As industry economics change, health care organizations are increasingly being pressured to provide financial transparency while improving the patient experience. Patient financial clearance (PFC) departments are increasingly under pressure to reduce costs and improve their own performancemetrics.
Yet it is difficult to improve baseline PFC key metrics such as days outs, denials, patient escalations, and write-offs without adding staff, an additional expense.
How can PFC departments reasonably achieve performance and productivity goals while still fulfillingtheir core functions? The first step toward PFC improvement is to understand how most PFC departments work, then sequentially adding measures to enhance PFC performance.
PFC departments, usually operating within a provider’s revenue cycle division, are typically resource challenged to curtail internal costs. A PFC department’s greatest cost is staffing, since most authorizations require staff-conducted phone calls to payers. Furthermore, authorizations are often complex for PFC to obtain, since they are based on specific payer rules and valid for only a set period of time.
PFC staff are also responsible for communicating the status of the authorization to not only the patient but also clinic staff. Given that a PFC department’s most important metrics directly pertain to patient health, it is imperative that PFC’s work is done in a timely manner and that financial status and payment are explained clearly to both the patient and provider, so that both parties can be educated in their decision-making process.
The organizational structure of a PFC department can assist or impede its overall productivity, based on the PFC team’s technology, workflow, and communication. For example, keeping teams in siloes may make team members specialized in their work but it can also create difficulty in achieving a streamlined overall process, due to the number of handoffs required to complete simple takes. Factors such as these illustrate the need for PFC departments to emphasize continuous improvement and workflow “optimization” which aligns technology, people and processes.
Improving PFC Performance
PFC performance improvement starts with understanding the department’s technology limitations an exploring potential options to automate PFC functions. For example, technology to verify insurance and benefits should be considered to reduce manual intervention as well as optimizing work queues to improve performance. Most EHRs have integrated insurance verification tools which can be configured to maximize the organization’s payers.
Want to rapidly improve your hospital’s brand, reputation and financial prospects? Look no further than patient access (PA), typically the front-line “face” of a healthcare provider and instrumental to an organization’s clinical, financial and reputational success.
While the definition of “patient access” may vary from organization to organization, generally it means the department responsible for handling new patient intake, including registration, insurance verification, billing, admissions, cash collection and more. According to the National Association of Healthcare Access Management (NAHAM), PA representatives handle access for “patients, providers and payors into, through and out of their healthcare experience.”
PA also significantly impacts a healthcare facility’s revenue cycle and finances, due to its role in benefit verification, pre-certification and even financial counseling. NAHAM estimates that about 80 cents of every dollar collected by a healthcare facility is handled by PA representatives. Considering the significant shift in health insurance toward high-deductible health plans, and the likelihood that patients will have an ever-larger portion of their overall bill to pay, the importance of PA has never been greater.
You would think a department and function as critical as PA would be considered a healthcare facility’s crown jewel and receive sufficient resources and internal approval accordingly. Yet too often, some in healthcare view PA as a necessary expense – a transactional, high-cost center often faulted for bad debt, claims denials, administrative delays and sub-optimal patient experiences. While that may be the case in some PA departments, high-performing healthcare providers know differently, and ensure that their PA staff members receive all that they need to succeed. Following are the most common characteristics of high-performing PA departments.
It Starts at the Top
A PA department is only as good as the system it supports, and most of that system is beyond PA’s direct control. For example, if a healthcare system lacks sufficient providers to meet the demand for care, or the right mix of specialists, PA will bear the patient-facing brunt of these issues. Similarly, if a facility doesn’t offer the time availability or convenient location to meet local patients’ needs, PA will suffer.
Operationally, healthcare organizations need to be sure they have in place the right care delivery strategy and resources to meet patient requirements – and allow their PA team to correspondingly perform well. That’s especially important in today’s era of healthcare, with patient experience increasingly affected by factors like access, convenience and cordiality, in addition to patients’ baseline expectations of caregiving competence.
Support from the top for PA is not only strategic and philosophical, but also practical. This includes making sure that PA has the latest technological tools necessary to deliver quality PA workflow. This could mean providing PA staff members with improved visibility tools into ED and inpatient unit availability, allowing for better and more productive PA decision-making. For patients, this might entail offering a high-quality, 24/7 online patient portal, providing information on lab results, discharge summaries and billing and scheduling information.
It’s tough to see the big picture when you’re “inside the frame.” That’s the underlying principle behind enterprise portfolio management (EPM), a top-down way for healthcare organizations to select and manage multiple projects and resources across the entire enterprise to maximize project portfolio value.
With EPM, large projects are centrally evaluated to determine overall progress and effectiveness, actual project spend versus budget, and continued alignment with the larger, strategic objectives of the organization. EPM is particularly valuable for healthcare organizations which often run multiple large projects simultaneously and frequently encounter ongoing project resource conflicts.
That was the constraint faced by a rapidly growing healthcare system which quickly discovered it could no longer manage new large-scale projects as if it were its older, smaller organization. The healthcare system could readily assess individual projects but lacked a big-picture view of the type, size, duration and risk of all of its project investments. The result? Unplanned operational and financial impacts from conflicting projects which led to recurring staff frustration as well as delays in project implementations and the realization of project benefits.
In response, the healthcare system devised and implemented an EPM process to more effectively prioritize its project resource allocations, timing and capacity, and ultimately guide its project investment decisions. While establishing an EPM system took time and resources up-front, it has helped the organization standardize the decision-making information presented to review and approval authorities and improved internal visibility into inflight work and capacity constraints in the system. The lessons learned by this healthcare system around EPM can serve as a guide to other healthcare organizations seeking similar gains in major project processes and outcomes.
Four Key Steps for EPM Success
You’ll first want to determine if an EPM approach is appropriate for your organization. The answer is likely “yes” if you’re regularly encountering any of the following:
Projects which are frequently delayed, leading to additional remediation costs, uncollected revenue and/or a delayed return on investment
Projects which spiral into “turf battles,” pitting business units, departments or teams against one another
Projects which do not or no longer align with and support organization-wide business goals
Projects which do not or will not deliver long-term value to the organization
Once you’ve determined the need to institute an EPM approach, you’ll have a much higher likelihood of success if you adhere to the following four fundamental recommendations.
Ensure top-level buy-in across the enterprise – Understand that instituting EPM processes may represent a significant change to some within your organization. As with any significant change, some individuals may be resistant to EPM, no matter its merits, unless they’re brought on board early in the process to understand EPM and help establish it within the organization.
To gain top-level buy-in, consider facilitating brainstorming workshops with your organization’s senior executives to define the EPM scope, scale and desired outcomes. Ultimately, your goal is to design and develop a multi-phased, enterprise-wide rollout strategy for EPM, to facilitate gradual understanding and adoption of EPM by staff. A phased rollout strategy might include adding a new project intake and vetting process, standardizing project proposal documentation and creating a project inventory listing key criteria for evaluation.
As healthcare organizations pursue improvements in productivity and clinical outcomes, they are also increasingly turning to business intelligence (BI) systems and staff to provide the data and tools needed to achieve and sustain such gains. The problem is, many organizations’ BI teams – tasked with a myriad of urgent and competing internal demands – often lack the experience, bandwidth and/or big-picture strategic and analytical skills needed to adequately respond to their organizations’ heightened needs.
That was the dilemma faced by a health maintenance organization (HMO) that had doubled its membership and found its BI team ill-equipped to respond to its growing technology needs. The HMO’s experience in recognizing and addressing its BI issues provides a template that other organizations can follow when confronted with similarly pressing BI demands.
The Four R’s of Quality BI Performance
The greatest positive emerging from the HMO’s BI issues was a wholesale reassessment of its BI team’s role, responsibilities, responsiveness and resources. You can call these the four fundamental R’s of well-functioning BI team performance:
Role – Rather than being focused on “doing,” a well-functioning BI team should also consider itself to be a vital strategic partner in the health care organization’s business. Attitudinally and functionally, a BI team needs to operate as a key part of the organization’s business team.
The HMO installed a new BI leader who immediately focused on mentoring and developing existing staff, overseeing and assisting with business analysis and reporting functions and defining a strategic path for the team to meet the HMO’s organizational strategy. This leadership change quickly stabilized the BI team’s performance and enhanced its ability to more effectively respond to internal requests. Your BI team’s leadership should be capable of achieving similar performance.
Responsibilities – Instead of simply being “order-takers” and “project fulfillers,” well-functioning BI team members should be high-quality strategic and process partners with internal clients. Creating and having in place service level agreements (SLAs) between a BI team and its business clients is crucial for establishing expectations for timing, deliverables and process improvement measurement.
For the HMO, the BI team’s new SLAs defined responsibilities for each business team member involved in project requests, performance objectives, documentation and sign-off requirements at milestones. The SLAs also provided project quality measurement standards, project success definitions and internal satisfaction reporting. Do your SLAs provide similar levels of accountability and clarity?
Responsiveness – Delays in responsiveness to client requests are not only inappropriate, they detract from a BI team’s professionalism. Established operational guidelines should delineate proper responsiveness for members of your BI team.
Though ICD-10 is upon us and there is little, if anything, that can be done at this point other than wringing your hands in disbelief or praying for peace with the patience of a saint (depending on your religious worldview and personality), we wait for the storm to hit, then pass and roll on a bit for a time. And it will pass. The storm will dissipate.
For some reason, when I think of the current state of ICD-10 and its impact to healthcare I’m reminded of a hurricane. The analogy of a hurricane seems like an apt example of the phase healthcare currently is in in regard to ICD-10.
The road here has been long – there has been much fear and anticipation of the coming storm. Surges of energy, wind and waves have met us and battled at the banks of the beach. The wind and thunder has been loud, the elements seem to have shaken the very foundation of our lives and our “homes.” Pain, fear, struggle and stress have been the order of the day. But at last we’re here. The storm is upon us, in fact it is half over, and we stand in its eye, one of the most beautiful and peaceful times one can ever experience.
Peace, calm expectation and a subtle excitement of the storm’s beauty are in the eye, as is anxiety of the anticipation of what’s to come — the second half of the storm. Having personally stood in the eye of one of the largest hurricanes on US record, and having survived one of the most terrifying storms of my life, I can tell you that the eye of the storm is a brilliant, calm and peaceful place in what is actually an extremely deadly and dangerous place to be.
However, when the eye passes, the storm rages again, even more fierce than the penetrating force of the first half of the storm. Again, there’s more fear; more stress; more panic. Finally, the storm passes, slowly and subtly. The wind disappears, the sun breaks free and among the chaos, birds sing with striking clarify and beauty. It’s as if their songs are the only remaining sound because the storm has sucked all else away. Their song is an encouragement as you assess your losses and determine the first steps required to put your life back together.
Certainly, ICD-10 is not deadly, nor is it as dramatic as surviving a killer storm, but the process has been stressful, and painful and chaotic for millions. We’re in the eye, half way between beginning and end. Much has happened, but there is still a great deal more to come. I image that’s how many of you are feeling today; trying to ride out the storm — in peace, in fear or maybe a combination of the two. So, on this occasion, as we wait, I thought I’d provide a few final thoughts about ICD-10 from those working alongside you, in the trenches, who are also weathering the storm. Hopefully these insights provide you some peace, and help you get through this stressful time.
With the transition to ICD-10, we expect three types of industry disruption occurring at different times. First, starting in the first few days after the Oct. 1, 2015 cutover, when providers start transmitting claims containing ICD-10 codes (between 10/3 and 10/10), we predict that providers that chose to ignore the ICD-10 mandate will receive a monumental wake-up call when clearinghouses and payers immediately reject their ICD-9 coded claims as non-clean HIPAA transactions. We believe that most of the nonconformists will be smaller, rural professional providers and small practices. They will scramble to get ready in short order if they wish to be paid for their services.
Second, by mid- to late-October, providers will start receiving payments based on claims submitted using ICD-10 codes. Most professional claims are reimbursed based on the CPT/HCPCS codes and therefore are not susceptible to payment shifts. Institutional claims are paid via a wide range of reimbursement mechanisms, mainly due to combinations of both ICD-10 diagnosis as well as procedure codes. ICD-10 testing between providers and payers illustrates that four out of five payment disputes are because of poor coding accuracy from the provider. We see an increase in phone calls to payers and an elongated revenue cycle collection timeframe.
Third, throughout 2016, we see overall data quality issues emerging as the industry stabilizes and acclimates to the new code set. Although CMS relaxed coding accuracy requirements for Medicare fee for service claims, commercial payers have not followed suit. Be prepared for an increase in chart reviews and ongoing adjustments to previously paid claims.
Coastal Orthopedics has been serving the coastal South Carolina region for more than 30 years, and has helped countless members of our community regain and maintain a full quality of life. In those years of serving our community, ICD-10 has without a doubt been one of the biggest challenges that our practice has faced to date. With major overhauls to our practice workflow and ultimately our ability to provide the best care to our patients on the horizon, we set out early to meet the demands of the ICD-10 transition proactively.
The success of our transition to ICD-10 has been two-fold. One: our software partners (SRS Soft EHR and Allscripts Practice Management) have continued to deliver exceptional tools that have allowed our practice to leverage the power of healthcare information technology to expand our ability to provide exceptional care exponentially. Two: The dedicated staff and physicians of our practice, who truly love getting to be a part of helping our patients live their best life, have invested countless hours of preparation into being sure that our patients continue to receive only the best care. After months of updating our office systems/processes, working with care partners across the community, working with our software partners to fine tune our systems, and working with insurance companies to ensure that our patients get the most of their benefits, we’re ready to take ICD-10 head-on.
October 1st will be just another day of providing exceptional orthopedic care to our community for Coastal Orthopedics.
The day before, the day of and the day after ICD-10 goes live, it will be too late. But, as we get closer to ICD-10 go live, there are some final preparations that you can do before it does, and some remediation that can be done post go live. Physician practices and hospitals can focus on the procedures and visit types that drive their practices. We call this focus, the Codes that Matter. A very small percentage of procedures and visit types drive 95 percent of revenue so focus on those key areas to protect your revenue.
In addition, the physicians and hospitals need to take a snap shot of financial and revenue cycle performance prior to going live. This is especially critical at this point. The hospitals and physician practices have to know where they are today so they can effectively evaluate their financial and revenue cycle performance post go live. Financial “fire drills” need to be conducted to practice and prepare for revenue cycle impacts. How to prevent 10 percent to 15 percent revenue hits? If we see those issues arising, how do we quickly address and how do we rapidly deploy teams to close the issues. Waiting until the day before, similar to cramming for the test will not work well for the October go-live. There are a couple of things listed above that can still make a difference so the time is now before the die is cast.