August, 2016:

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.

Five Ways To Decrease Patient Wait Times-


Transforming Access Through Scheduling Redesign

Long wait times can be a symptom of scheduling and access problems. When new providers join a practice, significant time and effort is put forth to “create” the schedule and the scheduling guidelines.  Rarely is any effort spent reviewing the schedule once the on-boarding phase is completed.

Providers may be satisfied from the perspective of their practice when their schedule is full. However, this is not always a win-win if patients are complaining about the schedule. Delays in care can result in unnecessary costs and less revenue.

There are a variety of strategies which can be utilized to improve patient access. Some practices use team medicine such as the pairing of providers with Nurse Practitioners or Physician Assistants. When care is presented as a unit or a team (and in a positive light by the provider), patients are more likely to see an advance practice clinician when a provider is full.  Practices with significant capitated or bundled income may find it helpful to build the access infrastructure by adding non-provider touches to patient care such as dieticians, nurses or health coaches.  Another option is cutting edge methods such as mobile apps, social media, shared medical appointments, outreach through a patient portal, texting or telephone calls, or virtual care visits.

It can be helpful to review triage protocols to be sure they encourage patients to be seen when new acute conditions arise or established chronic conditions are worsen. Often times patients can be managed by a staff member and providers may miss important signs of a problem.  Determine if refill protocols include standards for visit frequency and ongoing surveillance with diagnostic testing such as lab or radiology.

Ensure the practice has optimized the clinical workflow to be efficient. This includes standardizing rooms and staff duties, co-locating providers near staff to enhance communication, adding huddles to the day to discuss potential issues/concerns and decreasing patient wait time for ancillaries which are ordered at the time of service or in advance by primary care physicians prior to referral to the specialists.

Governance can play an important role when it comes to managing access. Jointly develop standards and guidelines between providers, administrators and staff. Requests to change templates should run through the operations team in order to ensure the schedule is not compromised.  Review schedules in a meaningful way once or twice yearly; confirm a provider does in fact have the required number of patient care hours available and the designated number of new patient appointment slots each day.  Ask questions to understand the reason for blocked or appointment slots on hold. Scheduling protocols can erode over time with meetings and non-work responsibilities which can reduce productivity.   Employ use of automation features and ensure they are hard wired to allow for search optimization and same day visit access.

The “third next available appointment “ represents a nationally reported measure against which practices can monitor their performance with a goal of seeing patients when clinically indicated and when they desire to be seen. Offering this type of data to providers, managers and staff can help to engage them in solving the access puzzle together.  Given the complexity of scheduling, it may be necessary to utilize one or more interventions on a regular basis.

Jill Berger-Fiffy , MHA, FACMPE Senior Consultant

Jill Berger-Fiffy , MHA, FACMPE
Senior Consultant

CMS divulges CPC+ regions: What you need to know

Managed Healthcare Executive

CMS has announced regions for the Comprehensive Primary Care Plus (CPC+) program for Medicare beneficiaries.

access article here

Nurse Triage Raises the Bar for Centralized Patient Access Centers

Centralized patient access centers are an important investment for medical groups and health systems as they provide an access point for current and prospective patients. As a means to attract and retain patients, a centralized access center that focuses solely on revenue cycle functions (scheduling, registration, insurance verification and payment collection) may not meet the needs of your patient population and may result in missed opportunities to fully improve patient access and appropriately drive care and service delivery.

Why Do Anything?

Despite the implementation of centralized patient access centers, patients continue to have difficulty obtaining access to urgent or acute care services with their providers. Often times this is due to the non-clinical office personnel’s inability to clinically assess the acuity of the patient complaint or concern.  Same day appointments intended to be filled by the more urgent or acutely ill patient are instead filled with patients whose care needs should have been met in an alternate, more appropriate environment.  Add in call demand from patients recently discharged from the hospital or outpatient surgery, those with a newly prescribed medication or care regimen, and of course the chronic consumers of health care services.  These patient access issues have a secondary effect on the centralized patient access center in the form of higher call volumes and prolonged wait or callback times to find available appointments.  As a result there is an overutilization of emergency departments for urgent care and primary care concerns.  Not to mention the negative impact on patient satisfaction!

What’s The Answer?

Balance the revenue cycle centric patient access center with Nurse Triage. A centralized nurse triage service line staffed by registered nurses with various areas of expertise (ER, critical care, surgical, pediatric, obstetrics) that are guided using nationally standardized triage and practice specific protocols provide safe and clinically appropriate care advice and service referrals.  Telephone nurse practice (TNP) or triage nurses are able to provide medical advice encompassing the treatment of fevers, wound care, and emergent conditions such as chest pain. The nurses are trained to triage conditions to the appropriate level of care at home, with a same day physician appointment, at an urgent care center, or at an emergency department.

What Are The Benefits?

  • Already have a centralized patient access center? – the infrastructure is in place just add the clinical components
  • Decreases risk of delayed or inappropriate care advice – eliminate non-clinical office personnel giving clinical advice or that “silent” heart attack patient waiting hours for a callback
  • Improves physician practice efficiency – clinical staff focused on providing face-to-face services
  • Improves after-hour provider utilization – calls to providers require their expertise and level of care
  • Improves appropriate utilization of services – physician same day/next day appointments, urgent care center and emergency room utilization
  • Facilitates care delivery and coordination through collaboration and exchange of information
  • Improves patient satisfaction – patient needs are met in the moment, no wait for callback or extended emergency department wait times


Nurse Triage Comes in Many Shapes and Sizes

When adding Nurse Triage to a centralized patient access center this service line can accommodate more than just symptom based call management. The clinical expertise of a TNP nurse allows for coverage of calls for a variety of reasons: pre-screening for tests and procedures, post-operative/procedure follow-up calls, new medication or treatment compliance calls and calls for complex or chronic case management, to name a few.  Nurse Triage can be provided during business hours, 24-hours a day 7 days a week, or somewhere in the middle.  Nurse Triage services can be “built” or “bought,” brick and mortar based or deployed remotely, managed 100% within your organization or outsourced to regional or national call centers.  Larger medical groups and health systems are likely to use more than one of these approaches to meet the needs of their patient population and providers.

Does Your Centralized Patient Access Center Set The Bar?

Centralized patient access centers that include Nurse Triage allow medical group and hospital based staff to focus on the face-to-face patient interactions. Investing in a service line that ensures patient care needs are being met at the appropriate level of care by the appropriately licensed professional  improve operational efficiencies, decrease risk to the patient and the organization, increase patient satisfaction, and improve patient outcomes.  Does your centralized patient access center provide appropriate and safe clinical advice, prevent unnecessary readmissions, empower patients in self-care, ensure appropriate ED utilization, and initiate referrals to care providers and services within your organization?

Lisa Monteleone

Lisa Monteleone

Enhancing Team and Leadership Performance Through LEAN Principles


I recently finished an assignment with a client whom was fully immersed in developing a LEAN culture. The experience reminded me, how the use of LEAN principles can enhance learning, promote participation and create more value.   The spirit of LEAN emphasizes participation at all levels and works because solutions are generated from staff or “bottom up” rather than from management in a “top down.”  The following are LEAN tools which can be applied to your setting:

Huddles-Huddles are a great medium to obtain updates from the team, inform staff of changes or obtain suggestions. Huddles can utilize discussion prompts and address a wide variety of areas.  Prompts can tie into the departmental metrics or probe further discovery of problems or assess the status of solutions.

Problem Solving– Root cause analysis is an integral step in a LEAN culture. The process begins with identification of the problem or a “Point of Recognition.” During the problem solving phase, it is important to avoid adopting a solution prematurely.  One must observe the problem and ask probing questions.  This is referred to as “Going to the Gemba.”  Once one understands “why” the problem is occurring, the process can move to applying a containment measure, testing a solution and checking the impact of the applied solution.  Problem solving activities may include data collection, creating paredo charts, fishbone diagrams or the ranking of ideas.

Value Stream Mapping– This step involves the creation of workflows. Workflows should include the use of standardized symbols to illustrate the process from the start to the end. The first one should illustrate the process or the work as it exists before any intervention.  This workflow is referred to as the “current state.”  Include “decision points” which may result in different outcomes.  Once this is clearly mapped out, the team can envision the “future state” or what it would look like with all of the non-value added steps removed and/or the process working efficiently.  The future state can reflect optimization; with changes made to people, process and technology.

Suggestions– Small suggestions can have big results! These can be simple to implement or complex and involve other people/departments or a formal approval process. Encouraging staff members to participate can bring excitement, innovation and can help to transform the work.  Suggestions may fall into several phases- Suggestions Identified, Planning to Do, Doing, and Implemented.  These can be aligned with the traditional Plan-Do-Check-Act Cycle.

SMART GOALS– The old adage, “If you can’t measure it, you can’t manage it” can hold true. Focusing the team on a goal and measuring progress can serve as a motivational tool.  LEAN is built on the use of SMART objectives.  Or Specific (exactly what is to be accomplished), Measureable (concrete criterion, agreed upon (by all stakeholders), Realistic- must be achievable, but better yet; a reach and Time Based (inclusive of a date or timeframe).  These goals are tracked and reviewed at huddles.

Tom Carlyle said “The person without a purpose is like a ship without a rudder.” The use of LEAN principles can offer an environment of learning, participation and team spirit. Consider adding one or more of these concepts to your management tool box.


Jill Berger-Fiffy , MHA, FACMPE Senior Consultant

Jill Berger-Fiffy , MHA, FACMPE
Senior Consultant