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.