By William Ayres, director of financial management, Grant Thornton LLP.
A key element in achieving end-to-end revenue cycle success in any healthcare operation is proper dedication and maintenance of workflow tools, and those systems that support processes that help organizations meet net revenue expectations.
Workflow optimization and the deployment of tools should be viewed from four perspectives: People, process, technology and metrics/KPIs/reporting.
It is incumbent on healthcare organizations to explore each of these areas related to RCM workflow optimization and consider relevant questions before deploying a fresh approach to workflow processes and automation. First, they must recognize that a balance of concentration of these four components is needed when building operational effectiveness and for the success of workflow strategy, tools and support systems. Furthermore, it is critical for RCM workflows (front, middle and backend) to reflect the uniqueness (location, size, demographics, payer mix, etc.) of the organization.
While there are many benchmarks and strategies in the industry that an organization can follow, adapt to or adopt, the specific characteristics of the organization – whether it’s a rural versus urban facility, the size and makeup of its staff, budgets, effects of recent mergers and acquisitions, and more – must be inputs when building and maintaining effective workflow controls. Principally, dedication to establishing optimization in workflows within revenue cycle operations is a direct result of senior management’s objectives of lowering or maintaining organizational metrics involving departmental and organizational “cost to collect”.
Organizations’ achievement of desired “cost to collect” results comes from their empowerment of senior and middle management and line staff, adoption of sound strategies that are understood and embraced, provision of user-friendly processes and effective deployment of technology – as well as maintenance of technology in a manner that is adaptable and flexible to the user and the organization.
More importantly and in support the first three components, organizations pursuing workflow optimization must have a process in place for measuring and gauging the success of established RCM goals, as well as clear metrics. Metrics are where the rubber meets the road – they’re how organizations know whether the people, process and technology components are functioning efficiently and as intended.
As in any situation where there is a desire to get from one point to another effectively and efficiently, a sound understanding of how metrics support organizational expectations will inform the direction and strategy. It is also important to note that RCM workflow optimization is system agnostic. While each organization has different approaches to workflow support and automation, they need to look at this component relative to the system they have deployed as well as their own uniqueness.
With a dedicated, all-encompassing approach to workflow operations, organizations are better positioned to process patient access, improve eligibility/benefits verification administration processing, improve Point-of-Service (POS) collections, effectively manage claims loads, process appeals in a more timely manner and improve self-pay production and collections. They can also maintain proper coding requirements, improve overall processing, and possibly reduce denials or denial rates, all while improving overall aspects of the revenue cycle continuum to achieve organizational strategic and revenue goals.
While there is no off-the-shelf, cookie-cutter formula to deploy to achieve expected net revenues and RCM optimization, establishing and maintaining benchmarks consistent with the uniqueness of an organization is key to success.
Organizations must address many questions to understand whether workflow operations and technology are hitting the mark. While a holistic approach taking into account people, processes, technology, and metrics is fundamental for true system effectiveness and performance optimization, there are many considerations associated with each of these areas.
- Does your staff have the capacity to perform production requirements needed for organizational success? Additionally, in deploying resources, are team members in the right positions? Are there leaders who can enable others’ success?
- Do all RCM staff fully understand their roles relative to the RCM end-to-end continuum? Are staff interchangeable or cross-trained to increase operational understanding or in preparation to fill unexpected gaps?
- Does RCM management deploy outsource resources as a stopgap measure?
- Are teams looking at “root cause” issues that will affect workflow production goals and objectives?
- In the case of new RCM systems and upgrades to present systems, are workflow processes reviewed or challenged with respect to potential changes in technology?
- Are RCM operational workflow processes interchangeable so that any new introducing effects do not create abnormalities, gaps, and workarounds?
- Does the organization embrace outsourced help in achieving best practices in workflow processes?
- Should the organization consider a central billing office if one does not exist?
While there are more questions organizations ought to consider in reviewing – and correcting – the effectiveness of the RCM continuum, the areas of people and process should guide the use of resources in the most efficient and effective manner. Furthermore, the structure of operations should allow for adaptable departments(s) and an environment that promotes the achievement of organizational goals and the ability to manage expected and unexpected changes.