Spring 2016  
Emerging Patient Access and Revenue Cycle Trends
By Brad Boyd
Change is one of the only certainties facing the healthcare industry. The Patient Protection and Affordable Care Act has major implications for all aspects of patient care, including patient access. The strategic alignment of physicians and hospitals is required as population health, care coordination and patient-centered health are key components of value-based reimbursement models. Quality and outcome measures must be monitored as they are tied directly to reimbursement. Providers that are able to provide a comprehensive array of services, demonstrate outcomes and manage financial risk will be in the best position to succeed.
Patient access is at the center of this change, especially in an integrated delivery network environment. The expansion of Medicaid and the recently implemented health exchanges provide a new source for patient lives, however those newly insured patients will have a choice where to go and competition for those patients will increase. Patient satisfaction will become increasingly more important from the perspective of both outcomes as well as overall patient experience. Patient access represents significant opportunities to enhance the patient experience, to improve physician and resource productivity, and to more proactively manage patient populations. Each of these benefits translates to improved financial performance.
As clinical integration and physician-hospital alignment programs continue to expand, revenue cycle functions including customer support and statement processing can become the source of patient frustrations. Additionally, redundant revenue cycle functions across multiple entities within a health system, creates inefficiencies and often makes reporting at an enterprise-level challenging.
Within healthcare organizations, standardization of patient access and revenue cycle policies and procedures, supported by centralized operational units (centralized patient access unit and single billing office) represent ideal opportunities to enhance the patient experience (more timely access to services, efficient scheduling of multiple services, single patient statement, single customer service line), reducing operating expenses (staffing efficiencies, improved productivity), improving data capture (reduced denials), and improving management reporting.
While no one patient access or revenue cycle model is necessary for success, models which produced
the most dramatic results shared the following common themes: standardized policies and procedures, centralized registration/scheduling, standardized visit types, centralization of revenue cycle functions, consolidation of patient statements, the use of a patient portal to support patient engagement. Major success factors, or impediments to success include business application functionality and organizational culture.
Standardization and centralization are largely understood to offer several benefits, particularly from the perspective of the patient experience. Implementation design must account for internal alignment – the degree of change an organization is able to effectively implement. Culture, governance and leadership are often the factors that determine the extent to which functions can be completely centralized, especially scheduling.
Governance plays an extremely pivotal role for organizations utilizing or implementing fully integrated IT platforms (ex. Epic) due to the integrated nature of master files which support access, clinical and revenue cycle operations. Consolidation and standardization of these decisions can have a dramatic impact on clinical and financial operations as well as enterprise reporting. A centrally managed access unit is better positioned to make design decisions aligned to meet enterprise-wide objectives. The extent to which these decisions are made at the local level (hospital, specialty, practice) impacts the ease of meeting enterprise-goals.
Improving Patient Access by Assessing Provider Capacity
By Johanna Epstein
Spotlight Article
Over the years, the concept of improving patient access has morphed into something that a physician practice “should do” to something a physician practice “must do”. Better access to healthcare for patients will improve clinical outcomes and enhance patient satisfaction. As a result, physician practices can enjoy the benefits of Meaningful Use payments, Value Based Care incentives and patient retention through improved patient satisfaction. In most cases, practice managers already know when their physician group has a patient access problem. Patients will likely be complaining about long wait times for appointments. As a result, managers need to determine the magnitude of the problem. Is my problem limited to one provider or one specialty area? Are the bulk of the complaints related to long wait times for appointments?
If this is the case, take a moment to review key performance indicators to ensure that your access strategy is working. How many days to your providers’ third next available appointment? How many appointment slots are open to new patients each day? What are your patient cancellation and no show rates? Are my providers complaining that they do not have time to see more patients? Are you appropriately utilizing mid-level providers and nursing teams to facilitate patient care?
If the answers to the above questions cause you pause, it is time to conduct an in-depth analysis of your provider’s capacity. Increasing capacity isn’t as easy as simply adding another slot to an already-packed schedule.
The key to evaluating provider capacity is taking a hard look at factors such as:
  • Practice capacity policies and standards: Does each provider’s wRVUs match practice expectations? Establishing and enforcing administrative policies regarding the required number of patient care hours or wRVUs is essential to ensure long-term behavioral changes.
  • Benchmark data: Are you sharing peer benchmark data to help prompt behavioral changes needed to overcome capacity shortfalls?
  • Individual schedule variations: Are you taking a hard look at provider scheduling patterns? Is too much time being spent on activities that could be delegated to clinical support staff? In some cases, analysis might reveal that there are too many patients on a provider’s panel and as such, the panel should be closed for a time. In others, you may find that additional slots can be added to a provider’s schedule simply by reconfiguring workflow to utilize practice resources.
Once you have your assessment completed to include your associated provider capacity policy, it’s best to team up with physician leadership to drive policy enforcement. Physician leaders who can speak with their colleagues one-on-one are better able to focus the conversation on benefits to patient care and the patient experience, resulting in a more open dialogue and positive results. In the end, healthier and more engaged patients will improve provider satisfaction. A win for all.
Implementing Enhancements to your Revenue Cycle System
By Ken Maleske
My latest engagement was to work with a Physician practice that had been on GE (IDX) Centricity Business for the last 20 years. The decisions that were made 20 years ago made a lot of sense in how the software architecture allowed them to do the business that they needed to do. Now those decisions of the past were being replicated year after year without challenge. This group has and is doing a good job financially with how the system is currently set up and are in heavy growth mode. The large scale growth and consolidation that started in the 1990s and continues today resulted in many clients creating new billing groups for each new practice or department that came onto the system. These groups acted like they were in silos and did not like sharing their data even though they were all employed by the same entity. Implementing system changes in environments like this is challenging at best.
A Revenue Cycle System is like owning a home, if you just put a fresh coat of paint on the outside it may look nice but the inside core is still the same. The group I worked with has been very good with upgrading their system routinely and are in the midst of going to the most recent released version, but what hasn’t been happening is the implementation of the enhancements that go along with the upgrade. Some of these enhancements are on the project list but as many of you know, when in growth mode, the wish list gets moved to the bottom of the priority.
This practice did not need a reinstall, it needed a reconfiguration. A reinstall would take nine to twelve months where a reconfiguration would take three to four. Additionally the reinstall would be more of a disruption to the organization as it would pull more resources and would require the running of parallel systems similar to migrating to a brand new system. The review of the system yielded the following recommendations: their dictionaries were over populated by entries and that a clean-up needs to occur; system settings needed to be re-evaluated to reduce the amount of credit balances; re-work of statements and form letters to increase patient and physician satisfaction; changes to interface set-up/logic; consolidation of their BAR and MCA groups.
As a practice prepares for the next upgrade, it is a perfect time to take a look back at all the system enhancements that have been incrementally added with each version, but not implemented. It is also the right time to review all the new features of the upcoming version and prioritize the list of items that would be a good fit for the organization. Then plan out the rest of the year by implementing a couple of the items every 4-8 weeks and by the end of the year, your system will be able to support your long term strategy.
Mixed Use Patient Access Call Centers Improve the Patient Experience
By Lisa E Monteleone
Mixed use 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. A decentralized or splintered patient access design or a poorly performing centralized call center can result in patients being frustrated or turning away from your Health System altogether.
Patient Access
Effective implementation and management of a mixed use centralized patient access center is key to attracting and retaining patients for medical groups and health systems. But what is “patient access” really? Patient access means something different to everyone. For some, patient access refers to a department. For others, it refers to availability of care, services and providers. For those who focus on medical group or health system strategy, patient access has a much broader definition. It’s everything that affects a patient’s ability to get to the right care, at the right time, for the right reasons, at the right location. In either case, patient access most often includes the operational functions of:
  • Referral management
  • Scheduling
  • Insurance eligibility, benefit and authorization management
  • Registration
  • Payment collections
Patient access is so much more than operational functions. It includes effective management, staffing, IT systems, workflow design, the right mix and number of providers, as well as the coordination of care and services between multiple sites across the full continuum of care. Centralization of mixed use patient access centers impacts medical group and hospital system operations, patient satisfaction and quality outcomes.
When it goes wrong
In the recent past you have likely been subject to a poorly performing patient access workflow that resulted in multiple calls, repetitive requests for information, long hold times and inadvertent disconnects. All this to schedule an appointment, speak with your provider, or make a payment for care received. It’s likely this experience left you frustrated and questioning your choice in care provider. In today’s healthcare environment this experience can be detrimental to the success of the healthcare provider.
To be successful, providers must focus their patient access efforts on the complete patient experience, from the moment a call is placed to schedule an appointment to the time the patient receives the final bill. No step can be overlooked without adding to the risk of losing the patient to a competitor. When considering the implementation of a mixed use centralized patient access center, physician and patient satisfaction, operational, management and revenue cycle implications need to be taken into consideration.
When it goes right
I had a recent experience with a patient-centered provider of health care services where I placed a call during peak business hours to schedule a new patient appointment with internal medicine. During the call, the representative was alerted via their IT system that there was a financial hold on my account. The hold did not allow the appointment to be scheduled. The representative transferred my call to patient accounting. I thought to myself, here we go, this is going to take FOREVER! Boy was I surprised!
The patient accounting representative quickly explained the reason for the hold and we rectified the outstanding co-pay balance. The representative transferred my call back to scheduling where the scheduler quickly secured an upcoming appointment with the physician. At the end of the call, I asked the scheduler if it would be possible to speak to the physician’s nurse. The scheduler transferred my call to a nurse. Using standard protocols the nurse documented the reason for my call and submitted the non-urgent medical request to the appropriate physician via their EMR system. The physician returned my call in the call same day.
This is not a fictional description of an ideal state. It’s a real accounting of an experience I had with an effective mixed use patient access center. I’m not sure what they could have done to improve my experience! In one phone call, lasting less than 15 minutes, with minimal repetition of patient information and minimal on-hold time:
  • An outstanding payment was rectified
  • An appointment was scheduled
  • A non-urgent medical request was triaged by a nurse
Positive Outcomes
Centralizing call management reduces voicemail and email related frustration for the patient. It lowers expenditures on scheduling staff and office space, and realizes overall savings to annual operating expenses. In addition, centralized scheduling can create multi-practice / service line visibility which allows the patient and the network the opportunity to leverage system-wide availability.
Combined call management and scheduling, when effectively implemented and managed, improves medical group and health system efficiency, increases appropriate patient access to physician appointments and services, and tightens the referral network which reduces referral leakage or loss. Mixed use centralized patient access centers can accomplish many things for a medical group or health system, not the least of which is managing call demand with appropriate call routing.
  • Appointment scheduling & reminders
  • Physician & service referral management
  • Pre-registration functions
  • Post-Procedure / Post-Surgical / Post Hospital Discharge follow-up calls
  • Health promotion opportunities
  • New medication follow-up
  • Prescription refill management
  • Test result communication
  • Symptom based nurse triage
  • Non-symptom based nurse response to medical concerns
  • Complex case management
  • Physician on-call communications
  • Revenue cycle management
Nurses and nonclinical persons staffing the call centers use decision-support software to quickly and accurately address patient requests. Clinical decision-support content can be built around standardized guidelines or customized by practice. This creates consistency with each patient touch, develops staff confidence in the care and service they deliver, and ensures patient safety with every interaction. Which shape and size fits your need?
Mixed use patient access centers come in all shapes and sizes. The centers can be centralized in a single location or virtually though IT applications and systems. They can be operational during business hours or 24-hours a day 7 days a week. The centers can be staffed in-house by the medical group or health system or they can be outsourced to regional or national call centers. And lastly, the centers can be brick and mortar based or deployed remotely. Larger medical groups and health systems are likely to use more than one of these models to effectively manage the needs of the patient population and their providers.
Meeting the challenge head on
Health care providers are faced with several challenges at once: an aging and more consumer-oriented patient population alongside reduced payments and a more competitive marketplace. Investing in top notch people, policies, and processes are key to health care provider survival. Mixed use centralized patient access centers allow medical group and hospital based staff to focus on face-to-face patient management needs at their facilities and offices, and as a result improve operational efficiencies, patient satisfaction, and patient outcomes. How does your patient access measure up?
A Continued Focus on Interoperability
By Trudie Bruno
Being part of the healthcare industry means generating, collecting and interacting with enormous amounts of healthcare data. Once this data – clinical, financial, human resources, research, etc. – is generated, healthcare organizations need to analyze it to improve care delivery, increase cost savings, enhance operational efficiencies and so much more. As you can imagine the data that healthcare organizations collect and aggregate often don’t come from a single source and often not even from the same software platform. As organizations need these pieces of information to provide a complete picture for patient care and business needs, what are they to do?
The first step to this complex topic is ensuring you have access to the right data in order to identify appropriate initiatives for your organization. As the industry focuses on quality based initiatives such as Meaningful Use, Accountable Care Organizations and updated Reimbursement Models, sharing the collected patient data across organizations becomes even more crucial. Across the healthcare space, providers, developers, technologists and patients need to stand united in demanding interoperability improvement. It is an opportunity to create a data sharing infrastructure that may lead to healthcare developments beyond our current imaginations.
Interoperability and data aggregation is not without a set of unique challenges. Disparate systems and data on varying organizational levels requires careful adaptation in order to coordinate information. A single health system may have as many as 20 or more different EMR systems, all of which may not communicate with each other. Different providers treating the same patient may not be able to easily access a complete patient record because their EMR systems are disparate. Some EMR systems also handle different types of data that simply do not interchange. Yet another challenge to interoperability stands within the data itself. Health information data can often be limited simply because it is often based on billing standards, meaning that clinical data is conspicuously absent in providing an accurate picture of the patient record. Standards to maintain a complete patient record, separate from back-end processes are needed. Thus, what are the solutions that optimistically promise an increase in interoperability?
In order to improve interoperability, it is important to be able to aggregate data from disparate systems. To begin the process, awareness of the different systems and their respective data is essential. For example, it is helpful to know that a practice management system may hold mostly demographic and insurance information, while the EHR holds the clinical data. However well separated into systems this data may be, every detail is relevant to the overall patient record and to bringing the information together seamlessly. Interface systems, as one example, can then be set up to bridge the different systems, using the correct language standard depending on the information. While aggregating data is still a major challenge at the moment, the data must ultimately also be normalized in order to be used. This involves removing duplicate or invalid entries as data is merged and ensuring that meaning is preserved as it is added into a new system. It is essential to create a consistent, complete patient record that can be confidently queried.
There is always the concern of security with shared data, especially when that data involves PHI. Thus, healthcare IT professionals can turn to banking as an industry with answers. The core solution is being able to take health information and translate it into a set of “transactions” which can be uniformly filed and shared through a centralized health system, minimizing human interaction. At the end of the day, it is important to be aware of the risk of data breach and essential to maintain high standards to avoid it. Tactics include “encryption, cell suppression, field aggregation and statistical techniques to de-identify data.”
It is only becoming more essential to share health data across systems for the health of patients. With benefits for both the individual and the population, interoperability provides a spectacular opportunity to change the healthcare status quo and empower patients. While there are unique challenges to developing interoperability within healthcare systems, the benefits are worthwhile. Do you have the right resources, experience and solutions you need to make interoperability a reality within your organization?
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