The Turning Tide in Revenue Cycle Management · Revenue Cycle Management An evolving healthcare marketplace is rapidly driving shifts to new financial performance metrics focused

The Turning Tide in Revenue Cycle Management

Lisa Leonard TonkinsonHFMA-Des Moines, IowaJuly 17, 2019

Today’s Objectives

• Review “Traditional” Revenue Cycle Management

• Define Value Based Economics

• Outline change management that supports an outcomes-based care model

• Discuss data integrity concerns

• Technology challenges

• How to innovate from past mistakes

• Achieving Better Outcomes for All!

Traditional Revenue Cycle Management

Traditional Revenue Cycle Complexities

Is Any Thing Missing in the “Old” Revenue Cycle?

VALUE BASED ECONOMICS

IS MOVEMENT AWAY FROM TRADITIONAL “OLD SCHOOL” REVENUE CYCLE MANAGEMENT TO

UNDERSTANDING THE UNDERLYING PRESSURES ON MARGIN AND ITS BIDIRECTIONAL CORRELATION TO

PATIENT OUTCOMES.

Setting the Stage for Future Success

• Initiate change from status quo of traditional revenue cycle

• Communicate “change” across the revenue stream

• Adopt a cross-functional team approach

• Strong data integrity to align with Decision Support/Value Analysis

• Explore alternative resourcing considerations

• Technology driven data approach

• Patient-centric focus

• Outcome-based results

• Paradigm shift towards root cause analysis and issue-based resolution

Change is Driving Innovation

Capitation Fee for Service

NowPrevious Recent

Population HealthFFS/Value Based

Today/

Tomorrow

Value Cycle Management

Revenue Cycle Management

An evolving healthcare marketplace is rapidly driving shifts to new financial performance metrics focused on value.

Traditional Revenue Cycle

• One chargemaster supporting billing

• Claims based denials management

• Compliance “concerned”

• Pharmacy & Supply Chain existed in “silos” from other services

• Clinics operated independently from other hospital departments

• Focus on increasing volume, spend & cost cutting initiatives

• Reliance on vendors to lower prices & supply the “newest” widgets

• Disparate systems linked though interfacing

• “Need-to-know” information sharing

• Fee-for-service

• Connect charges to units of service provided

“All administrative and clinical functions that contribute to the capture, management, and collection of patient service revenue”

• Improving margins in fee-for-service while enabling success with value-based and other alternative payment models

• Connect costs to units of service and charges

• Evolves from acute/ambulatory to comprehensive care strategy

• “The process and culture by which healthcare providers pursue quality patient outcomes and optimal financial performance through the management of clinical, operational and financial assets.”

OperationalData

Financial Data

Clinical Data

Patient Access

ServiceCharge Capture

Coding ClaimDenial Mgmt.

Revenue Cycle Value Cycle

Value Based Economics Driving Revenue Integrity

• Operate in cooperative, interdepartmental alliance

• Codependence of hospital departments for success

• Strategic initiatives based in revenue integrity model

• Vendors partnerships forged on economic dependencies

• EAPs, pricing tables, multiple CDMs

• Root-cause identification

Value Based Economics Driving Revenue Integrity…continued

• Shift to compliance focused

• Episode of Care costs

• Transparency & visibility

• Integration in EHRs, ERPs, systems, etc.

• Interoperability (TBD)

Change Management Steps

Lead Change

Educate

Resolve Issues

Create Shared Need

Engage Teams

Communicate Vision

Share Information

Replicate Processes

Standardize

Measure Effectiveness

Celebrate Success

Pharmacy & Supplies

Billing Claims

Remit & Audit

Decision Support

FINANCIAL DATA

Pricing Transparency

Contract Management

Cost Analytics

Service-Line Analytics

OPERATIONAL DATA

Your Population

Right Treatment

Right Cost

Right Payment

CLINICAL DATA

Data Integrity Accuracy Affects Outcomes

Data: Driving Real Results

• Data normalization for today’s decision support

• Zero tolerance for “garbage in” mantra

• Responsibility factor in managing all this data

• Data safety / cyber security training and enhancements• Ransomware – don’t be held hostage for bitcoin

• Usability and scalability for strategic objectives• IT overload, delayed project starts due to data needs-issues of the past

• Information sharing

• Relevant data driven dash boards• No longer measuring to say we have metrics; meaningful tracking

Technology Driven Approach

• Invest in technology that makes sense

• ROI may really be just a number!

• Evaluate other forms of return• Time, labor, capacity vs. investment

• IT demands

• Interoperability needs

• Education to support learning curve

• Product adoption

• Application support & maintenance

• Options that limit output of overcommitted internal resources• Vendor managed software

Future State: The Value Cycle• Innovation driven • Intra/inter-departmental communication is mission

critical!• Data normalization crucial for outcomes based

decision support• Pharmacy & Supply Chain can no longer operate in a

vacuum• Physician Practices & Clinic interoperability• Global direction supporting departmental success• Change “Adaptable”• “No” to Status Quo • Diminished tolerance for business as usual• Dashboards demonstrating success management• Patient Satisfaction• Think Google, Amazon - anything is possible when we

think outside of the box

PHARMACY

CDM / REVENUE INTEGRITY

OPERATING ROOM

INFORMATION SYSTEMS / IT

SUPPLY CHAIN / MATERIALS MGMT

Thinking Outside of the Box

• Alternative Resourcing Options

• Employee-only resource model to “functioning for success”

• Remove the threat factor by elevating internal resources as dynamic performers

• Impactful external consultant use

• Virtual / flexible staffing

• Vendor resource alignment

• Stimulate technology success by assuring product adoption

• Identify automation opportunities

• Technology

• Processes

• Adaptable work force

Achieving Value Based Economics

• Cross functional approach with interdependencies

• EMRs with relational databases driving a team approach

• Value based care / outcomes driven

• Strategic Vendor Alliances

• Lean oriented with reproducible, standardized processes

• Metric determined

• Interoperability dependent

• Financially solvent

• Patient Centric

• Increased Patient Satisfaction

Innovation Driving Better Outcomes

• Value Cycle Revenue Integrity• Option to outsourcing Revenue Cycle

• Efficiency based processes• Revenue Cycle Software Solutions (EHR agnostic)

• Expert Consultants (SME, Product, Lean, etc.)

• Root cause analysis

• Data driven decision support

• Utilize Vendor supported technology/reports/resources• Exception based results

• Clean claim submission

• Optimized reimbursements

• Pricing transparency

• Data integrity • Linking clean data to product viability, provider performance & patient outcome

• Increased Patient Satisfaction!

Lisa Leonard TonkinsonRevenue Integrity Executive, [email protected]