount of in-house technical expertise an organization would need to have on the brand-new application — which is not typically present. However, such data conversions involve a concentrated work effort for only a finite period of time. If qualified resources aren’t available internally, organizations may find it worthwhile to engage with an outside consultant. Automating data conversion offers a major ROI opportunity compared against tens of thousands of hours of manual data entry.

7. Test, test, test. The importance of system testing cannot be overstated. At a minimum, organizations should test their top volume- and top revenue-generating clinical services through a fully integrated clinical and revenue cycle. That means testing that starts with patient access, continues through the clinical encounter (including clinical documentation and charge capture), and continues through the entire billing cycle (including claims production, remittance, denial management, payment variance analysis, and reporting).

As healthcare organizations continue to align with affiliated practices, IT system builds are becoming more complex. Consider, for example, what happens when multiple practices and facilities all share a common billing system, yet their disparate financial information must be kept separate. In all such situations, a vendor’s standard implementation approach and timeline must be vetted and either validated or modified according to practice needs. Training and go-live strategies should always be grounded in reality; it’s better to reset expectations upfront than to put revenue at risk on the back end.


Brad Boyd is president of Culbert Healthcare Solutions.

Clinical Operations Insight into Revenue Cycle Revitalizations

Lisa Monteleone

Lisa Monteleone

On the surface revenue cycle revitalization initiatives for physician practice groups, hospitals and health care organizations appear to only require the involvement of patient access, patient financial services, information systems and the various functions of the health information management department. Often times it’s the areas where clinical operations overlap, areas that perpetuate patient care and cultivate patient trust, that are overlooked and are not considered part of any transformation effort.  As a result, process improvement teams that fail to include members with clinical operations insight could potentially produce a prolonged or unsuccessful revitalization initiative.

Areas where clinical and revenue cycle operations overlap are relatively easy to identify. These are areas where care is being delivered, reviewed and monitored with underlying processes that ensure continued patient access and ongoing effective revenue cycle outcomes.  Pre-admission testing (PAT) operations for clinical testing, non-invasive studies and surgical procedures require clinical personnel, (registered nurses, advanced practice nurses, and physicians) as well as revenue cycle activities (registration, scheduling, coding and financial counseling).  Exclusion of either side of this tightly integrated unit could lead to poor patient outcomes, decreased patient satisfaction, operational inefficiencies and suspension of the revenue cycle before it truly gets underway.

Care and utilization management teams as well as revenue integrity teams are examples of where the gap has been bridged between clinical and financial areas. These teams are composed of professionals with both clinical and financial backgrounds.  Their knowledge and expertise are leveraged to ensure optimal clinical documentation, discharge planning with the intent for re-admission reduction, and optimal reimbursement for the care and services delivered.   They have the ability to review clinical components and translate the information into financial outcomes. These three teams can prevent denials and are positioned to report on status issues as they occur and can positively affect the ability to improve processes that lead to greater revenue capture. Telephone nurse triage, pre-test screening, transfer center operations, and complex case management are also areas where there is overlap and a need for clinician and non-clinical alike to understand the impact they have on the revenue cycle.

These overlap areas require staff to have a broad understanding of the “business” of healthcare as well as a clear understanding of the care being delivered. Medical assistants, emergency medical technicians, registered nurses, advanced practice nurses, physicians’ assistants and physicians need to understand their impact on the revenue cycle.  The same can be said of the revenue cycle team with regard to clinical operations and its impact on the care delivery model.  The interdependencies of these two seemingly polar groups cannot be overlooked when undertaking a revenue cycle revitalization initiative, large or small.

When formulating the ideal revenue cycle revitalization project team, include team members with clinical operations expertise as they ensure there is effective translation between the care being delivered and the financial transaction being conducted, directly impacting the bottom line. Clinical operations team members add value by understanding the challenges and barriers when attempting to obtain accurate information in the clinical care delivery environment.    Process improvement teams that include members with clinical operations insight produce successful and long-lasting revenue cycle improvement initiatives.

How to Align Physician Compensation with Value Based Care

From The Consultant’s Corner 5/5/16

How to Align Physician Compensation with Value-Based Care

The move from volume-based to value-based reimbursement models is undeniable. Care quality, clinical outcomes, patient satisfaction, and cost containment all will play increasingly larger roles in reimbursement over the next few years. However, the pace at which this change is occurring varies significantly from payer to payer. Not all payers are moving simultaneously.

CMS has taken the lead with initiatives such as the Physician Quality Reporting System, the Value-based Payment Modifier, and the upcoming Merit-based Incentive Payment System (MIPS). While some commercial payers are following CMS closely, others have committed themselves to evolving their own value-based programs.

In the midst of this flux, practices face the difficult task of retaining some focus on volume to remain financially viable while the industry transitions. What this means from a practical perspective is that practices can no longer use past compensation plans as a model for the future. In fact, they can’t expect to nail down a physician compensation plan today that will last for even the next three years; physician compensation models must progress with the industry.

Flexibility is Key

Compensation plans developed today need to allow for flexibility, so they can accommodate current productivity requirements while supporting a changing culture and incentivizing the behaviors necessary for success over the long term. One way to achieve flexibility involves the periodic evaluation of payer progress toward value-based reimbursement.

The degree to which a practice accelerates its value-based physician payment model should mirror the practice’s payer mix. Over time, the percentage of overall compensation tied to value-based incentives should increase to align with the percentage of overall reimbursement tied to value-based programs.

The task now is to prepare for — or align with — those new reimbursement incentives. Practices must start turning away from their historic focus on independence and production, and toward a new focus on collaboration, communication, and overall outcomes and cost. By setting the right foundation, practices can ensure that their provider compensation packages accurately reflect their emerging quality, outcomes, cost, and patient satisfaction goals. It’s a significant opportunity to create compensation models that support the dramatic culture shift necessary to achieve value-based care.

Set a Value-Based Foundation

Practice and health system governance frameworks range widely, and include any number of different employment or contract agreements. While the governance model will affect how a practice implements its value-based physician compensation plan — for example, its physician engagement, design, timeline, and communication strategies — it shouldn’t affect the compensation plan’s basic structure. No matter the governance model, all value-based physician compensation plans must incentivize care quality, patient outcomes, and the patient experience. The reason is simple: These factors lie at the center of value-based care delivery. Primary care providers are also part of the nucleus.

Achieving value-based care requires someone — predominately primary care providers — to coordinate care among patients, internal staff, hospitalists, and specialists. That takes time, which fee-for-service models have seldom reimbursed. In comparison, value-based financial incentives should encourage providers to spend time on those care coordination activities and preventive measures that result in favorable patient outcomes. Typically, this kind of compensation plan is structured as base salary (often determined by years of experience) plus incentives for factors such as:

  • Care quality —Practices can use HEDIS, PQRS, Meaningful Use, and other existing quality metrics to measure and incentivize physician quality. Care coordination is another essential component of quality.
  • Patient access — Ensuring patients are seen in a timely manner helps improve outcomes and reduce costs. Strong access capabilities may also play a role not only in lowering cost, but in satisfying patients.
  • Patient satisfaction — Patient communication, education, and engagement activities can increase satisfaction, as well as improve care plan compliance. (Plus, better compliance could result in improved outcomes and decreased costs.) Practices can use existing satisfaction surveys to measure and incentivize physicians for their patient engagement efforts.
  • Corporate citizenship — Practices can further incentivize physicians to follow evidence-based clinical protocols.
  • Productivity — Productivity will not entirely disappear as an element of compensation plans, but should take a different shape. For example, practices should ensure that physician panel sizes are appropriate to their care coordination and management responsibilities.

Smooth the Transition

Traditionally, most value-based factors have been difficult to manage and control. However, the adoption of EHRs and CMS quality programs such as PQRS and MU have established a means for data capture, decision support, and reporting. Consequently, practices now have a good foundation on which to build physician compensation plans that align with the core tenets of value-based care. Still, it won’t happen overnight. Over the next few years, those practices with the flexibility to evolve alongside their payers are most likely to experience the smoothest — and most rewarding — transitions.


Brad Boyd is president of Culbert Healthcare Solutions.