Re­vamp­ing the Rev­enue Cy­cle

More an­a­lyt­ics and IT ex­per­tise are being ap­plied to keep dol­lars flow­ing to health­care or­ga­ni­za­tions.

Health Data Management - - MOST POWERFUL WOMEN IN HEALTHCARE IT - By Linda Wil­son

In ac­counts re­ceiv­able, cash has al­ways been king. Now so is data. Value- and qual­ity-based re­im­burse­ment con­tracts are be­com­ing more com­mon, mak­ing the rev­enue cy­cle ever-more com­plex and po­ten­tially squeez­ing mar­gins. In re­sponse, rev­enue cy­cle man­agers are load­ing up on data to try to im­prove ev­ery facet of the rev­enue cy­cle and squeeze more cash flow out of op­er­a­tions. To do so they are ag­gre­gat­ing and an­a­lyz­ing in­for­ma­tion to drive work­flow changes through­out the rev­enue cy­cle—from appointment sched­ul­ing to de­nials man­age­ment. They are also au­tomat­ing rou­tine work­flows, such as pro­cess­ing claims and pre­vent­ing payer de­nials. Ul­ti­mately, they’d like to uti­lize ar­ti­fi­cial in­tel­li­gence and pre­dic­tive an­a­lyt­ics for their ef­forts. How­ever, those tools are not on the short-term radar of most rev­enue cy­cle op­er­a­tions. First things first: To glean re­ally use­ful in­sights, rev­enue cy­cle man­agers need to work with ag­gre­gated data from dis­parate in­for­ma­tion sys­tems de­ployed in both the financial and clin­i­cal realms. But many hos­pi­tals and health sys­tems have not reached that level of in­te­gra­tion. As they merge and buy physi­cian prac­tices and other health­care en­ti­ties, the num­ber of dis­parate in­for­ma­tion sys­tems they man­age is ris­ing. In­cor­po­rat­ing data from out­side sources—such as health in­for­ma­tion ex­changes—also con­trib­utes to in­ter­op­er­abil­ity chal­lenges. “The in­abil­ity to get a com­plete holis­tic view of a pa­tient record—in­clud­ing the pa­tient billing cy­cle, the financial pic­ture of the pa­tient—makes it very dif­fi­cult to per­form large-scale an­a­lyt­ics,” says Blain New­ton, ex­ec­u­tive

vice pres­i­dent of HIMSS An­a­lyt­ics. “It is re­ally across many plat­forms.”

RCM mish­mash

And lots of dif­fer­ent types of data is being pushed through a mish­mash of rev­enue sys­tem tech­nolo­gies. Many or­ga­ni­za­tions use mul­ti­ple soft­ware prod­ucts even within the rev­enue cy­cle area, ac­cord­ing to a 2018 sur­vey of 95 hos­pi­tal and health sys­tem lead­ers con­ducted by HIMSS An­a­lyt­ics. A to­tal of 29.5 per­cent of sur­vey re­spon­dents re­ported us­ing an elec­tronic health record with three or more other sys­tems; 18.9 per­cent re­lied solely on an EHR ven­dor’s busi­ness mod­ules to man­age the rev­enue cy­cle.

Mean­while, other or­ga­ni­za­tions re­ported us­ing mul­ti­ple solutions from non-EHR ven­dors in rev­enue cy­cle man­age­ment: 13.7 per­cent used three or more ven­dor prod­ucts, 6.3 per­cent used two or more prod­ucts, and 13.7 per­cent used a sin­gle so­lu­tion.

Given the num­ber of in­for­ma­tion sys­tems both in­side and out­side of the rev­enue cy­cle area, it is not sur­pris­ing that sur­vey re­spon­dents cited in­ter­op­er­abil­ity (75.8 per­cent) and data stuck in si­los (66.7 per­cent) as the key chal­lenges they face.

Sharp Health­Care, for one, would like to au­to­mat­i­cally feed data from a com­mer­cial cod­ing prod­uct to its en­ter­prisewide data ware­house. So far, the ven­dor of the cod­ing prod­uct has not com­plied with the health sys­tem’s re­quest. In­stead, Sharp uses the ven­dor’s pro­pri­etary re­port writer to pull data and then join it with data from other in­for­ma­tion sys­tems, such as pay­roll, for spe­cific projects—eval­u­at­ing coders’ pro­duc­tiv­ity, for ex­am­ple.

“It makes us jump through ex­tra hoops,” says Me­lanie Be­tan­court, di­rec­tor of sys­tem in­te­gra­tion for rev­enue cy­cle op­er­a­tions at Sharp Health­Care. She did not dis­close the name of the ven­dor.

Lack of con­trol

Another chal­lenge to cor­ralling all the data is in­ad­e­quate con­trol over the data and dash­boards nec­es­sary for rev­enue cy­cle man­age­ment, lim­it­ing man­agers’ flex­i­bil­ity to re­spond to prob­lems quickly, con­tends Jer­ica Hop­kins, re­search di­rec­tor for Health­care Busi­ness In­sights, a re­search and train­ing or­ga­ni­za­tion, which is part of De­ci­sion Re­sources Group, a re­search firm. “Rev­enue cy­cle lead­ers ac­tu­ally

want to ac­cess the data in real time, so they need to have more ac­cess or more own­er­ship over the data.”

In a 2018 sur­vey, Health­care Busi­ness In­sights found that most re­spon­dents had set up a for­mal struc­ture to ded­i­cate per­son­nel with data ex­per­tise to rev­enue cy­cle op­er­a­tions. Many em­bed­ded an­a­lysts in the rev­enue cy­cle de­part­ment; oth­ers as­signed an­a­lysts from the IT de­part­ment to rev­enue cy­cle projects.

But re­spon­dents used a va­ri­ety of re­port­ing struc­tures. Some an­a­lysts re­ported to both IT and rev­enue cy­cle man­agers, while oth­ers re­ported only to man­agers in one of th­ese ar­eas or the other.

An­a­lyt­ics as­sem­ble

Messy data and re­port­ing struc­tures aside, rev­enue cy­cle man­agers are mak­ing head­way in their ef­forts to an­a­lyze and act on in­creas­ingly large data sets.

For ex­am­ple, Be­tan­court and oth­ers at Sharp Health­Care an­a­lyzed how much it costs the health sys­tem to code each claim. This en­abled Sharp to as­sess the rel­a­tive pro­duc­tiv­ity of each coder and led the health sys­tem to de­velop stan­dard­ized cod­ing pro­ce­dures.

The Univer­sity of Pitts­burgh Med­i­cal Cen­ter also an­a­lyzed staffing is­sues and made changes to im­prove per­for­mance. Staff in its cen­tral sched­ul­ing op­er­a­tion have been or­ga­nized into pods based on med­i­cal spe­cial­ties, which has stream­lined end-to-end op­er­a­tions. “This al­lows us to more ef­fec­tively han­dle pa­tient de­mand as the sched­ulers be­come highly ef­fi­cient in their as­signed pod while also al­low­ing the man­age­ment and an­a­lyt­ics teams to bet­ter man­age re­sults,” says Lu­cas Foust, se­nior di­rec­tor of rev­enue cy­cle sys­tem devel­op­ment.

Foust, who re­ports to the vice pres­i­dent of rev­enue cy­cle at UPMC, said the to­tal num­ber of calls th­ese staff mem­bers han­dle per day in­creased 53 per­cent from April 2017 to April this year.

The Univer­sity of Iowa Hos­pi­tals and Clin­ics is us­ing an­a­lyt­ics to track re­im­burse­ment from pay­ers and pa­tients, process claims faster, and re­duce and man­age de­nials.

Chris Voss, rev­enue cy­cle man­ager in pa­tient financial ser­vices at Univer­sity of Iowa Health Care, which in­cludes Univer­sity of Iowa Hos­pi­tals and Clin­ics, and oth­ers in the de­part­ment are us­ing elec­tronic dash­boards to pin­point trends and help au­to­mate the process of track­ing ac­counts.

The dash­boards dis­play met­rics re­lated to out­stand­ing ac­counts re­ceiv­able, pay­ments, trans­ac­tions and de­nials. The health sys­tem pulls data di­rectly from Epic’s billing sys­tem, writes queries us­ing SQL, and cre­ates the dash­board vi­su­al­iza­tion us­ing Tableau. In self-pay ac­counts specif­i­cally, Voss and his team use the in­for­ma­tion re­ported in the dash­boards to im­prove how they man­age pa­tient bal­ances.

For ex­am­ple, the team iden­ti­fies pa­tient bal­ances that oc­cur when an in­surer de­nies a claim be­cause it doesn’t know if it is the pri­mary payer on an ac­count. In ad­di­tion to de­nials, the self-pay team also fo­cused on ag­ing ac­counts and those with large bal­ances.

The com­bi­na­tion of th­ese strate­gies has led to sig­nif­i­cant per­for­mance im­prove­ments. Voss pre­dicts the ef­fort will have re­duced days in ac­counts re­ceiv­able for self-pay ac­counts by half a day for the cur­rent fis­cal year, which ends June 30. He also ex­pects the num­ber of ac­counts sent to col­lec­tion agen­cies to be down by 10 per­cent.

Deal­ing with de­nial

As is the case for Univer­sity of Iowa Health Care, de­nials are a pri­or­ity for many health sys­tems’ an­a­lyt­ics ef­forts. In the HIMSS study on rev­enue cy­cle man­age­ment, 73 per­cent of re­spon­dents said cop­ing with de­nials is the big­gest chal­lenge for their op­er­a­tions.

De­nials cer­tainly are a pri­or­ity at Sharp Health­Care, where staff in rev­enue cy­cle man­age­ment have au­to­mated the billing process to de­crease the num­ber of de­nials and in­crease the num­ber of clean claims.

The health sys­tem pro­grammed rules around the claims-pro­cess­ing re­quire­ments for each payer into soft­ware that alerts billers to sit­u­a­tions where the in­for­ma­tion en­tered from staff mem­bers ear­lier in the rev­enue cy­cle process does not fol­low the rules. Ex­am­ples in­clude an en­rollee iden­ti­fi­ca­tion num­ber that doesn’t con­form to an in­surer’s stan­dard num­ber­ing sys­tem or a miss­ing di­ag­nos­tic code or mod­i­fier. Staff mem­bers then fix the is­sues high­lighted by the soft­ware be­fore the claim is trans­mit­ted to a payer, re­duc­ing the risk of a de­nial.

Ger­i­lynn Sevenikar, vice pres­i­dent of rev­enue cy­cle man­age­ment at Sharp Health­Care, says the health sys­tem is con­tin­u­ally up­dat­ing the soft­ware as pay­ers add new re­quire­ments to the cod­ing and billing process. “Ev­ery time we talk about some­thing that has caused a de­lay in the trans­mis­sion of a claim, our first ques­tion is: Can we build a rule?”

Sharp is re­vis­ing the soft­ware to pre­vent staff mem­bers from over­rid­ing ex­cep­tions. The soft­ware “re­ally lends it­self to stan­dard­ized work and highly re­li­able out­comes,” notes Be­tan­court, the di­rec­tor of sys­tem in­te­gra­tion for rev­enue cy­cle op­er­a­tions. □

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